Notes

Outline

Using a Guideline-Centered Approach for the Design of a Clinical Decision Support System to Promote Smoking Cessation Richard N. Shiffman, MD, MCIS George Michel, MS Abdelwaheb Essaihi, MD Theodore W. Marcy, MD, MPH Yale Center for Medical informatics University of Vermont College of Medicine

Knowledge Acquisition from Guidelines: What’s the Problem? Ambiguity; guideline terms often lack explicit definitions Incomplete specification Additional knowledge is always necessary to create a decision support tool Creation of DSS KB risks error Local adaptation (necessary) risks preservation of habit, self interest Knowledge maintenance is a largely unaddressed but critical issue

Representation of Guideline Knowledge for Decision Support Members of the InterMed Collaboratory encoded  representations of guidelines for vaccination and workup of breast masses Tested with patient scenarios Different recommendations were given for the same patient

Guideline Implementation Gap

Goal (Intention) of This Work Overview of Presentation Articulate a systematic, explicit, and transparent process for translating GL knowledge into DS tools GEM Overview Handheld, wireless DSS (under construction) for smoking cessation

Advantages of Document-Centered DSS Design Preservation of authenticity of knowledge Audit of local adaptation (knowledge modifications) Diminished variability of DSS designs

GEM

Element Sources

GEM: Top Levels

Knowledge Components

Conditional

GEM Cutter

Maintaining Links to Guideline Text Each GEM element has a unique identifier attribute a source attribute: default value is “explicit” changes to “inferred” if content is modified

GEM Polishing Select (GL & Rec) Semantic Refinement (Markup) Atomize De-abstract Disambiguate Verify completeness Build executables

Smoking Cessation Cigarette smoking is most common cause of preventable death in the US Cessation can dramatically reduce risk of cancer and other diseases Smokers are more likely to quit if physicians counsel them Physicians infrequently counsel -->USPHS Guideline

Markup Bupropion SR should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of bupropion SR treatment and potential concomitant smoking.

Semantic Refinement Atomize: “Bupoprion should be used”                               ->   Prescribe bupoprion Deabstract: “potential benefits outweigh the risks” Benefits:  avoid smoking-induced stillbirths, spontaneous abortions, decreased fetal growth, premature births, low birth weight, placental abruption, sudden infant death syndrome (SIDS), cleft palates and cleft lips, and childhood cancers. and infant respiratory disease  Risks:  unknown + seizures in 1:1000;  may be ineffective

Extractor -> Decision Variables,

Workflow Integration Identify origins of DVs, insertions of actions Define action type Describe associated beneficial services

Guideline Action Classifier (N=405)

System for Delivering Advice

Conclusion Bridging the gap between guideline text and valid, useful decision support tools is complex Extraction of DVs and actions from contextual narrative facilitates clarification Document-centered approach helps maintain authenticity of knowledge