Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2012

Open Access 01-12-2012 | Research article

A study of diverse clinical decision support rule authoring environments and requirements for integration

Authors: Li Zhou, Neelima Karipineni, Janet Lewis, Saverio M Maviglia, Amanda Fairbanks, Tonya Hongsermeier, Blackford Middleton, Roberto A Rocha

Published in: BMC Medical Informatics and Decision Making | Issue 1/2012

Login to get access

Abstract

Background

Efficient rule authoring tools are critical to allow clinical Knowledge Engineers (KEs), Software Engineers (SEs), and Subject Matter Experts (SMEs) to convert medical knowledge into machine executable clinical decision support rules. The goal of this analysis was to identify the critical success factors and challenges of a fully functioning Rule Authoring Environment (RAE) in order to define requirements for a scalable, comprehensive tool to manage enterprise level rules.

Methods

The authors evaluated RAEs in active use across Partners Healthcare, including enterprise wide, ambulatory only, and system specific tools, with a focus on rule editors for reminder and medication rules. We conducted meetings with users of these RAEs to discuss their general experience and perceived advantages and limitations of these tools.

Results

While the overall rule authoring process is similar across the 10 separate RAEs, the system capabilities and architecture vary widely. Most current RAEs limit the ability of the clinical decision support (CDS) interventions to be standardized, sharable, interoperable, and extensible. No existing system meets all requirements defined by knowledge management users.

Conclusions

A successful, scalable, integrated rule authoring environment will need to support a number of key requirements and functions in the areas of knowledge representation, metadata, terminology, authoring collaboration, user interface, integration with electronic health record (EHR) systems, testing, and reporting.
Appendix
Available only for authorised users
Literature
1.
Health Information Technology in the United States: The Information Base for Progress. 2006, Robert Wood Johnson Foundation, George Washington University Medical Center, and Institute for Health Policy
2.
Part III: Department of Health and Human Services. 45 CFR Part 170: Health Information Technology: initial set of standards, implementation specifications, and certification criteria for electronic health record technology; final rule. Federal register. Services DoHaH. 2010
3.
Garg AX, Adhikari NK, McDonald H, Rosas-Arellano MP, Devereaux PJ, Beyene J: Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. JAMA. 2005, 293 (10): 1223-1238. 10.1001/jama.293.10.1223.CrossRefPubMed
4.
Kawamoto K, Houlihan CA, Balas EA, Lobach DF: Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005, 330 (7494): 765-10.1136/bmj.38398.500764.8F. Clinical research edCrossRefPubMedPubMedCentral
5.
Shahar Y, Young O, Shalom E, Galperin M, Mayaffit A, Moskovitch R: A framework for a distributed, hybrid, multiple-ontology clinical-guideline library, and automated guideline-support tools. J Biomed Inform. 2004, 37 (5): 325-344. 10.1016/j.jbi.2004.07.001.CrossRefPubMed
6.
Seyfang A, Miksch S, Marcos M, Wittenberg J, Polo-Conde C, Rosenbrand K: Bridging the Gap between Informal and Formal Guideline Representations. Proceedings of the 2006 conference on ECAI 2006. 17th European Conference on Artificial Intelligence August 29 -- September 1, 2006. 2006, IOS Press: Riva del Garda, 447-451.
7.
Hripcsak G: Arden syntax for medical logic modules. MD Comput. 1991, 8 (2): 76-78.PubMed
8.
Shahar Y, Miksch S, Johnson P: The Asgaard project: a task-specific framework for the application and critiquing of time-oriented clinical guidelines. Artif Intell Med. 1998, 14 (1-2): 29-51. 10.1016/S0933-3657(98)00015-3.CrossRefPubMed
9.
Musen MA, Tu SW, Das AK, Shahar Y: EON: a component-based approach to automation of protocol-directed therapy. J Am Med Inform Assoc. 1996, 3 (6): 367-388. 10.1136/jamia.1996.97084511.CrossRefPubMedPubMedCentral
10.
Shiffman RN, Karras BT, Agrawal A, Chen R, Marenco L, Nath S: GEM: a proposal for a more comprehensive guideline document model using XML. J Am Med Inform Assoc. 2000, 7 (5): 488-498. 10.1136/jamia.2000.0070488.CrossRefPubMedPubMedCentral
11.
Hajizadeh N, Kashyap N, Michel G, Shiffman RN: GEM at 10: a decade's experience with the Guideline Elements Model. Proc AMIA Annu Symp. 2011, 520-528.
12.
Ohno-Machado L, Gennari JH, Murphy SN, Jain NL, Tu SW, Oliver DE: The guideline interchange format: a model for representing guidelines. J Am Med Inform Assoc. 1998, 5 (4): 357-372. 10.1136/jamia.1998.0050357.CrossRefPubMedPubMedCentral
13.
Quaglini S, Stefanelli M, Lanzola G, Caporusso V, Panzarasa S: Flexible guideline-based patient careflow systems. Artif Intell Med. 2001, 22 (1): 65-80. 10.1016/S0933-3657(00)00100-7.CrossRefPubMed
14.
Johnson PD, Tu S, Booth N, Sugden B, Purves IN: Using scenarios in chronic disease management guidelines for primary care. Proc AMIA Symp. 2000, 389-393.
15.
Fox J, Johns N, Rahmanzadeh A: Disseminating medical knowledge: the PROforma approach. Artif Intell Med. 1998, 14 (1-2): 157-181. 10.1016/S0933-3657(98)00021-9.CrossRefPubMed
16.
Tu SW, Campbell JR, Glasgow J, Nyman MA, McClure R, McClay J: The SAGE guideline model: achievements and overview. J Am Med Inform Assoc. 2007, 14 (5): 589-598. 10.1197/jamia.M2399.CrossRefPubMedPubMedCentral
17.
Jafarpour B, Abidi S, Abidi S: Exploiting OWL reasoning services to execute ontologically-modeled clinical practice guidelines. Artificial Intelligence in Medicine. Edited by: Peleg M, Lavrac N, Combi C. 2011, Berlin: Springer, 307-311.CrossRef
18.
Peleg M, Tu S, Bury J, Ciccarese P, Fox J, Greenes RA: Comparing computer-interpretable guideline models: a case-study approach. J Am Med Inform Assoc. 2003, 10 (1): 52-68. 10.1197/jamia.M1135.CrossRefPubMedPubMedCentral
19.
Leong TY, Kaiser K, Miksch S: Free and open source enabling technologies for patient-centric, guideline-based clinical decision support: a survey. Yearb Med Inform. 2007, 74-86.
20.
De Clercq P, Kaiser K, Hasman A: Computer-interpretable guideline formalisms. Stud Health Technol Inform. 2008, 139: 22-43.PubMed
21.
Isern D, Moreno A: Computer-based execution of clinical guidelines: a review. Int J Med Inform. 2008, 77 (12): 787-808. 10.1016/j.ijmedinf.2008.05.010.CrossRefPubMed
22.
Miksch S, Kosara R, Shahar Y, Johnson P: AsbruView: visualization of time-oriented, skeletal plans. Proceedings of the 4th International Conference on Artificial Intelligence Planning Systems 1998 (AIPS-98). 1998, Carnegie Mellon University: AAAI Press
23.
Steele R, Fox J: Tallis PROforma Primer – Introduction to PROforma Language and Software with Worked Examples. Technical report, Advanced Computation Laboratory. 2002, London: Cancer Res
24.
Gennari JH, Musen MA, Fergerson RW, Grosso WE, Crub ezy M, Eriksson H, Noy NF, Tu SW: The evolution of Prot¯eg¯e: an environment for knowledge-based systems development. Int J Human Computer Studies. 2003, 58 (1): 89-123. 10.1016/S1071-5819(02)00127-1.CrossRef
25.
Kosara R, Miksch S, Seyfang A, Votruba P: Tools for acquiring clinical guidelines in Asbru. Proceeding of the Sixth World Conference on Integrated Design and Process Technology (IDPT’02). 2002, Society for Design and Process Science, Pasadena, California, U.S, 22-27.
26.
27.
Shahar Y, Young O, Shalom E, Mayaffit A, Moskovitch R, Hessing A, Galperin M, DEGEL: A hybrid, multiple-ontology framework for specification and retrieval of clinical guidelines. Artificial Intelligence in Medicine: 9th Conference on Artificial Intelligence, in Medicine in Europe, AIME 2003, LNAI 2780, pages 122–131. Edited by: Dojat M, Keravnou E, Barahona P. 2003, Protaras: Springer-Verlag
28.
Shiffman RN, Michel G, Rosenfeld RM, Davidson C: Building better guidelines with BRIDGE-Wiz: development and evaluation of a software assistant to promote clarity, transparency, and implementability. J Am Med Inform Assoc. 2012, 19 (1): 94-101. 10.1136/amiajnl-2011-000172.CrossRefPubMed
29.
Regier R, Gurjar R, Rocha RA: A clinical rule editor in an electronic medical record setting: development, design, and implementation. AMIA Annual Symposium proceedings / AMIA Symposium. 2009, 537-541.
30.
Jenders RA, Dasgupta B: Assessment of a knowledge-acquisition tool for writing Medical Logic Modules in the Arden Syntax. Proc AMIA Annu Fall Symp. 1996, 567-571.
31.
Hulse NC, Rocha RA, Del Fiol G, Bradshaw RL, Hanna TP, Roemer LK: KAT: a flexible XML-based knowledge authoring environment. J Am Med Inform Assoc. 2005, 12 (4): 418-430. 10.1197/jamia.M1701.CrossRefPubMedPubMedCentral
32.
Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E: Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006, 144 (10): 742-52.CrossRefPubMed
33.
Wright A, Goldberg H, Hongsermeier T, Middleton B: A description and functional taxonomy of rule-based decision support content at a large integrated delivery network. J Am Med Inform Assoc. 2007, 14 (4): 489-496. 10.1197/jamia.M2364.CrossRefPubMedPubMedCentral
34.
Paterno MD, Schaeffer M, Van Putten C, Wright A, Chen ES, Goldberg HS: Challenges in creating an enterprise clinical rules service. AMIA Annual Symposium proceedings / AMIA Symposium. 2008, 1086-
35.
Pathak J, Chute CG: Further revamping VA's NDF-RT drug terminology for clinical research. J Am Med Inform Assoc. 2011, 18 (3): 347-8. 10.1136/amiajnl-2011-000161.CrossRefPubMedPubMedCentral
36.
Nelson SJ, Zeng K, Kilbourne J, Powell T, Moore R: Normalized names for clinical drugs: RxNorm at 6 years. J Am Med Inform Assoc. 2011, 18 (4): 441-8. 10.1136/amiajnl-2011-000116.CrossRefPubMedPubMedCentral
37.
Hudson KL: Genomics, health care, and society. N Engl J Med. 2011, 365 (11): 1033-41. 10.1056/NEJMra1010517.CrossRefPubMed
38.
39.
Rospocher M, Eccher C, Ghidini C, Hasan R, Seyfang A, Ferro A, Miksch S: Collaborative encoding of Asbru clinical protocols. eHealth -3rd International ICST Conference on Electronic Healthcare for the 21st century, Casablanca, Morocco eHealth 2010, Casablanca, Morocco. Revised Selected Papers, Lecture Notes of the Institute for Computer Sciences, Social-Informatics and Telecommunications Engineering. Edited by: Szomszor M, Kostkova P. 2012, Berlin: Springer, 135-143. 69
40.
Goldberg HS, Vashevko M, Pastilnik A, Smith K, Plaks N, Blumenfeld BM: Evaluation of a commercial rule engine as a basis for a clinical decision support service. AMIA Annual Symposium proceedings / AMIA Symposium. 2006, 294-298.
41.
Medlock S, Opondo D, Eslami S, Askari M, Wierenga P, de Rooij SE: LERM (Logical Elements Rule Method): a method for assessing and formalizing clinical rules for decision support. Int J Medical Informatics. 2011, 80 (4): 286-95. 10.1016/j.ijmedinf.2011.01.014.CrossRef
42.
Boxwala AA, Rocha BH, Maviglia S, Kashyap V, Meltzer S, Kim J: A multi-layered framework for disseminating knowledge for computer-based decision support. J Am Med Inform Assoc. 2011, 18 (Suppl 1): i132-9. 10.1136/amiajnl-2011-000334.CrossRefPubMedPubMedCentral
43.
44.
Cornet R, de Keizer N: Forty years of SNOMED: a literature review. BMC Medical Informatics and Decision Making. 2008, 8 (Suppl 1): S2-10.1186/1472-6947-8-S1-S2.CrossRefPubMedPubMedCentral
45.
McDonald CJ, Huff SM, Suico JG, Hill G, Leavelle D, Aller R: LOINC, a universal standard for identifying laboratory observations: a 5-year update. Clinical chemistry. 2003, 49 (4): 624-33. 10.1373/49.4.624.CrossRefPubMed
46.
Wright A, Sittig DF, Ash JS, Sharma S, Pang JE, Middleton B: Clinical decision support capabilities of commercially-available clinical information systems. J Am Med Inform Assoc. 2009, 16 (5): 637-644. 10.1197/jamia.M3111.CrossRefPubMedPubMedCentral
Metadata
Title
A study of diverse clinical decision support rule authoring environments and requirements for integration
Authors
Li Zhou
Neelima Karipineni
Janet Lewis
Saverio M Maviglia
Amanda Fairbanks
Tonya Hongsermeier
Blackford Middleton
Roberto A Rocha
Publication date
01-12-2012
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2012
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/1472-6947-12-128

Other articles of this Issue 1/2012

BMC Medical Informatics and Decision Making 1/2012 Go to the issue

Research article

The effect of clinical experience, judgment task difficulty and time pressure on nurses’ confidence calibration in a high fidelity clinical simulation

Research article

Evaluating quality of care for patients with type 2 diabetes using electronic health record information in Mexico

Research article

A dialogue-based web application enhances personalized access to healthcare professionals – an intervention study

Research article

Efficient algorithms for fast integration on large data sets from multiple sources

Study protocol

Shared decision-making and health for First Nations, Métis and Inuit women: a study protocol

Debate

Why technology matters as much as science in improving healthcare