Information technology and the future of child health care: a revolution is occurring.
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Child↗
Biomedical subjects
R N Shiffman
Publications and source records attributed to R N Shiffman.
An approach to guideline implementation with GEM.
Implementation of practice guidelines refers to the creation of strategies and systems to operationalize the knowledge and recommendations set forth by guideline developers. We describe an approach to guideline implementation that makes direct use of the guideline document as a knowledge base. The Guideline Elements Model (GEM) provides an XML-based guideline document model that facilitates implementation of guidelines. Knowledge extraction using GEM requires document markup rather than programming and can promote authenticity and consistent knowledge encoding. Knowledge customization for the local enterprise requires addition of meta-information to pertinent components of the GEM hierarchy in a design database. GEM provides an audit trail to track local adaptation. Knowledge integration with patient data can be promoted using information management services. A design goal is to devise a system that can be applied by local clinical domain experts, quality assurance experts, and information systems programmers without requiring trained informaticians and knowledge engineers to serve as intermediaries
Artificial Intelligence↗
Evaluation of guideline quality using GEM-Q.
A variety of rating instruments that evaluate the quality of practice guidelines have been published. Application of these instruments can be difficult and time-consuming. In a literature review, we identified two evaluation instruments that are comprehensive, have clearly defined constructs, and have undergone validation/testing-the Guidelines Quality Assessment Questionnaire (GQAQ) and the Appraisal Instrument for Clinical Guidelines (AICG). Overall, the AICG is more comprehensive. The AICG addresses the implementability of a guideline, which is not evaluated by the GQAQ. However, the GQAQ is more amenable to computerization. GEM-Q is a Guideline Elements Model (GEM)-derived application intended to facilitate automated evaluation of guideline quality using one of the published instruments. To develop GEM-Q, various items in the GQAQ were mapped to corresponding elements in the GEM hierarchy and a customized XSL stylesheet was designed based on this mapping. GEM-Q selectively extracts text components of the guideline relevant to quality evaluation and displays the results in HTML format. GEM-Q was applied to a set of six guidelines to test its reliability. It ranked two guidelines as of "good" quality, two as "intermediate", and two as "poor". In all six instances, GEM-Q ranked guidelines in the same order of quality as the experts who validated the GQAQ. This work demonstrates the feasibility of developing an application to facilitate automated guideline quality evaluation.
Evaluation Studies as Topic↗
Using GEM-encoded guidelines to generate medical logic modules.
Among the most effective strategies for changing the process and outcomes of clinical care are those that make use of computer-mediated decision support. A variety of representation models that facilitate computer-based implementation of medical knowledge have been published, including the Guideline Elements Model (GEM) and the Arden Syntax for Medical Logic Modules (MLMs). We describe an XML-based application that facilitates automated generation of partially populated MLMs from GEM-encoded guidelines. These MLMs can be further edited and shared among Arden-compliant information systems to provide decision support. Our work required three steps: (a) Knowledge extraction from published guideline documents using GEM, (b) Mapping GEM elements to the MLM slots, and (c) XSL transformation of the GEM-encoded guideline. Processing of a sample guideline generated 15 MLMs, each corresponding to a conditional or imperative element in the GEM structure. Mechanisms for linking various MLMs are necessary to represent the complexity of logic typical of a guideline.
Decision Making, Computer-Assisted↗
An implementation framework for GEM encoded guidelines.
Access to timely decision support information is critical for delivery of high-quality medical care. Transformation of clinical knowledge that is originally expressed in the form of a guideline to a computable format is one of the main obstacles to the integration of knowledge sharing functionality into computerized clinical systems. The Guideline Element Model (GEM) provides a methodology for such a transformation. Although the model has been used to store heterogeneous guideline knowledge, it is important to demonstrate that GEM markup facilitates guideline implementation. This report demonstrates the feasibility of implementation of GEM-encoded guideline recommendations using Apache Group s Cocoon Web Publishing Framework. We further demonstrate how XML-based programming allows for maintaining the separation of guideline content from processing logic and from presentation format. Finally, we analyze whether the guideline authors original intent has been sufficiently captured and conveyed to the end user.
Artificial Intelligence↗
Assessing growth patterns--routine but sometimes overlooked.
We performed a retrospective chart review for 149 randomly selected well-child encounters to evaluate the frequency with which clinicians plot growth measurements and document growth abnormalities during health maintenance visits. Providers failed to plot at least one measurement of height, weight, and/or head circumference in 31 of 149 encounters (21%, 95% CI = 14.5% to 27.5%). Growth abnormalities in size, velocity, and/or disproportion were not documented in 22 of 40 relevant encounters (55%, 95% CI = 40% to 70%). Overall, 52 of 149 encounters (35%) were associated with an unplotted measurement and/or an undocumented growth abnormality. We feel that both documentation and assessment of growth represent potential areas for quality improvement.
Ambulatory Care Facilities↗
A guideline implementation system using handheld computers for office management of asthma: effects on adherence and patient outcomes.
OBJECTIVE: To evaluate effects on the process and outcomes of care brought about by use of a handheld, computer-based system that implements the American Academy of Pediatrics guideline on office management of asthma exacerbations. DESIGN: A before-after trial with randomly selected, office-based Connecticut pediatricians. In both the control and intervention phases, physicians collected data from 10 patient encounters for acute asthma exacerbations. During the intervention phase, the computer provided for structured encounter documentation and offered recommendations based on the guideline of the American Academy of Pediatrics. Patients were contacted by telephone 7 to 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 93% of encounters. Use of the intervention was associated with increased mean frequency/visit of: 1) measurements of peak expiratory flow rate (2.18 vs 1.57) and oxygen saturation (1.12 vs.42), and 2) administration of nebulized beta2-agonists (1.25 vs.71). Visits in the intervention phase lasted longer and fees were higher ($145.61 vs $103.11). There were no significant differences in immediate disposition or subsequent emergency department visits, hospitalizations, missed school, or caretaker's missed work during the 7 days post visit. CONCLUSION: Use of handheld computers that provide guideline-based decision support was associated with increased physician adherence to guideline recommendations; however, visits were prolonged, fees were higher, and no improvement could be demonstrated with regard to the observed intermediate-term patient outcomes. Guideline implementers (and users) should be cautious about putting unvalidated recommendations into practice.
Adolescent↗
A preliminary evaluation of guideline content mark-up using GEM--an XML guideline elements model.
OBJECTIVE: To describe application of GEM to analysis and categorization of guideline content. METHOD: We examined the application of GEM constructs to the AAP guideline on neurodiagnostic evaluation of febrile seizures. Subjects at 4 sites marked-up the guideline content using a hierarchical template that includes branches for identity, developer, purpose, intended audience, method of development, knowledge components, testing, and review. The types of elements used were tabulated. Subjects were surveyed regarding the usability of the model. RESULTS: Eight subjects analyzed the guideline, using between 46 and 149 elements to model its content. There was considerable variation in the application of elements. The number of elements used correlated with time to complete the task. Subjects found application of GEM to be straightforward in 6 of 8 categories and sufficiently comprehensive to model the guideline's information content. CONCLUSIONS: Subjects found GEM constructs were able to model the content of the guideline. Improved editing tools will facilitate translation.
Decision Making, Computer-Assisted↗
An object-oriented framework for the development of computer-based guideline implementations.
Clinical practice guidelines provide a means of directing medical care towards clinically appropriate and cost-effective interventions. A direct relationship exists between the integration of a guideline into clinical workflow and the effectiveness of the guideline in influencing clinicians' behavior. Computer-based guideline implementations, used at the point-of-care, accomplish this integration. Employing object-oriented technologies, we propose a framework of reusable components for the development of guideline implementation systems. We have identified eight information management services that are common to such systems. Our framework integrates these services and their respective reusable components into clinical workflow to promote the development of comprehensive guideline implementation systems, which should ultimately enhance guideline compliance and the overall quality of care.
Guideline Adherence↗
User satisfaction and frustration with a handheld, pen-based guideline implementation system for asthma.
OBJECTIVE: To evaluate clinicians' satisfaction and frustrations with the use of a handheld computer system that implements a guideline for management of childhood asthma exacerbations. SETTING: Nine primary-care pediatric practices. DESIGN: Survey component of a randomized, prospective before-after trial. INTERVENTION: Newton MessagePad outfitted with custom software (called "AsthMonitor") that assists in documentation of clinical findings and provides guideline-based recommendations. RESULTS: Overall, 3 users gave strongly positive global ratings while 6 users were neutral. The majority used the documentation functions concurrently with care. Except for recommendations to administer oxygen (which were unsupported by evidence), users found the recommendations appropriate and appreciated the reminders. Seven of 9 participants believed it took more time to document with AsthMonitor. CONCLUSIONS: Handheld computers are acceptable to some office-based practitioners to provide guideline-based advice within the context of the clinical encounter.
Asthma↗
Transition to a computer-based record using scannable, structured encounter forms.
OBJECTIVE: To evaluate the quality of documentation and user satisfaction with a structured documentation system for pediatric health maintenance encounters, using scanned paper-based forms to generate an electronic medical record. DESIGN: (1) A retrospective medical record review comparing 16 structured (ST) records with 16 contemporaneously created unstructured records, (2) a questionnaire evaluation of user satisfaction, and (3) an electronic records review of patients seen 1 year following the full implementation of the system to evaluate persistence of the effect. SETTING: The Yale-New Haven Hospital Pediatric Primary Care Center, New Haven, Conn, an inner-city clinic in an academic center. PARTICIPANTS: (1) A random sample of 16 health maintenance records completed by first- and second-year residents in February 1996 matched for patient's age and provider training level with 16 contemporaneously documented visits, (2) 16 of 18 pediatric level 1 residents and 14 of 16 pediatric level 2 residents who completed questionnaires, and (3) all electronic records of health maintenance visits during February 1997. MAIN OUTCOME MEASURES: The number of data elements documented and the percentage of records that record specific components of the health maintenance encounter. User satisfaction was specified on a Likert scale. RESULTS: Overall, residents in the ST records group documented more data elements per visit than did those in the unstructured records group. The number of developmental items documented was 11.5 per visit in the ST records group and 4.8 per visit in the unstructured records group (P = .004). Likewise, anticipatory guidance was more thoroughly documented in the ST records group--8.3 items per visit vs 2.5 items per visit (P < .001). Ninety percent of the users preferred the ST records. One year after the adoption of the ST recording system, high levels of thoroughness persisted. CONCLUSIONS: Structured, scannable encounter forms can facilitate documentation of patient care and are well accepted by users. They can provide an effective mechanism to ease the transition to a computer-based patient record.
Computers↗
Visualizing the logic of a clinical guideline: a case study in childhood immunization.
IMM/Graph is a visual model designed to help knowledge-base developers understand and refine the guideline logic for childhood immunization. The IMM/Graph model is domain-specific and was developed to help build a knowledge-based system that makes patient-specific immunization recommendations. A "visual vocabulary" models issues specific to the immunization domain, such as (1) the age a child is first eligible for each vaccination dose, (2) recommended, "past due" and maximum ages, (3) minimum waiting periods between doses, (4) the vaccine brand or preparation to be given, and (5) the various factors affecting the time course of vaccination. Several lessons learned in the course of developing IMM/Graph include the following: (1) The intended use of the model may influence the choice of visual presentation; (2) There is a potentially interesting interplay between the use of visual and textual information in creating the visual model; (3) Visualization may help a development team better understand a complex clinical guideline and may also help highlight areas of incompleteness.
Child, Preschool↗
Operationalization of clinical practice guidelines using fuzzy logic.
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.
Age Factors↗
Guideline maintenance and revision. 50 years of the Jones criteria for diagnosis of rheumatic fever.
OBJECTIVE: To understand better the factors that led to revisions of the Jones criteria, a widely used diagnostic guideline for diagnosis of rheumatic fever. DESIGN: The original publication of the Jones criteria and the four revisions were examined to identify changes. A computer software maintenance paradigm was applied, and modifications were categorized as corrective (error correction), perfective (enhancements in response to user needs), or adaptive (responses to new knowledge). RESULTS: Modifications of the Jones criteria were primarily corrective and perfective. Disease characteristics, originally characterized as major manifestations, were subsequently categorized as minor manifestations and vice versa. Twenty years after the initial publication, a requirement was added to enhance specificity (evidence for antecedent streptococcal infection). Descriptions of rheumatic manifestations became more detailed over time to eliminate ambiguous definitions and provide information to help clinicians decide about borderline cases. This emphasis on corrective and perfective maintenance contrasts with an expectation that adaptive changes would predominate, as with most knowledge-based systems. In fact, despite 50 years of technologic and methodologic advances in medicine, only echocardiography and new antibody testing contributed new knowledge that bears on the diagnosis of rheumatic fever. CONCLUSIONS: Corrective and perfective maintenance can be avoided by making effective use of knowledge that exists at the time a guideline is published. Despite the apparent durability of the Jones criteria, carefully structured, evidence-based guidelines should require less corrective and perfective maintenance. Adaptive maintenance can be anticipated if the quality of evidence or the level of consensus that supports each recommendation is explicitly recorded.
Guidelines as Topic↗
A findings model for an ambulatory pediatric record: essential data, relational modeling, and vocabulary considerations.
Effective, computer-based representation of clinical observations requires balancing the advantages of structured, coded descriptions against those of free text narrative. An essential data set of relevant signs and symptoms was defined by a multidisciplinary group based on management goals published in a national guideline to meet the needs of clinicians in the Spina Bifida Clinic at Yale-New Haven Hospital. These core data elements are stored in a structured format. Additional material is stored as free text. A relational schema was devised that permits storage of both coded findings and narrative. Symptoms and signs are represented as subtypes of a supertype patient finding entity; they inherit common attributes and specialize others. The IVORY vocabulary was supplemented and modified to provide terms that describe relevant clinical observations. For this application, fields were added that enable predictive data entry of findings based on patient age and gender.
Ambulatory Care Information Systems↗
Informatics and general pediatrics.
Medical informatics is both a science, which seeks to understand the information requirements of medical practice, research, and education, and an engineering discipline, which applies new technologies to help manage the explosion of data and new knowledge that confront contemporary physicians. Computerization of the patient record is expected to resolve long-standing problems with the current paper-based system. Medical decision support applications provide patient-specific advice and remind clinicians about problems that might otherwise be overlooked. New methods are required to evaluate the performance of expert systems in the medical domain where a single "gold standard" solution may not exist. Modern technologies can facilitate communication among multiple providers and between clinicians and patients. The need for improvements in user-interface design and for standards for recording and interchanging information pose ongoing challenges for informatics research.
Communication↗
Towards effective implementation of a pediatric asthma guideline: integration of decision support and clinical workflow support.
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.
Asthma↗
Translation of appropriateness criteria into practice guidelines: application of decision table techniques to the RAND criteria for coronary artery bypass graft.
The process of creating clinical practice guidelines from collected evidence has not been well defined. We have developed a technique for translation of a comprehensive set of appropriateness criteria into a usable set of practice guidelines. The criteria are derived from a formal consensus process conducted by RAND and relate to indications for coronary artery bypass graft in acute myocardial infarction. The clinical indications defined by the expert panel are entered as conditions in a decision table. For each combination of relevant clinical findings, the recommended action is defined from the median ranking of the Rand panel. The fully constructed table is next compacted by conventional decision table techniques and sorted to facilitate parsing the knowledge. Ultimately, 8 narrative statements are derived from 51 rules. Augmented decision tables permit display of detailed data in the summary table and its access on an as-needed basis.
Coronary Artery Bypass↗