How to translate therapeutic recommendations in clinical practice guidelines into rules for critiquing physician prescriptions? Methods and application to five guidelines
1 Laboratoire d'Informatique Médicale et de Bioinformatique (LIM&BIO), UFR SMBH, University of Paris 13, 74 rue Marcel Cachin, 93017 Bobigny cedex, France
2 Université Paris 12, UFR de Médecine, Créteil, France; AP-HP, Hôpital Henri Mondor, Département d'Information Hospitalier, Créteil, France
3 U936 INSERM, University of Rennes 1, IFR 140, Rennes, France
4 Université Paris 6, UFR de Médecine, Paris, France; AP-HP, Hôpital Tenon, Département de Santé Publique, Paris, France
5 AP-HP, DSI, STIM, Paris, France; INSERM, UMR_S 872, eq. 20, Paris, France
6 Silk Informatique, 40 bis avenue du général Patton, 49000 Angers, France
7 RESIP, Centre Directionnel 56 rue Ferdinand Buisson BP 455, 62206 Boulogne sur Mer Cedex, France
8 ESIRIM, 39 allée de la Pitancerie F94230 Cachan, France
9 Université Paris Descartes, Faculté de Médecine, Département de Médecine Générale, 75015 Paris; Société de Formation Thérapeutique du Généraliste (SFTG), 233 bis rue de Tolbiac, 75013 Paris, France
BMC Medical Informatics and Decision Making 2010, 10:31 doi:10.1186/1472-6947-10-31Published: 28 May 2010
Clinical practice guidelines give recommendations about what to do in various medical situations, including therapeutical recommendations for drug prescription. An effective way to computerize these recommendations is to design critiquing decision support systems, i.e. systems that criticize the physician's prescription when it does not conform to the guidelines. These systems are commonly based on a list of "if conditions then criticism" rules. However, writing these rules from the guidelines is not a trivial task. The objective of this article is to propose methods that (1) simplify the implementation of guidelines' therapeutical recommendations in critiquing systems by automatically translating structured therapeutical recommendations into a list of "if conditions then criticize" rules, and (2) can generate an appropriate textual label to explain to the physician why his/her prescription is not recommended.
We worked on the therapeutic recommendations in five clinical practice guidelines concerning chronic diseases related to the management of cardiovascular risk. We evaluated the system using a test base of more than 2000 cases.
Algorithms for automatically translating therapeutical recommendations into "if conditions then criticize" rules are presented. Eight generic recommendations are also proposed; they are guideline-independent, and can be used as default behaviour for handling various situations that are usually implicit in the guidelines, such as decreasing the dose of a poorly tolerated drug. Finally, we provide models and methods for generating a human-readable textual critique. The system was successfully evaluated on the test base.
We show that it is possible to criticize physicians' prescriptions starting from a structured clinical guideline, and to provide clear explanations. We are now planning a randomized clinical trial to evaluate the impact of the system on practices.