Tierney WM et al. 2005 "Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial."

Tierney WM, Overhage JM, Murray MD, et al. Can computer-generated evidence-based care suggestions enhance evidence-based management of asthma and chronic obstructive pulmonary disease? A randomized, controlled trial. Health Serv Res 2005;40(2):477-497.
"Objective. Translation of evidence-based guidelines into clinical practice has been inconsistent. We performed a randomized, controlled trial of guideline-based care suggestions delivered to physicians when writing orders on computer workstations.
Study Setting. Inner-city academic general internal medicine practice.
Study Design. Randomized, controlled trial of 246 physicians (25 percent faculty general internists, 75 percent internal medicine residents) and 20 outpatient pharmacists. We enrolled 706 of their primary care patients with asthma or chronic obstructive pulmonary disease. Care suggestions concerning drugs and monitoring were delivered to a random half of the physicians and pharmacists when writing orders or filling prescriptions using computer workstations. A 2 x 2 factorial randomization of practice sessions and pharmacists resulted in four groups of patients: physician intervention, pharmacist intervention, both interventions, and controls.
Data Extraction/Collection Methods. Adherence to the guidelines and clinical activity was assessed using patients' electronic medical records. Health-related quality of life, medication adherence, and satisfaction with care were assessed using telephone questionnaires.
Principal Findings. During their year in the study, patients made an average of five scheduled primary care visits. There were no differences between groups in adherence to the care suggestions, generic or condition-specific quality of life, satisfaction with physicians or pharmacists, medication compliance, emergency department visits, or hospitalizations. Physicians receiving the intervention had significantly higher total health care costs. Physician attitudes toward guidelines were mixed.
Conclusions. Care suggestions shown to physicians and pharmacists on computer workstations had no effect on the delivery or outcomes of care for patients with reactive airways disease."
To evaluate the impact of guideline-based care suggestion alerts on physicians and pharmacists in an ambulatory urban academic primary care setting.
Tools Used
Type Clinic
Primary care
Type Specific
Internal medicine
Other Information
The study was conducted at four hospital-based practices (Indiana University Medical Group, Primary Care), consisting of a total of 25 attending physicians and over 100 residents caring for 13,000 patients during 50,000 visits per year.
Type of Health IT
Computerized clinical reminders (CRs) and alerts
Type of Health IT Functions
"The physician received the patient's paper chart along with a computer-generated paper encounter form that included a list of active medications. Any study care suggestions for which a patient was eligible that day were printed at the bottom of the medication list" and also displayed on the physician's workstation, where the physician was required to view them. Pharmacists filling medication orders were also required to view the care suggestions for patients randomized to the pharmacist intervention group. "Care suggestions focused on: (1) performing pulmonary function tests, (2) giving influenza and pneumococcal vaccinations, (3) prescribing inhaled steroid preparations in patients with frequent symptoms of dyspnea, (4) prescribing inhaled anticholinergic agents in patients with COPD [chronic obstructive pulmonary disease], (5) escalating doses of inhaled b-adrenergic agonists for all patients with persistent symptoms, (6) prescribing theophylline for patients with COPD and continued symptoms despite aggressive use of inhaled anticholinergic agents, b-agonists, and steroids, and (7) encouraging smoking cessation."
Context or other IT in place
An electronic medical record (EMR) system has been in place since 1984.
Workflow-Related Findings
There were no significant differences in response to the suggestions for the four study groups: physician intervention, pharmacist intervention, physician and pharmacist intervention, or control. Thirty-two percent of the suggestions were adhered to in all groups except the physician and pharmacist intervention group, for which 37 percent of the suggestions were adhered to.
"Physicians' opinions of practice guidelines were mixed.... They generally felt that guidelines were a good educational tool, a convenient source of information, and intended to improve the quality of care. Yet many physicians felt that guidelines represented oversimplified 'cookbook' medicine, were often too rigid to apply to individual patients, hampered physician autonomy, and were used to decrease health care costs."
"The content, timing, and presentation of such decision-support tools need to be improved." In this study, physicians could press "escape" to move past the care suggestions, and many may have habitually ignored them.
Despite the intervention designed to encourage pharmacists to contact physicians about the care suggestions, "communication between physicians and pharmacists in this study was practically nonexistent."
Study Design
Randomized controlled trial (RCT)
Study Participants
The study participants included 274 physicians, 20 pharmacists, and 706 of their patients with asthma or COPD.