Guest Editorial: Guidelines and Clinical Pathways in the Health Professions.

In the early 20th century, it was the work of science fiction writers to imagine the world being taken over by aliens and what effect this might have upon the human race. With the advent of computers, even before the personal computer phase, these writers shifted their attention to the possibility that a man-made computer could develop a separate "life" which ultimately could dominate mankind with possible extinction of humans, or at least their subjugation.

In the early 1980s, groups of health informatics experts in USA explored the potential of computers in taking over the role of the clinician in diagnosis, assessment and treatment of illness. They made significant progress with the development of artificial intelligence, and identified that, whilst it was unlikely that the clinician would be replaced by computer technology, there were many areas where artificial intelligence could significantly enhance clinical practice, both by automating some routine but important activities, and by providing the clinician with ready access to relevant information. It is in these two areas that most of the current developments belong.

A wide range of clinical tools is now available for the clinician, including the following:

• Alerts and reminders, both for efficient time-management and also for recalls of patients for various procedures such as immunisations, etc. Alerts for prescribing are available aimed at reducing the risk of the patient being prescribed incompatible medications.
• Diagnostic tools to assist the clinician at the point of care both in developing an appropriate differential diagnosis, and also in refining the answer by recommending differentiating tests. 
• Evidence-based health information in focussed form that is readily available to the clinician at the point of patient contact. 
• "Expert" opinions are available especially involving the transmission of data from organ imaging scanning technologies.

To many of us, these tools open a Pandora’s box of exciting treasures, and yet the level of adoption by clinicians remains disappointingly low. In this edition, we explore some of the reasons why this is happening, when the evidence of the potential seems to be overwhelming.

In the article by Entwistle and Shiffman they suggest that "In an ideal world, guidelines embody a clear statement of the most appropriate practice based on excellent scientific evidence. Implementation is straightforward and intended users gratefully integrate guideline recommendations into their daily practice". As they discuss, there are potential issues in almost every part of this process. It is (unfortunately) not an ideal world, and whilst guidelines do sometimes embody a clear statement, many experienced clinicians will contest, for very sound, scientifically-based reasons, that it may not be the most appropriate practice. This arises because of the common problem of the lack of "excellent scientific evidence".

Implementation is similarly difficult for a wide variety of reasons from "technophobia", "inconvenience" or "negativity". It is in the implementation that the innovator should focus. There is no doubt that many products currently in existence will be very gratefully accepted by the clinician – without the issues of credibility, or difference in personal practice. These include the reminder and drug interaction systems. The PREDICT^TM system reported in this edition is getting closer to addressing the potential issues we are alluding to. PREDICT^TM is based upon sound, transparent and scientific principles and, therefore, one would expect that it would be accepted and acknowledged as a valuable tool, by clinicians working in the relevant fields.

The material must be available at the point of care, and whilst this is presently possible, it must be available almost intuitively for the clinician to use it routinely. Entwistle and Shiffman consider ways of doing this – including having the patient’s electronic health record available for "intelligent interrogation" by the expert system thereby personalising the information that is produced. This could be especially effective with prescribing issues such as interactions, renal or liver impairment, secondary diagnoses (pregnancy, hypertension, etc) or previous experience (reactions or allergies).

It is true that some clinical tasks lend themselves very well to the clinical pathway concept. Many nursing procedures are excellent examples and the pathway would not only serve as an excellent practice tool but also be a powerful educational one for nurses in training.

Despite the undoubted enthusiasm and expertise of those working in this field, the progress in adoption has been demoralisingly slow. Why do they persist? They believe that by using these tools the health consumer will be part of a much safer clinical environment. Improvement in patient safety by the reduction of clinical error is the overriding goal. Where decision support systems have been used there is strong evidence to support this belief.

What must be done to accelerate the adoption process? The tools must be readily and quickly available where and when they are needed, and be there with minimal, if any, need for computer technical skills or knowledge. The tools must be reliable and especially applicable not only for the patient involved, but also for the local environment. The information must be current at all times – content maintenance will undoubtedly become a major industry of the future. The information must be focussed and designed for the user – whether that person is a health professional or consumer.

The path to acceptance almost certainly does not involve legislation, but rather one of gentle introduction of high-quality effective and useful examples with more becoming available at a time when earlier ones are adopted as part of clinical life. Success can be celebrated when the health professional or other consumer begins to ask for the development of guidelines and clinical pathways that hitherto were not available.