Introduction

The technological advancement of Clinical Decision Support System (CDSs) take place to tackle the deal of rising tide of information due to rapid growth of clinical data for every patient and the increase amount of relevant medical research. CDSS is defined as a system that helps physicians, nurses and other clinical workers to make clinical decision more effectively. The two types of CDSS are namely; knowledge base system and non-knowledge base system. Lots of hospitals and physicians are taking advantage of different CDS system that has develop by different experts. After a lots of observation and research on this topic we believe that the ClinicalKey is most appropriate CDSS for Maldives context.

The objectives of this report is to present the basic knowledge about clinical decision support system, suggestion for Maldivian medical issue by providing appropriate CDS system and adequate implementation plan to fit the Maldivian scenario. Before selecting a CDSS, the considered factors are geographical condition of islands and most common issues such as inexperienced doctors and misdiagnoses. Similarly, this report take into account some of ClinicalKey usage in other countries and its evaluation based on the Maldivian setting.

Benefits of CDS system

CDSS is defines as is a software which provide direct aids to clinical decision making to the clinicians, nurses, patients and other individuals. The benefit or advantage of CDS system is very broad from individual to managerial level. As mentioned before it’s a system in which executives, physicians, nurses and patients uses information to make the clinical decision more safely. This is because it enables them to keep up to date information in relation with current knowledge. Smarter clinical search engine for example, up to date reference like books, reports and videos are available for physicians and other users to have deep evidence. The constant updates clinical knowledge helps to build trust with patients and reduce the risk of medical errors.

The conveniences of CDSS achieves as it offer most of its user to reduce their time consuming to give proper service. It allows the users to share, discover and especially apply clinical circumstances in a well systematized method to save the time of both physician and patient. Typically, the quicker the patient treated the more efficient diagnose will be. Moreover, information or knowledge is intelligently filtered through continuously updated content related to clinical concept. Therefore, accessibility of information in one place makes the users to make decision aptly (Robert Hitchcock, 2011).

Another advantage is the standardized care that patients gets by using CDSS. For example, Electronic Health Record (EHR) assist the physician to diagnose the patient with respect of their clinical history as well as the current situation. This improve the quality of service and patients safety by supporting most critical decisions to make (Raths, 2014). In short, CDSS improves the overall efficiency of the health service by recognizing relevant clinical concepts.

**ClinicalKey uses in other countries**

In In today’s world technology is increasing in a faster rate in all the fields. ClinicalKey is one of the technological advancement in Medical field which is developed by Elsevier in 2012. Today there are more than 45 countries using this program, such as Bangkok and United States (Elsevier Inc, 2013).

Bangkok

In 2013, the Bangkok Hospital and Bangkok Health Research Center implemented ClinicalKey as their online medical information resource. The purpose of implementing ClinicalKey in these hospital are to support the clinical decision making and medical research. As per Vice President and Chief Operating Officer-Medical Affairs, Dr Chatree Duangnet, to deliver accurate and timely diagnosis and innovation ClinicalKey plays a huge roll. Moreover is provides the current and most specific information of healthcare. They also believe that ClinicalKey can help the work efficiently and smarter. It is the main purpose of implementing ClinicalKey in the hospital and research center.

ClinicalKey helps to achieve the target goals as per Dr.Paitoon Boonma, Director of Bangkok Health Research Center. Since the number of cases in their hospital is are increasing year by year. To cope with the increasing number of cases they require more information which can be gained from the ClinicalKey. It also allowed to increase their business (Elsevier Inc, 2013).

United States

John Hopkins university of United States World implemented ClinicalKey in their university for the better patient care and develop research and education. They started using the ClinicalKey in order to update the systems used by their students and physicians. The available courses from ClinicalKey, such as books, journals, reports, researches as well as information from experts led the John Hopkins University to implement it. At their University librarians help the physician to observer their patients. Moreover they use the ClinicalKey as a practical activity in the University. Moreover, as the clinical can be used for all types of diseases the users are enable to search, save, locate and refer valid information conveniently (Elsevier Inc., 2014).

ClinicalKey

The offered CDS system for Maldivian scenario is ClinicalKey, as it is a knowledge based system with specialty specify clinical content. It’s a system developed by a well-known company called Elsevier, in which it helps the physician and other health professions to find and apply relevant knowledge. In the sight of current error in the diagnose process in Maldives the ClinicalKey gives a key to open uo opportunity to enhance the health facilities.

ClinicalKey is the fastest and most reliable search engine for the physicians, medical librarians, CMO/CMIO’s, and healthcare professionals. It supports all the clinical decision requirements for the workers in medical field (Elsevier Inc., n,d). And this system was launched in 2012 by Elsevier to get answers to all the questions on medical field with the views of experts.

**Features**

ClinicalKey comes with many features which helps the users to use t more appropriately. There are 9 main features of ClinicalKey.

1. Browse: In browse function there are two ways in which users can use this tool. If the user knows what exactly he/she is searching then directly searching thought the ClinicalKey button will give the answers. The other ways is to search through the alphabetic list of sources. Filters are used to refine the results quickly through relevant category or specificity (Elsevier Inc., 2016). So the workers in the medical field in Maldives, can find any information they want thought browse function, in order to proceed with the situation.

2. Presentation Maker: Since most of the Maldivians are not familiar with medical information’s, the hospitals or clinics can use these feature to teach the employees and customers. This feature helps to add content to without interruption, automatic citation on the information’s taken, easy exporting to the presentation (Elsevier Inc., 2016). This allows the presenters to prepare their medical presentation easily and helps to deliver it to the customers in an efficient way.

3. Customized Patient Education Handouts: In Maldives there are many people who doesn’t have proper literature or haven’t studied. Mostly the elderly people, they are the once need medical attention the most. ClinicalKey provides a customized handout for the patients which is set as per the language, text, size and special instructions preferred by the patients (Elsevier Inc., 2016).

4. Smart Search: The smart search in ClinicalKey is different from other search keys. This key provides relevant results and the user doesn’t have to dig through irrelevant information to refine the required information. Moreover autosuggest, saved researches and history can be easily found in ClinicalKey which allows Maldivian to restore their information and work faster in the organization with a reliable information (Elsevier Inc., 2016).

5. EHR Integration: EHR allows to give care teams instant point of care access. And allows them to identify the patient specific knowledge because ClinicalKey understands EHR’s HL7 standard infobutton. Normally the medical workers and professional as they can find out any book or journal they want from the intranet.

This will be very beneficial for Maldivian medical field, since almost all the patients are different from one another. If the EHR provides the specific information about the patients, then it will be very easy for their treatments (Elsevier Inc., 2016).

6. Topic Pages: topic key offers brief and to-the-point information about the patient and the disease epidemiology, risk factors, clinical manifestations treatments and so on. Since the location of Maldives is very different than other countries, and it is very difficult to bring all the patients to capital City Male’. So in order to provide treatments at the patient home island topic page will be very much helpful. This provide all the relevant information of the procedure, such as from assessment to the discharging of the patient (Elsevier Inc., 2016).

7. Filters: Filter is a key which used to shorten or find the exact information needed from the ClinicalKey. This key supports the browse and smart search. By using these feature the information can be narrowed down to the most wanted information. Due to these feature patients can be given a quick and affective treatment. This feature also prevents extra clicks which results in saving more time (Elsevier Inc., 2016).

8. Usage Report: through usage report the history of all the data can be identified. This allows the staffs to identify the most researched and used information. So that information can be again stored in a helpful way. For example assuming most searched information are the most important information, those can be in stored in most important files. This will help refer the data easily and misplacing the documents will be reduced (Elsevier Inc., 2016).

9. Mobile: ClinicalKey supports all the smart phones, tablets and computers. It allows to use this at any wear and anytime. As mentions before in Maldives transportation is very difficult. So the patient can be treated in the existing hospital or clinic with the help of ClinicalKey (Elsevier Inc., 2016).

**Benefits**

1. Updated and current clinical knowledge: The information in the ClinicalKey is the continuously updated by the experts. And it always provide the current and completed information to its users. Its features, such as customizes handouts, EHR integrations also ways of keeping their information up-to-date. For the Maldives medical field ClinicalKey is very important. Since Maldives is a developing country and it has very few facilities for medical purpose. So if the ClinicalKey is installed and used in Maldives, will provide more up to date information which can be used or applied with lower facilities. Moreover knowledge about the latest facility the possibility of bringing those to Maldives will higher (Elsevier Inc., 2016).

2. Saves time: ClinicalKey helps to save time by providing the relevant information to its users. Browsing, smart search and filtering helps to deliver the most relevant information because it understands and recognizes the relevant concept. Moreover it provides short cut to the answers. In capital city of Maldives there are two main hospital. Namely Indira Gandhi Memorial Hospital and ADK. They two hospital provided services to more than 10,000 people per day. So in order to provide all the customers a good treatment time plays a very huge roll. The more time saved on getting knowledge allows better treatments to more people (Elsevier Inc., 2016)

3. Convenient and mobile: As mentioned above ClinicalKey can be applicable to mobile phones, laptops, IPad. The information needed can be searched anywhere at any time. For example a nurse doesn’t have to run back to her computer to find the information about the disease in time of emergency (Elsevier Inc., 2016). The clear instruction can be given to others and patients on time. In Maldives most of the serious cases patients are brought to the Male’ or the atoll hospital. So at the tie of transport it might be very difficult to carry the laptops. The smart phones can be used instead. It reduces the problem of lacking the information and procedures to carryout.

4. Improve and standardized care: ClinicalKey tends to increase the knowledge of clinicians. The ClinicalKey incudes books, journal, expert knowledge and many other material which helps to develop the knowledge of its users. Nowadays number of Maldivian nurses are increasing in a high rate. The ClinicalKey can provide knowledge and information they haven’t received while studying (Elsevier Inc., 2016). If the knowledge of them are increasing better treatment and care will be received by the patients. Additionally the treatment will be standardized.

**Limitation**

1. Low internet speed: with many benefits there are some disadvantages of the ClinicalKey. Since the ClinicalKey can only be used with an internet connection. In Maldives all the places and people are not connected with internet. Moreover in the hospital internet is connected only in the computers. So if anyone needs any information, they have to run back to their computers, this makes it very difficult to corporate and apply the knowledge to the patients.

2. Lack of maintenance: Proper maintenance is very important in ClinicalKey. The information should be update continuously. If the hospital or clinic fails to maintain it properly then the information used by the clinician will be inappropriate. In Maldives it is very difficult to update all the information. This may lead to mistreatment of the patients.

3. Dispersed islands makes less expert or knowledgeable workers: one of the most difficult task is to identify the experts or knowledge worker in Maldives. As mentioned before the medical field is one of the least developed sector in Maldives. So to develop this kind of decision support system lot of expert are required. Since it is very rare to find these many experts, providing training will be the only way to implement this system in Maldives. This leads to more expenses and problems because the training cost are very high in medical field.

**Design and Implementation plan**

In order to implement such vast advance technology, it needs to be well designed and well organized. ClinicalKey is evidence-based system that has search engine for clinician and other professions. In fact, resources that needs to be allocate very effective and efficiently to make best use of it. Since it’s a search engine, users has to subscribe in order to use the ClinicalKey services. Besides, ClinicalKey subscription includes free official MARC 21 records for journals, books are available after two weeks of its publication for its users to improve healthcare outcomes (Relx Group plc, 2016).

As it’s a web-based consolidated and up-to-date sources of medical reference information, the estimated duration for registration is a week. The total estimated duration for this implementation is less than six month. It is planned to allocate the resources in 26 islands in every atoll. In each atoll the most populated island will be selected that needs to be implement. ClinicalKey can be integrated with Electronic Health Record (EHR) in which patients nursing notes and test result of laboratory are recorded for later reference. The time period for installation is measured using Gantt chart in which it shows the overall time scale for the project.

The implementation and development cost for ClinicalKey system varies from personnel time. The required personnel were pharmacist, physician, project coordinator, informatics project manager, computer program specialists and health service researcher. Some of them were going to pay hourly basis as a consultant like programmer, project coordinator. The time estimation for programming is based on the budget that they get. In the analysis of this project is divided namely content, blueprints and instruction preparation of the ClinicalKey, project management, programming, testing the system and implementation. It is estimated to train all the contributors in two weeks’ time before starting the action plan.

In the following go live date it is predicted to finish within 16 weeks period. The clinical can develop this system within the existing facilities such as computer system, furniture. Therefore, facilities specific cost is estimated to be low. However, wages of participants, travelling cost, registration fees and other necessary cost were estimated. The table below shows budget of cost estimated.

**Cost analysis**

Mvr

Registration/suscribtion packages

50,000

Related software/browser

10,000

Hardware

100,000

Implementation staffing

150,000

Implementation travel/training

80,000

**Work flow integration**

Work flow reengineering and changing management technique into development of system are one vital procedure. It’s about the implementation of organizational and financial resources. Especially, the integration of EHR with this system makes the workflow more multipart. Therefore, reimbursement regarding the policies and other legal requirement needs to be highly concern in this implementation process. The most crucial factor is to maintain of knowledge with in the system. After the implementation it needs to Upgrades and on-going maintenance which are one key factors that helps to use the system more effectively. As the implementation of ClinicalKey spreads through hospital, outpatient and care setting in the long-term, the applicable decision support is one major benefit it give to the health service of Maldives to build trust.