From practice guidelines to clinical decision support: closing the loop

Abstract

Chidgey, Leng and Lacey1 review the successes and some outstanding issues facing the UK National Institute for Health and Clinical Excellence (NICE) in improving the routine delivery of care in the National Health Service and similar organizations. The focus of their essay is the NICE programme of guideline development, ‘arguably the largest in the world’, whose objective is to carry out rigorous reviews of the evidence for alternative treatments, develop clinical guidance that ensures clinical decisions are based on the best evidence, target use of resources optimally and maintain ongoing reviews of new evidence. Chidgey et al. point to convincing examples of successes in changing practice, while accepting that overall the record of translating guidance into successful implementation is ‘mixed’. Editorials in the same issue of JRSM discuss this assessment. Iain Chalmers asks ‘How are we to know whether all this work [on guideline development] has led to better patient care in the NHS?’ Gupta and Warner observe that ‘although NICE guidelines can be very helpful in guiding clinicians and patients, they focus on the clinical problem and cannot take into account various other factors (e.g. physical and psychological co-morbidities, social and cultural issues) that make each patient unique’. Finally the editor of the JRSM, Kamran Abbasi, comments that ‘Guidelines have a miserable record in changing clinical practice’ and ‘The central problem for NICE is that too many clinicians view its rationing role with displeasure and each decision and guidance brings its own enemies. … Clinicians feel increasingly isolated from the decision-making process and increasingly resentful of the inflexibility of high level commandments.’ Chidgey et al. suggest a number of ways to improve guideline implementation, ranging from educational and outreach mechanisms to the use of clinical audit and reminders and ‘computer-based decision support’. In this paper we wish to pick up the last remark because it was only mentioned in passing and we believe that Clinical Decision Support (CDS) technology actually offers a major new implementation strategy. Specifically, we wish to draw attention to ways in which CDS can make a significant contribution to the effective dissemination of evidence-based practice. Furthermore we will argue that decision support technology can address a number of issues raised in the editorials: providing clinical guidance in a form that is specific to individual patients; permitting and indeed supporting the exercise of professional clinical judgement if this conflicts with general guidelines, and involving working clinicians in the translation of research into practice. This is not a commentary on NICE, or the UK, but about a strategy for improving the quality and safety of patient care in modern medical services. We will explain these claims in the context of a long-term research programme supported by Cancer Research UK (CRUK) which, while focused on cancer, has resulted in techniques for supporting clinical decision-making which are believed to be applicable across clinical specialties, sectors and countries. CDS technology is a rapidly developing field.2 We have not attempted to write a detailed review of different approaches to CDSs for this paper because several already exist.3–5 Short overviews of many systems can be found at http://www.openclinical.org. In the first section of the paper we briefly overview international efforts to develop and disseminate evidence-based clinical practice guidelines (CPGs), their perceived impact on clinical practice and the issues that have emerged.2 Next we describe advances in the field of decision support, drawing particularly though not exclusively on our own experience. The last part of the paper focuses on how CDS technology can address challenges in implementing clinical guidelines and help clinicians and others to comply with evidence-based recommendations. A novel capability that CDS services can offer is to capture clinicians' experience in using a CPG, thereby informing the treatment policies of the healthcare organization, and feeding back information about CPG use and impact to the authors and reviewers of guidance and clinical researchers.