Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation

Richard N Shiffman,George Michel,Abdelwaheb Essaihi,Elizabeth Thornquist

doi:10.1197/jamia.m1444

Abstract

ObjectiveA gap exists between the information contained in published clinical practice guidelines and the knowledge and information that are necessary to implement them. This work describes a process to systematize and make explicit the translation of document-based knowledge into workflow-integrated clinical decision support systems. DesignThis approach uses the Guideline Elements Model (GEM) to represent the guideline knowledge. Implementation requires a number of steps to translate the knowledge contained in guideline text into a computable format and to integrate the information into clinical workflow. The steps include: (1) selection of a guideline and specific recommendations for implementation, (2) markup of the guideline text, (3) atomization, (4) deabstraction and (5) disambiguation of recommendation concepts, (6) verification of rule set completeness, (7) addition of explanations, (8) building executable statements, (9) specification of origins of decision variables and insertions of recommended actions, (10) definition of action types and selection of associated beneficial services, (11) choice of interface components, and (12) creation of requirement specification. ResultsThe authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute's guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system. ConclusionUsing the guideline document as a knowledge source promotes authentic translation of domain knowledge and reduces the overall complexity of the implementation task. From this framework, we believe that a better understanding of activities involved in guideline implementation will emerge.

Highlights

Tierney et al[9] described their frustration in creating a computer-based implementation for an evidence-based guideline to assist with management of heart failure
The authors illustrate these component processes using examples drawn from recent experience translating recommendations from the National Heart, Lung, and Blood Institute’s guideline on management of chronic asthma into a workflow-integrated decision support system that operates within the Logician electronic health record system
Clinical practice guidelines provide a rich source of up-todate knowledge about best clinical practices

Summary

Introduction

Tierney et al[9] described their frustration in creating a computer-based implementation for an evidence-based guideline to assist with management of heart failure. Peleg et al.[10] observed specialty society experts as they created flowcharts based on narrative guidelines and found excessive ambiguity and problems in sequencing. In addition to these problems, guidelines are often incomplete, i.e., they regularly fail to describe appropriate behavior for an exhaustive set of situations that may befall practitioners.[11] conditional recommendations are regularly undecidable, i.e., they fail to specify in a clear, consistent manner the parameters on which decisions are based. The level of abstraction at which decision variables and actions are described is inappropriate for implementation. Grol et al.[12] found that clinicians were considerably less likely to adhere to vague and nonspecific recommendations

Methods

Discussion

Conclusion