The evolution of eProtocols that enable reproducible clinical research and care methods.

Unnecessary variation in clinical care and clinical research reduces our ability to determine what healthcare interventions are effective. Reducing this unnecessary variation could lead to further healthcare quality improvement and more effective clinical research. We have developed and used electronic decision support tools (eProtocols) to reduce unnecessary variation. Our eProtocols have progressed from a locally developed mainframe computer application in one clinical site (LDS Hospital) to web-based applications available in multiple languages and used internationally. We use eProtocol-insulin as an example to illustrate this evolution. We initially developed eProtocol-insulin as a local quality improvement effort to manage stress hyperglycemia in the adult intensive care unit (ICU). We extended eProtocol-insulin use to translate our quality improvement results into usual clinical care at Intermountain Healthcare ICUs. We exported eProtocol-insulin to support research in other US and international institutions, and extended our work to the pediatric ICU. We iteratively refined eProtocol-insulin throughout these transitions, and incorporated new knowledge about managing stress hyperglycemia in the ICU. Based on our experience in the development and clinical use of eProtocols, we outline remaining challenges to eProtocol development, widespread distribution and use, and suggest a process for eProtocol development. Technical and regulatory issues, as well as standardization of protocol development, validation and maintenance, need to be addressed. Resolution of these issues should facilitate general use of eProtocols to improve patient care.

Collaborative practice: usability of text-based, electronic patient care guidelines.

The Intermountain Healthcare system has developed a text-based, electronic reference system for nonphysician staff to provide patient care guidelines intended to reduce variability in bedside care processes and improve patient outcomes. Implementation issues with two interface tools used to deploy the electronic documents at the bedside have caused difficulty with document accessibility. A third interface tool (Viewer) was designed to solve the accessibility problems. This study was designed to compare the time spent searching for information and success of information retrieval from all three interfaces before clinical deployment of the Viewer interface. Study results were used by nursing leadership in a decision to continue supporting the electronic dissemination of text-based practice guidelines for nonphysician staff within our health system's acute care settings.