Exploring openEHR-based clinical guidelines in acute stroke care and research

Largely speaking, health information systems today are not able to exchange data between each other and understand the data’s meaning automatically by means of their information technology components. This lack of ‘interoperability’ also leads to patients experiencing an undesired discontinuity in their care. This thesis is a part of a health informatics field which tackles interoperability barriers by offering standardised information models for electronic health records. More specifically, this work explores possibilities of combining standardised information models offered by the openEHR interoperability approach with knowledge from evidence-based clinical practice guidelines. The applied methodology includes openEHR archetypes, the openEHR reference information model, standard medical terminologies such as SNOMED CT, the international stroke treatment registry SITS, a newly developed model for representing guideline knowledge (the ‘Care Entry-Network Model’), and rules authored in the Guideline Definition Language, a formalism recently endorsed by openEHR as a part of its specifications. The study design used is based on evaluating the work done by means of retrospectively checking the compliance of completed patient cases with guidelines from the domain of acute stroke management in Europe, both experimentally and using thousands of real patient cases from SITS. Our overall findings are that i) the Care Entry-Network Model facilitates an intermediate step between narrative guideline text and computer-interpretable guidelines to be deployed in openEHR systems, ii) the Guideline Definition Language is practicable for creating and automatically running openEHR-based computer-interpretable guidelines, where we also provide detailed accounts of our employed GDL technologies, and iii) the Guideline Definition Language combined with real patient data from patient data registries can generate new clinical knowledge, which in our case has benefited stroke carers and researchers working with acute stroke thrombolysis. In conclusion, using our methodology, health care stakeholders would get evidence-based knowledge components in their electronic health records based on shareable, well maintainable information and knowledge models in the form of archetypes and GDL rules respectively. However, our approach still needs to be tested at the point of clinical decision making and compared to other approaches for providing exchangeable computer-interpretable guidelines

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

Applying openEHR\u2019s Guideline Definition Language to the SITS international stroke treatment registry: a European retrospective observational study

Abstract 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