Morris A H
Pulmonary Division, LDS Hospital and University of Utah School of Medicine, Salt Lake City 84143, USA.
Ann Intern Med. 2000 Mar 7;132(5):373-83. doi: 10.7326/0003-4819-132-5-200003070-00007.
Humans have only a limited ability to incorporate information in decision making. In certain situations, the mismatch between this limitation and the availability of extensive information contributes to the varying performance and high error rate of clinical decision makers. Variation in clinical practice is due in part to clinicians' poor compliance with guidelines and recommended therapies. The use of decision-support tools is a response to both the information revolution and poor compliance. Computerized protocols used to deliver decision support can be configured to contain much more detail than textual guidelines or paper-based flow diagrams. Such protocols can generate patient-specific instructions for therapy that can be carried out with little interclinician variability; however, clinicians must be willing to modify personal styles of clinical management. Protocols need not be perfect. Several defensible and reasonable approaches are available for clinical problems. However, one of these reasonable approaches must be chosen and incorporated into the protocol to promote consistent clinical decisions. This reasoning is the basis of an explicit method of decision support that allows the rigorous evaluation of interventions, including use of the protocols themselves. Computerized protocols for mechanical ventilation and management of intravenous fluid and hemodynamic factors in patients with the acute respiratory distress syndrome provide case studies for this discussion.
人类在决策过程中整合信息的能力有限。在某些情况下，这种局限性与大量信息的可获取性之间的不匹配，导致了临床决策者的表现各异且错误率较高。临床实践中的差异部分归因于临床医生对指南和推荐疗法的依从性较差。使用决策支持工具是对信息革命和依从性差的一种应对措施。用于提供决策支持的计算机化协议可以配置得比文本指南或纸质流程图包含更多细节。此类协议可以生成针对特定患者的治疗指导，临床医生之间的差异很小就能执行；然而，临床医生必须愿意改变个人的临床管理方式。协议不必完美。对于临床问题有几种合理且可辩护的方法。然而，必须选择其中一种合理方法并纳入协议，以促进一致的临床决策。这种推理是一种明确的决策支持方法的基础，该方法允许对干预措施进行严格评估，包括对协议本身的使用。急性呼吸窘迫综合征患者机械通气以及静脉输液和血流动力学因素管理的计算机化协议为本次讨论提供了案例研究。
