Table 1 Translating knowledge for use at the point of encounter: stakeholders and challenges to integration

Creation of evidence

Researchers in academic medical centers funded by NIH, AHRQ etc.; industry funded RCTs; Foundation funded initiatives

RCT evidence is often limited in how it can be generalized for use in routine clinical practice; everyday clinical questions, especially for multi-morbid patients are not specifically addressed. The lack of comparative effectiveness data limits utility of existing evidence

Synthesizing and ummarizing evidence

Medical societies, health systems, clinical content vendors

Synthesis and summary are foci for this process, not application and actionability; many clinical actions do not have sufficient RCT evidence for action

Translate evidence for use by EHRs

Health systems, health information technology and clinical content companies, software companies

No established standards to operationalize alerts, order sets, documentation templates, or hyperlinks to content to facilitate the use and delivery of CPGs; lack of knowledge of effectiveness of computer-based intervention options and of meaningful use of HIT

Site-specific adaptation & implementation

IT staff, providers at clinics with EHRs

Adapt to local workflow, policies, best practices; map content to local nomenclature or orderable catalogs

Use at the point of encounter

Providers

Changing physician behavior; accurate identification of exceptions; overwhelming number of non-specific recommendations

Evaluation of the effect of the evidence as implemented on patient outcomes

Quality assurance, risk management, or organizational administrative departments

No standard way to identify patients for either the numerator or denominator of the measures; many key data items not available in coded portion of the EHR; current quality measures not linked to CDS interventions.