Hi Paul and Adrian
Regarding "a system designed to present guidelines to clinicians should
include a system for collecting and channelling from the point of use
disagreement back to the originators and controllers,and that when a
guideline was not followed there should be a simple way of recording why
not.designed our decision support system to do just that."
Our system does!
Over the last 4 years we have been collaboratively working with
clinicians (primary and secondary care), health authorities, NZ
Guideline Groups, Heart Foundation, Diabetes NZ, IT companies etc and
have developed PREDICT.
PREDICT = a web-based CVD and Diabetes risk assessment and management
programme integrated with GP patient management system provides in
"real-time" recommendations and actions based on NZ CVD and Diabetes
guidelines and tailored to the patient's CVD/Diabetes profile. Currently
being used by over 500 GPs and nurses, with a large scale pilot starting
At the moment GPs and nurses use a feedback link on the input form to
raise any issues and this is collated and triaged. All feedback is
responded to. If any patient safety issues are raised this is
immediately addressed. If issues are IT, then this is referred for
continuing software enhancement. If the problem is a guideline issue
then this is raised with New Zealand Guideline Group. Examples of
current GP concern is over the lack of advice for impaired fasting
glycaemia/previous gestational diabetes and implication for CV risk;
practical advice for a diabetic with eGFR between 30-60mls/min (other
than refer to renal clinic). The guidelines are due for update and these
questions have been put on the agenda- hopefully recommendations will be
forthcoming and we will directly update the decision support system.
The PREDICT programme has also been modified for a busy Coronary care
unit and has a text box linked with each recommended "Action". CCU
nurses/docs can record why the guideline was not followed. Our GPs were
not so keen at present to have this option (just seemed like more form
filling to them)
Dr Sue Wells
Senior Lecturer Clinical Epidemiology
Section of Epidemiology and Biostatistics
School of Population Health
University of Auckland
PO Box 92-019
09 3737 599 ext 82463
From: Evidence based health (EBH)
[mailto:[log in to unmask]] On Behalf Of Paul Glasziou
Sent: Friday, 8 September 2006 1:59 a.m.
To: [log in to unmask]
Subject: Re: Do you have examples of rational disagreement with
Such feedback on guidelines would be a great idea! If you ever manage to
get a guideline producer to take it up please let me know.
Interestingly the AGREE tool to assess guidelines has "piloting with end
users" as one of its criteria but I can recall a guideline I've seen
Dr Adrian Midgley wrote:
> -----BEGIN PGP SIGNED MESSAGE-----
> Hash: SHA1
> Paul Glasziou wrote:
>> Are you aware of examples of rational disagreement with guidelines?
> I wrote some time ago that systems designed to present guidelines to
> clinicians should include a system for collecting and channelling
> the point of use disagreement back to the originators and controllers,
> and that when a guideline was not followed there should be a simple
> of recording why not.
> The implication was that this was electronic record system /medical
> automation systems, but I suppose it would apply to paper guidelines
> they actually worked.
> I am unaware of any example of a system actually doing that.
> - --
> -----BEGIN PGP SIGNATURE-----
> Version: GnuPG v1.4.1 (GNU/Linux)
> Comment: Using GnuPG with Mozilla - http://enigmail.mozdev.org
> -----END PGP SIGNATURE-----
Director, Centre for Evidence-Based Medicine,
Department of Primary Health Care,
University of Oxford www.cebm.net
ph +44-1865-227055 fax +44-1865-227036