Clinical Prediction Rules

Daniel J Vreeman

To the editor

I am writing to commend Childs and Cleland1 for their timely and insightful article on clinical prediction rules (CPRs) (January 2006). Their article highlights the potential value for practicing physical therapists who incorporate such rules into their clinical decision making and care delivery. As the authors note, however, the mere existence of high-quality guidelines does not guarantee that they will actually influence practitioner behavior. An important challenge is that guidelines demand the attention and memory of clinicians who are already overburdened.

I concur with the authors’ recognition and discussion of the practical barriers to using CPRs, but was hoping that they would elaborate further on potential ways to overcome these challenges. I would like to extend their discussion of these issues to include consideration of a widely studied intervention for changing clinician behavior: the computerized suggestion.

While humans struggle with the “prospective recall” necessary to implement guidelines such as CPRs, computers are unflagging data processors. We have convincing evidence that computergenerated suggestions to clinicians about preferred care options can have a measurable and important impact on care outcomes.25 Indeed, in the same issue of JAMA where Stiell et al6 published their implementation trial of the Ottawa ankle rules, McDonald and Overhage7 wrote in an editorial that the Ottawa rules were exemplary not only because of the rigor with which they were developed, but also because they were decidable and actionable—the kind of guideline whose processing could be turned over to a computer. Physical therapists can glean much from the medical informatics community’s 30-plus years of experience in developing and evaluating systems that support clinical decision making. Although computer systems with advanced features such as clinical decision support are not yet common in physical therapist practice,8 they may be an essential tool for enabling busy clinicians to put CPRs and other guidelines into practice.

Many evaluations of systems that implement computerized guidelines have found a substantial benefit. For example, a systematic review of the functionality and effectiveness of such systems found that guideline adherence improved in 14 of 18 systems in which it was measured.9 Additionally, effective systems have described important factors for success in implementing computerized guidelines.10 Certainly, computerized systems are not a panacea for guideline adherence. In particular, the complex sociotechnical interaction presents many challenges, as illustrated in a randomized controlled trial of a computer system with automated care suggestions that was previously shown to increase preventive care and reduce costs, but failed to show improvement in adherence to evidence-based guidelines for managing asthma and chronic obstructive pulmonary disease.11

Childs and Cleland highlighted the value of CPRs, a special subset of the larger body of clinical practice guidelines. Clinical practice rules may have unique challenges to implementation and computerization, in part because executing them often requires input data from both the patient and the provider. Successful computerized implementations may demand creative interfaces to capture and process the needed information. One working example of a clinical decision support system designed to overcome the myriad barriers to implementing guidelines in a busy outpatient pediatric clinic is Child Health Improvement Through Computer Automation (CHICA).12,13 CHICA provides patientspecific suggestions that are informed by both existing information in the electronic health record and data collected at the encounter from families and clinicians. Interestingly, the interface for families and clinicians who interact with CHICA is not a computer workstation, but rather computer-interpretable, bilingual paper forms.

By applying the lessons learned from existing studies of computerized guideline implementations and by adopting systems with effective features that “make it easy to do it right,”14 physical therapists can move more quickly toward our goal of delivering more informed and effective care.


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