Pediatric Informatics: Computer Applications in Child Health (Health ...

9 Pediatric Care, Safety, and Standardization 123
as indicators of the quality of cancer screening: “(1) not properly considering
illness severity of the sample population audited for adherence to screening, (2) not
distinguishing screening from diagnostic procedures when setting achiev able target
screening rates, and (3) not accounting for patient preferences or clinician judgment
when scoring performance measures.”
It has been proposed that if CPGs were available at the point of care, enabling
the clinician to access timely and relevant knowledge and support at the time of
decision making, compliance with CPGs might be enhanced. 18 However, there
are conflicting reports on the success of implementing point-of-care CPGs. Chin
described the experience at Kaiser Permanente, Northwest region, embedding CPGs
into the CPOE process on the computerized patient record. Ordering according to
the CPG was designed as the default mode. 19 For example, the authors reported a
marked increase in orders for upper gastrointestinal (UGI) series conforming to the
guidelines when appropriate indications for the test were embedded in the order
requisition. In contrast, Asaro et al. did not see improved compliance with a CPG
for acute coronary syndrome that was embedded in their commercial CPOE system.
They attributed this to the lack of co-embedded patient-specific decision support,
and suggested that vendors consider the feasibility of incorporating patient-specific
support in designing their systems. 20
Clinical informatics affords us the opportunity to expand the cadre of CPGs
available for use at the point of care. It is likely that some guidelines, perhaps those
that are more generic, will be amenable to more rapid and successful incorporation
and adoption through informatics. Only by capturing and understanding the barriers
to use will future systems be able to be more capably designed.
9.4 Clinical Algorithms and Care Maps
Clinical algorithms (CAs) describe a diagnostic, therapeutic, or management
approach to a given clinical problem, which is outlined by a detailed, step-by step
account, often presented as a flow chart. They facilitate application of consistent
care, save time for the user, expedite care, and provide the decision support to enable
providers to function outside their usual knowledge or skill set. 21 Furthermore
they provide a framework for thinking about clinical problems, and are particularly
useful for the clinician who lacks mental models for this problem because
he has not seen this problem recently or ever. 22 Although diagnostic, therapeutic,
and management algorithms can theoretically be embedded into CPOE systems
(Chapter 18), physician use may be the rate-limiting factor. For example, Margolis
et al. reported that a barrier to the adoption of computerized CAs was the time
required for what was considered a “lockstep recording procedure that was both
irritating and tiring”. 23 Fischer et al. recently reported their experience developing
and using an algorithmic CPOE to select patients for treatment with activated
protein C, which at that time was an investigational drug. 24 The embedded decision
support was able to delineate whether the patient was a candidate for use of this