BMJ  2003;326:1087-1088 (17 May), doi:10.1136/bmj.326.7398.1087-b

Letter

Computerised evidence based guidelines in primary care

Computerised decision support and reflection in action

EDITOR—Eccles et al have shown not only the lack of effectiveness of a computerised decision support system based on evidence based guidelines but also some of the reasons why general practitioners found it unusable in everyday clinical practice.^{1 2}

General practitioners value information on demand but need to be able to recognise the need for information and to possess the skills to obtain and interpret it at the point of use. These skills (usually taught as evidence based medicine)³ are difficult and not widespread,⁴ so it is understandable that efforts to implement the findings of research should have concentrated on implementing the recommendations of expertly produced evidence based guidelines in a linear, top-down process. The use of research evidence is thus simplified and codified as a checklist of tasks in response to predefined prompts.

The issue with this approach is not whether its computerised form is user friendly but whether it is a practical or desirable way of making clinical decisions about individuals. Experienced clinicians mostly make decisions in an apparently intuitive way—"reflection in action"—rather than by proceeding through a rational technical process such as that exemplified by computerised guidelines.⁵

In a setting such as general practice, where doctors are attempting to address patients' agendas in psychological and social as well as biological terms, the intrusion of a checklist (whether computerised or not) may disrupt the smooth flow of a consultation and lead neither to implementation of a guideline nor to tackling the patient's own concerns.

Information on demand is now available online through the National Electronic Library for Health to all general practitioners. All guidelines from the National Institute for Clinical Excellence, the Cochrane Library, Clinical Evidence, and much else may be accessed while the patient is present. Clinicians need to acquire confidence in using information technology and evidence based medicine skills.

Westerhope Medical Group, Newcastle upon Tyne NE5 2LH toby{at}tobylipm.demon.co.uk

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Competing interests: TL is the co-organiser of an evidence based practice workshop.

References

1. Eccles M, McColl E, Steen N, Rousseau N, Grimshaw J, Parkin D, et al. Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial. BMJ 2002;325: 941.[Abstract/Free Full Text]
2. Rousseau N, McColl E, Newton J, Grimshaw J, Eccles M. Practice based, longitudinal, qualitative interview study of computerised evidence based guidelines in primary care. BMJ 2003;326: 314-8. (8 February.)[Abstract/Free Full Text]
3. Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practise and teach EBM. London: Churchill Livingstone, 1997.
4. McColl A, Smith H, White P, Field J. General practitioners' perceptions of the route to evidence based medicine: a questionnaire survey. BMJ 1998;316: 361-5.[Abstract/Free Full Text]
5. Schon DA. From technical rationality to reflection-in-action. In: Dowie J, Elstein A, eds. Professional judgement: a reader in clinical decision making. Cambridge: Cambridge University Press, 1983: 60-77.

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The use of internet during consultation can provide an answer

Dirk Van Duppen, et al.
bmj.com, 29 May 2003 [Full text]