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IMPLEMENTATION AND EVALUATION 83 a direct mailing; the cost of a desktop compendium of guidelines versus a computer-based expert system. â¢ The demands made on target users by different alternatives. Example: the learning required for user-friendly versus non-user-friendly computer software. â¢ The manageability of the tasks for administrators or others responsible for implementing a decision. Example: setting up a system of financial incentives compared with setting up an information feedback system. Selecting the particular elements of an implementation plan requires assessment of these and other variables. Inevitably, trade-offs will be required among some factors such as expected effectiveness and cost or manageability. ELEMENTS OF IMPLEMENTATION In this context, implementation has four main aspects: formatting, disseminating, applying, and updating. These categorizations partly reflect OBRA 89 language. As a result, the discussion below uses some rather narrow definitions that should not be applied rigidly. Formatting Formatting refers to the presentation of guidelines in physical arrangements or media that can be readily understood by a designated set of users, for example, practitioners or patients. Different formats may be appropriate for different users and settings, for different means of dissemination, and for different types of guidelines. To the extent that the Forum asks developers of guidelines to assume responsibility for formatting, this task is less an implementation step than an initial design step. However, because formatting is so closely related to dissemination and application and because the responsibility for formatting is likely to be shared between developers and implementers, it is discussed here rather than in Chapter 3. In any case, the Forum will need to prepare some instructions on layout and sequencing of material for its panels and contractors. Formatting here emphasizes physical layout and logic; dissemination, on the other hand, focuses on the roles of different parties and media in getting information to different groups. Thus, for example, the physical properties and logic of documents or computer software are formatting issues, but decisions about how much and when to rely on written documents versus computer software are dissemination issues. Although the committee examined an extensive set of examples of
IMPLEMENTATION AND EVALUATION 84 printed formats of practice guidelines and related materials,2 it was not able to review any empirical evidence on the effectiveness of different formats. Thus, the committee considered it inappropriate to recommend specific formats to the Forum. The materials examinedâviewed in the context of the attributes described in Chapter 3âdid lead to several subjective judgments about simple features that distinguish better formats from inferior formats. These features include (1) one- or two-page summaries of key recommendations and rationales; (2) readily located descriptions of the development process, assumptions, objectives, methods, definitions, and participants; (3) selective use of boldface, subheadings, and other highlighting techniques; (4) attractive typefaces and graphic aids; and (5) uncrowded layouts (for example, pages with ample margins and other "white space"). An index to major elements of the guidelines and a glossary of key terms and symbols might also be considered. In addition, a prominent listing of sources for additional information on the guidelines (or for related guidelines) may be a useful adjunct. More generally, regardless of whether formatting is treated as a design step or an implementation step, the attributes of guidelines related to credibility and accountability should be reinforced by the physical layout. For example, the user should quickly "see" that the guidelines emerged from a multidisciplinary process strongly grounded in scientific evidence and analysis including projections of health and cost outcomes. The attributes of clarity and reliability/reproducibility discussed in the preceding chapter are central. Logical presentation, precise terminology, clear and consistent use of words, phrases, and symbols, and similar properties must be features of acceptable formats so that the guidelines are correctly and consistently understood. Likewise, users should be able to locate easily the descriptions of the populations covered by the guidelines and the identified exceptions. If guidelines describe patient care documentation that practitioners should provide, a prominent summary or checklist of such documentation needs is desirable. How the attributes of good guidelines can best be reinforced by formatting choices will differ depending on whether the medium of dissemination is, for example, a journal article or a computerized decision support system. 2 The majority of the materials reviewed by the committee pertained to clinicians (mainly physicians but also nurses) and included algorithms to guide patient management; statements about the appropriateness (or inappropriateness) of specific preventive, diagnostic, or therapeutic procedures; information about prescription drugs from the Physician's Desk Reference (1990); the AMA Diagnostic and Therapeutic Technology Assessment (DATTA) Evaluation series; the online cancer protocols of Physician Data Query (PDQ); and up-to-date information from Scientific American Medicine (Rubenstein and Federman, 1989). The committee also considered materials aimed at patients, such as the algorithms developed by Vickery and Fries (1986) to guide decisionmaking by patients at home, and other materials focused more exclusively on medical education.