title: Designing an automated clinical decision support system to match clinical practice guidelines for opioid therapy for chronic pain.
abstract: BACKGROUND
  Opioid prescribing for chronic pain is common and controversial, but recommended clinical practices are followed inconsistently in many clinical settings. Strategies for increasing adherence to clinical practice guideline recommendations are needed to increase effectiveness and reduce negative consequences of opioid prescribing in chronic pain patients.
  
  
  METHODS
  Here we describe the process and outcomes of a project to operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to encourage good opioid prescribing practices during primary care visits. We based the DSS on the existing ATHENA-DSS. We used an iterative process of design, testing, and revision of the DSS by a diverse team including guideline authors, medical informatics experts, clinical content experts, and end-users to convert the written clinical practice guideline into a computable algorithm to generate patient-specific recommendations for care based upon existing information in the electronic medical record (EMR), and a set of clinical tools.
  
  
  RESULTS
  The iterative revision process identified numerous and varied problems with the initially designed system despite diverse expert participation in the design process. The process of operationalizing the guideline identified areas in which the guideline was vague, left decisions to clinical judgment, or required clarification of detail to insure safe clinical implementation. The revisions led to workable solutions to problems, defined the limits of the DSS and its utility in clinical practice, improved integration into clinical workflow, and improved the clarity and accuracy of system recommendations and tools.
  
  
  CONCLUSIONS
  Use of this iterative process led to development of a multifunctional DSS that met the approval of the clinical practice guideline authors, content experts, and clinicians involved in testing. The process and experiences described provide a model for development of other DSSs that translate written guidelines into actionable, real-time clinical recommendations.
authors.affiliation: Center for Health Care Evaluation (CHCE), VA Palo Alto Health Care System and Stanford University Medical School, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA. jodie.trafton@va.gov
authors.forename: Jodie A
authors.initials: JA
authors.lastname: Trafton
authors.forename: Susana B
authors.initials: SB
authors.lastname: Martins
authors.forename: Martha C
authors.initials: MC
authors.lastname: Michel
authors.forename: Dan
authors.initials: D
authors.lastname: Wang
authors.forename: Samson W
authors.initials: SW
authors.lastname: Tu
authors.forename: David J
authors.initials: DJ
authors.lastname: Clark
authors.forename: Jan
authors.initials: J
authors.lastname: Elliott
authors.forename: Brigit
authors.initials: B
authors.lastname: Vucic
authors.forename: Steve
authors.initials: S
authors.lastname: Balt
authors.forename: Michael E
authors.initials: ME
authors.lastname: Clark
authors.forename: Charles D
authors.initials: CD
authors.lastname: Sintek
authors.forename: Jack
authors.initials: J
authors.lastname: Rosenberg
authors.forename: Denise
authors.initials: D
authors.lastname: Daniels
authors.forename: Mary K
authors.initials: MK
authors.lastname: Goldstein
references.citation: Pain Med. 2007 Jan-Feb;8(1):25-35
references.pmid: 17244101
references.citation: Proc AMIA Symp. 2001;:214-8
references.pmid: 11825183
references.citation: Pain Med. 2010 Apr;11(4):575-85
references.pmid: 20202142
references.citation: JAMA. 2007 Jan 17;297(3):249-51
references.pmid: 17227967
references.citation: Proc AMIA Symp. 2000;:863-7
references.pmid: 11080007
references.citation: CMAJ. 1997 Jun 15;156(12):1705-12
references.pmid: 9220922
references.citation: Cochrane Database Syst Rev. 2008 Jul 16;(3):CD004398
references.pmid: 18646106
references.citation: J Am Med Inform Assoc. 1996 Nov-Dec;3(6):429-31
references.pmid: 8930859
references.citation: Proc AMIA Symp. 1999;:420-4
references.pmid: 10566393
references.citation: Pain Physician. 2008 Mar;11(2 Suppl):S63-88
references.pmid: 18443641
references.citation: JAMA. 2008 Jan 2;299(1):70-8
references.pmid: 18167408
references.citation: J Am Med Inform Assoc. 1995 Sep-Oct;2(5):316-22
references.pmid: 7496881
references.citation: J Biomed Inform. 2008 Apr;41(2):387-92
references.pmid: 18029232
references.citation: J Am Med Inform Assoc. 2003 Nov-Dec;10(6):523-30
references.pmid: 12925543
references.citation: Proc AMIA Symp. 2000;:300-4
references.pmid: 11079893
references.citation: AMIA Annu Symp Proc. 2006;:539-43
references.pmid: 17238399
references.citation: J Am Med Inform Assoc. 2003 Mar-Apr;10(2):154-65
references.pmid: 12595405
references.citation: Support Care Cancer. 1997 Nov;5(6):451-6
references.pmid: 9406358
references.citation: J Opioid Manag. 2008 Jul-Aug;4(4):201-11
references.pmid: 18837203
references.citation: JAMA. 2005 Mar 9;293(10):1223-38
references.pmid: 15755945
references.citation: J Am Board Fam Pract. 2001 May-Jun;14(3):211-8
references.pmid: 11355054
references.citation: J Am Med Inform Assoc. 2004 Sep-Oct;11(5):368-76
references.pmid: 15187064
references.citation: Addict Sci Clin Pract. 2008 Jun;4(2):4-25
references.pmid: 18497713
references.citation: BMJ. 2005 Apr 2;330(7494):765
references.pmid: 15767266
references.citation: JAMA. 1998 Oct 21;280(15):1339-46
references.pmid: 9794315
references.citation: J Am Med Inform Assoc. 2004 Sep-Oct;11(5):418-26
references.pmid: 15187061
references.citation: Pain Physician. 2007 May;10(3):479-91
references.pmid: 17525783