Download PDF
Methods Inf Med 2010; 49(06): 550-570
DOI: 10.3414/ME10-01-0056
Review Article
Schattauer GmbH

From Clinical Practice Guidelines to Computer-interpretable Guidelines

A Literature Overview
A. Latoszek-Berendsen
1   Caphri School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
,
H. Tange
1   Caphri School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
,
H. J. van den Herik
2   TiCC, Tilburg Centre for Cognition and Communication, Tilburg University, Tilburg, The Netherlands
,
A. Hasman
3   KIK, University of Amsterdam, Amsterdam, The Netherlands
› Author Affiliations
Further Information

Publication History

received: 04 August 2010

accepted: 08 October 2010

Publication Date:
18 January 2018 (online)

    Permissions and Reprints

Summary

Background: Guidelines are among us for over 30 years. Initially they were used as algorithmic protocols by nurses and other ancillary personnel. Many physicians regarded the use of guidelines as cookbook medicine. However, quality and patient safety issues have changed the attitude towards guidelines. Implementing formalized guidelines in a decision support system with an interface to an electronic patient record (EPR) makes the application of guidelines more personal and therefore acceptable at the moment of care.

Objective: To obtain, via a literature review, an insight into factors that influence the design and implementation of guidelines.

Methods: An extensive search of the scientific literature in PubMed was carried out with a focus on guideline characteristics, guideline development and implementation, and guideline dissemination.

Results: We present studies that enable us to explain the characteristics of high-quality guidelines, and new advanced methods for guideline formalization, computerization, and implementation. We show how the guidelines affect processes of care and the patient outcome. We discuss the reasons of low guideline adherence as presented in the literature and comment upon them.

Conclusions: Developing high-quality guidelines requires a skilled team of people and sufficient budget. The guidelines should give personalized advice. Computer-interpretable guidelines (CIGs) that have access to the patient’s EPR are able to give personal advice. Because of the costs, sharing of CIGs is a critical requirement for guideline development, dissemination, and implementation. Until now this is hardly possible, because of the many models in use. However, some solutions have been proposed. For instance, a standardized terminology should be imposed so that the terms in guidelines can be matched with terms in an EPR. Also, a dissemination model for easy updating of guidelines should be established. The recommendations should be based on evidence instead of on consensus. To test the quality of the guideline, appraisal instruments should be used to assess the guideline as a whole, as well as checking the quality of the recommendations individually. Only in this way optimal guideline advice can be given on an individual basis at a reasonable cost.

Keywords

Clinical practice guidelines - paper-based guidelines - computer-based guidelines - computerized (clinical) guidelines - computerinterpretable guidelines - guideline formalization - decision support system
 

  • References

  • 1 Field M, Lohr K. (eds). Guidelines for clinical practice: from development to use. Institute of Medicine, Washington, DC: National Academy Press; 1992
    Google Scholar
  • 2 Shaneyfelt TM, Mayo-Smith MF, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA 1999; 281 (20) 1900-1905.
    CrossrefPubMedGoogle Scholar
  • 3 Clinical Practice Guidelines (cited 01.05.2009). Available from: http://www.openclinical.org/guidelines.html
    PubMed
  • 4 Shankar RD, Tu SW, Martins SB, Fagan LM, Goldstein MK, Musen MA. Integration of textual guideline documents with formal guideline knowledge bases. Proc AMIA Symp 2001 pp 617-621.
    PubMedGoogle Scholar
  • 5 American Heart Association (cited 15.10.2009).. Available from: http://www.americanheart.org/downloadable/heart/1279224109481Methodology_Manual%206.2010.pdf
    PubMed
  • 6 Tricoci P, Allen JM, Kramer JM, Califf RM, Smith Jr SC. Scientific evidence underlying the ACC/ AHA clinical practice guidelines. JAMA 2009; 301 (Suppl. 08) 831-841.
    CrossrefPubMedGoogle Scholar
  • 7 Shaneyfelt TM, Centor RM. Reassessment of clinical practice guidelines: go gently into that good night. JAMA 2009; 301 (Suppl. 08) 868-869.
    CrossrefPubMedGoogle Scholar
  • 8 Patel VL, Arocha JF, Diermeier M, How J, MotturPilson C. Cognitive psychological studies of representation and use of clinical practice guidelines. Int J Med Inform 2001; 63 (Suppl. 03) 147-167.
    CrossrefPubMedGoogle Scholar
  • 9 Cook DJ, Greengold NL, Ellrodt AG, Weingarten SR. The Relation between Systematic Reviews and Practice Guidelines. Ann Intern Med 1997; 127: 210-216.
    CrossrefPubMedGoogle Scholar
  • 10 Codish S, Shiffman RN. A model of ambiguity and vagueness in clinical practice guideline recommendations. AMIA Annu Symp Proc 2005 pp 146-150.
    PubMedGoogle Scholar
  • 11 Littlejohns P, Cluzeau F. Guidelines for evaluation. Fam Pract 2000; 17 (Suppl. 01) S3-6.
    CrossrefPubMedGoogle Scholar
  • 12 Burgers JS, Cluzeau FA, Hanna SE, Hunt C, Grol R. Characteristics of high-quality guidelines: evaluation of 86 clinical guidelines developed in ten European countries and Canada. Int J Technol Assess Health Care 2003; 19 (Suppl. 01) 148-157.
    CrossrefPubMedGoogle Scholar
  • 13 Shiffman RN, Dixon J, Brandt C, Essaihi A, Hsiao A, Michel G. et al. The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation. BMC Med Inform Decis Mak 2005; 5: 23.
    CrossrefPubMedGoogle Scholar
  • 14 Appraisal of Guidelines for Research and Evaluation (cited 16.12.2009).. Available from: www.agreecollaboration.org
    PubMed
  • 15 Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization. Ann Intern Med 2003; 139 (Suppl. 06) 493-498.
    CrossrefPubMedGoogle Scholar
  • 16 Shiffman RN, Michel G, Essaihi A, Thornquist E. Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation. J Am Med Inform Assoc 2004; 11 (Suppl. 05) 418-426.
    CrossrefPubMedGoogle Scholar
  • 17 Boxwala AA, Tu S, Peleg M, Zeng Q, Ogunyemi O, Greenes RA. et al. Toward a representation format for sharable clinical guidelines. J Biomed Inform 2001; 34 (Suppl. 03) 157-169.
    CrossrefPubMedGoogle Scholar
  • 18 Grimshaw J, Eccles M, Thomas R, MacLennan G, Ramsay C, Fraser C. et al. Toward evidence-based quality improvement. Evidence (and its limitations) of the effectiveness of guideline dissemination and implementation strategies 1966-1998. J Gen Intern Med 2006; 21 (Suppl. 02) S14-20.
    CrossrefPubMedGoogle Scholar
  • 19 Prior M, Guerin M, Grimmer-Somers K. The effectiveness of clinical guideline implementation strategies – a synthesis of systematic review findings. J Eval Clin Pract 2008; 14 (Suppl. 05) 888-897.
    CrossrefPubMedGoogle Scholar
  • 20 Grol R, Zwaard A, Mokkink H, Dalhuijsen J, Casparie A. Dissemination of guidelines: which sources do physicians use in order to be informed?. Int J Qual Health Care 1998; 10 (Suppl. 02) 135-140.
    CrossrefPubMedGoogle Scholar
  • 21 Lin KW, Slawson DC. Identifying and using good practice guidelines. Am Fam Physician 2009; 80 (Suppl. 01) 67-70.
    PubMedGoogle Scholar
  • 22 Dufour JC, Fieschi D, Fieschi M. Coupling computer-interpretable guidelines with a drug-database through a web-based system – The PRESGUID project. BMC Med Inform Decis Mak 2004; 4: 2.
    CrossrefPubMedGoogle Scholar
  • 23 Morris AH. Developing and implementing computerized protocols for standardization of clinical decisions. Ann Intern Med 2000; 132 (Suppl. 05) 373-383.
    CrossrefPubMedGoogle Scholar
  • 24 Patel VL, Allen VG, Arocha JF, Shortliffe EH. Representing clinical guidelines in GLIF: individual and collaborative expertise. J Am Med Inform Assoc 1998; 5 (Suppl. 05) 467-483.
    CrossrefPubMedGoogle Scholar
  • 25 Gillois P, Chatellier G, Jaulent MC, Colombet I, Fieschi M, Degoulet P. From paper-based to electronic guidelines: application to French guidelines. Medinfo 2001; 10 Pt 1 196-200.
    PubMedGoogle Scholar
  • 26 Fox J, Black E, Chronakis I, Dunlop R, Patkar V, South M. et al. From guidelines to careflows: modelling and supporting complex clinical processes. Stud Health Technol Inform 2008; 139: 44-62.
    PubMedGoogle Scholar
  • 27 Trivedi MH, Kern JK, Marcee A, Grannemann B, Kleiber B, Bettinger T. et al. Development and implementation of computerized clinical guidelines: barriers and solutions. Methods Inf Med 2002; 41 (Suppl. 05) 435-442.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 28 Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318 7182 527-530.
    CrossrefPubMedGoogle Scholar
  • 29 Biondich PG, Downs SM, Carroll AE, Shiffman RN, McDonald CJ. Collaboration between the medical informatics community and guideline authors: fostering HIT standard development that matters. AMIA Annu Symp Proc 2006 pp 36-40.
    PubMedGoogle Scholar
  • 30 Shekelle PG, Woolf SH, Eccles M, Grimshaw J. Clinical guidelines: developing guidelines. BMJ 1999; 318 7183 593-596.
    CrossrefPubMedGoogle Scholar
  • 31 Goud R, Hasman A, Strijbis AM, Peek N. A parallel guideline development and formalization strategy to improve the quality of clinical practice guidelines. Int J Med Inform 2009; 78 (Suppl. 08) 513-520.
    CrossrefPubMedGoogle Scholar
  • 32 Peleg M, Gutnik LA, Snow V, Patel VL. Interpreting procedures from descriptive guidelines. J Biomed Inform 2006; 39 (Suppl. 02) 184-195.
    CrossrefPubMedGoogle Scholar
  • 33 Musen MA, Fagan LM, Combs DM, Shortliffe EH. Use of a domain model to drive an interactive knowledge-editing tool. Int J Man-Mach Stud 1987; 26 (Suppl. 01) 105-121.
    PubMedGoogle Scholar
  • 34 Peleg M, Tu SW. Design patterns for clinical guidelines. Artif Intell Med 2009; 47 (Suppl. 01) 1-24.
    CrossrefPubMedGoogle Scholar
  • 35 Tran N, Michel G, Krauthammer M, Shiffman RN. Embedding the Guideline Elements Model in Web Ontology Language. AMIA Annu Symp Proc 2009 pp 645-649.
    PubMedGoogle Scholar
  • 36 Votruba P, Miksch S, Seyfang A, Kosara R. Tracing the formalization steps of textual guidelines. Stud Health Technol Inform 2004; 101: 172-176.
    PubMedGoogle Scholar
  • 37 Svatek V, Ruzicka M. Step-by-step mark-up of medical guideline documents. Int J Med Inform 2003; 70 2–3 329-335.
    CrossrefPubMedGoogle Scholar
  • 38 Shahar Y, Young O, Shalom E, Galperin M, Mayaffit A, Moskovitch R. et al. A framework for a distributed, hybrid, multiple-ontology clinical-guideline library, and automated guideline-support tools. J Biomed Inform 2004; 37 (Suppl. 05) 325-344.
    CrossrefPubMedGoogle Scholar
  • 39 Leslie SJ, Hartswood M, Meurig C, McKee SP, Slack R, Procter R. et al. Clinical decision support software for management of chronic heart failure: development and evaluation. Comput Biol Med 2006; 36 (Suppl. 05) 495-506.
    CrossrefPubMedGoogle Scholar
  • 40 Goldstein MK, Hoffman BB, Coleman RW, Tu SW, Shankar RD, O’Connor M. et al. Patient safety in guideline-based decision support for hypertension management: ATHENA DSS. Proc AMIA Symp 2001 pp 214-218.
    PubMedGoogle Scholar
  • 41 Vogelzang M, Zijlstra F, Nijsten MW. Design and implementation of GRIP: a computerized glucose control system at a surgical intensive care unit. BMC Med Inform Decis Mak 2005; 5: 38.
    CrossrefPubMedGoogle Scholar
  • 42 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ 2005; 330 7494 765.
    CrossrefPubMedGoogle Scholar
  • 43 Mollon B, Chong Jr J, Holbrook AM, Sung M, Thabane L, Foster G. Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials. BMC Med Inform Decis Mak 2009; 9: 11.
    CrossrefPubMedGoogle Scholar
  • 44 Wright A, Sittig DF. A four-phase model of the evolution of clinical decision support architectures. Int J Med Inform 2008; 77 (Suppl. 10) 641-649.
    CrossrefPubMedGoogle Scholar
  • 45 Wright A, Sittig DF. A framework and model for evaluating clinical decision support architectures. J Biomed Inform 2008; 41 (Suppl. 06) 982-990.
    CrossrefPubMedGoogle Scholar
  • 46 Patel VL, Branch T, Wang D, Peleg M, Boxwala A. Analysis of the process of encoding guidelines: a comparison of GLIF2 and GLIF3. Methods Inf Med 2002; 41 (Suppl. 02) 105-113.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Wang D, Peleg M, Tu SW, Boxwala AA, Ogunyemi O, Zeng Q. et al. Design and implementation of the GLIF3 guideline execution engine. J Biomed Inform 2004; 37 (Suppl. 05) 305-318.
    CrossrefPubMedGoogle Scholar
  • 48 De Clercq P, Kaiser K, Hasman A. Computer-interpretable Guideline Formalisms. Stud Health Technol Inform 2008; 139: 22-43.
    PubMedGoogle Scholar
  • 49 Isern D, Moreno A. Computer-based execution of clinical guidelines: a review. Int J Med Inform 2008; 77 (Suppl. 12) 787-808.
    CrossrefPubMedGoogle Scholar
  • 50 Sonnenberg FA, Hagerty CG. Computer-interpretable clinical practice guidelines. Where are we and where are we going? Yearb Med Inform 2006 pp 145-158.
    PubMedGoogle Scholar
  • 51 Peleg M, Tu S, Bury J, Ciccarese P, Fox J, Greenes RA. et al. Comparing computer-interpretable guideline models: a case-study approach. J Am Med Inform Assoc 2003; 10 (Suppl. 01) 52-68.
    CrossrefPubMedGoogle Scholar
  • 52 Wang D, Peleg M, Tu SW, Boxwala AA, Greenes RA, Patel VL. et al. Representation primitives, process models and patient data in computer-interpretable clinical practice guidelines: a literature review of guideline representation models. Int J Med Inform 2002; 68 1–3 59-70.
    CrossrefPubMedGoogle Scholar
  • 53 Seroussi B, Bouaud J, Chatellier G. Guideline-based modeling of therapeutic strategies in the special case of chronic diseases. Int J Med Inform 2005; 74 2–4 89-99.
    CrossrefPubMedGoogle Scholar
  • 54 Bouaud J, Seroussi B, Falcoff H, Venot A. Design factors for success or failure of guideline-based decision support systems: an hypothesis involving case complexity. AMIA Annu Symp Proc 2006 pp 71-75.
    PubMedGoogle Scholar
  • 55 de Clercq PA, Blom JA, Korsten HH, Hasman A. Approaches for creating computer-interpretable guidelines that facilitate decision support. Artif Intell Med 2004; 31 (Suppl. 01) 1-27.
    CrossrefPubMedGoogle Scholar
  • 56 Wang D, Peleg M, Bu D, Cantor M, Landesberg G, Lunenfeld E. et al. GESDOR – a generic execution model for sharing of computer-interpretable clinical practice guidelines. AMIA Annu Symp Proc 2003 pp 694-698.
    PubMedGoogle Scholar
  • 57 Tu SW, Campbell J, Musen MA. The SAGE guideline modeling: motivation and methodology. Stud Health Technol Inform 2004; 101: 167-171.
    PubMedGoogle Scholar
  • 58 Tu SW, Campbell JR, Glasgow J, Nyman MA, McClure R, McClay J. et al. The SAGE Guideline Model: achievements and overview. J Am Med Inform Assoc 2007; 14 (Suppl. 05) 589-598.
    CrossrefPubMedGoogle Scholar
  • 59 Fox JP, Bury J, Humber M, Rahmanzadeh A, Thomson R. Publets: clinical judgement on the web. Proc AMIA Symp 2001 pp 179-183.
    PubMedGoogle Scholar
  • 60 Kawamoto K, Lobach DF. Proposal for fulfilling strategic objectives of the U. S. Roadmap for national action on clinical decision support through a service-oriented architecture leveraging HL7 services. J Am Med Inform Assoc 2007; 14 (Suppl. 02) 146-155.
    CrossrefPubMedGoogle Scholar
  • 61 Kawamoto K, Lobach DF. Design, implementation, use, and preliminary evaluation of SEBASTIAN, a standards-based Web service for clinical decision support. AMIA Annu Symp Proc 2005; pp 380-384.
    PubMedGoogle Scholar
  • 62 Dominguez E, Perez B, Zapata M. Towards a Traceable Clinical Guidelines Application. Methods Inf Med 2010; 49: 571-580 (this issue).
    Article in Thieme ConnectPubMedGoogle Scholar
  • 63 Skonetzki S, Gausepohl HJ, van der Haak M, Knaebel S, Linderkamp O, Wetter T. HELEN, a modular framework for representing and implementing clinical practice guidelines. Methods Inf Med 2004; 43 (Suppl. 04) 413-426.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 64 Musen MA, Eriksson H, Gennari JH, Tu SW, Puerta AR. PROTEGE-II: a suite of tools for development of intelligent systems from reusable components. Proc Annu Symp Comput Appl Med Care 1994 p 1065.
    PubMedGoogle Scholar
  • 65 Johnson PD, Tu SW, Musen MA, Purves I. A virtual medical record for guideline-based decision support. Proc AMIA Symp 2001; pp 294-298.
    PubMedGoogle Scholar
  • 66 Marcos M, Roomans H, ten Teije A, van Harmelen F. Improving medical protocols through formalization: a case study. In: Proc of the 6th Int Conf on Integrated Design and Process Technology (IDPT-02) 2002
    PubMedGoogle Scholar
  • 67 Martens JD, Werkhoven MJ, Severens JL, Winkens RA. Effects of a behaviour independent financial incentive on prescribing behaviour of general practitioners. J Eval Clin Pract 2007; 3: 369-373.
    PubMedGoogle Scholar
  • 68 Bindels R, Hasman A, Kester AD, Talmon JL, De Clercq PA, Winkens RA. The efficacy of an automated feedback system for general practitioners. Inform Prim Care 2003; 11 (Suppl. 02) 69-74.
    PubMedGoogle Scholar
  • 69 Carton M, Auvert B, Guerini H, Boulard JC, Heautot JF, Landre MF. et al. Assessment of radiological referral practice and effect of computer-based guidelines on radiological requests in two emergency departments. Clin Radiol 2002; 57 (Suppl. 02) 123-128.
    CrossrefPubMedGoogle Scholar
  • 70 Lugtenberg M, Burgers JS, Westert GP. Effects of evidence-based clinical practice guidelines on quality of care: a systematic review. Qual Saf Health Care 2009; 18 (Suppl. 05) 385-392.
    CrossrefPubMedGoogle Scholar
  • 71 Butzlaff M, Vollmar HC, Floer B, Koneczny N, Isfort J, Lange S. Learning with computerized guidelines in general practice? A randomized controlled trial. Fam Pract 2004; 21 (Suppl. 02) 183-188.
    CrossrefPubMedGoogle Scholar
  • 72 Jousimaa J, Makela M, Kunnamo I, MacLennan G, Grimshaw JM. Primary care guidelines on consultation practices: the effectiveness of computerized versus paper-based versions. A cluster randomized controlled trial among newly qualified primary care physicians. Int J Technol Assess Health Care 2002; 18 (Suppl. 03) 586-596.
    PubMedGoogle Scholar
  • 73 Shiffman RN, Liaw Y, Brandt CA, Corb GJ. Computer-based guideline implementation systems: a systematic review of functionality and effectiveness. J Am Med Inform Assoc 1999; 6 (Suppl. 02) 104-114.
    CrossrefPubMedGoogle Scholar
  • 74 Shiffman RN, Brandt CA, Liaw Y, Corb GJ. A design model for computer-based guideline implementa tion based on information management services. J Am Med Inform Assoc 1999; 6 (Suppl. 02) 99-103.
    CrossrefPubMedGoogle Scholar
  • 75 Hunt DL, Haynes RB, Hanna SE, Smith K. Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 1998; 280 (Suppl. 15) 1339-1346.
    CrossrefPubMedGoogle Scholar
  • 76 Garg AX, Adhikari NK, McDonald H, Rosas Arellano MP, Devereaux PJ, Beyene J. et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA 2005; 293 (Suppl. 10) 1223-1238.
    CrossrefPubMedGoogle Scholar
  • 77 Ambresin AE, D’Acremont V, Mueller Y, Martin O, Burnand B, Genton B. www.fevertravel.ch an online study prototype to evaluate the safety and feasibility of computerized guidelines for fever in returning travellers and migrants Comput Methods Programs Biomed 2007; 85 (Suppl. 01) 19-31.
    CrossrefPubMed
  • 78 Overhage JM, Tierney WM, Zhou XH, McDonald CJ. A randomized trial of “corollary orders” to prevent errors of omission. J Am Med Inform Assoc 1997; 4 (Suppl. 05) 364-375.
    CrossrefPubMedGoogle Scholar
  • 79 Goud R, Engen-Verheul Mv, Keizer Nd, Bal R, Hasman A, Hellemans IM. et al. The effects of computerized decision support on barriers to guideline implementation: A quality study in out-patient cardiac rehabilitation. Int J Med Inform 2010; 79 (Suppl. 06) 430-437.
    CrossrefPubMedGoogle Scholar
  • 80 Goud R, Jaspers MW, Hasman A, Peek N. Subjective usability of the CARDSS guideline-based decision support system. Stud Health Technol Inform 2008; 136: 193-198.
    PubMedGoogle Scholar
  • 81 Chan AS, Coleman RW, Martins SB, Advani A, Musen MA, Bosworth HB. et al. Evaluating provider adherence in a trial of a guideline-based decision support system for hypertension. Medinfo 2004; 11 Pt 1 125-129.
    PubMedGoogle Scholar
  • 82 Worrall G, Chaulk P, Freake D. The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review. CMAJ 1997; 156 (Suppl. 12) 1705-1712.
    PubMedGoogle Scholar
  • 83 Eagle KA, Montoye CK, Riba AL, DeFranco AC, Parrish R, Skorcz S. et al. Guideline-based standardized care is associated with substantially lower mortality in medicare patients with acute myocardial infarction: the American College of Cardiology’s Guidelines Applied in Practice (GAP) Projects in Michigan. J Am Coll Cardiol 2005; 46 (Suppl. 07) 1242-1248.
    CrossrefPubMedGoogle Scholar
  • 84 Heselmans A, Van de Velde S, Donceel P, Aertgeerts B, Ramaekers D. Effectiveness of electronic guideline-based implementation systems in ambulatory care settings – a systematic review. Implement Sci 2009; 4 (Suppl. 01) 82.
    CrossrefPubMedGoogle Scholar
  • 85 Bryan C, Boren S. The use and effectiveness of electronic clinical decision support tools in the ambulatory/primary care setting: a systematic review of the literature. Inform Prim Care 2008; 16 (Suppl. 02) 79-91 (13).
    PubMedGoogle Scholar
  • 86 Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342 8883 1317-1322.
    CrossrefPubMedGoogle Scholar
  • 87 Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA. et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15) 1458-1465.
    CrossrefPubMedGoogle Scholar
  • 88 Lugtenberg M, Zegers-van Schaick JM, Westert GP, Burgers JS. Why don’t physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci 2009; 4: 54.
    CrossrefPubMedGoogle Scholar
  • 89 Espeland A, Baerheim A. Factors affecting general practitioners’ decisions about plain radiography for back pain: implications for classification of guideline barriers – a qualitative study. BMC Health Serv Res 2003; 3 (Suppl. 01) 8.
    CrossrefPubMedGoogle Scholar
  • 90 Tehrani FT, Roum JH. Intelligent decision support systems for mechanical ventilation. Artif Intell Med 2008; 44 (Suppl. 03) 171-182.
    CrossrefPubMedGoogle Scholar
  • 91 Grol R, Dalhuijsen J, Thomas S, Veld C, Rutten G, Mokkink H. Attributes of clinical guidelines that influence use of guidelines in general practice: observational study. BMJ 1998; 317 7162 858-861.
    CrossrefPubMedGoogle Scholar
  • 92 LaBresh KA. Quality of acute stroke care improvement framework for the Paul Coverdell National Acute Stroke Registry: facilitating policy and system change at the hospital level. Am J Prev Med 2006; 31 6 Suppl 2 S246-250.
    CrossrefPubMedGoogle Scholar
  • 93 Fieschi M, Dufour JC, Staccini P, Gouvernet J, Bouhaddou O. Medical decision support systems: old dilemmas and new paradigms?. Methods Inf Med 2003; 42 (Suppl. 03) 190-198.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 94 Gibbons RJ, Antman EM, Smith SC. Has guideline development gone astray? No. BMJ 340-c343.
    PubMedGoogle Scholar
  • 95 Grol R. Has guideline development gone astray? Yes. BMJ 340-c306.
    PubMedGoogle Scholar
  • 96 Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. A roadmap for national action on clinical decision support. J Am Med Inform Assoc 2007; 14 (Suppl. 02) 141-145.
    CrossrefPubMedGoogle Scholar
  • 97 Marcos M, Berger G, van Harmelen F, ten Teije A, Roomans H, Miksch S. Using critiquing for improving medical protocols: harder than it seems. In: Proc of the 8th European Conference on Artificial Intelligence in Medicine (AIME-2001) 2001 pp 431-441.
    PubMedGoogle Scholar
  • 98 Hommersom A, Groot P, Balser M, Lucas P. Formal methods for verification of clinical practice guidelines. Stud Health Technol Inform 2008; 139: 63-80.
    PubMedGoogle Scholar
  • 99 Schmitt J, Balser M, Reif W. Verification of medical guidelines in KIV. Stud Health Technol Inform 2008; 139: 253-262.
    PubMedGoogle Scholar
  • 100 Groot P, Hommersom A, Lucas P. Adaptation of clinical practice guidelines. Stud Health Technol Inform 2008; 139: 121-139.
    PubMedGoogle Scholar
  • 101 Chesani F, Lamma E, Mello P, Montali M, Storari S, Baldazzi P. et al. Compliance checking of cancer-screening. Careflows: an approach based on Computational Logic. Stud Health Technol Inform 2008; 139: 183-192.
    PubMedGoogle Scholar
  • 102 Groot P, Hommersom A, Lucas PJ, Merk RJ, Ten Teije A, van Harmelen F. et al. Using model checking for critiquing based on clinical guidelines. Artif Intell Med 2008
    PubMedGoogle Scholar
  • 103 Quaglini S. Compliance with clinical practice guidelines. Stud Health Technol Inform 2008; 139: 160-179.
    PubMedGoogle Scholar