Following initial dissemination steps,⁹ guideline developers may proceed with an array of activities such as cooperating with other interested parties in disseminating information to patients or consumers. This is where the second response noted above comes into play. The lay press, patient groups, computerized information systems, and directories may begin to make guidelines more widely available or known to practitioners, patients, and others. As noted earlier, the AMA publishes quarterly update listings of guidelines developed by both the AMA and specialty societies. In addition, publications are emerging that reprint or summarize selected guidelines or otherwise report on the field; the Report on Medical Guidelines & Outcomes Research, published by Health & Sciences Communications and now nearing the end of its second year, is an example. The NLM, as described elsewhere in this report, will store, index, and otherwise make available information on practice guidelines, specifically including those from AHCPR panels.

Those involved in the development and use of guidelines are paying increasing attention to a series of strategic "who, what, why, when, and how" questions. Specifically: Who do you want to reach and why? What do they need? How quickly do you want to reach them? What relevant techniques are available, and how do they vary in effectiveness and cost? Answers to these questions will influence some dissemination decisions such as whether to use professional or mass media, direct mailings, or journal publication. The length and complexity of the guideline will also influence the choice of dissemination technique. As noted in Chapter 4, options for dissemination now include a variety of computer-based tools including on-line literature search systems, floppy disks, and CD-ROM disks.

Other decisions will be contingent on a variety of environmental factors. What are the opportunities for dissemination and application within the intended audience? What are the barriers? How can different dissemination strategies be combined and coordinated with other implementation strategies to increase the probability of effective application of guidelines? Answers to these questions will yield ideas about who else will be or should be involved in dissemination, whether it should be a one-time effort or a continuous process, and what resources are needed. Many of the issues raised in the discussion of education in Chapter 4 will apply here as well.

Several specific factors related to dissemination might be considered legitimate and realistic concerns of guidelines developers, even if develop-