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Information technology is becoming increasingly available at the point of care. Electronic health records, bar-code medication administration, and computerized provider order entry are a few of the innovations found in most healthcare facilities. Simply automating a process, however, does not contribute to patient care quality. The true value-added component of automation is derived from being able to use collected information in a new and different way, especially to facilitate the decision making of nurses and other healthcare professionals. The purpose of this article is to describe decision support systems (DSSs), explore their relevance to nursing, and identify ways the clinical nurse specialist (CNS) can be integral in their design and implementation.



A DSS is an "interactive, flexible, adaptable computer-based information system" designed to support decision making by groups or individuals.1(p88) It is designed to assist clinicians with making a decision, not to provide "the answer." There are 4 components of a DSS: data management, model management, user interface, and knowledge base. Each of these components will be discussed in reference to a clinical system.


The data management component contains data about the topic of interest, notably, patients. Development of data management systems is greatly enhanced by the presence of an electronic health record. The key is to have data available at the appropriate level of specificity (often referred to as granularity) and at the appropriate time for decision making to occur.


The model management subsystem consists of software that is required to analyze the data. Models range from simple mathematical formulas to sophisticated statistical and analytic tools. The type of model is driven by the type of decision to be made and the type of data available.


The user interface consists of the hardware and software by which a clinician communicates with the system. Some examples of a hardware user interface include touch screen, keyboard, mouse, and bar-code reader. Examples of software interface include the dashboards that are being used more commonly to track quality indicators. These dashboards tend to provide a graphical representation of data to facilitate a quick synopsis and status report.


Finally, the knowledge base can be thought of as the repository of expertise related to the problem. In healthcare, it may consist of evidence-based practice protocols and research literature.



Within the healthcare environment, clinical DSSs are used by a clinician at the point of care to facilitate the decision-making process. There are a variety of systems available. These include systems for diagnosis, reminder systems for prevention, systems for disease management, and systems for drug dosing and drug prescribing.2


A recent review reported that quality of patient care was positively impacted when decision support was used to facilitate adherence to clinical guidelines. Specifically, "Health information technology has been shown to improve quality by increasing adherence to guidelines, enhancing disease surveillance, and decreasing medication errors."3(p743) For systems to support decision making of advanced practice nurses, the involvement of CNSs in system development and implementation is crucial.



The role of the CNS with respect to DSSs is guided by the CNS core competency: "Design, implement, and evaluation innovative individual and/or population-based programs of care to achieve desired quality, cost-effective nurse-sensitive outcomes."4 The design of a clinical DSS to support patient care must be guided by expert clinicians such as the CNS. So where do you start?


1. Assess the need for decision support within your agency.


2. Identify desired outcomes and participate in the planning process.


3. Collaborate in the development and testing of innovative decision support solutions.


4. Evaluate the effects of the innovation.



Systems that deal with reminders and alerts and those that facilitate the disease management process are clearly within the purview of nursing.


It is essential that the CNS become involved with information technology implementations to take advantage of these innovations to make a positive impact on the quality of patient care. With the core of CNS practice being clinical expertise in the patient sphere, involvement in the development and implementation of clinical decision support also impacts the nursing practice and organizational spheres of influence.




1. Turban E, Aronson JE, Liang TP, Sharda R. Decision Support and Business Intelligence Systems. 8th ed. Upper Saddle River, NJ: Pearson Prentice Hall; 2007. [Context Link]


2. Garg AX, Adhikari NKJ, McDonald H, et al. Effects of computerized clinical support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005;293:1223-1238. [Context Link]


3. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742-752. [Context Link]


4. National Association of Clinical Nurse Specialists. Statement on Clinical Nurse Specialist Practice and Education. 2nd ed. Harrisburg, PA: NACNS; 2004. [Context Link]