Richard Shiffman, Tina Tolomeo, Seymour Codish,

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TranslatingGuideline Knowledge Into Systems That
Improve Care

• Richard Shiffman, Tina Tolomeo, Seymour Codish,
• Nancy Banasiak, Alesha Braithwaite, Peggy
  Simonette
• ERICCA Project
• Yale University School of Medicine
• Electronic Records to Improve Care for Children
  with Asthma

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Overview

• ERICCA Project goals
• Asthma a chronic disease shared by adults and
  kids
• Guideline-centered DSS development
• Evaluation

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1. To implement a sustainable network for
improving communication among health care
providers in pediatric primary care, school
health, specialty care, and emergency medicine.
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2. To demonstrate improvements in quality of care
for children with asthma.

• Reduce communication errors that threaten safety
• Improve effectiveness of care through clinical
  decision support

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3. To understand organizational barriers and
factors that enhance IT acceptance
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4. To provide administrative and technical
elements of a community-wide health network
infrastructure that can be further extended to
additional health partners.
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Asthma

• Most common chronic illness in childhood
• Accounts for 25 of school absences
• Rates of OP visits, hospitalizations rising
• Asthma care cost 12.7B in 1998
• Despite effective therapy, evidence of
  inconsistent and suboptimal care
• lt50 using anti-inflammatory agents, have written
  action plan

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Woe is us!

• Widespread practice variation
• Suboptimal care
• Soaring costs

The Problem
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NHLBI Asthma Guideline

• Mild Intermittent
• Mild Persistent
• Mod Persistent
• Severe Persistent

• STEP 1
• STEP 2
• STEP 3
• STEP 4

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Asthma Classification
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Selecting Long Term Control Meds

• Asthma classification
• Current treatment Step
• Duration at current treatment step
• Level of control
• Treatment strategy preference
• Age
• Exercise-linked symptoms
• Side effects

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Knowledge-Based Clinical Decision Support Systems

• Input information about individual clinical
  situation
• Output inferences that can assist practitioners
  in decision-making, eg
• Assistance with diagnostic classification
• Reminders about appropriate care
• Workflow assistance, e.g., prescriptions,
  referrals, handouts

Guideline-Based CDSS
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Implementation Process
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GEM

• Knowledge model for guideline documents
• Multi-level hierarchy (gt100 elements)
• Models heterogeneous information contained in
  guidelines
• Conceived and developed in XML
• GEM DTD adopted as a standard (ASTM E2210-02)

Shiffman, et al. JAMIA 2000
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Implementation stepsGEM Polisher

• Selection (GL Rec)
• Data Preparation
• Markup

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Used to Work with Highlighters

• UTI 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...

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XML From a small number of discrete colors to an
unlimited palette
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MORO
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Markup Once, Reuse Often

• Guideline quality appraisal (GEM-Q)
• Feedback to developers (Extractor, GEM-COGS,
  GLIA)
• GEM Polisher framework for implementation

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Implementation stepsGEM Polisher

• Workflow integration
• Origins and insertions
• Define action types
• Assocd Beneficial Svcs
• Development of requirement specification
• Encoding, Interface design, Testing

• Selection (GL Rec)
• Data Preparation
• Markup
• Atomization
• De-abstraction
• Disambiguation
• Verification of completeness
• Explanation

Shiffman et al. J Am Med Inform Assoc 2004
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Guideline Action Classifier (N405)
Action
Essaihi. Proc AMIA 2003
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Action-Type Classification

• Increase daily long term control medication to
  high dose inhaled corticosteroids
• Prescribe action-type
• A pulmonary consultation is stronglyrecommended
• Refer/Consult action-type
• Develop a written action plan to help the patient
  manage asthma exacerbations
• Educate/Counsel action-type

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An action palette of reusable components

• Prescribe
• Formulary manager
• Generate prescription
• Transmit (fax, electronic transfer)
• Refer/Consult
• Type of service requested justified? approved?
• Create/transmit clinical summary
• Appointment scheduling, prioritization,
  notification of patient, referring clinician
• Educate/counsel
• Handout editor
• Language translation manager

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Evaluation of CDSS Effectiveness (next year)

• Before/after
• 300 children with asthma
• Pediatric residents, PNPs in continuity clinics
• Intervention guideline-based DS audit/feedback
• Frequency of classification of asthma severity
• Anti-inflammatory meds for persistent asthma
• ED visits, hospitalizations, courses systemic
  steroid

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Challenges

• Getting clinicians to use CDSS
• Carrot and stick
• Water main break
• Resident transition

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In conclusion

• General-purpose approach to translation of
  guideline knowledge into systems that influence
  care
• Demonstrate the value of CDSS in management of a
  complex chronic illness (shared by adults and
  children)

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THANK YOU!
richard.shiffman_at_yale.edu