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
Overview GEM – the Guideline Elements
Model Implementation Issues 3 Tasks in Implementation
Knowledge extraction Knowledge customization Knowledge integration
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
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
GEM: Major Components
Guideline
Identity
Purpose
Intended Audience
Method ofDevelopment
KnowledgeComponents
Testing RevisionPlan
TargetPopulation
DocumentHeader
DocumentBody
Developer
JAMIA 2000
Knowledge Components
Recommendation
Conditional Imperative
Definition
Term
TermMeaning
Algorithm
SyncStep
ActionStep
Condit’lStep
BranchStep
KnowledgeComponents
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
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
Implementation Process
Black BoxPublished Guideline
Computer-Based Guideline Implementation
What goes on in the black box?
3 sets of activities Knowledge extraction Knowledge customization Knowledge integration
GEM tools and solutions
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
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...
GEM Cutter
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>
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
Prose Guideline Document
GEM Cutter
GEM Document
Logician ER
DOM
Metadata
Knowledge Customization
Knowledge Extraction
XSLStylesheet
Decidable?
Decision Variable
Value
Age 2 months to 2 years
Unexplained fever
{true}
Ill Sufficient…to warrant immediate antimicrobial therapy
Element “source” attribute Explicit Inferred Selection from controlled
vocabulary (NGC)
Knowledge integration Support local workflow Source of information Codes / vocabularies User interface
Knowledge Integration Activities Decide mode of delivery for advice
Prescriptive Critiquing
Set bounds based on evidence quality, recommendation strength
Incorporate patient preference
Provide Services for Information Management Documentation Recommendation Explanation Registration
Communication Calculation Presentation Aggregation
Shiffman, et al., JAMIA 1999
In conclusion… GEM documents can serve as portable
knowledge repositories for decision support systems. Knowledge extraction Knowledge customization Knowledge integration
