Should we primarily publish electronic guidelines as reminders?

Abstract

I believe that creating guidelines as word processed documents primarily for paper publication leads to a number of problems: • There is a risk of the document expanding into a lengthy evidence based textbook which takes years to write and is expensive to revise [Eccles 02] • The bulk makes it hard for users to find the specific page, paragraph and sentence that applies to this patient this visit. It also makes it hard for human authors to ensure that the guideline is complete and that words are used consistently • Any versions for different audiences (eg. patients, nurses, audit clerks) need to be written separately and kept by hand synchronised with the master version • The evidence shows that it is rare for such guideline documents themselves to change clinical practice or patient behavior [Grimshaw 04] • The material is designed to be read linearly, limiting our ability to extract text fragments to populate computer screens. To use the knowledge contained in the guideline for reminders or decision support, someone must spend weeks trying to locate and model small parts of the guideline as a knowledge base, only to find that it lacks detail or even disagrees with itself in places. I will argue that we should instead focus our evidence search and authoring process around proven clinical problems (ie. health decisions or actions with demonstrated and unexplained variation or deviation from evidence or patient preferences), rather than on a large number of questions spread out along the patient pathway. In addition, I believe we should publish guidelines primarily as a set of well structured computer reminders and alerts, with a secondary hypertext version reserved for browsing on screen