Intended for healthcare professionals


Effect of computerised evidence based guidelines

BMJ 2003; 326 doi: (Published 15 February 2003) Cite this as: BMJ 2003;326:394
  1. Emery Jon D (, Cancer Research UK clinician scientist
  1. Department of Public Health and Primary Care, University of Cambridge, Institute of Public Health, Cambridge CB2 2SR
  2. Sowerby Centre for Health Informatics at Newcastle, University of Newcastle on Tyne, Newcastle on Tyne NE2 4AB
  3. Faculty of Medical Informatics, Royal College of Surgeons of Edinburgh, Edinburgh EH8 9DW
  4. Tayside Centre of General Practice, University of Dundee, Dundee DD2 4AD
  5. Division of Primary Health Care, University of Bristol, Bristol BS6 6JL
  6. Department of Applied Computing, University of Dundee, Dundee DD1 4HN
  7. Department of Medical Informatics, Erasmus MC, University Medical Centre Rotterdam, PO Box 1738, NL-3000 DR Rotterdam, Netherlands
  8. Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4AA
  9. Health Services Research Unit, University of Aberdeen, Aberdeen AB25 2ZD
  10. Department of Economics, City University, London EC1V 0HB

    Computer support is complex intervention

    EDITOR—Eccles et al's rigorous approach to the evaluation of a computerised decision support system for the management of angina and asthma accounted for many of the flaws in previous trials of computer support.1 They were no doubt disappointed that no effect was seen, probably due to low usage of the system.

    Although not discussed in the paper, a possible explanation for this is that, given the comparatively high use of computers required for inclusion in the trial, the practices already used simpler computerised templates to promote collection of process of care data. Practitioners may therefore have perceived little further to be gained by using the more detailed decision support system, particularly if it did not allow easy switching between the guideline and the clinical system.

    The study by Eccles et al shows the complexity of interventions in primary care that incorporate computerised decision support systems. This complexity needs to be fully accounted for in designing and evaluating such interventions.2 Even with an apparently well developed piece of software, the trial assumed that offering brief training to a minority of practitioners in each practice would be sufficient for it to be incorporated into the increasingly complex care provided in routine general practice consultations.

    Trials of computer support in primary care need to acknowledge this complexity by embedding use of the software in a carefully specified model of care. For the high quality management of chronic disease, this model will probably require subspecialisation within a general practice, as proposed in the new general practitioner contract.3

    Providing focused training to key people in a practice and supporting subspecialisation through computer decision support may be a more appropriate approach to chronic disease management in primary care. Future trials of computer support must consider not only the technical features of the software …

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