Computerized clinical decision support systems, or CDSS, represent a paradigm shift in healthcare today. CDSS are used to augment clinicians in their complex decision-making processes. Since their first use in the 1980s, CDSS have seen a rapid evolution. They are now commonly administered through electronic medical records and other computerized clinical workflows, which has been facilitated by increasing global adoption of electronic medical records with advanced capabilities. Despite these advances, there remain unknowns regarding the effect CDSS have on the providers who use them, patient outcomes, and costs. There have been numerous published examples in the past decade(s) of CDSS success stories, but notable setbacks have also shown us that CDSS are not without risks. In this paper, we provide a state-of-the-art overview on the use of clinical decision support systems in medicine, including the different types, current use cases with proven efficacy, common pitfalls, and potential harms. We conclude with evidence-based recommendations for minimizing risk in CDSS design, implementation, evaluation, and maintenance.

An overview of clinical decision support systems: benefits, risks, and strategies for success.

The purpose of this review is to present a guide to help readers critically appraise the methodologic quality of an article or articles describing a clinical decision rule. This guide will also be useful to clinical researchers who wish to answer 1 or more questions detailed in this article. We consider the 6 major stages in the development and testing of a new clinical decision rule and discuss a number of standards within each stage. We use examples from emergency medicine and, in particular, examples from our own research on clinical decisions rules for radiography in trauma.

Iconographies supplémentaires de l'article : Methodologic Standards for the Development of Clinical Decision Rules in Emergency Medicine

Lack of neural innervation due to neurological damage renders muscle unable to produce force. Use of electrical stimulation is a medium in which investigators have tried to find a way to restore movement and the ability to perform activities of daily living. Different methods of applying electrical current to modify neuromuscular activity are electrical stimulation (ES), neuromuscular electrical stimulation (NMES), transcutaneous electrical nerve stimulation (TENS), and functional electrical stimulation (FES). This review covers the aspects of electrical stimulation used for rehabilitation and functional purposes. Discussed are the various parameters of electrical stimulation, including frequency, pulse width/duration, duty cycle, intensity/amplitude, ramp time, pulse pattern, program duration, program frequency, and muscle group activated, and how they affect fatigue in the stimulated muscle.

Neuromuscular electrical stimulation for skeletal muscle function.

METHODOLOGICAL REVIEW: Approaches for creating computer-interpretable guidelines that facilitate decision support

We have compared the auditory evoked potential (AEP) index (a numerical index derived from the AEP), 95% spectral edge frequency (SEF), median frequency (MF) and the bispectral index (BIS) during alternating periods of consciousness and unconsciousness produced by target-controlled infusions of propofol. We studied 12 patients undergoing hip or knee replacement under spinal anaesthesia. During periods of consciousness and unconsciousness, respective mean values for the four measurements were: AEP index, 60.8 (SD 13.7) and 37.6 (6.5); BIS, 85.1 (8.2) and 66.8 (10.5); SEF, 24.2 (2.2) and 18.7 (2.1); and MF, 10.9 (3.3) and 8.8 (2.0). Threshold values with a specificity of 100% for a state of unconsciousness were: AEP index, 37 (sensitivity 52%); BIS, 55 (sensitivity 15%); and SEF, 16.0 (sensitivity 9%). There was no recorded value for MF that was 100% specific for unconsciousness. Of the four measurements, only AEP index demonstrated a significant difference (P

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Analysis of the EEG bispectrum, auditory evoked potentials and the EEG power spectrum during repeated transitions from consciousness to unconsciousness.

The analysis of intravascular indicator dynamics is important for cardiovascular diagnostics as well as for the assessment of tissue perfusion, aimed at the detection of ischemic regions or cancer hypervascularization. To this end, indicator dilution curves are measured after the intravenous injection of an indicator bolus and fitted by parametric models for the estimation of the hemodynamic parameters of interest. Based on heuristic reasoning, the dilution process is often modeled by a gamma variate. In this paper, we provide both a physical and stochastic interpretation of the gamma variate model. The accuracy of the model is compared with the local density random walk model, a known model based on physics principles. Dilution curves were measured by contrast ultrasonography both in vitro and in vivo (20 patients). Blood volume measurements were used to test the accuracy and clinical relevance of the estimated parameters. Both models provided accurate curve fits and volume estimates. In conclusion, the proposed interpretations of the gamma variate model describe physics aspects of the dilution process and lead to a better understanding of the observed parameters, increasing the value and credibility of the model, and possibly expanding its diagnostic applications.

https://iopscience.iop.org/article/10.1088/0967-3334/29/3/001/pdf

On the physical and stochastic representation of an indicator dilution curve as a gamma variate.

We investigated the effect of incision and sternotomy on the auditory evoked potential (AEP) and EEG, to try to predict a haemodynamic response to incision or sternotomy using the AEP and EEG in 41 patients undergoing cardiac surgery during propofol and alfentanil anaesthesia. The AEP and EEG were recorded before incision, between incision and sternotomy, and after sternotomy. Peak latencies and amplitudes of AEP peaks V, Na, Pa, Nb, Pb and Nc were determined. From the EEG the median, spectral edge and peak power frequencies, and percentages of delta, theta, alpha and beta power were calculated. Each patient was classified as responsive, equivocally responsive or unresponsive to incision or sternotomy based on increase in arterial pressure and heart rate on incision and sternotomy. Before incision, Nb and Pb latency and propofol concentration were higher for unresponsive patients but heart rate and median frequency before incision were lower. After sternotomy, Pa and Nb amplitude, peak power frequency and percentage alpha power were higher, and percentage theta power lower for responsive patients. Pa latency was higher after sternotomy for unresponsive patients. Using a combination of heart rate, arterial pressures and features derived from the AEP (all recorded before incision), the occurrence of a response to incision could be predicted in individual patients with a sensitivity of 85%, positive predictive accuracy of 63% and total accuracy of 72%. We conclude that AEP are more sensitive to pain stimuli than spectral features of the spontaneous EEG. In addition, the AEP may help in predicting inadequate anaesthesia.

Haemodynamic responses to incision and sternotomy in relation to the auditory evoked potential and spontaneous EEG.

The intra-thoracic blood volume (ITBV) is a cardiovascular parameter related to the cardiac preload and left ventricular function. Its assessment is, therefore, important for diagnosis and follow-up of several cardiovascular dysfunctions. Nowadays, the ITBV can be accurately measured only by invasive indicator dilution techniques, which require a double catheterization of the patient. In this study, a novel technique is presented for ITBV assessment by dynamic magnetic resonance imaging after intravenous injection of a small bolus of gadolinium chelate. The dose was chosen on the basis of in vitro calibration. The bolus first pass is detected from a simultaneous dynamic image series of the right and left ventricles. Two indicator dilution curves are derived and used to inspect the transpulmonary dilution system. Various mathematical models for the interpretation of the measured indicator dilution curves are compared. The ITBV is assessed as the product of the transpulmonary mean transit time of the indicator and the cardiac output, obtained by phase contrast magnetic resonance angiography. In vitro measurements showed a correlation coefficient larger than 0.99 and preliminary tests with volunteers proved the feasibility of the method, opening new possibilities for noninvasive quantitative cardiovascular diagnostics.

Intra-thoracic blood volume measurement by contrast magnetic resonance imaging.

Clinical decision support systems (CDSS) are the new generation clinical support tools that 'make it easy to do it right'. Despite promising results, these systems are not common practice, although experts agree that the necessary revolution in health care will depend on its implementation. To accelerate adoption a strategy is handed for structured development and validation of CDSS' content (clinical rules). The first results show that the proposed strategy is easily applicable for creating specific and reliable rules, generating relevant recommendations.

Strategy for implementation and First results of advanced clinical decision support in hospital pharmacy practice

In the clinic, a major problem in train of four (TOF) muscle relaxation monitoring is incorrect placement of stimulation and recording electrodes, frequently resulting in incorrect estimates of the patient's degree of relaxation or in abandonment of relaxation monitoring. The aim of this study was to arrive at recommendations that describe how to find optimal positions for the electrodes, where 'optimal' is taken in the sense that small deviations from these positions introduce no or only a small decline in the accuracy of the computed degree of muscle relaxation. This study, which employed the Relaxograph as the stimulation and measuring device, established that incorrect positioning is a real problem that frequently occurs; that the correctness of positioning is not guaranteed when the calibration of the Relaxograph succeeds; that the inadequacy of the electrode position is sometimes discovered for the first time when relaxation deepens; that positioning errors can be discovered by analysing the shape of the evoked compound action potential (ECAP), not only upon calibration but also when relaxation deepens; that a set of optimal electrode positions can be found; and that recommendations of how to find these optimal positions could help clinicians to place the electrodes in such a way, that reliable relaxation monitoring was possible in 100% of the investigated cases. In a first test in 30 adult patients, we surveyed how clinicians routinely positioned electrodes and found that in 14 of the 30 cases positioning was unsuccessful. In a second test in 10 patients, we tested a variety of electrode positions in order to discover 'optimal' stimulation, recording and ground electrode sites. In a third test in 10 patients, electrodes were positioned at these 'optimal' sites; stimulation and recording at these sites was successful in all 10 cases.

Hhm Erik Korsten

Papers

On the physical and stochastic representation of an indicator dilution curve as a gamma variate.

Haemodynamic responses to incision and sternotomy in relation to the auditory evoked potential and spontaneous EEG.

Intra-thoracic blood volume measurement by contrast magnetic resonance imaging.

Strategy for implementation and First results of advanced clinical decision support in hospital pharmacy practice

Optimal surface electrode positioning for reliable train of four muscle relaxation monitoring