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Methods Inf Med 2004; 43(04): 413-426
DOI: 10.1055/s-0038-1633885
Original Article
Schattauer GmbH

HELEN, a Modular Framework for Representing and Implementing Clinical Practice Guidelines

S. Skonetzki
1   Department of Medical Informatics, Heidelberg University Medical Center, Germany
,
H.-J. Gausepohl
2   Department of Neonatology, Heidelberg University Medical Center, Germany
,
M. van der Haak
1   Department of Medical Informatics, Heidelberg University Medical Center, Germany
,
S. Knaebel
2   Department of Neonatology, Heidelberg University Medical Center, Germany
,
O. Linderkamp
2   Department of Neonatology, Heidelberg University Medical Center, Germany
,
T. Wetter
1   Department of Medical Informatics, Heidelberg University Medical Center, Germany
› Institutsangaben
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Publikationsverlauf

Publikationsdatum:
05. Februar 2018 (online)

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Summary

Objectives: In order to implement clinical practice guidelines for the Department of Neonatology of the Heidelberg University Medical Center we developed a modular framework consisting of tools for authoring, browsing and executing encoded clinical practice guidelines (CPGs).

Methods: Based upon a comprehensive analysis of literature, we set up requirements for guideline representation systems. Additionally, we analyzed further aspects such as the critical appraisal and known bridges and barriers for implementing CPGs. Thereafter we went through an evolutionary spiral model to develop a comprehensive ontology. Within this model each cycle focuses on a certain topic of management and implementation of CPGs.

Results: In order to bring the resulting ontology into practice we developed a framework consisting of a tool for authoring, a server for web-based browsing, and an engine for the execution of certain elements of CPGs. Based upon this framework we encoded and implemented several CPGs in varying medical domains.

Conclusions: This paper shall present a practical framework for both authors and implementers of CPGs. We have shown the fruitful combination of different knowledge representations such as narrative text and algorithm for implementing CPGs. Finally, we introduced a possible approach for the explicit adaptation of CPGs in order to provide institution-specific recommendations and to support sharing with other medical institutions.

Keywords

Clinical practice guidelines - representation - acquisition - implementation - local adaptation - execution - decision support
 

  • References

  • 1 Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342 8883 1317-22.
    CrossrefPubMedGoogle Scholar
  • 2 Hibble A, Kanka D, Pencheon D. et al. Guidelines in general practice: the new Tower of Babel?. BMJ 1998; 317 7162 862-3.
    CrossrefPubMedGoogle Scholar
  • 3 Woolf SH, Grol R, Hutchinson A. et al. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318 7182 527-30.
    CrossrefPubMedGoogle Scholar
  • 4 Cabana MD, Rand CS, Powe NR. et al. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282 (15) 1458-65.
    CrossrefPubMedGoogle Scholar
  • 5 Dahlberg K. Reasons physicians do not follow clinical practice guidelines. JAMA 2000; 283 (13) 1686
    CrossrefPubMedGoogle Scholar
  • 6 Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997; 157 (04) 408-16.
    PubMedGoogle Scholar
  • 7 Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. BMJ 1998; 317 7153 273-6.
    CrossrefPubMedGoogle Scholar
  • 8 Grimshaw J, Russell I. Achieving health gain through clinical guidelines. I: Developing scientifically valid guidelines. Qual Health Care 1993; 2 (04) 243-8.
    CrossrefPubMedGoogle Scholar
  • 9 Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines II: Ensuring guidelines change medical practice. Qual Health Care 1994; 3 (01) 45-52.
    PubMedGoogle Scholar
  • 10 Keffer JH. Guidelines and algorithms: perceptions of why and when they are successful and how to improve them. Clin Chem 2001; 47 (08) 1563-72.
    PubMedGoogle Scholar
  • 11 Duff L, Casey A. Implementing clinical guidelines: how can informatics help?. J Am Med Inform Assoc 1998; 5 (03) 225-6.
    CrossrefPubMedGoogle Scholar
  • 12 Frankel HL, FitzPatrick MK, Gaskell S. et al. Strategies to improve compliance with evidence- based clinical management guidelines. J Am Coll Surg 1999; 189 (06) 533-8.
    CrossrefPubMedGoogle Scholar
  • 13 Patel VL, Arocha JF, Diermeier M. et al. Cognitive psychological studies of representation and use of clinical practice guidelines. Int J Med Inf 2001; 63 (03) 147-67.
    CrossrefPubMedGoogle Scholar
  • 14 Boxwala AA, Tu S, Peleg M. et al. Toward a representation format for sharable clinical guidelines. J Biomed Inform 2001; 34 (03) 157-69.
    CrossrefPubMedGoogle Scholar
  • 15 Corb GJ, Liaw Y, Brandt CA. et al. An objectoriented framework for the development of computer-based guideline implementations. Methods Inf Med 1999; 38 (03) 148-53.
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 16 Silagy C, Weller D, Lapsley H. et al. The effectiveness of local adaptation of nationally produced clinical practice guidelines. Fam Pract 2002; 19 (03) 223-30.
    CrossrefPubMedGoogle Scholar
  • 17 Tierney WM, Overhage JM, Takesue BY. et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. JAMIA 1995; 2 (05) 316-22.
    PubMedGoogle Scholar
  • 18 Smith WR. Evidence for the effectiveness of techniques To change physician behavior. Chest 2000; 118 (Suppl. 02) Suppl 8S-17S.
    CrossrefPubMedGoogle Scholar
  • 19 Greco PJ, Eisenberg JM. Changing physicians’ practices. N Engl J Med 1993; 329 (17) 1271-3.
    CrossrefPubMedGoogle Scholar
  • 20 Johnston ME, Langton KB, Haynes RB. et al. Effects of computer-based clinical decision support systems on clinician performance and patient outcome. A critical appraisal of research. Ann Intern Med 1994; 120 (02) 135-42.
    CrossrefPubMedGoogle Scholar
  • 21 Shea S, DuMouchel W, Bahamonde L. A metaanalysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. JAMIA 1996; 3 (06) 399-409.
    PubMedGoogle Scholar
  • 22 Shiffman RN, Liaw Y, Brandt CA. et al. Computer- based guideline implementation systems: a systematic review of functionality and effectiveness. JAMIA 1999; 6 (02) 104-14.
    PubMedGoogle Scholar
  • 23 Greenes RA, Peleg M, Boxwala A. et al. Sharable computer-based clinical practice guidelines: rationale, obstacles, approaches, and prospects. Medinfo 2001; 10 (Pt 1) 201-5.
    PubMedGoogle Scholar
  • 24 Lukoff JY, Dolin RH, McKinley CS. et al. Validation of an XML-based process to automatically web-enable clinical practice guidelines: experience with the smoking cessation guideline. Proc AMIA Symp. 1999: 311-4.
    Google Scholar
  • 25 Hoelzer S, Schweiger R, Dudeck J. Representation of practice guidelines with XML – modeling with XML schema. Methods Inf Med 2002; 41 (04) 305-12.
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 26 Dufour JC, Fieschi M, Fieschi D. et al. A Platform to Develop and to Improve Effectiveness of Online Computable Guidelines. Stud Health Technol Inform 2003; 95: 445-51.
    PubMedGoogle Scholar
  • 27 Agrawal A, Shiffman RN. Evaluation of guideline quality using GEM-Q. Medinfo 2001; 10 (Pt 2) 1097-101.
    PubMedGoogle Scholar
  • 28 Agrawal A, Shiffman RN. Using GEM-encoded guidelines to generate medical logic modules. Proc AMIA Symp 2001; 7-11.
    PubMedGoogle Scholar
  • 29 Gershkovich P, Shiffman RN. An implementation framework for GEM encoded guidelines. Proc AMIA Symp. 2001: 204-8.
    Google Scholar
  • 30 Terenziani P, Molino G, Torchio M. A modular approach for representing and executing clinical guidelines. Artif Intell Med 2001; 23 (03) 249-76.
    CrossrefPubMedGoogle Scholar
  • 31 Lobach DF, Gadd CS, Hales JW. Structuring clinical practice guidelines in a relational database model for decision support on the Internet. Proc AMIA Annu Fall Symp. 1997: 158-62.
    Google Scholar
  • 32 Ohno-Machado L, Gennari JH, Murphy SN. et al. The guideline interchange format: a model for representing guidelines. J Am Med Inform Assoc 1998; 5 (04) 357-72.
    CrossrefPubMedGoogle Scholar
  • 33 Tu SW, Musen MA. A flexible approach to guideline modeling. Proc AMIA Symp 1999; 420-4.
    PubMedGoogle Scholar
  • 34 Boxwala AA, Greenes RA, Deibel SR. Architecture for a multipurpose guideline execution engine. Proc AMIA Symp. 1999: 701-5.
    Google Scholar
  • 35 Greenes RA, Boxwala A, Sloan WN. et al. A framework and tools for authoring, editing, documenting, sharing, searching, navigating, and executing computer-based clinical guidelines. Proc AMIA Symp. 1999: 261-5.
    Google Scholar
  • 36 Peleg M, Boxwala AA, Ogunyemi O. et al. GLIF3: the evolution of a guideline representation format. Proc AMIA Symp. 2000: 645-9.
    Google Scholar
  • 37 Peleg M, Ogunyemi O, Tu S. et al. Using features of Arden Syntax with object-oriented medical data models for guideline modeling. Proc AMIA Symp. 2001: 523-7.
    Google Scholar
  • 38 Zielstorff RD, Teich JM, Paterno MD. et al. P-CAPE: a high-level tool for entering and processing clinical practice guidelines. Partners Computerized Algorithm and Editor. Proc AMIA Symp. 1998: 478-82.
    Google Scholar
  • 39 Kuperman GJ, Teich JM, Bates DW. et al. Detecting alerts, notifying the physician, and offering action items: a comprehensive alerting system. Proc AMIA Annu Fall Symp. 1996: 704-8.
    Google Scholar
  • 40 Purves IN, Sugden B, Booth N. et al. The PRODIGY project – the iterative development of the release one model. Proc AMIA Symp. 1999: 359-63.
    Google Scholar
  • 41 Johnson PD, Tu S, Booth N. et al. Using scenarios in chronic disease management guidelines for primary care. Proc AMIA Symp. 2000: 389-93.
    Google Scholar
  • 42 Shahar Y, Miksch S, Johnson P. The Asgaard project: a task-specific framework for the application and critiquing of time-oriented clinical guidelines. Artif Intell Med 1998; 14 1-2 29-51.
    CrossrefPubMedGoogle Scholar
  • 43 Barahona P, Azevedo F, Veloso M. et al. A computerised guideline for the management of diabetes. Stud Health Technol Inform 2000; 77: 600-4.
    PubMedGoogle Scholar
  • 44 Fox J, Johns N, Rahmanzadeh A. Disseminating medical knowledge: the PROforma approach. Artif Intell Med 1998; 14 1-2 157-81.
    CrossrefPubMedGoogle Scholar
  • 45 Musen MA, Tu SW, Das AK. et al. EON: a component-based approach to automation of protocol-directed therapy. J Am Med Inform Assoc 1996; 3 (06) 367-88.
    CrossrefPubMedGoogle Scholar
  • 46 Tu SW, Musen MA. From guideline modeling to guideline execution: defining guidelinebased decision-support services. Proc AMIA Symp. 2000: 863-7.
    Google Scholar
  • 47 Elkin PL, Peleg M, Lacson R. et al. Toward the standardization of electronic guidelines. MD Comput 2000; 17 (06) 39-44.
    PubMedGoogle Scholar
  • 48 Peleg M, Tu S, Bury J. et al. Comparing computer- interpretable guideline models: a case-study approach. JAMIA 2003; 10 (01) 52-68.
    PubMedGoogle Scholar
  • 49 AeZQ, Checkliste zur Bewertung der Methodischen Qualität von Leitlinien. Dt Ärzteblatt 2000; 97 (17) A1170-1172.
    PubMedGoogle Scholar
  • 50 Gruber TR. A Translation Approach to Portable Ontology Specification. Knowledge Acquisition 1993; (05) 199-220.
    PubMedGoogle Scholar
  • 51 Musen MA. Dimensions of knowledge sharing and reuse. Comput Biomed Res 1992; 25 (05) 435-67.
    CrossrefPubMedGoogle Scholar
  • 52 Angele J, Decker S, Studer R. Domain and Task Modeling in MIKE. In: Domain Knowledge for Interactive Systems Design, Proceedings of IFIP WG 8.1/13.2 Joint Working Conference. 1996. Genevam Nay: Chapman & Hall;
    Google Scholar
  • 53 Boehm BW. A Spiral Model of Software Development and Enhancement. ACM SIGSOFT 1988; 4 (11) 21-42.
    PubMedGoogle Scholar
  • 54 AGREE, Guideline development in Europe. An international comparison. Int J Technol Assess Health Care 2000; 16 (04) 1039-49.
    CrossrefPubMedGoogle Scholar
  • 55 Burgers J, Grol R, Klazinga N. et al. International comparison of 19 clinical guideline programs – a survey of the AGREE Collaboration. Z Arztl Fortbild Qualitatssich 2003; 97 (01) 81-8.
    PubMedGoogle Scholar
  • 56 Cluzeau FA, Littlejohns P, Grimshaw JM. et al. Development and application of a generic methodology to assess the quality of clinical guidelines. Int J Qual Health Care 1999; 11 (01) 21-8.
    CrossrefPubMedGoogle Scholar
  • 57 Bernstam E, Ash N, Peleg M. et al. Guideline classification to assist modeling, authoring, implementation and retrieval. Proc AMIA Symp. 2000: 66-70.
    Google Scholar
  • 58 Helou A, Perleth M, Bitzer EM. et al. Methodological quality of clinical practice guidelines in Germany: results of a systemic assessment of guidelines presented on the Internet. Z Ärztl Fortbild Qualitätssich 1998; 92 (06) 421-8.
    PubMedGoogle Scholar
  • 59 Shiffman RN, Karras BT, Agrawal A. et al. GEM: a proposal for a more comprehensive guideline document model using XML. JAMIA 2000; 7 (05) 488-98.
    PubMedGoogle Scholar
  • 60 Mayerhoff L. Optimal embedding of a knowledge based system in an existing clinical environment. Specification of requirements and design based upon the CommonKADS methodology. Institute for Medical Biometry and Informatics, Department of Medical Informatics, University of Heidelberg; Heidelberg: 2000: 151
    Google Scholar
  • 61 SIGN, SIGN 50: A guideline developers’ handbook. 1992, Scottish Intercollegiate Guidelines Network. www.sign.ac.uk/guidelines/fulltext/50/index.html Last Access: January 10 2004
    PubMedGoogle Scholar
  • 62 Gerlach FM, Beyer M, Berndt M. et al. The DEGAM-concept – development, dissemination, implementation and evaluation of guidelines for general practice. Z Ärztl Fortbild Qualitätssich 1999; 93 (02) 111-20.
    PubMedGoogle Scholar
  • 63 de Clercq PA, Blom JA, Hasman A. et al. An ontology-driven approach for the acquisition and execution of clinical guidelines. Stud Health Technol Inform 2000; 77: 714-9.
    PubMedGoogle Scholar
  • 64 Uschold M, Grunninger M. Ontologies: Principles, Methods and Applications. Knowledge Engineering Review 1996; 1 (02) 93-155.
    PubMedGoogle Scholar
  • 65 NGC, NGC Classification for CPGs. 2002. www.guideline.gov/FRAMESETS/static_fs.asp?view=about.overview.classify Last Access: December 15 2003
    PubMedGoogle Scholar
  • 66 Noy FN, McGuiness DL. Ontology Development 101: A Guide to Creating Your First Ontology. 2001. Stanford Medical Informatics; Stanford: 25
    Google Scholar
  • 67 Gennari JH, Musen MA, Fergerson RW. et al. The Evolution of Protégé: An Environment for Knowledge-Based Systems Development. 2002. Stanford Medical Informatics; Stanford: 32
    Google Scholar
  • 68 Ollenschlager G, Helou A, Kostovic-Cilic L. et al. Checklist for methodological quality of guidelines. A contribution to quality promotion of medical guidelines. Z Ärztl Fortbild Qualitätssich 1998; 92 (03) 191-4.
    PubMedGoogle Scholar
  • 69 Fallside DC. XML Schema Part 0: Primer. 2001 W3C Recommendation
    PubMedGoogle Scholar
  • 70 Sun, JAVA Servlet Technology. 2003 http://java.sun.com/products/servlet/index.html Last Access: 21.01.2004
    PubMedGoogle Scholar
  • 71 Jakarta, The Apache Jakarta Project. 2003. http://jakarta.apache.org/tomcat/ Last Access: January 21 2004
    PubMedGoogle Scholar
  • 72 Protege, Protégé Plug-ins Library. 2002. http://protege.stanford.edu/plugins.html Last Access: January 21 2004
    PubMedGoogle Scholar
  • 73 Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003; 362 9391 1225-30.
    CrossrefPubMedGoogle Scholar
  • 74 Gell G, Schmucker P, Pedevilla M. et al. SAP and partners: IS-H and IS-H* MED. Methods Inf Med 2003; 42 (01) 16-24.
    Artikel in Thieme ConnectPubMedGoogle Scholar
  • 75 AAP, Practice parameter: management of hyperbilirubinemia in the healthy term newborn. American Academy of Pediatrics. Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Pediatrics 1994; 94 (4 Pt 1) 558-65.
    PubMedGoogle Scholar
  • 76 Bhatia J. Current options in the management of apnea of prematurity. Clin Pediatr (Phila) 2000; 39 (06) 327-36.
    CrossrefPubMedGoogle Scholar
  • 77 Emborn C, Humphrey JA. Apnea of prematurity. 1999, National Association of Neonatal Nurses – Professional Association.
    PubMedGoogle Scholar
  • 78 Biswas J. Practical concepts in the management of uveitis. Indian J Ophthalmol 1993; 41 (03) 133-41.
    PubMedGoogle Scholar
  • 79 Becker MD, Rosenbaum JT. Essential laboratory tests in uveitis. Dev Ophthalmol 1999; 31: 92-108.
    PubMedGoogle Scholar
  • 80 Becker H, Drings P, Havemann K. et al. Treatment of small-cell lung cancer. In: Quality assurance in oncology. Diagnosis and therapy malignany diseaes, I.f.S.i.d.O. (ISTO), Editor: Deutsche Krebsgesellschaft e.V.: Muenchen. 1999: 218-229.
    Google Scholar
  • 81 Beeler GWJ. Taking HL7 to the next level. MD Comput 1999; 2 (16) 21-4.
    PubMedGoogle Scholar
  • 82 Cornet R, Abu-Hanna A. Usability of expressive description logics – a case study in UMLS. Proc AMIA Symp. 2002: 180-4.
    Google Scholar