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. 1998 May-Jun;5(3):227-36.
doi: 10.1136/jamia.1998.0050227.

Online practice guidelines: issues, obstacles, and future prospects

R D Zielstorff  1
Affiliations

Online practice guidelines: issues, obstacles, and future prospects

R D Zielstorff. J Am Med Inform Assoc. 1998 May-Jun.

Abstract

The "guidelines movement" was formed to reduce variability in practice, control costs, and improve patient care outcomes. Yet the overall impact on practice and outcomes has been disappointing. Evidence demonstrates that the most effective method of stimulating awareness of and compliance with best practices is computer-generated reminders provided at the point of care. This paper reviews five steps along the path from the development of a guideline to its integration into practice and the subsequent evaluation of its impact on practice and outcomes. Issues arising at each step and obstacles to moving from one step to the next are described. Last, developments that could help overcome the obstacles are highlighted. These include 1) more rapid knowledge acquisition using data mining, 2) better accommodation to imprecise knowledge in clinical algorithms using fuzzy logic, 3) development of a shareable model for guideline representation and execution, and 4) more widespread availability of clinically robust information systems that support decision-making at the point of care.

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Figures

Figure 1
Figure 1
Example of a text guideline made available to clinicians through an agency's intranet.
Figure 2
Figure 2
A, Example of a text guideline that allows the clinician to retrieve sections of interest. Here, the clinician wants to search for sections related to “urge incontinence.” B, Having entered the search, the clinician has been presented with a list of sections containing the phrase “urge incontinence,” has selected a section, and gets the text shown here.
Figure 3
Figure 3
Example of an interactive algorithm, this one on managing tissue loads. The clinician has responded to a series of questions and has received the recommendation shown above. When the clinician then asks the system to “explain” the recommendation, the explanation appears at the bottom of the screen. There is also an optional link to vendor descriptions of the recommended product.
Figure 4
Figure 4
Example of an evidence-based guideline embedded in a patient record system. Here, the physician has ordered an abdominal radiograph, has responded to prompts for the patient's history, and gets this advisory.
Figure 5
Figure 5
Continuum of decision support offered by various modes of online practice guidelines.
Figure 6
Figure 6
Steps toward fully integrating online guidelines into practice.
See this image and copyright information in PMC

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