Guideline and protocol

based systems
HEALTH INFORMATICS, 2ND SEM 2019-2020
LILY ANN D. BAUTISTA, PT, DPT, PTRP, COMT, VCS

SOURCE: GUIDE TO HEALTH INFORMATICS, 3E, COIERA, 2015

Clinical guidelines vs protocols

 Documents that provide best practice guidance supported by research

from experts
 Clinical Practice guidelines: contains recommendation or strategies to
assist healthcare practitioners in making clinical decisions
 Usually long
 Usually referred synonymously with protocol; emphasis is to offer guidance
 Advisory, the clinician still has to decide esp when instructions are not
appropriate
 Protocol: more prescriptive version of a guideline, contains specific
instructions to follow.
 More precise
Other names of “protocol”

 Algorithm: set of instructions to carry out some task

programmatically
 Usually small, specific and well defined
 Protocol: steps in management of a clinical condition with
diagnosis, illness and treatment
 Guideline: often used synonymously with protocol, guidance,
advisory in nature
 Care Pathway: does not show steps, but focuses on expected
course of the patient’s management
 Checklist: when steps taken are executed in a specific order; once
then, checklist are crossed off
 Practice parameter: emphasizes on the role of instructions to set
boundaries or parameters in the course of patient’s silent case
Protocol application

 Research
 Basis of comparison among studies
 Application of a particular treatment
 Delegation of responsibility
 Highly trained staff delegates routine problems to a more generally
trained colleagues
 Patients can be given instructions to do at home
 Demarcation of responsibility
 To make clear what each member of the team does
Protocol application

 Safety critical or complex situations:

 Checklists done to make sure that steps are taken
 Education
 minimum standard of training needed for delivery of care
 Uncommon conditions:
 Important forrare conditions, something that the person has
not experienced before
 Increased compliance with guideline
should result in decreased variation in
clinical practice,
 Review of 59 evaluations of clinical
guidelines: all but 4 showed improvement
in care ffg introduction of a guideline
(Grimshaw and Russell, 1993)
Protocol characteristics / different
presentations

 Always starts with an inclusion, eligibility or entry

criteria – defines intended use
 Example: Rehab following ACL reconstruction
 Flow chart: simplest way to represent a protocol
 Graphical, with decision points and flow of logic, can
be detailed or can be simple
A decision tree: can be yes not OR, if-then
statements. Protocol expressed in set of rules
Protocol characteristics / different
presentations

 Care Pathways
 Sets of stages; contributes to effective
communication
 Structured multidisciplinary plan of care
 Translate guidance or evidence in local structures
 Detail the steps in a course of treatment
 Have timeframe or criteria that guide progression
 Standardized care for a particular clinical problem
Criteria that will affect protocol

 Patient condition: pt may have concurrent

illness; different fitness level, different body type,
etc.
 Treatment variation: treatment may deviate
from the standard due to one reason or another
 Resource constraints: sometimes even if the
protocol gives you step 2 and the person doing
step 2 is not available, you might need deviate
from protocol
Computer
based
protocol
systems
Computer based systems

 Passive protocol:
 Acts as a source of information only, not
integrated in the care process
 Makes it easier for clinicians to access
protocol during routine care
 Can be integrated in the computer system
through search button, info button, links
Computer based systems

 Active protocol
 Guide the clinicians
 Must be integrated in the organization’s
informational system – record keeping is important
(automated or semi automated)
 Protocol driven record keeping: provides direct
benefit only to those who use the system -
 Must have the ability to be shared among
stakeholders
Computer based systems

 Active protocol
 Can alert, provide reminders and task
recommendations
 Alert: It can trigger someone to act
accordingly
 Reminder: situational, providing guidance on
what to do in certain scenarios
Prerequisite for developing computer
guideline systems

 Creationof computer-interpretable
representations of the clinical knowledge
contained in clinical guidelines
Example of protocol representation systems

 Arden Syntax:
 Computer language
 widely recognized standard for representing clinical and scientific
knowledge in executable format
 Can be used to code decision and actions within the clinical protocol
system
 Protégé
 Structured around tasks
 Widely used open source tool that allows user to build a protocol
 Once constructed, protocol is translated into machine readable form
 Allows 3rd party plug ins to connect protocols with other information
components that run under different standards
Example of protocol representation systems

 PROforma
 Designed to emphasize on safe guidelines
 Simple and intuitive
 Guideline Interchange Format
 Supports sharing of guidelines among different
institutions and software systems
 Build most useful features of other guidelines and
incorporate standards used in healthcare
DESIGNING,
DISSEMINATING
AND APPLYING
PROTOCOLS
Dissemination

 Every clinician has immediate and easy

access to evidence based practice
 But even if better treatment, not all
clinician will know about it
Barriers on limiting use of evidence in
clinical settings

 Clinicians lack of awareness of existing guideline

 Clinicians may lack familiarity with content of a
guideline
 Clinicians may disagree with guideline, because
they interpret research different and they believe
that benefit is not worth to the comfort of the
patient
 Clinician do not believe that guideline is
applicable to their practice
Barriers on limiting use of evidence in
clinical settings

 They believe that guidelines are oversimplified or

“cookbooks” or that guidelines reduce autonomy
 Clinicians may not feel able to execute the content of a
guideline (also known as low self-efficacy)
 There may be a lack of belief that there will be any
outcome benefit if guideline is used
 Clinicians feel constrained and unable to change from
previous practice
 The guidelines may not be easy or convenient to use or
may be confusing
Factors that might affect likelihood of
adaptation of a guideline

 Clinical inertia: failure of the healthcare providers to initiate

or intensify therapy even when a treatment is indicated and
clinician is aware of the need to do so
 Time
 Limited data
 Multiple problems
 Complexity (adoption of guideline inversely proportional to
complexity)
 Clinical informatics skills: difficulty with use of online
evidence resources, due to insufficient training in database
searching and general technology skills
Factors that might affect likelihood of
adaptation of a guideline

 Organizational support: people who

enthusiastically support innovation; accepts
the uptake of new innovations
 Professional differences:
 Doctors emphasize on role of evidence from
biomedical literature
 Nurses place greater valued on policies and
procedures
Measurement of efficacy and
adoption rate of guidelines

 The effect on clinical outcome that a

treatment produces
 The actual rate of adoption of a guideline that
recommends the treatment
 Discoverability of information – that the community
finds this information
 Utility of information – can the reader find
something useful, they don’t already have
Measurement of efficacy and
adoption rate of guidelines

 **
IMPORTANT to consider both efficacy and
adoption rate
A treatment may be found effective with research
but if with limited adoption rate due to one reason
or another, success of guideline use is still not high
Requirements to meet for guidelines
and protocols to reflect best evidence

 Protocolutility: there must be an

improvement in clinical processes compared
to current
 Protocol designability: must be feasible to
prescribe a course of action ahead of time
 Protocol usability: consider accessibility and
applicability
Protocol rigidity can be decreased by
specific planning

 Treatment goals: should be able to guide, example nurse triage has

to ascertain who are truly needing medical assistance
 The patient: protocol has to manage patient variation and likely to
meet clinical needs
 Local resources: limited by available resources
 Users: skill level of the user affects different types of protocols
 Local process and workflow: a protocol has to be designed with
understanding of how it be used within existing processes
Design principles for protocols include

 Making assumptions about context of use

 Creating protocolsthat are no more specific
than necessary to achieve a specific goal
 Reflecting the
skill level and circumstances
of those who will eventually use them
 Activity
will presented next visit (no
more than 8 mins each
presentation) – group of 8
FIND AN EXAMPLE OF A PROTOCOL OR GUIDELINE
RELATED TO PHYSICAL THERAPY
BRIEFLY DISCUSS ITS USABILITY, UTILITY AND
DESIGNABILITY