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Welcome to the March edition of Health Care and Informatics Review Online. This edition focuses on an exciting area in the application of health informatics, that of clinical guideline based electronic decision support.
The potential for guidelines to form part of the solution to widespread, unwarranted variations in clinical practice, poor implementation of recommended interventions, inappropriate health care and escalating costs of health care has been the impetus behind an explosion of guideline publications. However, the effective dissemination and use of guidelines in clinical care remain major challenges.
Successful delivery of the knowledge that is incorporated into guidelines requires a systematic approach which integrates knowledge with workflow using existing clinical information systems. Electronic decision support systems are one means through which the knowledge embedded in guidelines can be managed and delivered effectively.
In fact, the patient-tailored advice that can be available at the time and place of a consultation from integrated guideline-based decision support applications is regarded to be the most effective method of influencing clinicians’ behaviour toward guideline adherence.[ 1 ]
In this edition, we have the pleasure of presenting four excellent papers exploring the development and implementation of clinical guideline based electronic decision support systems.
The term "system" in the above sentence warrants some attention. To be successful, clinical guideline based electronic decision support must be considered from a systems, rather than simply a software application, perspective.
The need for a systems perspective is highlighted in the review "Turning Guidelines into Practice: Making It Happen With Standards" by Professor Richard Shiffman, Associate Director, Center for Medical Informatics, Yale University School of Medicine, New Haven, Connecticut, US, and Dr Martin Entwistle Chair, HL7 New Zealand and CEO, Enigma Publishing Ltd, Auckland, New Zealand.
The paper reports on the "Clinical Guideline and Decision Support Workshop" held at the 2nd Guidelines International Network Conference "Evidence in Action" held in Wellington, New Zealand, 1–3 November 2004. The workshop explored a number of issues related to the use of decision support for "turning guidelines into practice", with a particular focus on the use of standards.
The paper is in two sections. "Part I: Issues and Barriers to the Success of Guideline-based Decision Support" begins by looking at barriers to the success of guideline-based decision support. These are considered under two heads: guideline-related obstacles and electronic decision support issues.
In "Part 2: Solutions for Guideline-based Decision Support", steps toward solutions to the obstacles facing effective development of guideline-based electronic clinical decision support (ECDS) systems are considered in two areas: improvement to the guidelines and improvements to the process of translating guidelines into ECDS. This section also includes a summary of the New Zealand experience in developing guideline-based decision support, setting out what has been learned from that experience.
The paper highlights that, among other demands, a systems perspective requires that electronic decision support is supported by standards-based applications which are interoperable with related clinical information systems.
A key finding from the New Zealand experience relates to the requirement for and role of standards in electronic decision support development and implementation.
The importance of standards is also highlighted in "Guideline Representation Formalism and Electronic Decision Support Systems: Addressing the Guideline - Implementation Gap" presented by Dr Stephen Chu, Associate Professor of Health Informatics, Department of Information Systems and Operations Management, The University of Auckland, Auckland, New Zealand.
Chu presents a comprehensive review of electronic guideline representation formalisms, considering document-centric and (execution) model-centric approaches, Chu proposes a solution in a tri-model guideline representation architecture and scenario-based authoring methodology that aims at accommodating document-centric and improved (execution) model-centric formalisms.
Chu notes that a number of international projects have been established to develop computerised guideline implementation and decision support systems but that each has adopted a different approach in guideline representation architecture and implementation. He highlights the significant variability in guideline representation models and inexact mapping from experts’ internal knowledge to the external representations as narratives and then to machine-executable formats, and the negative impact this has had on the usability of clinical guidelines both at human and machine implementation levels.
The paper highlights the almost complete absence of standards, which has created major difficulties for guideline implementers and decision-support systems designers. Importantly, Chu notes that the international health informatics community has recognised the benefit of standards and has expressed interest in developing a standardised approach to guideline representation and implementation at a number of recent Health Level Seven (HL7) technical workgroup meetings.
The New Zealand experience in developing guideline-based decision support, introduced in the Shiffman and Entwistle paper, and the findings from that experience are further detailed in the paper from Dr Susan Wells, Senior Lecturer in Clinical Epidemiology and Dr Rod Jackson, Professor of Epidemiology, Section of Epidemiology & Biostatistics, School of Population Health, The University of Auckland, Auckland, New Zealand.
In "Online Management of Cardiovascular Risk in New Zealand with PREDICTTM – Getting Evidence To the Moment of Care", Jackson and Wells very clearly set out the pathway that has been taken in the development of a web-based clinical decision support programme to address infrequent use of both paper-based and stand-alone software tools to assess cardiovascular risk, despite their widespread dissemination in New Zealand.
Jackson and Wells describe the web-based PREDICTTM -CVD program that was developed in response to this issue. The program, which is integrated into a practitioner’s electronic medical record (EMR) system, includes a risk assessment component and a risk management component which returns a series of patient-specific management recommendations, based on the patient’s current risk and current management against nationally agreed guidelines on managing CVD risk.
Evaluations indicate that PREDICTTM –CVD is usable in busy clinical settings and can have a significant impact on practice. Preliminary analyses have indicated that general practitioners using PREDICTTM –CVD increased risk assessment and risk factor documentation by more than four-fold.
This programme started in one focused area, it is potentially a forerunner of a major shift towards IT-based evidence-based medicine and the way chronic disease will be managed.
Importantly, the system generates clinical information in a standardised form that can be used for risk profiling populations, developing new risk prediction tools and for clinical audit.
Our guest editorial this month comes from Dr John Gillies, Senior Lecturer in Informatics, University of Otago, Dunedin, New Zealand. Gillies highlights the wide range of electronic clinical tools now available including alerts and reminders and diagnostic tools and evidence-based health information available at the point of care. He notes, however, that while these tools might open a "Pandora’s box of exciting treasures", the level of adoption by clinicians remains disappointingly low.
Gillies proposes options to accelerate the process of adoption of electronic clinical tools, including the requirement for the tools be reliable, readily and quickly available, based on current information, and applicable for both the patient involved and the local environment.
- Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet. 1993 Nov 27; 342(8883): 1317-22.
