Implementation of clinical guidelines through an electronic medical record: physician usage, satisfaction and assessment

Abstract

Context: We developed and evaluated the Emergency Department Expert Charting System (EDECS) to provide real-time guidance regarding the care of low back pain in adults, fever in children, and occupational exposure to blood and body fluids in health care workers, by embedding clinical guidelines within an electronic medical record. Objective: To describe the behaviors and attitudes of physicians who used EDECS. Design: Pre-post questionnaires were used to assess physician attitudes. Time studies of the intervention phase were observational, using clocks embedded in the software. Participants: One hundred and forty two residents and interns in emergency, pediatric, internal, and family medicine and patients with the above-mentioned complaints. Main outcome measures: Physician utilization of EDECS, time spent using EDECS, physician satisfaction and beliefs. Results: Eighty four percent of the 142 eligible physicians used EDECS at least once. Five hundred and ninety one of 789 (75%) eligible cases were completed using EDECS. Median session time decreased from 12 min for session 1, to 5.5 min for sessions 16 and above. Physicians generally agreed that care with EDECS was better than standard care, particularly with respect to documentation. There was, however, considerable heterogeneity in belief among complaints. Conclusions: These data illuminate both the potentials of computer-assisted decision making and the need for context-specific approaches when attempting to implement guidelines.

Introduction

In the past, decade physicians have been bombarded with a Brobdingnagian amount of information in the form of clinical guidelines. The time required of physicians to sort through even a small fraction of available guidelines and institute change in their clinical practice is daunting. It is, therefore, not surprising that publication of a clinical guideline is an insufficient means of implementation [1]. Publication alone does not lead to the decreased variance in practice patterns and improvements in quality and cost-effectiveness that guidelines are touted to produce [2], [3], [4], [5], [6], [7], [8]. Therefore, if guidelines are to work, they must be actively implemented. Physicians need a facile means of integrating guidelines into everyday practice. In the 1990s, we began to examine whether computers could aid the physician with this task.

We sought to determine if, by embedding guidelines in an electronic charting system (EDECS—the Emergency Department Expert Charting System), we could improve the quality and cost-effectiveness of emergency care for three common chief complaints [9]. We found that while EDECS consistently improved the documentation of the medical record and after-care instructions, its effects on appropriateness of care were less consistent [10], [11], [12]. We only observed consistent, substantial improvements in appropriateness of care and cost-effectiveness in the module that guided care of health care workers incurring occupational exposures to blood or body fluids (OEBBF) [10]. The effects of EDECS on the care of febrile children (PF), and adults with low back pain (BP) were less pronounced [11], [12]. The heterogeneous nature of our results has been observed by others [13].

In this descriptive paper, we examine the feasibility of this method of guideline implementation, focusing on issues related to the physicians who used the system. We describe their patterns of EDECS use, EDECS session length and how it changed with experience, and physician's use of screens that provided the rationale for the recommendations. We also report on physicians’ attitudes about clinical guidelines and computers, assessed before and after EDECS use, and the physicians’ evaluation of the EDECS software.