Method to integrate clinical guidelines into the electronic health record (EHR) by applying the archetypes approach.
Clinical guidelines are documents that assist healthcare professionals, facilitating and standardizing diagnosis, management, and treatment in specific areas. Computerized guidelines as decision support systems (DSS) attempt to increase the performance of tasks and facilitate the use of guidelines. Most DSS are not integrated into the electronic health record (EHR), ordering some degree of rework especially related to data collection. This study's objective was to present a method for integrating clinical guidelines into the EHR. The study developed first a way to identify data and rules contained in the guidelines, and then incorporate rules into an archetype-based EHR. The proposed method tested was anemia treatment in the Chronic Kidney Disease Guideline. The phases of the method are: data and rules identification; archetypes elaboration; rules definition and inclusion in inference engine; and DSS-EHR integration and validation. The main feature of the proposed method is that it is generic and can be applied toany type of guideline.
Health Technology Post-graduate Program - Pontifical Catholic University of Paraná, Brazil.
Diego
D
Garcia
Claudia Maria Cabral
CM
Moro
Paulo Eduardo
PE
Cicogna
Deborah Ribeiro
DR
Carvalho
D001938:Brazil; D020000:Decision Support Systems, Clinical / Q000592:standards*; D057286:Electronic Health Records / Q000592:standards*; D016247:Information Storage and Retrieval / Q000592:standards*; D008498:Medical Record Linkage / Q000592:standards*; D017410:Practice Guidelines as Topic; D018511:Systems Integration