Evaluation and quality assurance Clinicians have always used knowledge in the consultation and there are now valid and reliable techniques for assessing the quality of the research that produced the evidence, and therefore the strength of the evidence itself, whether that knowledge is presented as a simple conclusion or in the form of a guideline. The NeLH and NHS Direct Online have criteria by which they appraise some of the evidence and the National Knowledge Service is doing further work on the most appropriate way of describing and presenting information which describes the quality of the knowledge presented. Computer-assisted decision support systems require a different approach, however. Such a
system is an intervention which the clinician uses in addition to their clinical skills and best current knowledge. It is an intervention analogous to a biochemical test or a drug or an operation, and should be evaluated with equal rigour because computer-assisted decision support systems can do harm as well as good. It is also important to appreciate that clinical decision or prediction rules and algorithms are also decision support systems, even if they exist as a list on paper rather than being expressed in software. Such rules and algorithms also need rigorous evaluation.
The evaluation of decision aids for patients also needs this approach but the approach is complicated by the fact that decision aides are used to achieve different outcomes, ranging from better clinical outcomes to greater satisfaction with decision-making. Nevertheless, each decision aid also needs rigorous evaluation because a decision aid is an intervention distinct from the direct provision of best current knowledge to patients.
The clinician, of course, can also be regarded as an intervention because there is now considerable evidence that the way in which the clinician presents the evidence influences the choice made. Methods are also being developed to appraise the input of the clinician, and tools and training designed to reduce the bias that the professional can unknowingly impart.