Extracting and transforming clinical guidelines into pathway models for different hospital information systems

Leveraging American College of Obstetricians and Gynecologists Guidelines for Point-of-Care Decision Support in Obstetrics

BACKGROUND

The American College of Obstetricians and Gynecologists (ACOG) provides numerous narrative documents containing formal recommendations and additional narrative guidance within the text. These guidelines are not intended to provide a complete "care pathway" for patient management, but these elements of guidance can be useful for clinical decision support (CDS) in obstetrical and gynecologic care and could be exposed within electronic health records (EHRs). Unfortunately, narrative guidelines do not easily translate into computable CDS guidance.

OBJECTIVE

This study aimed to describe a method of translating ACOG clinical guidance into clear, implementable items associated with specific obstetrical problems for integration into the EHR.

METHODS

To translate ACOG clinical guidance in Obstetrics into implementable CDS, we followed a set of steps including selection of documents, establishing a problem list, extraction and classification of recommendations, and assigning tasks to those recommendations.

RESULTS

Our search through ACOG clinical guidelines produced over 500 unique documents. After exclusions, and counting only sources relevant to obstetrics, we used 245 documents: 38 practice bulletins, 113 committee opinions, 16 endorsed publications, 1 practice advisory, 2 task force and work group reports, 2 patient education, 2 obstetric care consensus, 60 frequently asked questions (FAQ), 1 women's health care guidelines, 1 Prolog series, and 9 others (non-ACOG). Recommendations were classified as actionable (n = 576), informational (n = 493), for in-house summary (n = 124), education/counseling (n = 170), policy/advocacy (n = 33), perioperative care (n = 4), delivery recommendations (n = 50), peripartum care (n = 13), and non-ACOG (n = 25).

CONCLUSION

We described a methodology of translating ACOG narrative into a semi-structured format that can be more easily applied as CDS in the EHR. We believe this work can contribute to developing a library of information within ACOG that can be continually updated and disseminated to EHR systems for the most optimal decision support. We will continue documenting our process in developing executable code for decision support.

Exploring approaches to identify, incorporate and report patient preferences in clinical guidelines: Qualitative interviews with guideline developers

BACKGROUND

Clinical guidelines informed by patient preferences are more likely to be used and widely advocated, yet research shows that few guidelines reflect patient preferences.

OBJECTIVE

Explore how developers generate guidelines informed by patient preferences.

PATIENT INVOLVEMENT

Seventeen patients were involved as interview participants.

METHODS

Using a basic descriptive approach, we conducted and analyzed semi-structured telephone interviews with 50 participants who were involved in developing guidelines on various topics. The sample included 17 patients, 16 clinicians and 17 managers from a total of 7 countries.

RESULTS

Participants used one or more approaches to identify preferences, patient panelists, focus groups, surveys and review of published research, despite acknowledging they identified similar preferences. Participants said they incorporated preferences in all guideline development steps, but provided little detail of specific processes. Few participants said their guidelines explicitly reported how patients were engaged, preferences identified, or how preferences influenced development processes or the guideline. Enablers were patient and clinician training, supportive coordinators and chairs, involving experienced patients, and assistance from qualitative and review experts. Barriers were finding and preparing patients, clinician skepticism about benefits, and token patient involvement. Participants recommended research on how to generate preference-informed guidelines.

DISCUSSION

Ideal approaches to identify, incorporate and report patient preferences in guidelines are unclear and unproven.

PRACTICAL VALUE

Findings revealed specific ways that developers can enhance their processes (e.g. patient training, supportive coordinators and chairs, involve experts in qualitative researcher and systematic reviews) and key issues that warrant ongoing research (e.g. how best to incorporate and report preferences).

Co-design and feasibility of a pharmacist-led minor ailment service

BACKGROUND

Community pharmacies provide an appropriate setting to deliver minor ailment services (MASs). Many community pharmacy services have been developed previously without stakeholder involvement. As a result, implementation of services may fail to produce the expected impact. The aim of this research was to co-design and test the feasibility of an Australian MAS for minor ailment presentations.

METHODS

This study used co-design methodology which included two phases: (1) a focus group with stakeholders to allow the conceptualization of the service and agreement on service elements; (2) a literature review of clinical guidelines and three working meetings with a team of editors and general practitioners for the development of treatment pathways. Following this, a study evaluating the feasibility of the co-designed service was undertaken. The qualitative part of the methodology associated with the feasibility study comprised semi-structured interviews with MAS pharmacists, observation and completion of a tool by change facilitators identifying barriers and facilitators to service delivery. Qualitative data obtained for all phases were analysed using thematic analysis.

RESULTS

The developed service included the following components: (i) an in-pharmacy consultation between the patient and pharmacist, (ii) treatment pathways accessible to pharmacists on the internet to guide consultations, (iii) existing digital communication systems used by general practice to exchange patient information, (iv) training, and (v) change facilitation. As a result of feasibility testing, twenty-six implementation factors were identified for practice change, with the main change being the simplification of the pharmacist-patient consultation and data collection processes.

CONCLUSIONS

An Australian MAS was generated as a result of co-design, while testing revealed that the co-designed service was feasible. As a result of integrating the views of multiple stakeholders, the designed MAS has been adapted to suit healthcare practices, which may increase the acceptance and impact of MAS when implemented into practice.

Development and Optimization of Clinical Informatics Infrastructure to Support Bioinformatics at an Oncology Center

Translational bioinformatics for therapeutic discovery requires the infrastructure of clinical informatics. In this chapter, we describe the clinical informatics components needed for successful implementation of translational research at a cancer center. This chapter is meant to be an introduction to those clinical informatics concepts that are needed for translational research. For a detailed account of clinical informatics, the authors will guide the reader to comprehensive resources. We provide examples of workflows from Moffitt Cancer Center led by Drs. Perkins and Markowitz. This perspective represents an interesting collaboration as Dr. Perkins is the Chief Medical Information Officer and Dr. Markowitz is a translational researcher in Melanoma with an active informatics component to his laboratory to study the mechanisms of resistance to checkpoint blockade and an active member of the clinical informatics team.

How to identify, incorporate and report patient preferences in clinical guidelines: A scoping review

BACKGROUND

Clinical guidelines optimize care delivery and outcomes. Guidelines support patient engagement and adherence if they reflect patient preferences for treatment options, risks and benefits. Many guidelines do not address patient preferences. Developers require insight on how to develop such guidelines.

OBJECTIVE

To conduct a scoping review on how to identify, incorporate and report patient preferences in guidelines.

SEARCH

We searched MEDLINE, EMBASE, Scopus, CINAHL, OpenGrey and GreyLit from 2010 to November 2019.

ELIGIBILITY

We included English language studies describing patient preferences and guidelines.

DATA EXTRACTION AND SYNTHESIS

We reported approaches for and determinants and impacts of identifying patient preferences using summary statistics and text, and interpreted findings using a conceptual framework of patient engagement in guideline development.

RESULTS

Sixteen studies were included: 2 consulted patients and providers about patient engagement approaches, and 14 identified patient preferences (42.9%) or methods for doing so (71.4%). Studies employed single (57.1%) or multiple (42.9%) methods for identifying preferences. Eight (57.1%) incorporated preferences in one aspect of guideline development, while 6 (42.9%) incorporated preferences in multiple ways, most commonly to identify questions, benefits or harms, and generate recommendations. Studies did not address patient engagement in many guideline development steps. Included studies were too few to establish the best approaches for identifying or incorporating preferences. Fewer than half of the studies (7, 43.8%) explored barriers. None examined reporting preferences in guidelines.

CONCLUSIONS

Research is needed to establish the single or multiple approaches that result in incorporating and reporting preferences in all guideline development steps.

Facilitating the design of HL7 domain models through a model-driven solution

Background and goal

Health information systems are increasingly sophisticated and developing them is a challenge for software developers. Software engineers usually make use of UML as a standard model language that allows defining health information system entities and their relations. However, working with health system requires learning HL7 standards, that defines and manages standards related to health information systems. HL7 standards are varied, however this work focusses on v2 and v3 since these are the most used one on the area that this work is being conducted. This works aims to allow modeling HL7 standard by using UML.

Methods

Several techniques based on the MDE (Model-Driven Engineering) paradigm have been used to cope with it.

Results

A useful reference framework, reducing final users learning curve and allowing modeling maintainable and easy-going health information systems.

Conclusions

By using this approach, a software engineer without any previous knowledge about HL7 would be able to solve the problem of modeling HL7-based health information systems. Reducing the learning curve when working in projects that need HL7 standards.

Constructing a knowledge-based heterogeneous information graph for medical health status classification

Applying Pearson correlation and semantic relations in building a heterogeneous information graph (HIG) to develop a classification model has achieved a notable performance in improving the accuracy of predicting the status of health risks. In this study, the approach that was used, integrated knowledge of the medical domain as well as taking advantage of applying Pearson correlation and semantic relations in building a classification model for diagnosis. The research mined knowledge which was extracted from titles and abstracts of MEDLINE to discover how to assess the links between objects relating to medical concepts. A knowledge-base HIG model then was developed for the prediction of a patient's health status. The results of the experiment showed that the knowledge-base model was superior to the baseline model and has demonstrated that the knowledge-base could help improve the performance of the classification model. The contribution of this study has been to provide a framework for applying a knowledge-base in the classification model which helps these models achieve the best performance of predictions. This study has also contributed a model to medical practice to help practitioners become more confident in making final decisions in diagnosing illness. Moreover, this study affirmed that biomedical literature could assist in building a classification model. This contribution will be advantageous for future researchers in mining the knowledge-base to develop different kinds of classification models.

Considerations on the Improved Integration of Medical Guidelines into Routine Clinical Practice - a Review and Concept Proposal

Medical guidelines have become established as the standard for the comprehensive synopsis of all available information (scientific trials, expert opinion) on diagnosis and treatment recommendations. The transfer of guidelines to clinical practice and subsequent monitoring has however proven difficult. In particular the potential interaction between guideline developers and guideline users has not been fully utilised. This review article analyses the status quo and existing methodological and technical information solutions supporting the guideline life cycle. It is shown that there are numerous innovative developments that in isolation do not provide comprehensive support. The vision of the "Living Guidelines 2.0" is therefore presented. This outlines the merging of guideline development and implementation on the basis of clinical pathways and guideline-based quality control, and building on this, the generation of information for guideline development and research.