Biomedical subjects

Richard N Shiffman

Publications and source records attributed to Richard N Shiffman.

13 recordsLinked to original sources

PubMed2005

The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation.

BACKGROUND: Clinical practice guidelines are not uniformly successful in influencing clinicians' behaviour toward best practices. Implementability refers to a set of characteristics that predict ease of (and obstacles to) guideline implementation. Our objective is to develop and validate a tool for appraisal of implementability of clinical guidelines. METHODS: Indicators of implementability were identified from the literature and used to create items and dimensions of the GuideLine Implementability Appraisal (GLIA). GLIA consists of 31 items, arranged into 10 dimensions. Questions from 9 of the 10 dimensions are applied individually to each recommendation of the guideline. Decidability and Executability are critical dimensions. Other dimensions are Global, Presentation and Formatting, Measurable Outcomes, Apparent Validity, Flexibility, Effect on Process of Care, Novelty/Innovation, and Computability. We conducted a series of validation activities, including validation of the construct of implementability, expert review of content for clarity, relevance, and comprehensiveness, and assessment of construct validity of the instrument. Finally, GLIA was applied to a draft guideline under development by national professional societies. RESULTS: Evidence of content validity and preliminary support for construct validity were obtained. The GLIA proved to be useful in identifying barriers to implementation in the draft guideline and the guideline was revised accordingly. CONCLUSION: GLIA may be useful to guideline developers who can apply the results to remedy defects in their guidelines. Likewise, guideline implementers may use GLIA to select implementable recommendations and to devise implementation strategies that address identified barriers. By aiding the design and operationalization of highly implementable guidelines, our goal is that application of GLIA may help to improve health outcomes, but further evaluation will be required to support this potential benefit.

Benchmarking↗

PubMed2005

A draft framework for measuring progress towards the development of a National Health Information Infrastructure.

BACKGROUND: American public policy makers recently established the goal of providing the majority of Americans with electronic health records by 2014. This will require a National Health Information Infrastructure (NHII) that is far more complete than the one that is currently in its formative stage of development. We describe a conceptual framework to help measure progress toward that goal. DISCUSSION: The NHII comprises a set of clusters, such as Regional Health Information Organizations (RHIOs), which, in turn, are composed of smaller clusters and nodes such as private physician practices, individual hospitals, and large academic medical centers. We assess progress in terms of the availability and use of information and communications technology and the resulting effectiveness of these implementations. These three attributes can be studied in a phased approach because the system must be available before it can be used, and it must be used to have an effect. As the NHII expands, it can become a tool for evaluating itself. SUMMARY: The NHII has the potential to transform health care in America--improving health care quality, reducing health care costs, preventing medical errors, improving administrative efficiencies, reducing paperwork, and increasing access to affordable health care. While the President has set an ambitious goal of assuring that most Americans have electronic health records within the next 10 years, a significant question remains "How will we know if we are making progress toward that goal?" Using the definitions for "nodes" and "clusters" developed in this article along with the resulting measurement framework, we believe that we can begin a discussion that will enable us to define and then begin making the kinds of measurements necessary to answer this important question.

Health Policy↗

PubMed2005

Metadata-driven Delphi rating on the Internet.

Paper-based data collection and analysis for consensus development is inefficient and error-prone. Computerized techniques that could improve efficiency, however, have been criticized as costly, inconvenient and difficult to use. We designed and implemented a metadata-driven Web-based Delphi rating and analysis tool, employing the flexible entity-attribute-value schema to create generic, reusable software. The software can be applied to various domains by altering the metadata; the programming code remains intact. This approach greatly reduces the marginal cost of re-using the software. We implemented our software to prepare for the Conference on Guidelines Standardization. Twenty-three invited experts completed the first round of the Delphi rating on the Web. For each participant, the software generated individualized reports that described the median rating and the disagreement index (calculated from the Interpercentile Range Adjusted for Symmetry) as defined by the RAND/UCLA Appropriateness Method. We evaluated the software with a satisfaction survey using a five-level Likert scale. The panelists felt that Web data entry was convenient (median 4, interquartile range [IQR] 4.0-5.0), acceptable (median 4.5, IQR 4.0-5.0) and easily accessible (median 5, IQR 4.0-5.0). We conclude that Web-based Delphi rating for consensus development is a convenient and acceptable alternative to the traditional paper-based method.

Delphi Technique↗

PubMed2005

Facilitating adherence to the tobacco use treatment guideline with computer-mediated decision support systems: physician and clinic office manager perspectives.

BACKGROUND: A majority of physicians do not adhere to all the elements of the evidence-based USPHS guideline on tobacco use and dependence treatment. Among physicians and clinic office managers in Vermont we assessed perceived barriers to guideline adherence. We then assessed attitudes towards a computer-mediated clinical decision support system (CDSS) to gauge whether this type of intervention could support performance of the guideline. METHODS: A random sample of 600 Vermont primary care and subspecialty physicians were surveyed with a mailed survey instrument. A separate survey instrument was mailed to the census of 93 clinic office managers. RESULTS: The response rates of physicians and clinic office managers were 67% and 76%, respectively. Though most physicians were aware of the guideline and had positive attitudes towards it, there was a lack of familiarity with Vermont's smoking cessation resources as 35% would refer smokers to non-existent counseling resources and only 48% would refer patients to a toll-free quit line. Time constraints and the perception that smokers are unreceptive to counseling were the two most common barriers cited by both physicians and office managers. The vast majority of physicians (92%) have access to a computer in their outpatient clinics, and 68% have used computers during the course of a patient's visit. Four of the eight information management services that a CDSS could provide were highly valued by both physicians and clinic office managers. CONCLUSIONS: Interventions to improve adherence to the guideline should address the inaccurate perception that smokers are unreceptive to counseling, and physicians' lack of familiarity with resources. A CDSS may improve knowledge of these resources if the design addresses cost, space, and time limitations.

Adult↗

PubMed2004

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

OBJECTIVE: A 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. DESIGN: This 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. RESULTS: 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. CONCLUSION: Using 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.

Asthma↗

PubMed2004

Toward improved guideline quality: using the COGS statement with GEM.

The Conference on Guideline Standardization (COGS) was convened to create a standardized documentation checklist for clinical practice guidelines in an effort to promote guideline quality and facilitate implementation. The statement was created by a multidisciplinary panel using a rigorous consensus development methodology. The Guideline Elements Model (GEM) provides a standardized approach to representing guideline documents using XML. In this work, we demonstrate the sufficiency of GEM for describing COGS components. Using the mapping between COGS and GEM elements we built an XSLT application to examine a guideline's adherence (or non-adherence) to the COGS checklist. Once a guideline has been marked up according to the GEM hierarchy, its knowledge content can be reused in multiple ways.

Congresses as Topic↗

PubMed2004

Using a guideline-centered approach for the design of a clinical decision support system to promote smoking cessation.

Knowledge acquisition for the design of clinical decision support systems can be facilitated when clinical practice guidelines serve as a knowledge source. We describe application of the Guideline Elements Model (GEM) in the design of a decision support system to promote smoking cessation. Following selection of relevant recommendations and markup of knowledge components with the GEM Cutter editor, the Extractor stylesheet was used to create a list of decision variables and actions for further processing. Decision variables and actions that reflect similar concepts were consolidated. Action types were identified. Extracting the critical concepts from the narrative text facilitates clarification of necessary content. The guideline-centric approach promotes accurate translation of guideline knowledge.

Decision Support Systems, Clinical↗

PubMed2004

A convocation of wizards: synergies at the intersection of child health care, public health, and information technology.

Although great opportunities for synergies exist, experts in children's health care, public health, and informatics often practice in silos--unaware of advances in related fields. The conference "A Vision for Child Health Information Systems: Developing Child Health Information Systems to Meet Medical Care and Public Health Needs," was held in Atlanta, Georgia, December 3-4, 2003 in an effort to break down barriers. Issues--germane to each group and bridging the boundaries between them--are presented. A vision of health care with obstacles removed is described. Experts should work to diminish the insularity that interferes with effective collaboration, focus on the intersections of child health, public health and information technology, and recognize and promulgate the message that one-size technology solutions that are designed for adult medicine don't fit this area of practice.

Adolescent↗

PubMed2003

Take note(s): differential EHR satisfaction with two implementations under one roof.

OBJECTIVE: The aim of this study was to rigorously evaluate perceived differences in satisfaction with an electronic health record (EHR) between residents of two medical specialties who share the same health record, practice location, administration, and information technology support. DESIGN: A cross-sectional survey was used comparing user satisfaction between pediatrics residents and internal medicine residents in an academic practice. MEASUREMENTS: The survey was designed to measure baseline demographic characteristics, attitudes toward computers, general satisfaction with an EHR, and perceived practicality of use, variation from familiar practice, organizational support, and impact on delivery of care. RESULTS: Medicine subjects were similar to pediatrics subjects in baseline demographic characteristics. Satisfaction with the EHR implementation was very high for both sets of subjects, but internal medicine residents were significantly less likely to be satisfied with the EHR implementation (relative risk [RR]=0.84, 95% confidence interval [CI]=0.73-0.98) and considerably less likely to believe that their colleagues were satisfied with it (RR=0.56, 95% CI=0.41-0.77). The only surveyed characteristic independently predicting satisfaction was medical specialty (p=0.04). Medicine subjects were less likely to believe template-based documentation improved their efficiency (RR=0.64, 95% CI=0.46-0.88). They were significantly more likely to believe the system had been designed to improve billing (RR=1.50, 95% CI=1.05-2.04) and not to improve patient care (RR=0.61, 95% CI=0.44-0.85). CONCLUSION: The authors found a difference in satisfaction between internal medicine and pediatrics users of an EHR. Although many potential factors that influence satisfaction were similar between subjects in the two specialties, differences in previous experience may have influenced the results. Medicine residents had more previous experience with a different EHR implementation, which they may have perceived as superior to the one involved in this study. Pediatric residents had more previous experience with structured data entry prior to EHR implementation and more preventive care patient encounters for which structured data entry may be well suited. Since successful implementations generally require satisfied users, understanding what factors affect satisfaction can improve chances of a system's success.

Adult↗

PubMed2003

Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization.

Despite enormous energies invested in authoring clinical practice guidelines, the quality of individual guidelines varies considerably. The Conference on Guideline Standardization (COGS) was convened in April 2002 to define a standard for guideline reporting that would promote guideline quality and facilitate implementation. Twenty-three people with expertise and experience in guideline development, dissemination, and implementation participated. A list of candidate guideline components was assembled from the Institute of Medicine Provisional Instrument for Assessing Clinical Guidelines, the National Guideline Clearinghouse, the Guideline Elements Model, and other published guideline models. In a 2-stage modified Delphi process, panelists first rated their agreement with the statement that "[Item name] is a necessary component of practice guidelines" on a 9-point scale. An individualized report was prepared for each panelist; the report summarized the panelist's rating for each item and the median and dispersion of rankings of all the panelists. In a second round, panelists separately rated necessity for validity and necessity for practical application. Items achieving a median rank of 7 or higher on either scale, with low disagreement index, were retained as necessary guideline components. Representatives of 22 organizations active in guideline development reviewed the proposed items and commented favorably. Closely related items were consolidated into 18 topics to create the COGS checklist. This checklist provides a framework to support more comprehensive documentation of practice guidelines. Most organizations that are active in guideline development found the component items to be comprehensive and to fit within their existing development methods.

Documentation↗

PubMed2003

Improving diagnostic testing and reducing overuse of antibiotics for children with pharyngitis: a useful role for the electronic medical record.

BACKGROUND: Because of rising resistance to antibiotics, appropriate use of antibiotics is an important measure of quality of care. The purpose of this study was to use an electronic medical record (EMR) to assess use of diagnostic testing and of antibiotics for pharyngitis in a pediatric outpatient setting and to target areas for improvement. METHODS: Using data retrieved from the EMR, we analyzed visits from March 1, 2001 to February 28, 2002 for children 3 to 18 years old diagnosed with pharyngitis. We determined the proportion of episodes with a diagnostic test for group A streptococci, the proportion for which a prescription for an antibiotic was dispensed and factors that predicted prescribing and testing. RESULTS: Of 391 episodes of pharyngitis, a test was ordered for 303 (78%). Antibiotics were prescribed for 90 (23%); for 76 of 90 (84%) a test was ordered. Clinicians were less likely to order tests late in the week [relative risk (RR), 0.76; 95% confidence interval (CI), 0.66, 0.87)], more likely to order tests for patients with an exudate (RR 1.2; 95% CI 1.1, 1.3) and more likely to prescribe an antibiotic for patients with an exudate (RR 1.5; 95% CI 1.1, 2.1). When prescribing an antibiotic clinicians were less likely to order tests late in the week (RR 0.1; 95% CI 0.02, 0.5) and for patients diagnosed with scarlet fever (RR 0.07; 95% CI 0.01, 0.4). CONCLUSION: Using data from the EMR, we could assess adherence to the guidelines for antibiotic use and identify areas to target for improving diagnostic testing and reducing overuse of antibiotics in our clinic.

Adolescent↗

PubMed2003

Comprehensive categorization of guideline recommendations: creating an action palette for implementers.

Transforming guideline recommendations into executable statements for computerized decision support systems requires a clear understanding of what tasks must be performed. We sought (a) to determine whether a limited set of action types could be defined to comprehensively categorize activities recommended by the majority of clinical guidelines, (b) to describe the relative frequency of these action types, and (c) to create a library of recommendations for future validation activities. We randomly selected test and validation sets of 50 recommendations each from the National Guideline Clearinghouse and randomly extracted 3 recommendations from each guideline. We tested the ability of a preliminary palette of action types to categorize guideline-prescribed activities and expanded it to accommodate several unanticipated actions. Ultimately, the following actions were sufficient to categorize all 405 actions: Prescribe, Perform therapeutic procedure, Educate/Counsel, Test, Dispose, Refer/Consult, Conclude, Monitor, Document, Advocate, Prepare, and No recommendation., and Prepare. Thus, we define a set of terms that can facilitate guideline implementation in clinical information systems. These action types can be used to construct a framework for design of clinical decision support systems.

Decision Making, Computer-Assisted↗

PubMed2003

Delphi rating on the internet.

We designed an application to allow respondents to rate components of clinical guidelines on the Internet. Twenty-three invited experts completed the rating followed by a satisfaction survey using a 5-level Likert scale. The experts felt that Web data entry was convenient, acceptable and easily accessible. We conclude that Web-based Delphi rating for consensus development is a convenient and acceptable alternative to the traditional paper-based method.

Consensus↗