Computer-Mediated Guideline Implementation Projects
Overview
AsthMonitor
Information Management Services Model
PalmAsthma
Object-Oriented Framework
Publications
Shiffman RN. Towards effective implementation of a pediatric asthma guideline: integration of decision support and clinical workflow support. In: Ozbolt JG, ed., Proceedings of the Eighteenth Symposium on Computer Applications in Medical Care. Washington, DC: 1994; 797&endash;801.
Successful local implementation of national guideline recommendations requires attention to factors that promote clinician compliance. Design of a computerized system is described that will implement recommendations from a recently published guideline for outpatient management of childhood asthma exacerbations. Logical analysis of the guideline shows that it is incomplete and contains several ambiguities that must be addressed before the guideline can be operationalized. Once the user-audience is defined guideline decision points are examined and a structured data entry system is devised. Support of clinicians' workflow is provided by an integrated capability for encounter documentation, dosage calculation, and prescription-writing. A pen-based, graphical interface represents an appropriate platform for implementation of the system because of its ease of use and portability.
Shiffman RN. Representation of clinical practice guidelines in conventional and augmented decision tables. J Am Med Informatics Assoc 1997; 4:382-93.
Objective: To develop a knowledge representation model for clinical practice guidelines that is linguistically adequate, comprehensible, reusable, and maintainable.
Design: Decision tables provide the basic framework for the proposed knowledge representation model. Guideline logic is represented as rules in conventional decision tables. These tables are augmented by layers where collateral information is recorded in slots beneath the logic.
Results: Decision tables organize rules into cohesive rule sets wherein complex logic is clarified. Decision table rule sets may be verified to assure completeness and consistency. Optimization and display of rule sets as sequential decision trees may enhance the comprehensibility of the logic. The modularity of the rule formats may facilitate maintenance. The augmentation layers provide links to descriptive language, information sources, decision variable characteristics, costs and expected values of policies, and evidence sources and quality.
Conclusion: Augmented decision tables can serve as a unifying knowledge representation for developers and implementers of clinical practice guidelines.
Brandt CA, Frawley SJ, Powsner SM, Shiffman RN, Miller PL. Visualizing the logic of a clinical guideline: a case study in childhood immunization. Meth Inform Med 1997; 36:179&endash;83.
Liu JCS, Shiffman RN. Operationalization of clinical practice guidelines using fuzzy logic. In: Masys DR, ed. Proceedings of the Annual Meeting of the American Medical Informatics Association; Nashville (TN); 1997; 283-7.
There are a number of obstacles to successful operationalization of clinical practice guidelines, including the difficulty in accurately representing a statement's decidability or an action's executability. Both require reasoning with incomplete and imprecise information, and we present one means of processing such information. We begin with a brief overview of fuzzy set theory, in which elements can have partial memberships in multiple sets. With fuzzy inferencing, these sets can be combined to create multiple conclusions, each with varying degrees of truth. We demonstrate a fuzzy model developed from a published clinical practice guideline on the management of first simple febrile seizures. Although the creation of fuzzy sets can be an arbitrary process, we believe that fuzzy inferencing is an effective tool for the expression of guideline recommendations, and that it can be useful for the management of imprecision and uncertainty.
Shiffman RN, Brandt CA, Liaw Y, Corb GJ. A design model for computer-based guideline implementation based on information management services. J Am Med Informatics Assoc 1999; 6:99-103.
Clinical practice guidelines must be implemented effectively if they are to influence the behavior of clinicians. We describe a model for computer-based guideline implementation that identifies eight information management services needed to integrate guideline-based decision support with clinical workflow. Recommendation services determine appropriate activities in specific clinical circumstances. Documentation services involve data capture. Registration services integrate demographic and administrative data. Explanation services enhance the credibility of automated recommendations by providing supportive evidence and rating the quality of evidence. Calculation services measure time intervals, suggest medication dosages, and perform other computational tasks. Communication services employ standards for information transfer and provide data security. Effective presentation services facilitate understanding of complex data, clarify trends, and format written materials (including prescriptions) for patients. Aggregation services associate outcomes with specific guideline interventions. We provide examples of the eight services that make up the model from five evidence-based practice parameters developed by the American Academy of Pediatrics.
Shiffman RN, Liaw Y, Brandt CA, Corb GJ. Computer-based guideline implementation systems: a systematic review of functionality and effectiveness. J Am Med Informatics Assoc 1999;6:104-14.
In this systematic review, we analyze the functionality provided by recent computer-based guideline implementation systems and characterize the effectiveness of the systems. Twenty-five studies published between 1992 and January 1998 were identified.
Articles were included if the authors indicated an intent to implement guideline recommendations for clinicians and if the effectiveness of the system was evaluated.
Provision of 8 information management services and effects on guideline adherence, documentation, user-satisfaction, and patient outcome were noted.
All systems provided patient-specific recommendations. In 19, recommendations were available concurrently with care. Explanation services were described for 9 systems. Nine systems allowed interactive documentation and 17 produced paper-based output. Communication services were present most often in systems integrated with electronic medical records. Registration, calculation, and aggregation services were infrequently reported. There were 10 controlled trials (9 randomized) and 10 time-series correlational studies. Guideline adherence improved in 14/18 systems where it was measured Documentation improved in 4/4.
Corb GJ. Liaw Y, Brandt CA, Shiffman RN. An object-oriented framework for the development of computer-based guideline implementations. 1998 (in press).
Shiffman RN, Freudigman KA, Brandt CA, Liaw Y, Navedo DD. A guideline implementation system using handheld computers for office management of asthma: effects on adherence and patient outcomes Presented at the Annual Meeting of the Pediatric Academic Societies, San Francisco, CA. May 1-4, 1999.
Background: Practice guidelines have been proposed as a means to diminish inappropriate variations in clinical management and to control increasing health care costs. Guideline-based, computer-mediated decision support systems have been demonstrated to improve clinical care and patient outcomes in some diseases.
Objective: To evaluate the effects on the process and outcomes of care of a handheld, computer-based system (Newton MessagePad running custom software) that implements the American Academy of Pediatrics (AAP) guideline on office management of asthma exacerbations.
Design: A before-and-after trial was conducted with office-based Connecticut pediatricians randomly selected from the AAP Fellowship Directory. The intervention system provided for structured encounter documentation by the physician, offered recommendations based on the AAP guideline, calculated dosages and predicted peak expiratory flow rates (PEFR), and generated an encounter summary and prescriptions. In the control phase, physicians collected data on their management of 10 patients who presented to the office with asthma exacerbations. Next, the physicians were trained to use the intervention and asked to enroll 10 additional patients whose management was assisted by the intervention. Patients were contacted by telephone 7-14 days after the visit to assess outcomes.
Results: Nine study-physicians enrolled 91 patients in the control phase and 74 in the intervention phase. Follow-up information was available for 92.7% of encounters (n=153). Use of the intervention was associated with increased mean frequency/visit of (1) measurements of PEFR (2.18 vs 1.57, p2.0001) and oxygen saturation (1.12 vs .42, p2.0001) and (2) administration of nebulized ß-2 agonists (1.25 vs 0.71, p2.0001). Prescription of steroids was related to the severity of the exacerbation, but not the intervention. Pediatricians adhered to a recommendation to administer oxygen in only 3 of 50 visits. Visits in the intervention phase lasted longer (X2=15.62, p2.0004) and fees were higher ($145.61 vs $103.11, p2.00001). There were no significant differences either in immediate disposition (home or ED/hospitalization) or in subsequent ED visits, hospitalization, missed school, and caretaker's missed work during the 7 days post-visit.
Conclusion: Use of a handheld computer that provides guideline-based decision support was associated with increased adherence to recommendations to assess PEFR/oxygen saturation and to give ß-2 agonists. A recommendation to administer oxygen&emdash;which was unsupported by evidence&emdash;was disregarded. Guideline adherence was associated with prolongation of visits and higher fees. This study was unable to demonstrate any benefit with regard to the observed patient outcomes immediately or at 1 week.
Shiffman RN, Liaw Y, Navedo DD, Freudigman KA. User satisfaction and frustration with a handheld, pen-based guideline implementation system for asthma. (in press)
Chen RS, Shiffman RN, Miller PL, Baker CB. Issues in implementing a guideline for depression modeled using an object-oriented state machine. (in press)
Karras B, Nath S, Engles-Horton L, Shiffman R. PalmAsthma: design of a system for the implementation of asthma guidelines on handheld computers (in press).