Modeling guidelines for integration into clinical workflow.

The success of clinical decision-support systems requires that they are seamlessly integrated into clinical workflow. In the SAGE project, which aims to create the technological infra-structure for implementing computable clinical practice guide-lines in enterprise settings, we created a deployment-driven methodology for developing guideline knowledge bases. It involves (1) identification of usage scenarios of guideline-based care in clinical workflow, (2) distillation and disambiguation of guideline knowledge relevant to these usage scenarios, (3) formalization of data elements and vocabulary used in the guideline, and (4) encoding of usage scenarios and guideline knowledge using an executable guideline model. This methodology makes explicit the points in the care process where guideline-based decision aids are appropriate and the roles of clinicians for whom the guideline-based assistance is intended. We have evaluated the methodology by simulating the deployment of an immunization guideline in a real clinical information system and by reconstructing the workflow context of a deployed decision-support system for guideline-based care. We discuss the implication of deployment-driven guideline encoding for sharability of executable guidelines.