Policy implementation experts’ model can be reproduced and repeated, in many different practices
For the last three decades, medical associations, including the American Academy of Pediatrics (AAP), have placed increasing attention on the systematic development and implementation of clinical reports and practice guidelines. The medical associations have been producing reports assessing guideline quality and addressing standardization and implementation challenges. These reports emphasize the need for a transparent, systematic review of evidence and recommendations articulated in an actionable, standardized format.
Regenstrief Institute Research Scientist Randall Grout, M.D., M.S., is a liaison informatician working with the Partnership for Policy Implementation (PPI), an expert team of clinical informaticians who collaborate with authoring groups within the Academy to ensure that clinical recommendations are actionable and decidable. Dr. Grout is also the chief health informatics officer at Eskenazi Health and an assistant professor of pediatrics at the Indiana University School of Medicine.
As a collaborating author of pediatric guidelines, Dr. Grout provides input and analysis on guideline development, including contradictions and previous ambiguous recommendations that could potentially endanger patients and frustrate clinicians. His duty as a trained informatician working through the partnership is to apply various tools and techniques to eliminate vagueness and concerns about whether there is an effective procedure that can be implemented by practicing clinicians and electronic health record (EHR) developers.
“Medical societies can contribute to improved care and improved recommendations by paying special attention to how the policies, guidelines and reports are formulated in their language and their logic and the algorithms that they produce,” said Dr. Grout. “Informaticians are ideally suited to help with the implementation and the clarity that guidelines need to be implemented or incorporated into EHRs that are widely prevalent in our healthcare systems.”
Examples of the recommendations provided in a recent set of published guidelines are:
- Preservation of human rights and human dignity for all youth is essential while promoting autonomy of patients.
- Pediatricians should advocate for the least restrictive decision-making environment for their patients.
- Discussions about decision-making should be a part of the structured transition planning for youth with intellectual and/or developmental disabilities (IDD) and start between the ages of 12 and 14 years.
Adherence to recommendations from well-written clinical practice guidelines improves clinical outcomes, decreases unexplained variation in care and improves care efficiency. However, guideline recommendations may not be followed because of intrinsic guideline factors, workflow or implementation challenges.
In a peer-reviewed article, the PPI identified that with the increasing use of EHRs in pediatrics, medical societies need to eliminate ambiguity in their guidelines to standardize care delivery, improve care quality and patient outcomes and reduce variation and costs. This work is ongoing.
Trained informaticians assist by using a variety of tools to support guideline authorship. Each of the tools supports a particular phase of guidance for authoring or implementation. Depending on the guideline authors’ needs, a policy implementation expert can select the relevant tool for the guideline or policy development. When the recommendations have already been authored, refinements can be offered. Experts can also guide an assessment that evaluates key domains of the recommendation, including barriers and facilitators to implementation.
In some cases, the analysis includes an evaluation of discrete clinical concepts as a precursor to quality measures. A term such as “ill appearing” may be clear and understandable when communicated by an author to a provider, but when used for logic in an EHR or another electronic document, it could be a difficult concept to represent.
“The overarching objective is EHRs need to be programmed, and if we don’t have a consistent and clear logic, explanation or recommendation in a guideline, then there can be variability when someone goes to program the recommendations from a guideline into their EHR, and that could change from one place to another,” said Dr. Grout. “We try to reduce the chances that we have that unintended variability when a clinician or EHR developer is trying to take a plain text recommendation and put it into a structured executable format in their EHR.
“The model of the PPI is something that can be repeated or reproduced, in many different areas,” said Dr. Grout. “We really hope that medical societies, or anybody that is creating guidelines or recommendations, uses a systematic approach to create clearer and more actionable guidelines for their intended recipients.”
“Better Guidelines and Policies: AAP’s Partnership for Policy Implementation,” is published in the journal Pediatrics.
Randall Grout, M.D., M.S.
In addition to his role as a research scientist with the Clem McDonald Center for Biomedical Informatics at Regenstrief Institute, Randall Grout, M.D., M.S., is the chief health informatics officer of Eskenazi Health. He is also an assistant professor of pediatrics at the Indiana University School of Medicine.
