Table 1.
Computer-based Guideline Implementation Systems
| Study (year) | Domain; System; Site | Source of Guideline | Recommendation | Explanation | Documentation | Registration | Communication | Calculation | Presentation | Aggregation |
|---|---|---|---|---|---|---|---|---|---|---|
| Bouhaddou et al.12 (1994) | Three procedure preauthorizations (cholecystectomy, cataract extraction, knee arthroscopy); ILIAD; IHC Health Plan and University of Utah Medical Center, Salt Lake City, Utah | Locally developed | Surgical preauthorization; delayed | Logic and deviations from preauthorization criteria | Surgical indications documented on paper and phoned or faxed to central office; prompted, noninteractive | Nd | None | Nd | Paper: status of preauthorization; full report of guideline compliance/deviations | Nd |
| Burack et al.13 (1994) | Mammography screening; multiple practice sites in Detroit, Mich. | USPSTF and other authorities | Mammography reminder; concurrent | Breast cancer risk factors | Procedure indication (screening or diagnostic) initiator, patient response to referral; prompted, noninteractive | Yes | Nd | Age | Paper: reminder form, previous mammography results, appointment postcard | Nd |
| Burack and Gimotty14 (1997) | ||||||||||
| Day et al.15 (1995) | Low back pain; Emergency Department Expert Charting System; UCLA Emergency Medicine Center, Los Angeles, Calif. | AHCPR with local adaptation | Advice about appropriate tests, treatment, and disposition; prompts for missing history or physical exam items; concurrent | Nd | Core history and physical examination items; clinician's rationale for deviation from recommendations; prompted, interactive | Nd | None | Nd | Paper: after-care instructions for patients, laboratory and treatment orders, prescriptions | Nd |
| On-screen: color-coded suggestion prompts and order screens | ||||||||||
| Dexter et al.16 (1998) | Advanced directives; Regenstrief Medical Records System; General Medicine Practice, Indianapolis, Ind. | Nd | Reminders to discuss advanced directives; concurrent | Nd | Paper-based encounter sheet allows choice of discussed, deferred, or rationale for deviation; prompted, noninteractive | EMR | EMR (Regenstrief system) | Age | Paper: reminders on encounter forms | Nd |
| Goethe and Bronzino17 (1995) | Pharmacotherapy in psychiatry; Clinical Evaluation and Monitoring System; Institute of Living, Hartford, Conn. | Locally developed | Alerts for appropriate psychotropic medications based on diagnosis, appropriate baseline and followup laboratory testing and drug monitoring, potential for drug-drug interactions; concurrent | Summary information about medications, potential for drug-drug interactions | Documentation checklists for key symptoms and behavioral issues; rationale for deviation; prompted, interactive | Nd | Laboratory, pharmacy, and diagnostic data | Nd | On-screen: alerts, historical laboratory values, medications, medical problems | Nd |
| Goethe et al.18 (1997) | ||||||||||
| Litzelman et al.19 (1993) | Preventive care (fecal occult blood, mammography, Pap smear); Regenstrief Medical Records System; Indianapolis, Ind. | Canadian Task Force on the Periodic Health Exam, Lifetime Health Monitoring, American Cancer Society | Reminders about fecal occult blood testing annually if age >50, mammography for women over age 50, Pap testing based on age and previous test results; concurrent | Explanation of rule that generated reminder | Clinic visit notes handwritten on encounter forms; rationale for deviation; prompted, noninteractive | EMR | EMR (Regenstrief system) | Age | Paper: indicated tests on the encounter form, reminder report | Nd |
| Lobach and Hammond20 (1997) | Diabetes; CAMP; Duke University Medical Center, Durham, N.C. | American Diabetes Association with local adaptation | Care recommendations regarding which studies or procedures are currently due and due at next visit; concurrent | Nd | Handwritten documentation that a recommended action was performed, declined, or never to be done; data entry by clinic personnel; prompted, noninteractive | EMR | EMR, scheduling, accounting, laboratory orders, results (TMR system) | Age, intervals | Paper: recommendations on encounter form, prescriptions, orders | Nd |
| Margolis et al.21 (1992) | Six common pediatric problems; CHARTS; Community Pediatrics Clinic, Olfaqqueem, Israel | Nd | Advice from clinical management algorithms; concurrent | Nd | Clinical observations recorded on clinical algorithm serve as visit form; prompted, interactive | Nd | Nd | Nd | On-screen: clinical algorithm Paper: record of the visit | Nd |
| Nilasena et al.22 (1994) | Diabetes; University of Utah Medical Center and the VA Medical Center, Salt Lake City, Utah | American Diabetes Association with local adaptation | Alerts about high-risk aspects of clinical profile; concurrent | Nd | Seven data entry forms, self-contained database; data entry by clerical personnel from paper forms; prompted, noninteractive | Demographics | None | Nd | Paper: health maintenance report with demographics, preventive health status, schedule of upcoming and past-due preventive activities | Nd |
| Nilasena and Lincoln23 (1995) | ||||||||||
| Ornstein et al.24 (1993) | 13 preventive services; Division of Family Medicine, Medical University of South Carolina, Charleston, S.C. | USPSTF | Reminders of deficient preventive services, e.g., dental, diet, injury prevention counseling, immunizations, screening of blood pressure, fecal occult blood, Pap smears, mammograms; concurrent | Explanation and citations for each preventive service tracked | Integrated with EMR (problem lists, progress notes, social history); tracks preventive services; some notes dictated and transcribed; prompted, interactive | EMR | EMR system, laboratory results | Age, intervals | Paper: reminders to physicians, annual letters to patients to alert them about preventive services | Nd |
| On-screen: reminders to physicians | ||||||||||
| Ornstein et al.25 (1995) | ||||||||||
| Overhage et al.26 (1996) | 22 adult preventive care in hospitalized patients; Regenstrief Medical Record System; Wishard Memorial Hospital, Indianapolis, Ind. | USPSTF | Preventive care reminders, suggested orders; concurrent | Citations of literature to support recommendations | Integrated with Regenstrief inpatient and outpatient EMR; prompted, interactive | EMR | Order entry for laboratory and pharmacy; EMR (Regenstrief system) | Age, creatinine clearance | Paper: reminder on daily rounds reports | Nd |
| On-screen: reminders displayed during order entry | ||||||||||
| Robbins et al.27 (1993) | Lipid Management Program; private practice, Norfolk, Va. | National Cholesterol Education guidelines with local adaptation | Reminders about patients for whom laboratory data are due; concurrent | Nd | Lipid results and current therapy; prompted, noninteractive | Nd | Nd | Nd | Paper: reminders of laboratory tests due; results sent to patients and referring physicians | Nd |
| Rossi and Every28 (1997) | Pharmacotherapy with calcium channel blockers in hypertension; DHCP and ACQUIP; Seattle VA Medical Center, Seattle, Wash. | JNC V | Advice regarding use of diuretic and beta blocker for at-risk patients; concurrent | Cardiovascular risk associated with calcium channel blockers | Paper-based form documents appropriate indications for calcium channel blocker therapy; data entry by clerical personnel; prompted, noninteractive | EMR | EMR (DHCP, ACQUIP systems) | None | Paper: reminder attached to prescription refill form | Nd |
| Safran et al.29 (1995) | HIV management; Center for Clinical Computing, Beth Israel Hospital, Boston, Mass. | Locally developed | Alerts and reminders regarding HIV patients, including laboratory results, recommended medications and dosages, referrals, immunizations; concurrent | Nd | Integrated with EMR that includes problems, medications, preventive screenings, progress notes; prompted, interactive | EMR | EMR, scheduling, test ordering (Clinical Computing System) | Nd | On-screen: alerts, reminders (appear only when patient record is accessed) | Laboratory, scheduling, demographics, dates of admission and discharge and alerts triggered |
| Schriger et al.30 (1997) | Occupational exposure; Emergency Department Expert Charting System; UCLA Emergency Medicine Center, Los Angeles, Calif. | Locally developed | Tests and treatments recommended, optional, not recommended; concurrent | Computer's reasoning for each recommendation | History of exposure event, exposed worker, and source; rationale for deviation; prompted, interactive | Nd | Nd | Nd | Paper: after-care instructions for patients (modifiable by clinician), prescriptions | Deviation rates by decision |
| Tape and Campbell31 (1993) | Health maintenance; COSTAR medical record system; University of Nebraska Internal Medicine Clinic, Omaha, Neb. | Nd | Reminders about health maintenance deficiencies based on age, sex, chronic disease, and past health maintenance records; concurrent | Nd | Paper-based document; prompted, noninteractive | EMR | EMR (COSTAR system) | Age, intervals | Paper: problem list, medication list, and most recent progress note | Nd |
| Turner et al.32 (1994) | Preventive care; private practices in eastern North Carolina | Nd | Reminders about influenza vaccine, Pap smears, breast exams, and mammography; concurrent | Nd | Nd | Nd | Nd | Age | Paper: reminder | Nd |
| Vincent et al.33 (1995) | Disease prevention, cancer detection, immunization; Quality Care Program; Swedish Hospital, Seattle, Wash. | Nd | Recommended health maintenance procedures based on individual risk factors; concurrent | Nd | Paper-based worksheet completed at encounter and entered into system by clerical staff; prompted, noninteractive | Yes | Nd | Age, intervals | Paper: worksheet attached to medical record; health maintenance reminder letters for patients | Nd |
| Willson et al.34 (1995) | Pressure ulcer prevention and treatment; LDS Hospital, Salt Lake City, Utah | AHCPR | Reminders to nurses to perform Braden assessments; stage appropriate treatment recommendations; concurrent | Nd | General screening and Braden scale; prompted, interactive | EMR | EMR (HELP system) | Nd | On-screen: alerts | Nd |
| Zielstorff et al.35 (1996) | Pressure Ulcers; Pressure Ulcer Prevention & Management System; Massachusetts General Hospital, Boston, Mass. | AHCPR | Treatment plan, risk status; concurrent | Definitions of individual data items | Data entry screens provide explicit cues for assessment data; prompted, interactive | Nd | Nd | Nd | Paper: patient-specific treatment plan | Nd |
| Zielstorff et al.36 (1997) |
||||||||||
| Note: ACQUIP indicates Ambulatory Care Quality Improvement Program; AHCPR, Agency for Health Care Policy and Research; CAMP, computer-assisted management protocol; COSTAR, Computer-stored Ambulatory Record; DHCP, decentralized hospital computer system; EMR, electronic medical record; JNC V, Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure; Nd, not discussed; USPSTF, U.S. Preventive Services Task Force; VA, Veterans Administration. | ||||||||||