Developing and implementing computerized protocols for standardization of clinical decisions

Humans have only a limited ability to incorporate information in decision m aking. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performanc e and high error rate of clinical decision makers. Variation in clinical pr actice is due in part to clinicians' poor compliance with guidelines and re commended therapies. The use of decision-support tools is a response to bot h the information revolution and poor compliance. Computerized protocols us ed to deliver decision support can be configured to contain much more detai l than textual guidelines or paper-based flow diagrams. Such protocols can generate patient-specific instructions for therapy that can be carried out with little interclinician variability; however, clinicians must be willing to modify personal styles of clinical management. Protocols need not be pe rfect. Several defensible and reasonable approaches are available for clini cal problems. However, one of these reasonable approaches must be chosen an d incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the proto cols themselves. Computerized protocols for mechanical ventilation and mana gement of intravenous fluid and hemodynamic factors in patients with the ac ute respiratory distress syndrome provide case studies for this discussion.