BACKGROUND: Opioid prescribing for chronic pain is common and controversial, but 
recommended clinical practices are followed inconsistently in many clinical 
settings. Strategies for increasing adherence to clinical practice guideline 
recommendations are needed to increase effectiveness and reduce negative 
consequences of opioid prescribing in chronic pain patients.
METHODS: Here we describe the process and outcomes of a project to 
operationalize the 2003 VA/DOD Clinical Practice Guideline for Opioid Therapy 
for Chronic Non-Cancer Pain into a computerized decision support system (DSS) to 
encourage good opioid prescribing practices during primary care visits. We based 
the DSS on the existing ATHENA-DSS. We used an iterative process of design, 
testing, and revision of the DSS by a diverse team including guideline authors, 
medical informatics experts, clinical content experts, and end-users to convert 
the written clinical practice guideline into a computable algorithm to generate 
patient-specific recommendations for care based upon existing information in the 
electronic medical record (EMR), and a set of clinical tools.
RESULTS: The iterative revision process identified numerous and varied problems 
with the initially designed system despite diverse expert participation in the 
design process. The process of operationalizing the guideline identified areas 
in which the guideline was vague, left decisions to clinical judgment, or 
required clarification of detail to insure safe clinical implementation. The 
revisions led to workable solutions to problems, defined the limits of the DSS 
and its utility in clinical practice, improved integration into clinical 
workflow, and improved the clarity and accuracy of system recommendations and 
tools.
CONCLUSIONS: Use of this iterative process led to development of a 
multifunctional DSS that met the approval of the clinical practice guideline 
authors, content experts, and clinicians involved in testing. The process and 
experiences described provide a model for development of other DSSs that 
translate written guidelines into actionable, real-time clinical 
recommendations.