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J Am Med Inform Assoc 5:227-236 doi:10.1136/jamia.1998.0050227
  • Focus on Clinical Guidelines and Patient Preferences

Online Practice Guidelines

Table 1

Summary of Steps and Obstacles to Online Guidelines Fully Integrated into Practice

Step Description Obstacles
Step 1: Develop guideline. Distill relevant knowledge, provide recommendations reflecting “best practices.”

  • Inadequate knowledge base

  • Conflicting evidence

  • Difficulty achieving consensus among experts
Step 2: Develop algorithm from text guideline. Distill decision points and criteria for decisions; convert to decision flowchart or decision table.

  • Incompletely specified decision criteria

  • Ambiguity

  • Lack of comprehensiveness
Step 3: Disseminate rules and protocols in a local environment. Implement guideline in local setting through education of clinicians, “detailing” by personnel, reminders, etc.

  • Conflicts with individual clinicians' values and beliefs

  • Ethicla concerns

  • Legal concerns

  • Lack of confidende in validity of guideline

  • Lack of evidence for impact on outcomes

  • Difficulty applying general guideline to case at hand

  • Lack of administrative support, especially infrastructure
Step 4: Integrate guideline-based rules into clinical record system with computer-based reminders. Install software that runs guideline algorithm within electronic patient record; use existing data or query clinician for needed data; provide patient-specific reminders integrated into workflow.

  • Lack of clinically focused patient record systems with structured, coded data amenable to processing of rules

  • Difficulty designing systems that are easy to use by clinicians

  • Variable accuracy of data stored in computer record

  • Incomplete data in computer record

  • Time and effort to write programs for each guideline to be implemented
Step 5: Examine impact on processes and outcomes, monitor new knowledge, and refine guideline as needed. Establish mechanisms for measuring impact on processes and outcomes; carry out as appropriate.

  • Lack of infrastructure for carrying out studies on processes and outcomes

  • Lack of resources for carrying out knowledge synthesis, revision of guideline

  • Expense
Establish mechanisms for periodic review of knowledge and revision of guideline as appropriate.

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