Lobach DF et al. 1997 "Computerized decision support based on a clinical practice guideline improves compliance with care standards."
Reference
Lobach DF, Hammond WE. Computerized decision support based on a clinical practice guideline improves compliance with care standards. Am J Med 1997;102(1):89-98.
Abstract
"PURPOSE: Clinical guidelines are designed to assist in the management of specific diseases; however, these guidelines are often neglected in the delivery of care. The purpose of this study was to determine whether clinician use of a clinical practice guideline would increase in response to having, at the patient visit, a decision support system based on a practice guideline that generates a customized management protocol for the individual patient using data from the patient's electronic medical record.
SUBJECTS AND METHODS: In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care.
RESULTS: Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group.
CONCLUSION: Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care."
SUBJECTS AND METHODS: In a 6-month controlled trial at a primary care clinic, 58 primary care clinicians were randomized to receive either a special encounter form with the computer-generated guideline recommendations or a standard encounter form. The effect of computer-generated advice on clinician behavior was measured as rate of compliance with guideline recommendations. Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care.
RESULTS: Availability of patient management recommendations generated by the decision support system resulted in a two-fold increase in clinician compliance with care guidelines for diabetes mellitus (P = 0.01). Median compliance for the group receiving the recommendations was 32.0% versus 15.6% for the control group.
CONCLUSION: Decision support based on a clinical practice guideline is an effective tool for assisting clinicians in the management of diabetic patients. This decision support system provides a model for how a clinical practice guideline can be integrated into the care process by computer to assist clinicians in managing a specific disease through helping them comply with care standards. Use of decision support systems based on clinical practice guidelines could ultimately improve the quality of medical care."
Objective
"To determine whether clinician use of a clinical practice guideline would increase in response to having, at the patient visit, a decision support system ... that generates a customized management protocol for the individual patient using data from the patient's electronic medical record."
Tools Used
Type Clinic
Primary care
Size
Large
Geography
Urban
Other Information
The study was conducted at the Duke Family Medical Center at Duke University Medical Center.
Type of Health IT
Decision support system
Type of Health IT Functions
"The [decision-support system] implemented the diabetes care guideline through a series of logic rules that performed temporal comparisons, mathematical calculations and/or logical comparisons using data selectively retrieved from the problem list, medications list (including immunizations), or studies section of a patient's electronic medical record. Following enactment of these rules, the program printed a set a patient-specific care recommendations ... that advised the clinician regarding which studies/procedures should be done during the current visit and which studies/procedures were next due in order to assist the clinician with managing the diabetic patient in accordance with a clinical practice guideline."
Context or other IT in place
An electronic medical record (EMR), including "demographic information, scheduling, accounting, problem lists, encounter summary, medications, quality assurance, laboratory orders/results, and medications/immunizations" was already in place. It is "suppl
Workflow-Related Findings
"No statistically significant difference existed between the mean length of encounters during which the [decision support system] was and was not supplied (P=0.1) (95% confidence interval: 5.9 to 8.8)."
"The overall reliability of the [system], calculated as the number of correct recommendations over the total number of recommendations, was 77% ... The majority of incorrect recommendations resulted either from a transient disruption in [the system's] functioning following the introduction of a new version of [the EMR] one month into the study (ie, systems errors: 86.8% of total errors) or from the presence of data in the paper chart which had not been captured electronically (ie, recording errors: 13.2% of total errors). More than 70% of the system errors were false positive recommendations in which the performance of studies/procedures was incorrectly suggested."
"The clinicians receiving the diabetes [DSS recommendations] had a statistically significant greater median level of compliance than the clinicians not receiving the [DSS recommendations] (P = 0.01, two-sided) ... Statistically significant differences were detected for [performing] the physical examination, the urine protein determination, and the cholesterol level."
"Informal questioning of [DSS] recipients revealed that the ... recommendations were neglected [for 26-81% of the patients for the various recommendations] because of time constraints, an overwhelming amount of other clinical information to process, insufficient time to document an intervention that was performed outside of the practice (ophthalmologic examination), an intervention was potentially painful or dangerous to a patient (pneumococcal vaccination), or because the recommendations were not considered appropriate for a given patient."
Study Design
Randomized controlled trial (RCT)
Study Participants
The study participants included 58 primary care clinicians, specifically: 20 family physicians, one general internist, two nurse practitioners, two physician assistants, and 33 family medicine residents. "Data from 30 clinicians were analyzed; data from 28 clinicians were excluded because these clinicians did not meet predefined criteria for minimum exposure to diabetic patient care." In total, 359 patient charts were studied.