User Control
CDS systems differ in how much control the user has over the decision to use CDS. These
decisions involve not only whether the CDS is set up to be displayed on demand, so that users
have full control over whether they choose to access it, but also the circumstances under which users can, after viewing the CDS information, choose whether to accept it. The two aspects of control are related and they connect with how closely the CDS advice matches a clinician’s intention. CDS may be designed to
(1) remind clinicians of things they intend to do, but should not have to remember.
(2) provideinformation when clinicians are unsure what to do.
(3) correct errors clinicians have made
(4) recommend thatthe clinicians change their plans. Conceived of in this way, it should be obvious that the users’reactions to CDS may differ with these diverse intents.
An analogy can be seen in some of the functions of common desktop computer applications.
When a user employs the calendar functions on the computer, the calendar alarm is an
automatically presented reminder of something oneintends to do. In thiscase the automatic
notification is one of the most helpful features. The spell checker in a word processing
application can both provide advice and correct errors, and can do so while one types
(automatically) or after one is finished and the function is accessed to check the final document (on demand). Two other word processing featuresmake suggestions to users about changing what they have done. The grammar checker, often accessed on demand, not only corrects obvious grammatical errors, but also makes suggestions for sentence revision, which may be ignored by writers who feel that they have expressed themselves exactly as they intended. Most users access the help function in their word processing program when they want advice on how to do something. However, as most people who use word processing programs attest, the automatic appearance of the help wizard (an example of automated decision support alerts) may lead the user to turn the automatic help function off immediately, if they have not already disabled it in advance. These reactions to nonclinical decision support have their parallels with CDS as well.
Achieving the five rights for CDS presents challenges, and the challenges differ depending
on how closely the CDS is tied to what the clinician already intends to do. Clinicians may
initially want certain reminders or, after performance assessments, agree that they need other reminders, but in either situation they are choosing to receive the reminders. The key issue in reminding the user about things they choose to be reminded about is the timing of the reminder.
For instance, should reminders for preventive care be given to the physician in advance of the
patient visit (e.g., the day before), or should the reminders appear during the patient’s visit?
Key issues for consultation that the user seeks out (on-demand CDS) are speed and ease of
access. Users may recognize the need for information, but may be willing to access it only if
they can do so efficiently. If access is too difficult or time-consuming, potential users may
choose not to use the CDS.
The major issue involved in correcting errors or making suggestions that users change what
they had planned is balancing clinicians’ desire for auto no my with other demands, from or on
clinicians, such as improving patient safety or decreasing practice costs. Another question related
to autonomy is how much control users have over how they respond to the CDS. This aspect
of control relates to whether users are required to accept the CDS suggestion, whether they can
easily ignore it, or whether it takes significant effort to override the advice. Table 2 below
provides a summary of these points.