The promise of emerging science and the challenges confronting today's health care system can both be addressed by fully embracing the IoM's vision of a learning health care system. ASCO's initial foray into realizing this vision for oncology shows great promise.
237 Background: CancerLinQ (CLQ) is a rapid learning system (RLS) for oncology in development by ASCO. CLQ is based on the transfer of electronic health records (EHR) from participating oncology practices to a data warehouse where data aggregation and de-identification occurs. A prototype was built using open source software and has collected de-identified data on 170,000+ pts with breast cancer (BC) from 31 community oncology practices using 4 different EHRs. The primary goals for the prototype were 1. Aggregate patient data from any EHR platform, process it and create a longitudinal record; 2. Develop quality reports from EHRs; 3. Point of care Clinical Decision Support (CDS) from ASCO guidelines; 4. Data visualization for hypothesis generation; 5. Demonstrate desire to share data for quality improvement; 6. Describe lessons learned (LL). This report focuses on LL about CDS. Methods: Physician experts identified specific elements from each ASCO BC guideline to make machine readable (MR). Abstractors then GEM-cut the elements using the GEM Abstraction Manual and Style Guide. The output reports were reviewed for comprehensiveness, accuracy, and style. Following verification of the GEM-cut content, reports were sent for meta-tagging, done by selecting widely used EHR vocabulary from the Unified Medical Language System (UMLS). The GEM-cut output and meta-tags were converted to DROOLS syntax and the resulting coded files were inserted into the DROOLS rules engine. When the rules engine encounters a combination of facts that match a rule, that rule is presented to the user. The enduring responses are collected using ‘queries’ and the CDS results are delivered to the EHR. Results: Guidelines are often not written as “if”/“then” statements which is key for computer-based CDS. Any unintentional ambiguity must be removed for machine MR CDS. Using new methodologies, we have been able to convert narrative guidelines into MR CDS. Conclusions: Conversion of ASCO’s clinical guidelines into a MR format is possible. New and emerging methods such as GLIDES, BRIDGE-Wiz, and GEM-cutting provide excellent tools to migrate existing narrative recommendations into MR format that can populate CDS tools, such as those provided by CancerLinQ.
Description of Best PracticeWe used the ADAPTE method to develop a care protocol for major depression in primary care tailored for the local context, with a consideration of the organisation of health care services in primary care. The work was monitored by an expert committee composed of mental health specialists, general practitioners, health care administrators and decision-makers at regional and provincial levels. The care protocol is based on two clinical practice guidelines: the NICE guideline on the treatment and management of depression in adults (2010) and the CANMAT clinical guidelines for the management of major depressive disorder in adults (2009). Lessons We will share the challenges associated with the adaptation of clinical recommendations and organisational strategies to the local context, and the actual implementation of the care protocol in primary care. We will discuss issues dealing with the applicability and successful uptake of recommendations in local contexts (ex.: availability of resources for guideline adaptation, types of professionals involved, barriers). Background Adaptation of high-quality external guidelines can be an efficient and effective means to develop guidance more rapidly, allowing for shifting of resources to knowledge transfer and health system implementation efforts. Context To describe successful guideline adaptation and implementation strategies used by a large US health care organisation to improve the quality of care for adults with chronic obstructive pulmonary disease (COPD). Description of Best Practice A multidisciplinary guideline team evaluated and adapted a guideline on Chronic Obstructive Pulmonary Disease (COPD) developed by the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society (ACP/ACCP/ ATS/ERS). Recommendations were evaluated and modified for implementability based on several dimensions of the GLIA tool. Implementation strategies targeted to physicians included electronic distribution of guidelines, interactive online continuing medical education, and point-of-care encounter support. Implementation efforts targeted to patients included point-of-care education booklets, online resources for COPD self-management, and proactive outreach for spirometry testing. Systems-level interventions included development of patient outreach lists and computerised decision support. Monthly reporting and review on three measures was conducted to monitor performance. Ongoing implementation efforts resulted in increased rates of spirometry testing and management of COPD exacerbations with systemic corticosteroid and bronchodilator medications over a four-year period. Lessons Challenges arise when externally developed guidelines lack the specificity necessary for recommendations to be successfully implemented. Systematic evaluation and modification of recommendations is necessary to enhance implementability at the patient, provider and systems levels, as well as to improve performance. Background...
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