What do you think of when you hear the words “clinical guidelines”? For many physicians, these words elicit mixed emotions. On the one hand, they remind us of “cookbook” medicine, an insult to our skill at devising exquisitely individualized care plans for each of our unique patients. In addition, they can be cumbersome, oversimplified, cost-driven and even biased. On the other hand, when clinical guidelines are well-developed and evidence-based, they can be useful clinical tools that teach us that our own care plans are often not as thorough or as scientifically grounded as they should be.

The project

Recently, our practice undertook a quality improvement project to assess how well we were caring for our patients with chronic conditions, particularly asthma. To judge our performance, we compared our care patterns for patients who have asthma with the National Institutes of Health's (NIH) “General Practice Guidelines for the Diagnosis and Management of Asthma.” The NIH guidelines were developed in 1997 and are generally regarded as having raised the bar for quality in the care of asthma patients. (To get a copy of the guidelines, go to www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.)

By examining our patient charts and enlisting every chart auditor's favorite dictum, “If it isn't documented, it wasn't done,” we discovered that, while we were treating a lot of exacerbations in our patients with asthma, we were not going beyond the acute problems and dealing with prevention, maintenance and patient education. In fact, we were deficient in all four components of care outlined by the NIH: 1) periodic assessment and monitoring, 2) control of factors contributing to asthma severity, 3) pharmacological therapy and 4) education for a partnership in asthma care. Because providers don't always document everything they say and do with their patients, we decided to give our physicians and midlevels a written examination that tested whether they knew to do what the guidelines recommended. Again, we found deficiencies.

When our feedback to the providers failed to improve compliance with the asthma guidelines, we developed a new strategy: provider education. Our “asthma team” presented four brief, focused educational sessions to the practice as a whole during our monthly staff meetings. The team presenters, led by the medical director, selected a few key NIH recommendations and challenged the physicians and staff to adopt them into regular practice. For example, session one stressed the importance of peak-flow monitoring. The team encouraged providers to instruct appropriate patients on the use of peak flow and to document this discussion (as well as the patient's subsequent reports about home self-monitoring). In addition, the nursing staff was asked to begin measuring peak flow as a vital sign on all asthma patient visits, regardless of the chief complaint. This step was designed to reinforce for patients the centrality of peak flow measurement and to remind the physician to address this issue during the visit.

After completing the first two educational sessions, we reviewed 215 charts to detect any positive changes in asthma-related practice behaviors. There were none. Concerned, our asthma team set about brainstorming other ways to achieve our goal of increased asthma-guideline adherence and decided to introduce a new intervention: a reminder note system.

This very simple reminder system consisted of memo slips inserted into the front of the medical charts of all patients with asthma, briefly outlining the four areas of treatment (peak flow measurement, discussion of asthma triggers, pharmacology review and development of an action plan) that should be addressed during all asthma visits, per the NIH guidelines.

The purpose of the reminder notes was simply to prompt providers to address the four key areas of treatment. When we conducted another chart review three months after implementing the reminder notes, we found that all four of the asthma-related treatment behaviors targeted in our intervention had improved. Anecdotal feedback from the physicians also supported our finding that the reminder notes were useful and efficient in helping them remember these key topics during visits with asthma patients.

Take-away lessons

What we learned from our project is that simple reminder tools are an effective way to assist providers in adopting clinical guidelines into daily practice. In fact, there are many benefits to such a system. The amount of time it took our staff to insert the reminder notes into the medical charts was minimal, especially compared to the time involved in preparing and delivering the less successful CME-like sessions. In addition, the reminder system is time efficient for the providers. It does not demand that they take significant time out of their limited schedules, as is often the case with educational sessions. In this regard, our project indirectly corroborates what larger research projects have found, that traditional CME strategies alone are ineffective in bringing about provider compliance with clinical guidelines.¹ Further, our results support recent literature that has found reminder systems to be quite effective in changing provider behaviors.^2,3,4

Admittedly, the use of provider documentation as evidence of provider behavior is methodologically weak. Did providers actually change their behavior, or did they simply do a better job of documenting what they were already doing? We have only anecdotal evidence to support that there was indeed a change in behavior, but we are confident in that conclusion. However, if improved documentation were the only result, the project still would have been worthwhile.

In the future, our family practice will take chart reminders to the next level by developing asthma care flow sheets (similar to those used for longitudinal care of hypertension or diabetes). The flow sheets will provide more detailed reminders of care and will serve as a shorthand documentation system for providers. Of course, our ultimate pursuit is not simply documented compliance with clinical guidelines. Our real goal is to improve patient care, not only for patients with asthma, but for all.