While evidence-based medicine has increasingly broad-based support in health care, it remains difficult to get physicians to actually practice it. Across most domains in medicine, practice has lagged behind knowledge by at least several years. The authors believe that the key tools for closing this gap will be information systems that provide decision support to users at the time they make decisions, which should result in improved quality of care. Furthermore, providers make many errors, and clinical decision support can be useful for finding and preventing such errors. Over the last eight years the authors have implemented and studied the impact of decision support across a broad array of domains and have found a number of common elements important to success. The goal of this report is to discuss these lessons learned in the interest of informing the efforts of others working to make the practice of evidence-based medicine a reality.

Background: Web-based personal health records (PHRs) have been advocated as a means to improve type 2 diabetes mellitus (DM) care. However, few Web-based systems are linked directly to the electronic medical record (EMR) used by physicians. Methods:We randomized 11 primary care practices. Intervention practices received access to a DM-specific PHR that imported clinical and medications data, provided patient-tailored decision support, and enabled the patient to author a "Diabetes Care Plan" for electronic submission to their physician prior to upcoming appointments. Active control practices received a PHR to update and submit family history and health maintenance information. All patients attending these practices were encouraged to sign up for online access. Results:We enrolled 244 patients with DM (37% of the eligible population with registered online access, 4% of the overall population of patients with DM). Study par-ticipants were younger (mean age, 56.1 years vs 60.3 years; PϽ.001) and lived in higher-income neighborhoods (median income, $53 784 vs $49 713; PϽ.001) but had similar baseline glycemic control compared with nonparticipants. More patients in the intervention arm had their DM treatment regimens adjusted (53% vs 15%; PϽ.001) compared with active controls. However, there were no significant differences in risk factor control between study arms after 1 year (P=.53).Conclusions: Previsit use of online PHR linked to the EMR increased rates of DM-related medication adjustment. Low rates of online patient account registration and good baseline control among participants limited the intervention's impact on overall risk factor control.

While almost half of physicians in Massachusetts are using an EHR, fewer than one in four practices in Massachusetts have adopted EHRs. Adoption rates are lower in smaller practices, those not affiliated with hospitals, and those that do not teach medical students or residents. Interventions to expand EHR use must address both financial and non-financial barriers, especially among smaller practices.

About half of CDS alerts were overridden by providers and about half of the overrides were classified as appropriate, but the likelihood of overriding an alert varied widely by alert type. Refinement of these alerts has the potential to improve the relevance of alerts and reduce alert fatigue.

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Background and objective Clinical guidelines discourage antibiotic prescribing for many acute respiratory infections (ARIs), especially for nonantibiotic appropriate diagnoses. Electronic health record (EHR)-based clinical decision support has the potential to improve antibiotic prescribing for ARIs. Methods We randomly assigned 27 primary care clinics to receive an EHR-integrated, documentationbased clinical decision support system for the care of patients with ARIs -the ARI Smart Form -or to

OBJECTIVE Electronic health records (EHRs) have potential to improve quality and safety, but many physicians do not use these systems to full capacity. The objective of this study was to determine whether this usage gap is narrowing over time. DESIGN Follow-up mail survey of 1,144 physicians in Massachusetts who completed a 2005 survey. MEASUREMENTS Adoption of EHRs and availability and use of 10 EHR functions. RESULTS The response rate was 79.4%. In 2007, 35% of practices had EHRs, up from 23% in 2005. Among practices with EHRs, there was little change between 2005 and 2007 in the availability of nine of ten EHR features; the notable exception was electronic prescribing, reported as available in 44.7% of practices with EHRs in 2005 and 70.8% in 2007. Use of EHR functions changed inconsequentially, with more than one out of five physicians not using each available function regularly in both 2005 and 2007. Only electronic prescribing increased substantially: in 2005, 19.9% of physicians with this function available used it most or all the time, compared with 42.6% in 2007 (p < 0.001). CONCLUSIONS By 2007, more than one third of practices in Massachusetts reported having EHRs; the availability and use of electronic prescribing within these systems has increased. In contrast, physicians reported little change in the availability and use of other EHR functions. System refinements, certification efforts, and health policies, including standards development, should address the gaps in both EHR adoption and the use of key functions.