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Table 2 Use of explanatory principles in constructing an electronic decision-support system to improve postoperative care (adapted from references [5, 6, 13, 41])

From: Understanding contexts: how explanatory theories can help

Explanatory principle

Use of the principle

Transfer/sharing of meaning

External knowledge from published literature on clinical guidelines, existing protocols from academic affiliates in the VA system, and discussions with subject matter experts was brought together with internal knowledge about the baseline strengths and limitations of a specific local VA hospital’s environment and its processes of care


Observed performance (i.e., proportion of prophylaxis-eligible patients whose orders for postoperative care were selected from the new electronic menu) improved demonstrably as staff familiarity with the system increased over time


Empirical evidence that anti-thrombosis regimens effectively reduce risk of postoperative thromboembolism (the regularity) was coupled with the increased thromboembolic risk that existed locally in eligible individual postoperative patients (the antecedent condition)

Separating out environmental components

The contributions of individuals, tasks, and technologies to an effective DVT prophylaxis strategy were re-examined iteratively during implementation of the emerging electronic decision support system

Unifying components of the environment

The following major components were unified into a coherent model of the local environment that improvers used in implementing the new postoperative DVT prophylaxis strategy: Individuals: surgical residents, who wrote most of the post-operative orders; Task: choosing and ordering clinical interventions appropriate for each patient’s degree of thromboembolic risk; Technology: electronic order menus embedded in a pre-existing electronic medical record

Adaptation to intended uses

Order menus were modified in response to the results of extensive repeated multilevel user testing; project staff (i.e., surgical residents, pharmacists, and nurses) also received education on the purpose and design of the new order system