Intention-Based Critiquing of Guideline-Oriented

Intention-Based Critiquing of Guideline-Oriented Medical Care Aneel Advani, MD, MPH, Kinkoi Lo, MS, and Yuval Shahar, MD, PhD Section on Medical Informatics, Stanford University School of Medicine Stanford University, Stanford, CA 94305-5479 which used human peers as "critiquing modules" to judge the nature of the task of integrated critiquing in medical care.3

We present a methodology and toolfor providing retrospective review and critiquing of guidelinebased medical care given to patients. We show how our guideline representation language, Asbru, which supports the use ofphysicians intentions in addition to physician's actions, allows us to compare the care given to a patient at the level ofthe intention to treat in addition to the more detailed plan carried out. We have developed an algorithm based on this representation for retrospective quality assessment of Our method takes the guideline-based care. physician 's and institution 's preferences andpolicies into account in explaining or justifying physician deviations from the recommendations of a guideline. I. INTRODUCTION

The increasingly widespread use of clinical guidelines to spur best practices in medical care and incorporate evidence-based medicine has given rise to the use of computer-based techniques to support guideline-oriented medical care. Indeed, there have been many efforts to provide automated decision support for guideline-based medical care."2 These systems must support several tasks associated with guideline-based care in order to be effective. An important task that must be supported is that of retrospective review to see if the care actually given to patients was consistent with the standards required in the guideline, and if there were deviations to try to explain them. This task recognizes that effective decision-support for guideline-based care must take into account that guideline specifications can never anticipate all the variations physicians see in treating particular patients. The most effective guidelines do allow the physician flexibility in their application. Thus, in order to have a more robust system of evaluating the care given to patients, a computerbased system must be able to adjust its critique. This adjustment is needed when the physician's actions in treating a particular patient differ from the detailed

Figure 1. The Asgaard architecture showing modules for decision-support of guideline-based medical care. The arrows represent data or knowledge flow between ontologies and/or problem-solving methods. Our group has been developing a methodology for accomplishing the critiquing task for guidelinebased medical care.4 In the Asgaardt project, we are developing different task-specific reasoning modules that perform various guideline support tasks as shown in Figure 1. In addition to the critiquing module, the architecture includes modules to abstract temporal patterns from the patient data and then process temporal queries about these data in the medical An execution interpreter component record. transforms general guidelines in the specification library into patient-specific instantiations of plans and recommendations. The system would be used in the setting of an institution's quality assessment efforts in the following fashion. Health care plans would use he Asbrut language to model clinical policies as guidelines, using a knowledge acquisition tool. The guideline execution tool would then output patientspecific recommendations that conform to the modeled guideline. Then the database module would

recommended actions of the guideline, but still follow the overall goals or intentions of the guideline designers for treating the patient's condition. Thus, we need an interactive approach to medical decisionsupport involving critiquing that recognizes the provider's close knowledge of the patient. This was poignantly pointed out in a recent study in JAMIA

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t Asgaard in Norse mythology was the land of final bliss. Asbru was the name of the bridge to get there.

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