Pragmatics of implementing guidelines on the front lines

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Abstract
We commend Shiffman and colleagues (“Bridging the Guideline Implementation Gap: A Systematic, Document-Centered Approach to Guideline Implementation”1) for highlighting the challenges of integrating guidelines into clinical practice and proposing pragmatic mechanisms for addressing them. We note, however, that the approach advocated by Shiffman et al., as well as by numerous other groups recently,2–8 is fundamentally a document-centric model. This approach may lead others to assume that representing a guideline correctly as a “computer-readable” document is the majority of the work required for implementation success. Although the “understanding” and representation of the clinical content of a guideline are a sine qua non for its local implementation, the document-centric approach leaves a substantial gap between the idealized document model and any specific guideline implementation in a local clinical system. This considerable gap is not unlike the “curly braces” problem documented for the Arden Syntax a decade ago.3–5 We estimate that 90% of the effort required for successful guideline implementation is (and must be) local, and the remaining 10% of the effort involves “getting the document right.”

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