To better understand the design factors responsible for the success or failure of computer-based guideline intervention strategies, we analyzed reports on 20 systems that were intended to implement guideline recommendations in clinical practice. Specifically, we assessed the use of eight information management services, which we believe may be useful in integrating computerized systems into clinical workflow. Many reports failed to describe the systems in sufficient detail to ascertain the presence or absence of some of these services. Therefore, we were unable to create meaningful summary ratings of individual systems that might correlate with the outcomes described. However, we were able to describe qualitatively many aspects of the reported design of current computer applications used as guideline intervention tools and to summarize measures of their effectiveness.
All systems delivered patient-specific recommendations, and in most cases the advice was made available concurrently with care, thus meeting Grimshaw and Russell's criteria for implementations with a high probability of success.9
However, providing recommendations in this manner was neither necessary nor sufficient to ensure adherence. Several authors were unable to influence guideline adherence with concurrent reminders. Even providing delayed feedback was associated in one case with increased procedure authorization rates, although this system's influence may have been related to financial incentives and disincentives.12
The level of specificity of the advice varied considerably, as evidenced by the number of factors that were weighed by the programs to trigger relevant recommendations. Some systems simply checked a patient's age and gender to discern appropriate preventive interventions, whereas others monitored ongoing clinical transactions and considered multiple factors (e.g., diagnoses, laboratory results, and medications) in arriving at recommendations for changing medications or dosages and for planning treatment.
Somewhat surprisingly, fewer than half the reports documented provision of explanation services. More than 15 years ago, Teach and Shortliffe37
showed the importance of providing explanation for computer-based advisories.37
One noteworthy benefit of the use of computers for implementation of guideline recommendations is their capability to link recommendations dynamically to the evidence that supports them.
Most reports described the use of on-screen and paper-based prompts to remind users of critical information that should be documented. Clinicians entered data into computers directly and interactively in fewer than half the systems. Even some long-established EMR systems depended on completion of paper forms with subsequent data entry by clerical personnel. Likewise, paper-based output was described for 17 of the 20 systems. It seems clear that the paperless office remains a vision of the future.
Registration, calculation, communication, and aggregation services were infrequently described. These components offer tremendous potential benefit for well-designed computer-based guideline implementation. Providing communication services requires networked systems. Registration services may seem mundane, but an interface to an administrative database that contains this information may be vital to the success of a computer-based initiative by diminishing the clerical workload for clinicians. Calculation and aggregation services are basic functions of many computer systems that were rarely reported in these guideline implementation systems.
The evaluations of system effectiveness varied markedly in design, implementation, and level of description. In many, the evaluations of effectiveness were methodologically weak. In addition, the guidelines that were implemented differed considerably in content, from health maintenance reminders to alerts for active management of specific disease states. There were also notable variations in clinical settings—inpatient, emergency room, ambulatory clinic, private office, and public health department—and in evaluation methodology.
Fourteen studies reported some improvement in adherence to guidelines, seemingly independent of the information management services provided. Clearly, adherence to guideline recommendations can be improved in many cases using computer-based interventions. Likewise, documentation is regularly assisted with computers, but user satisfaction may be affected adversely by tedious data entry requirements in the absence of offsetting system benefits. In both studies with negative evaluations of user satisfaction,21,23
arduous data entry was suggested as a reason for poor system acceptance. Few studies examined patient outcomes to validate the effectiveness of the systems.