An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD,...

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An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center for Medical Informatics Yale University School of Medicine New Haven, Connecticut USA

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Page 1: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

An Approach toGuideline ImplementationWith GEM

Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD,

Peter Gershkovich, MD, Aniruddha Deshpande, MD

Center for Medical InformaticsYale University School of Medicine

New Haven, Connecticut USA

Page 2: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Overview GEM – the Guideline Elements

Model Implementation Issues 3 Tasks in Implementation

Knowledge extraction Knowledge customization Knowledge integration

Page 3: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Guideline Elements Model Knowledge model for guideline documents

Multi-level hierarchy (>100 elements) Conceived and built in XML Permits modeling at several levels of

abstraction Models heterogeneous information

contained in guidelines in a standard way (ASTM, HL7)

Facilitates translation of guidelines into a format that can be processed by computers

Can be used throughout guideline lifecycleJAMIA 2000

Page 4: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

TitleCitation

Release DateAvailability

ContactStatus

Companion DocumentAdaptation

Developer NameCommittee Name

Funding

EndorserComparable Guideline

Health PracticesCategory

Target PopulationRationaleObjective

Available OptionsImplementation Strategy

Health OutcomesExceptions

Care SettingClinician Users

Evidence CollectionEvidence Time Period

Evidence GradingCombining Evidence

Specification of Harm/BenefitQuantification of Harm/Benefit

Value JudgmentPatient Preference

Qualifying StatementCost Analysis

RecommendationConditional (decision variable) .

Action .

Logic .

Reason .

Strength of Recommendation .

Evidence Quality . . .Cost .

Certainty .

AlgorithmEligibilityDefinition

External ReviewPilot Testing

Expiration DateScheduled Review

Developer

Purpose

Method

Knowledge

Audience

Identity

TestingRevision

HS INF

Page 5: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

GEM: Major Components

Guideline

Identity

Purpose

Intended Audience

Method ofDevelopment

KnowledgeComponents

Testing RevisionPlan

TargetPopulation

DocumentHeader

DocumentBody

Developer

JAMIA 2000

Page 6: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Knowledge Components

Recommendation

Conditional Imperative

Definition

Term

TermMeaning

Algorithm

SyncStep

ActionStep

Condit’lStep

BranchStep

KnowledgeComponents

Page 7: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Conditional

Reason FlexbltyEvidQuality

RecmdnStrength

Logic Cost Link Ref Certainty

ActionBenefit

ActionRiskHarm

ActionDescripn

ActionCostValue

Dec VariableDescripn

TestParam

DecVar

Cost

Sensitivity Specificity Predictive Value

DecVar

Action

Recommendation

Conditional

KnowledgeComponents

Page 8: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Guideline Implementation Creation of strategies, systems,

and tools to operationalize the knowledge and recommendations set forth by guideline developers

Aim is to change behavior Implementation differs from

dissemination

Page 9: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Implementation Process

Black BoxPublished Guideline

Computer-Based Guideline Implementation

Page 10: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

What goes on in the black box?

3 sets of activities Knowledge extraction Knowledge customization Knowledge integration

GEM tools and solutions

Page 11: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Knowledge extraction Not systematic / duplicable Requires dual expertise Inconsistency of encoding

Sequence of data collection Level of detail Atomic or composite statements Specification of data elements Omissions due to human error Different recommendations would be given

for the same patient Ohno-Machado L, JAMIA 1998Patel V, JAMIA, 1998

Page 12: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Markup is simpler than coding

Recommendation 3

If an infant or young child 2 months to 2 years of age with unexplained fever is assessed as being sufficiently ill to warrant immediate antimicrobial therapy, a urine specimen should be obtained by SPA or bladder catheterization; the diagnosis of UTI cannot be established by a culture of urine collected in a bag. (Strength of evidence: good) Urine obtained by SPA or urethral catheterization is unlikely to be contaminated...

Page 13: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

GEM Cutter

Page 14: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

UTI Recommendation in XML

<decision.variable id=dv1>age</decision.variable>

<value>2 months to 2 years</value>

<decision.variable id= dv2>unexplained fever </decision.variable>

<decision.variable id=dv3>sufficiently ill to warrant immediate antimicrobial therapy </decision.variable>

<action id=a1>obtain urine specimen by SPA</action>

<action id=a2>obtain urine specimen by catheterization</action>

<reason>the diagnosis of UTI cannot be established by a culture of urine collected in a bag</reason>

<evidence.quality>Good</evidence.quality>

<logic>IF (dv1=2m-2y) AND dv2 AND dv3 THEN a1 OR a2</logic>

Page 15: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Knowledge Customization Guideline content inadequate for

operationalization Guideline weaknesses

Lack explicit definitions (Tierney, JAMIA 1995) Focus on omission errors Do not account for comorbid conditions,

concurrent drug therapy, timing of interventions Level of abstraction often inappropriate Incompleteness, inconsistency

Protection of habit or self interest

Page 16: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Prose Guideline Document

GEM Cutter

GEM Document

Logician ER

DOM

Metadata

Knowledge Customization

Knowledge Extraction

XSLStylesheet

Page 17: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Decidable?

Decision Variable

Value

Age 2 months to 2 years

Unexplained fever

{true}

Ill Sufficient…to warrant immediate antimicrobial therapy

Page 18: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Element “source” attribute Explicit Inferred Selection from controlled

vocabulary (NGC)

Page 19: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Knowledge integration Support local workflow Source of information Codes / vocabularies User interface

Page 20: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Knowledge Integration Activities Decide mode of delivery for advice

Prescriptive Critiquing

Set bounds based on evidence quality, recommendation strength

Incorporate patient preference

Page 21: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

Provide Services for Information Management Documentation Recommendation Explanation Registration

Communication Calculation Presentation Aggregation

Shiffman, et al., JAMIA 1999

Page 22: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.
Page 23: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.
Page 24: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

In conclusion… GEM documents can serve as portable

knowledge repositories for decision support systems. Knowledge extraction Knowledge customization Knowledge integration

Page 25: An Approach to Guideline Implementation With GEM Richard N. Shiffman, MD, MCIS, Abha Agrawal, MD, Peter Gershkovich, MD, Aniruddha Deshpande, MD Center.

http:// ycmi.med.yale.edu

[email protected]


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