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November 19, 1997, Vol 278, No. 19 >
ARTICLE | November 19, 1997

Implementation of Clinical Guidelines Using a Computer Charting System: Title and subTitle BreakEffect on the Initial Care of Health Care Workers Exposed to Body Fluids FREE

David L. Schriger, MD, MPH; Larry J. Baraff, MD; William H. Rogers, PhD; Shan Cretin, PhD, MPH
[+] Author Affiliations

Drs Schriger and Baraff and UCLA are copyright owners of the software described in this article, but the program is a research tool and is not available commercially.

Corresponding author: David L. Schriger, MD, MPH, 924 Westwood Blvd, Suite 300, Los Angeles, CA 90024-2924 (e-mail: schriger@ucla.edu).


JAMA. 1997;278(19):1585-1590. doi:10.1001/jama.1997.03550190049043
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References

Context.  —While clinical guidelines are considered an important mechanism to improve the quality of medical care, problems with implementation may limit their effectiveness. Few empirical data exist about the effect of computer-based systems for application of clinical guidelines on quality of care.

Objective.  —To determine whether real-time presentation of clinical guidelines using an electronic medical record can increase compliance with guidelines.

Design.  —Prospective off-on-off, interrupted time series with intent-to-treat analysis.

Setting.  —University hospital emergency department.

Subjects.  —Patients were 280 health care workers (50 in the baseline control phase, 156 in the intervention phase, and 74 in the postintervention control phase) who presented for initial treatment of occupational body fluid exposures, including 89% (248/280) who sustained punctures and 81% (208/257) who were exposed to blood. Physicians included resident physicians and attending physicians working in the emergency department during the study.

Interventions.  —Implementation of a computer charting system that provides real-time information regarding history and recommendations for laboratory testing, treatment, and disposition based on rules derived from clinical guidelines.

Main Outcome Measures.  —Quality of care as determined by essential items documented in the medical record and in aftercare instructions, compliance with testing and treatment guidelines, and total charges and percentage of charges attributable to guideline-endorsed activities.

Results.  —Mean percent documentation of 7 essential items regarding patient history in the medical record increased from 57% during the baseline period to 98% in the intervention phase (42% increase; 95% confidence interval [CI], 34%-49%) and 11 items in aftercare instruction increased from 31% at baseline to 93% during the intervention phase (62% increase; 95% CI, 51%-74%), but both decreased to baseline when the computer system was removed. Percent compliance with 4 laboratory testing guidelines increased from 63% at baseline to 83% during the intervention phase (20% increase; 95% CI, 9%-31%) but decreased to 52% when the computer system was removed. Compliance with 5 treatment guidelines increased from 83% at baseline to 96% during the intervention phase (13% increase; 95% Ci, 9%-17%) and decreased to 84% following the intervention. Percentage of charges incurred for indicated laboratory tests and treatment increased from 44% at baseline to 81% during the intervention phase (37% increase; 95% CI, 22%-52%) and decreased to 36% following the intervention. Average total per-patient charges were $460, $384, and $373 in each phase, respectively.

Conclusions.  —Use of a computer-based system for clinical guidelines for management of patients with occupational exposure to body fluids improved documentation, compliance with guidelines, and percentage of charges spent on indicated activities, while decreasing overall charges. The parameters returned to baseline when the computer system was removed.

REFERENCES

1 +
Eddy DM.  Clinical policies and the quality of clinical practice . N Engl J Med . 1982;;307:343-347.
2 +
Eddy DM.  Practice policies—what are they? JAMA . 1990;;263:877-880.
3 +
McDonald CJ, Overhage JM.  Guidelines you can follow and can trust: an ideal and an example . JAMA . 1994;;271:872-873.
4 +
Toepp MC, Kuznets N, Herrara SP. Directory of Practice Parameters: Titles, Sources, and Updates . Chicago, Ill: American Medical Association; 1996;.
5 +
Lomas J.  Diffusion, dissemination, and implementation: who should do what? Ann N Y Acad Sci . 1993;;703:226-241.
6 +
Soumerai SB, Avorn JA.  Principles of educational outreach ('academic detailing') to improve clinical decision making . JAMA . 1990;;263:549-556.
7 +
Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J.  Opinion leaders vs audit and feedback to implement practice guidelines: delivery after previous cesarean section . JAMA . 1991;;265:2202-2207.
8 +
Schriger DL.  Emergency medicine clinical guidelines: we can make them, but will we use them? Ann Emerg Med . 1996;;27:655-657.
9 +
Grimshaw JM, Russell IT.  Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations . Lancet . 1993;;342:1317-1322.
10 +
Johnston ME, Langton KB, Haynes RB, Mathieu A.  Effects of computer-based clinical decision support systems on clinician performance and patient outcome: a critical appraisal of research . Ann Intern Med . 1994;;120:135-142.
11 +
US Congress, Office of Technology Assessment. Identifying Health Technologies That Work: Searching for Evidence. Washington, DC: US Government Printing Office; September 1994:198. OTA H-608.
12 +
McDonald CJ.  Protocol-based computer reminders, the quality of care, and the non-perfectibility of man . N Engl J Med . 1976;;295:1351-1355.
13 +
Tierney WM, McDonald CJ, Martin DK, Rogers MP.  Computerized display of past test results: effect on outpatient testing . Ann Intern Med . 1987;;107:569-574.
14 +
Tierney WM, McDonald CJ, Hui SL, Martin DK.  Computer predictions of abnormal test results: effects on outpatient testing . JAMA . 1988;;259:1194-1198.
15 +
Agency for Health Care Policy and Research. Guidelines for medical outcomes. Available at: http://www.ahcpr.gov/guide. Accessed October 26, 1997.
16 +
Balas EA, Zong RL, Spencer DC, Jaffrey F, Brent E, Mitchell JA.  An expert system for performance-based direct delivery of published clinical evidence . J Am Med Inform Assoc . 1996;;3:56-65.
17 +
Eisenberg JM, Williams SV.  Cost-containment and changing physician's practice behavior: can the fox guard the chicken coop? JAMA . 1981;;246:2195-2201.
18 +
Eddy DM. Analyzing indirect evidence. In: Methodology Perspectives. Rockville, Md: US Dept of Health Services, Public Health Service, Agency for Health Care Policy and Research; 1994:5-14.
19 +
Woolf SH. An organized analytic framework for practice guideline development: using the analytic logic as a guide for reviewing evidence, developing recommendations, and explaining the rationale. In: Methodology Perspectives. Rockville, Md: US Dept of Health Services, Public Health Service, Agency for Health Care Policy and Research; 1994:105-114.
20 +
Go G, Baraff LJ, Schriger DL.  Management guidelines for health care workers exposed to blood and body fluids . Ann Emerg Med . 1991;;20:1341-1350.
21 +
Schriger DL, Baraff LJ, Wilton R, McCoy JM.  EDECS: the Emergency Department Expert Charting System . In: Proceedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care . New York, NY: Institute of Electrical and Electronics Engineers Computer Society Press; 1989;:611-615.
22 +
Shiffman RN, Greenes RA.  Improving clinical guidelines with logic and decision-table techniques: application to hepatitis immunization recommendations . Med Decis Making . 1994;;14:245-254.
23 +
Glasziou PP.  Decision tables: an underutilized tool? Med Decis Making . 1994;;14:207.
24 +
Wears RL, Stenklyft P, Luten R.  Using decision tables to verity the logical consistency of clinical guidelines: fevers without sources in children under age three years . Acad Emerg Med . 1994;;1:A35.
25 +
Baraff LJ, Schriger DL, Starkman S.  Compliance with a standard for the emergency department management of epileptics who present after an uncomplicated convulsion . Ann Emerg Med . 1990;;19:45-50.
26 +
StataCorp. Stata Reference Manual. Release 5. College Station, Tex: Stata Press; 1997:U235-U239.
27 +
Rice JA. Mathematical Statistics and Data Analysis . 2nd ed. Belmont, Calif: Duxbury Press; 1995;:153-154.
28 +
Kahn KL, Roger WH, Rubenstein LV, et al.  Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system . JAMA . 1990;;264:1969-1973.
29 +
Holbrook J, Aghababian R.  A computerized audit of 15,009 emergency department records . Ann Emerg Med . 1990;;19:139-144.
30 +
US Congress, Office of Technology Assessment. Identifying Health Technologies That Work: Searching for Evidence. Washington, DC: US Government Printing Office; September 1994:177-198. OTA-H-608.
31 +
 Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV . MMWR Morb Mortal Wkly Rep . 1996;;45:468-480.

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1 +
Eddy DM.  Clinical policies and the quality of clinical practice . N Engl J Med . 1982;;307:343-347.
2 +
Eddy DM.  Practice policies—what are they? JAMA . 1990;;263:877-880.
3 +
McDonald CJ, Overhage JM.  Guidelines you can follow and can trust: an ideal and an example . JAMA . 1994;;271:872-873.
4 +
Toepp MC, Kuznets N, Herrara SP. Directory of Practice Parameters: Titles, Sources, and Updates . Chicago, Ill: American Medical Association; 1996;.
5 +
Lomas J.  Diffusion, dissemination, and implementation: who should do what? Ann N Y Acad Sci . 1993;;703:226-241.
6 +
Soumerai SB, Avorn JA.  Principles of educational outreach ('academic detailing') to improve clinical decision making . JAMA . 1990;;263:549-556.
7 +
Lomas J, Enkin M, Anderson GM, Hannah WJ, Vayda E, Singer J.  Opinion leaders vs audit and feedback to implement practice guidelines: delivery after previous cesarean section . JAMA . 1991;;265:2202-2207.
8 +
Schriger DL.  Emergency medicine clinical guidelines: we can make them, but will we use them? Ann Emerg Med . 1996;;27:655-657.
9 +
Grimshaw JM, Russell IT.  Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations . Lancet . 1993;;342:1317-1322.
10 +
Johnston ME, Langton KB, Haynes RB, Mathieu A.  Effects of computer-based clinical decision support systems on clinician performance and patient outcome: a critical appraisal of research . Ann Intern Med . 1994;;120:135-142.
11 +
US Congress, Office of Technology Assessment. Identifying Health Technologies That Work: Searching for Evidence. Washington, DC: US Government Printing Office; September 1994:198. OTA H-608.
12 +
McDonald CJ.  Protocol-based computer reminders, the quality of care, and the non-perfectibility of man . N Engl J Med . 1976;;295:1351-1355.
13 +
Tierney WM, McDonald CJ, Martin DK, Rogers MP.  Computerized display of past test results: effect on outpatient testing . Ann Intern Med . 1987;;107:569-574.
14 +
Tierney WM, McDonald CJ, Hui SL, Martin DK.  Computer predictions of abnormal test results: effects on outpatient testing . JAMA . 1988;;259:1194-1198.
15 +
Agency for Health Care Policy and Research. Guidelines for medical outcomes. Available at: http://www.ahcpr.gov/guide. Accessed October 26, 1997.
16 +
Balas EA, Zong RL, Spencer DC, Jaffrey F, Brent E, Mitchell JA.  An expert system for performance-based direct delivery of published clinical evidence . J Am Med Inform Assoc . 1996;;3:56-65.
17 +
Eisenberg JM, Williams SV.  Cost-containment and changing physician's practice behavior: can the fox guard the chicken coop? JAMA . 1981;;246:2195-2201.
18 +
Eddy DM. Analyzing indirect evidence. In: Methodology Perspectives. Rockville, Md: US Dept of Health Services, Public Health Service, Agency for Health Care Policy and Research; 1994:5-14.
19 +
Woolf SH. An organized analytic framework for practice guideline development: using the analytic logic as a guide for reviewing evidence, developing recommendations, and explaining the rationale. In: Methodology Perspectives. Rockville, Md: US Dept of Health Services, Public Health Service, Agency for Health Care Policy and Research; 1994:105-114.
20 +
Go G, Baraff LJ, Schriger DL.  Management guidelines for health care workers exposed to blood and body fluids . Ann Emerg Med . 1991;;20:1341-1350.
21 +
Schriger DL, Baraff LJ, Wilton R, McCoy JM.  EDECS: the Emergency Department Expert Charting System . In: Proceedings of the Thirteenth Annual Symposium on Computer Applications in Medical Care . New York, NY: Institute of Electrical and Electronics Engineers Computer Society Press; 1989;:611-615.
22 +
Shiffman RN, Greenes RA.  Improving clinical guidelines with logic and decision-table techniques: application to hepatitis immunization recommendations . Med Decis Making . 1994;;14:245-254.
23 +
Glasziou PP.  Decision tables: an underutilized tool? Med Decis Making . 1994;;14:207.
24 +
Wears RL, Stenklyft P, Luten R.  Using decision tables to verity the logical consistency of clinical guidelines: fevers without sources in children under age three years . Acad Emerg Med . 1994;;1:A35.
25 +
Baraff LJ, Schriger DL, Starkman S.  Compliance with a standard for the emergency department management of epileptics who present after an uncomplicated convulsion . Ann Emerg Med . 1990;;19:45-50.
26 +
StataCorp. Stata Reference Manual. Release 5. College Station, Tex: Stata Press; 1997:U235-U239.
27 +
Rice JA. Mathematical Statistics and Data Analysis . 2nd ed. Belmont, Calif: Duxbury Press; 1995;:153-154.
28 +
Kahn KL, Roger WH, Rubenstein LV, et al.  Measuring quality of care with explicit process criteria before and after implementation of the DRG-based prospective payment system . JAMA . 1990;;264:1969-1973.
29 +
Holbrook J, Aghababian R.  A computerized audit of 15,009 emergency department records . Ann Emerg Med . 1990;;19:139-144.
30 +
US Congress, Office of Technology Assessment. Identifying Health Technologies That Work: Searching for Evidence. Washington, DC: US Government Printing Office; September 1994:177-198. OTA-H-608.
31 +
 Update: provisional Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV . MMWR Morb Mortal Wkly Rep . 1996;;45:468-480.

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