Table 3.

Summary of significant findings for studies assessing clinical decision support for oncology clinical care.

Author (year)	Objective(s)	CDS Tool Type	Study or System Features	Study Target	Key outcomes associated with CDS
Computerized Physician Order Entry (CPOE)
Aziz MT (2015)20	Compare error rates and severity with paper orders	Integrated in EHR	Oracle-based system with computational intelligence including passive and active alerts	Clinician	Chemotherapy error rate decreased (0.26% vs. 2.4%)
Beer J (2002)21	Compare order review time with paper orders	Integrated in EHR	Electronic order system not described , pharmacist intervention data collected	Clinician	Pharmacist order review time increased 5.15 minutes, with similar intervention rates (7.47% vs 7.14%).
Chen AR (2011)22	Assess medication error rates	Integrated in EHR	Design included features to enhance safety and add order set functionality	Clinician	Medication-related safety events decreased by 39%.
Cho E (2013)23	Compare two CPOE systems for error rates and performance efficiency	Integrated in EHR	Study testing for efficiency outcomes was performed in a controlled space with computers setup for the study.	Clinician	Improved near misses (p < 0.0001); reduced regimen defects, drug omissions and incorrect data input errors more than 70% and efficiency measures (p < 0.0001).
Collins CM (2011)24	Assess process and prescribing errors for oral chemotherapy	Integrated in EHR	Prescriber training was not required due to prior CPOE experience	Clinician	Reduced prescribing error risk 69% [OR =0.31 (95% CI 0.11–0.86)] (P = 0.023)
Elsaid K (2013)25	Assess incidence and types of prescribing errors	Integrated in EHR	Prescriber, nurse and pharmacist education, reminders of form implementation communicated, adherence of form use measured, and a policy prohibiting handwritten orders instituted	Clinician	30% reduction in prescribing errors
Hanauer DA (2013)26	Quantify CPOE impact on workflow and patient care time	Integrated in EHR	Time spent on each activity and ordered sequence describing and quantify workflow, and patterns of use were measured	Clinician	Workflow fragmentation decreased; average continuous task time increased from 131.2 to 218.3 seconds (P<.01), with an 8-fold decrease in the number of paging interruptions.
Huertas Fernandez MJ (2006)27	Assess errors compared with manual prescribing	Integrated in EHR	Computerized prescriptions validated online by pharmacist; for handwritten orders no pharmacist validation, nursing staff calculates dilutions for treatment preparation.	Clinician	Prescriptions containing at least one error: 100% (manual) vs 13% (CPOE), p < 0.001. Mean error rate = 5 (1-12) for manual and 0 (0-1) for CPOE, p < 0.001
Mattsson TO (2015)28	Assess incidence, type, severity and related risk factors of prescription dose errors	Integrated in EHR	CPOE system not linked to EHR, comparison was conducted across two institutions.	Clinician	Error rate = 1.60 errors per 100 prescriptions (CPOE) vs 1.84 (paper-based); (OR) = 0.87 [95% CI 0.59-1.29, P = 0.49]. 15 types of errors and 4 risk factors identified.
Meisenberg BR (2014)29	Assess number and type of order errors among hand-written, preprinted and CPOE	Integrated in EHR	Quality improvement initiative, CPOE orders were included after a 2-month run-in time to allow for provider competency.	Clinician	Rate of order sets requiring significant rework reduced from 30.6% (handwritten) to 12.6% (preprinted), P<.001 to 2.2% with CPOE; P <.001). Errors capable of causing harm reduced 4.2% (handwritten) to 1.5% (preprinted), P <.001 to 0.1% with CPOE, P <.001.
Small MD (2008)30	Assess error rates, types and patterns and potential for harm. Compare error rates with order spreadsheets	Integrated in EHR	Comparison of Excel spreadsheet prescriptions with CPOE. Oral chemotherapy not included in CPOE ordering system.	Clinician	CPOE reduced errors 42% (RR 0.58; 95% CI 0.47–0.72).
Voeffray M (2006)31	Assess number of prescribing errors	Integrated in EHR	CPOE system was developed on software without professional programmer support.	Clinician	CPOE decreased error rate from 15% to 5% (95% CI 13%-18%).
Clinical Pathways
Beriwal S (2012)32	Assess efficacy of radiation oncology for bone metastases	Standalone	Online system enabled near real-time peer review of treatment choice	Clinician	Treatment with 1-5 fractions in academic vs community sites, 63% vs. 23%; p < 0.0001. Decrease mean number fractions p < 0.0001
Bertsche, T (2009)33	Asses guideline adherence with pain management tool	Integrated in other system	CDSS was integrated into the drug information system containing current information about formulary drugs	Clinician	Increased CPG concordance (p < 0.001), reduced pain in the intervention group. Physicians accept 85% recommendations
Chang PL (2002)34	Comparison of web- and paper-based pathways	Standalone	Pathway program was on separate computer system in nursing station.	Patient	Similar variance rate, less undetected variances and variance detection time in web-based group, P=0.0193 and 0.0162
Hsu YC (2008)35	Assess effects of web-based pathway on length of stay and practice variations for radical prostatectomy	Internet-based	Pathway program on separate system in nursing station.	Clinician	Average hospital stay decreased from 11.7 to 9.9 days (P < 0.01). Mean number of practice variations also decreased.
Patkar V (2012)36	Assess breast cancer treatment recommendations and clinical trial eligibility	Standalone	Active evaluation of patient data to offer guideline-based recommendations in real time,	Clinician	CPG concordance for tool recommendations 97% vs. 93% Clinical trial eligibility increased 61%
Van Erps J (2010)37	Assess validity and CPG concordance for anemia management	Standalone	Patient data entered at the point of care with guidance provided to clinicians that cite applicable guidelines.	Clinician	More rapid rate of hemoglobin (Hb) increase (P<0.006) and higher Hb by visit 4 (P=.006) and more rapid rate of Hb increase in post cohort. High concurrent validity.
Clinical Practice Guidelines
Bouaud J (2001)38	Assess compliance with tool decisions and transferability to another system	Standalone	CDS system used at point of care for all patients and justification required where not employed and followed a standard procedure	Clinician	Physician compliance with CPGs increased (61.42% to 85.03%; P<.0001 and clinical trial accrual increased 50%.
Bouaud J (2015)39	Evaluate physician attitudes toward CPG tool advice	Standalone	Evaluated compliance with CPGs and with the CDS system	Clinician	CDS systems and CPG compliance was 75.4% and 86.8%, respectively
Patient-Reported Outcomes (PROs)
Basch E (2016)42	Assess web-based PROs with clinician alerts for health-related quality of life (HRQL), survival, ER use, and hospitalization	Internet-based	Automated clinician alerts for severe/worsening symptoms, patient subgroup assignment for computer experience	Patient	Improved HRQL (34% v 18%, P< .001), fewer ER visits (34% v 41%, P=.02), and increased survival at 1 year (75% v 69%, P=.05) in intervention arm compared with usual care. Hospitalization rates were not significantly different.
Berry D (2011)40	Determine tool effect on clinician and patient discussions and duration	Standalone	Electronically collected PROs were provided to clinicians in real time at patient visit	Clinician and Patient	Discussion of symptoms and quality of life issues increased (p = 0.032) with no difference in visit duration
Ruland CM (2003)41	Compare patient-reported symptoms and preferences with those addressed at patient visit. Assess system ease of use, time required, and patient satisfaction.	Standalone	Tablet computers captured symptom reporting prior to consultation and was provided to the patient and clinician for consultation	Clinician and Patient	Symptoms were addressed in 51% intervention vs. 19% control groups. High ease of use, no difference in patient satisfaction between groups.
Prescriber Alerts
Hsu PI (2015)43	Evaluate screening and chemoprophylaxis rates for HBV	Integrated in EHR	Testing was recommended for patients who received testing outside of the system. Patients who received treatment outside the system were removed from screening queue.	Clinician	Hard stops improved screening and chemoprophylaxis and reduced severe acute Hepatitis B virus (HBV) exacerbations. Increased screening (99.3% vs. 40.2%, P < 0.001) and HBV prophylaxis rates (95.8% vs. 39.2%, P < 0.001) with therapeutic stage. Lower severe HBV acute exacerbations, 0% vs. 1.2% and 1.2%, respectively; P < 0.01 for both.

CPOE=Computerized Physician Order Entry; QoL=Quality of Life; CPG=Clinical Practice Guidelines; CDS=Clinical Decision Support; SQLI= Symptoms and quality-of-life issues; HBV=Hepatitis B Virus