| Description |
The development of practice guidelines has gathered momentum in the 1990's, with the involvement of many institutions, public and private. The value of guidelines would appear to be intuitively obvious - eliminating inappropriate procedures must improve the quality and cost-effectiveness of care. However, this assumption cannot be proven valid without proper evaluation of the impact of practice guidelines on patient outcome. Moreover, guidelines, once developed, are not self-implementing. Guidelines need to be used, that is their recommendations considered, then followed are rejected, to influence practice. To be effective, guidelines must be integrated into the physician's decision-making process in his or her daily practice. With the increasing presence of clinical information systems in patient care, it appears that a hospital information system may be an effective mechanism to provide practice guidelines for routine inpatient use. Keeping in mind the many guidelines that have been developed, and the potential numbers of guidelines to be developed, an object oriented model of guideline development, representation and implementation in hospital information system is proposed. This Problem-Oriented Patient Management System, implemented on a hospital information system, would contain multiple guidelines for a variety of clinical problems. By simply indicating the problem which the physician would like to manage, guidelines relevant to the problem would be activated. In addition, the Problem-Oriented Patient Management System would be able to take advantage of the patient data contained in the hospital information system to generate patient-specific guideline suggestions according to the patient's clinical situation at the time of generation. As a prototype, practice guidelines for the management of deep vein thrombosis are implemented in the Problem-Oriented Patient Management System on the HELP Hospital Information System at the LDS Hospital. A hierarchical, layered knowledge representation is used. The Problem-Oriented Patient Management System is able to generate patient-specific guidelines according to the clinical situation at the time of generation. A retrospective evaluation compared the appropriateness of the generated guidelines suggestions to the appropriateness of the case physician's management decisions. A significantly higher proportion of generated guidelines is evaluated to be appropriate, compared to the proportion of case physician's management decisions found to be appropriate. Although much work remains to move Problem-Oriented Patient Management System towards real time deployment, the preliminary findings described in this research appear to be encouraging. |
