Developing and Implementing Computerized Protocols for Standardization of Clinical Decisions

Developing and Implementing Computerized Protocols for Standardization of Clinical Decisions

Alan H. Morris, MD

From LDS Hospital and University of Utah School of Medicine, Salt Lake City, Utah.

Abstract

Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers. Variation in clinical practice is due in part to clinicians' poor compliance with guidelines and recommended therapies. The use of decision-support tools is a response to both the information revolution and poor compliance. Computerized protocols used to deliver decision support can be configured to contain much more detail than textual guidelines or paper-based flow diagrams. Such protocols can generate patient-specific instructions for therapy that can be carried out with little interclinician variability; however, clinicians must be willing to modify personal styles of clinical management. Protocols need not be perfect. Several defensible and reasonable approaches are available for clinical problems. However, one of these reasonable approaches must be chosen and incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the protocols themselves. Computerized protocols for mechanical ventilation and management of intravenous fluid and hemodynamic factors in patients with the acute respiratory distress syndrome provide case studies for this discussion.

Article and Author Information

Acknowledgments: The author thanks the medical, nursing, and respiratory therapy staffs of the Intermountain Respiratory Intensive Care Unit and the Shock-Trauma/Intermountain Respiratory Intensive Care Unit and the Respiratory Care Department of LDS Hospital for collaboration during the past 25 years. He recognizes the contributions of Drs. James Orme Jr., Terry Clemmer, Lin Weaver, Frank Thomas, Tom East, Jane Wallace, George Thomsen, James Pearl, Nat Dean, and Brad Rasmusson for collaboration in protocol development and implementation. He thanks Drs. Robert Crapo and C. Gregory Elliott for critically reviewing the manuscript and Drs. Roberta Goldring, Robert Rogers, and Waldemar Johanson who, through their vision and insight 14 years ago, enabled this decision-support effort.
Grant Support: By the National Institutes of Health (RO1-HL-36787, NO1-HR-46062), the Agency for Healthcare Research and Quality (HS 06594), the Deseret Foundation, the Respiratory Distress Syndrome Foundation, LDS Hospital, and IHC, Inc.
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