Applying openEHR's Guideline Definition Language to the SITS international stroke treatment registry: a European retrospective observational study.

BACKGROUND: Interoperability standards intend to standardise health information, clinical practice guidelines intend to standardise care procedures, and patient data registries are vital for monitoring quality of care and for clinical research. This study combines all three: it uses interoperability specifications to model guideline knowledge and applies the result to registry data. METHODS: We applied the openEHR Guideline Definition Language (GDL) to data from 18,400 European patients in the Safe Implementation of Treatments in Stroke (SITS) registry to retrospectively check their compliance with European recommendations for acute stroke treatment. RESULTS: Comparing compliance rates obtained with GDL to those obtained by conventional statistical data analysis yielded a complete match, suggesting that GDL technology is reliable for guideline compliance checking. CONCLUSIONS: The successful application of a standard guideline formalism to a large patient registry dataset is an important step toward widespread implementation of computer-interpretable guidelines in clinical practice and registry-based research. Application of the methodology gave important results on the evolution of stroke care in Europe, important both for quality of care monitoring and clinical research.

Retrospective checking of compliance with practice guidelines for acute stroke care: a novel experiment using openEHR's Guideline Definition Language.

BACKGROUND: Providing scalable clinical decision support (CDS) across institutions that use different electronic health record (EHR) systems has been a challenge for medical informatics researchers. The lack of commonly shared EHR models and terminology bindings has been recognised as a major barrier to sharing CDS content among different organisations. The openEHR Guideline Definition Language (GDL) expresses CDS content based on openEHR archetypes and can support any clinical terminologies or natural languages. Our aim was to explore in an experimental setting the practicability of GDL and its underlying archetype formalism. A further aim was to report on the artefacts produced by this new technological approach in this particular experiment. We modelled and automatically executed compliance checking rules from clinical practice guidelines for acute stroke care. METHODS: We extracted rules from the European clinical practice guidelines as well as from treatment contraindications for acute stroke care and represented them using GDL. Then we executed the rules retrospectively on 49 mock patient cases to check the cases' compliance with the guidelines, and manually validated the execution results. We used openEHR archetypes, GDL rules, the openEHR reference information model, reference terminologies and the Data Archetype Definition Language. We utilised the open-sourced GDL Editor for authoring GDL rules, the international archetype repository for reusing archetypes, the open-sourced Ocean Archetype Editor for authoring or modifying archetypes and the CDS Workbench for executing GDL rules on patient data. RESULTS: We successfully represented clinical rules about 14 out of 19 contraindications for thrombolysis and other aspects of acute stroke care with 80 GDL rules. These rules are based on 14 reused international archetypes (one of which was modified), 2 newly created archetypes and 51 terminology bindings (to three terminologies). Our manual compliance checks for 49 mock patients were a complete match versus the automated compliance results. CONCLUSIONS: Shareable guideline knowledge for use in automated retrospective checking of guideline compliance may be achievable using GDL. Whether the same GDL rules can be used for at-the-point-of-care CDS remains unknown.

OpenEHR-based representation of guideline compliance data through the example of stroke clinical practice guidelines.

In light of the lack of integration between electronic health records and decision support, this research explores how semantic electronic health record technology, particularly openEHR, can be used to represent clinical practice guidelines (CPGs). We used the tool Visual Understanding Environment (VUE) to build a graphical representation of the European ischaemic stroke clinical management guidelines. We used openEHR archetypes to conceptually support this process and also to represent clinical concepts in stroke treatment compliance criteria. Our results show that, as an intermediate step in authoring computer-interpretable guidelines, an openEHR-based representation of CPGs and their compliance criteria supports the process of identifying the relevant knowledge and data elements in the care process to be modelled. It further eases the separation of the CPGs into data and logic components and is useful as a communication means for guideline verification by clinicians. Additionally, we retrieved existing and authored new openEHR archetypes for the acute stroke clinical management process. We conclude that openEHR-based guideline and compliance data representations may be a promising first step in building future decision support applications that are well connected to the electronic health record, can be useful in locating discrepancies between different sets of guidelines within the same care context and provide a helpful tool for driving the archetype authoring and review process.

Implementability of stroke guidelines: a pragmatic comparison between US and European recommendations using eGLIA.

Due to the prevalence and severity of stroke, and the emergency of its management, the need of reaching a consensus towards its treatment is of prime importance. This paper's aim is to compare two stroke guidelines by using eGLIA in order to evaluate their implementability. Methods included a systematic assessment of the European (ESO) and American (AHA/ASA) guidelines with eGLIA and a review of literature and analysis of each recommendation with the program. The ESO performs better in Executability and Decidability, as 91.5% and 34.8% of recommendations show no barriers, compared to 81.0% and 14.0% in the AHA/ASA guidelines. On the other hand, AHA/ASA guideline have more recommendations with positive assessments in the Validity and Effect on the Process of Care (91.4% vs 83.0% and 58.1% vs 25%). Results show that ESO guidelines address a wider patient view and that the AHA/ASA guidelines are stricter, only publishing recommendations with a high level of evidence; AHA/ASA guidelines are updated with more frequency and have a clearer sequence of action. Both guidelines show some contradictions, but of minor importance. The strength of this study is the fact that the whole guidelines were read and analysed, and, although we would suggest an improvement of the tool by adding an automatic statistics chart and clarifying some questions, it showed that eGLIA should be used whenever such a text is published.

Changes in European Label and Guideline Adherence After Updated Recommendations for Stroke Thrombolysis: Results From the Safe Implementation of Treatments in Stroke Registry.

BACKGROUND: Intravenous thrombolysis (IVT) for acute ischemic stroke is subject to label and guideline contraindications. Updated European guidelines in 2008/2009 recommended IVT in selected patients aged >80 years and stroke onset-to-treatment time 3 to 4.5 hours, which the label still prohibited. Our aim was to compare contraindication nonadherence before and after the guideline update. METHODS AND RESULTS: Data on IVT-treated patients with stroke at 232 European hospitals participating in the Safe Implementation of Treatments in Stroke registry during both periods 2006 to 2007 (n=6354) and 2010 to 2011 (n=12 046). After the 2008/2009 guideline update, the proportion of patients nonadherent to label increased from 23.6% to 51.1% (P<0.001). Specifically, nonadherence to onset-to-treatment time >3 hours increased from 8.2% to 27.9% and IVT in patients aged >80 years from 8.9% to 17.2% (both P<0.001). Nonadherence also increased to the contraindications severe stroke (National Institutes of Health Stroke Scale score >25), onset-to-treatment time >4.5 hours, blood pressure >185/110 mm Hg, and ongoing oral anticoagulation (all P≤0.001). Higher hospital IVT patient volumes were associated with higher nonadherence rates. CONCLUSIONS: After the European guideline update, new recommendations were promptly adopted and nonadherence to the unchanged label increased. Label contraindications should be updated.

Integrated information visualization to support decision making for use of antibiotics in intensive care: design and usability evaluation.

Overuse of antibiotics is a critical problem in intensive care today. The situation is further complicated by the extremely data-intensive environment with clinical data presented in distributed, often stand-alone information systems. To access and interpret all data is a complex and time-consuming technical and cognitive challenge. We propose a holistic integrated visualization in the form of a patient overview to support physicians in decision making for use of antibiotics at intensive care units. Special emphasis is put on analysis of work processes to identify information needs, the development of a visualization tool based on an integrated data model, and usability testing of the tool in combination with an eye-tracking technology. The visualization tool was highly rated in terms of user performance and preferences, and the analysis of users' visual patterns showed that different types of data visualization may benefit specialist and resident intensive care physicians depending on the task to be performed. A highly interactive tool for integrated information visualization could potentially increase the understanding of a patient's infection status and ultimately enhance decision making for the use of antibiotics.

Early Experiences from a guideline-based computerized clinical decision support for stroke prevention in atrial fibrillation.

Atrial fibrillation (AF) affects 1-2% of the population. Twenty percent of all strokes are caused by AF. In this study, we represented the clinical knowledge in the European Society of Cardiology guideline using Guideline Definition Language (GDL), a format that binds openEHR archetypes, rule languages, and reference terminologies together. The computerized guidelines are applied to electronic health record (EHR) data retrospectively in order to identify possible gaps between current clinical practice and optimal care recommended by the evidence-based guidelines. Treatment compliance is checked in two patient groups: one received treatment from a cardiologist who is responsible for AF treatment in the region (n=514) and the other was a much larger patient group from the whole region (n=8130). The compliance checking shows the cardiologist group has substantially higher percentage of compliant treatment compared with that of the general population group. Based on this important finding, we are now implementing at-point-of-care clinical decision support reusing the same computerized guideline knowledge in GDL format in order to increase the guideline adherence of the treatment.