Tierney WM et al. 2003 "Effects of computerized guidelines for managing heart disease in primary care - a randomized, controlled trial."

Tierney WM, Overhage JM, Murray MD, et al. Effects of computerized guidelines for managing heart disease in primary care - a randomized, controlled trial. J Gen Intern Med 2003;18(12):967-976.
"BACKGROUND: Electronic information systems have been proposed as one means to reduce medical errors of commission (doing the wrong thing) and omission (not providing indicated care).
OBJECTIVE: To assess the effects of computer-based cardiac care suggestions.
DESIGN: A randomized, controlled trial targeting primary care physicians and pharmacists.
SUBJECTS: A total of 706 outpatients with heart failure and/or ischemic heart disease.
INTERVENTIONS: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients.
MEASUREMENTS: Adherence with the care suggestions, generic and condition-specific quality of life, acute exacerbations of their cardiac disease, medication compliance, health care costs, satisfaction with care, and physicians' attitudes toward guidelines.
RESULTS: Subjects were followed for 1 year during which they made 3,419 primary care visits and were eligible for 2,609 separate cardiac care suggestions. The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients vs. 22% for controls). There were no intervention-control differences in quality of life, medication compliance, health care utilization, costs, or satisfaction with care. Physicians viewed guidelines as providing helpful information but constraining their practice and not helpful in making decisions for individual patients.
"To assess the effects of computer-based cardiac care suggestions" on physician adherence with guideline recommendations.
Type Clinic
Primary care
Type Specific
Internal medicine
Other Information
The study took place in the Indiana University Medical Group-Primary Care, affiliated with an inner-city public teaching hospital.
Type of Health IT
Decision support system
Type of Health IT Functions
Using "evidence-based guidelines published by the Agency for Health Care Policy and Research (AHCPR) and national professional organizations," the authors developed care suggestions for cardiac patients. "For algorithms requiring symptom information, the workstation software required physicians to enter the current blood pressure, symptoms, and NYHA functional class at the start of each workstation order-writing session for enrolled patients." For the pharmacist intervention, "cardiac care suggestions generated by the [DSS] were stored in [an electronic system] which ... printed a note ... instructing the pharmacist to view the care suggestions... The pharmacist had 3 options: fill the prescription(s) as usual, discuss the suggestion(s) with the patient and encourage discussions with his or her primary care physician, or contact the ordering physician by telephone or e-mail."
Context or other IT in place
An electronic medical record (EMR) system and computerized provider order entry system were already in place.
Workflow-Related Findings
Reminders did not significantly affect practice. Authors postulated that allowing the provider to simply "escape" out of the reminder without having to take action or justify not taking action led to ineffective alerts.
"There was no evidence in any chart that the care suggestions were inappropriate (all met the guidelines' indications)."
"[T]here was no note in any chart that the physician disagreed with a suggestion [for patient cardiac care].... [But,] many physicians felt that guidelines were oversimplified 'cookbook' medicine, too rigid to apply to individual patients, hampering physician autonomy, and intended to decrease health care costs. However, there was no correlation between physicians' guideline attitude score and compliance with the study's cardiac care suggestions (P > .20)."
"The pharmacist intervention also had no effects on patients' care or their outcomes. However, pharmacists could not write orders for patients; they could only make suggestions to the primary care physicians either directly or through their patients. Even though we encouraged the pharmacists to make care suggestions directly to the physicians and provided a simple e-mail system for doing so, these interactions rarely took place."
Study Design
Randomized controlled trial (RCT)
Study Participants
Participants were practice staff (faculty, residents, fellows, nurse practitioners, and pharmacists) and their patients with heart failure or ischemic heart disease.