Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality

Abstract

While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

Figure 1.

Ordering digoxin. This screen from an application illustrates how an application can anticipate provider needs (here, the most recent digoxin and potassium levels and the dose forms that digoxin comes in) and bring this information to the clinician at the point of care.

Figure 2.

Example of a corollary order. Ordering gentamicin sulfate prompts a suggestion for a corollary order: drawing levels before and one hour after the third dose.

Figure 3.

Alert for a “redundant” laboratory order. We have found repeatedly that physicians resist stopping; in this instance, alerts for redundant orders often are overridden when there is no alternative plan of action suggested, even when the testing almost never identifies anything useful.

Figure 4.

Computerized guidelines. These guidelines for the use of human growth hormone were developed to help prevent inappropriate and unnecessary use of this expensive medication. Introducing computerized guidelines to the process of ordering human growth hormone decreased utilization by two thirds.

Figure 5.

Changing direction. In the case of abdominal radiography, suggesting the appropriate views given the indication often results in a change.