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The Guidance Project: Generic presentation of guidelines in electronic format for decision support

The Guidance Project: Generic presentation of guidelines in electronic format for decision support. Dr Jim Black Head of Epidemiology Victorian Infectious Diseases Service Royal Melbourne Hospital. The Guidance Project. Philosophy Look and feel Under the hood: The Guidance application

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The Guidance Project: Generic presentation of guidelines in electronic format for decision support

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  1. The Guidance Project:Generic presentation of guidelines in electronic format for decision support Dr Jim Black Head of Epidemiology Victorian Infectious Diseases ServiceRoyal Melbourne Hospital

  2. The Guidance Project • Philosophy • Look and feel • Under the hood: • The Guidance application • eDSML • The eDSML Builder • Closing thoughts (philosophy again)

  3. Guidance: “Philosophy”

  4. Many perspectives… Making life easier for clinicians Saving money Evaluation Evidence based Interaction with medication management systems Integration with hospital IT Improving patient outcomes ‘Just in time’ expert advice Collaboration with software vendor(s) Sustainability Content experts in control Earning money Using standards Maintenance of guidelines Transferability to other settings

  5. Prior experience at RMH • Antimicrobial approval system • Web based, hard coded • Advise project (ICU) • Isolate-specific antimicrobial advice • Results browser • Saves money and improves prescribing

  6. Clinicians may seek advice 3 ways • My ICU patient has Acinetobacter isolated from sputum. Should I give an antibiotic? Bug-to-drug = iMicro • What treatment should my ED patient with community-acquired pneumonia be given? Does she need admission? Syndromic guideline = iGuide • I (or my boss) think my patient with cellulitis should get Vancomycin. Should he? Antimicrobial approval = iApprove

  7. Audit information • Restricted drug approval numbers and lists for Pharmacy staff • More generic information for evaluation of guideline use • Who used what guideline for which patient, when, and what data did they enter at each decision node?

  8. Guidance: “Look and feel”

  9. Case No. 1- Antimicrobial approval A 52 year old man with myeloma is neutropenic after chemotherapy. He has become febrile and his fever has persisted despite initial therapy with cefepime. The unit would like to commence vancomycin. How does the resident obtain his approval number, and dosing information for vancomycin?

  10. Case No. 2- Empiric therapy for a ‘syndrome’ A 60 year old man, past history angina, hypertension. Now presents with a 2 day history of cough, dyspnoea and pleuritic chest pain. Confused, Temp 38C, HR 130, BP 100/ 70, RR 32, Sat 91% on room air. He has basal crepitations in the left chest and left sided opacification on CXR. Where can the new intern obtain information regarding the correct antibiotic therapy for this man?

  11. Guidance: “Under the hood”

  12. Guidance User interface iApprove iGuide iMicro Reports eDSML engine Guidance datastore Audit info Communication and translation Pathology database Micro database Patient database

  13. Guidance uses eDSML • electronic Decision Support Markup Language • An XML dialect – powerful and flexible • Includes mathematical and logical functions • Can represent ANY flowchart, protocol or guideline • Links html files to decision nodes – scope for many levels of support and background info

  14. eDSML Builder • The Guidance browser reads eDSML the way Internet Explorer reads HTML • Content completely separate from the program • Aiming to keep control in the hands of the content experts – minimum IT intervention • Hence eDSML Builder – a ‘visual’ authoring tool. (Flowchart in, eDSML out)

  15. eDSML Builder • Allows the content expert to build eDSML using a ‘visual’ interface • No need for programming skills to create or edit guidelines • Follows the typical pathway: review -> distillation document -> flowchart -> eDSML

  16. Not seen by content experts!

  17. On guidelines…

  18. “The practice of medicine is an art, based on science.” “The art of the practice of medicine is to be learned only by experience; ‘tis not an inheritance; it cannot be revealed.” “Often this ignorance must be very tantalizing, but it is more wholesome than an assurance which rests on a thin veneer of knowledge.” Sir William Osler: Aphorisms from His Bedside Teachings and Writings. Collected by Robert Bennett Bean, M.D. (1874-1944), Edited by William Bennett Bean, M.D. Third Printing, Charles C. Thomas: Springfield, Illinois, 1968. http://www.vh.org/adult/provider/history/osler/#TOC

  19. “And thirdly, the code is more what you'd call "guidelines" than actual rules. Welcome aboard the Black Pearl , Miss Turner .” Captain Barbossa, about to completely ignore the Pirates’ Code.

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