Medical Logic Modules White Paper [PDF} - IDS-Healthcare

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MICROMEDEX ®MEDICAL LOGIC MODULESGuideline developers can be divided into fourcategories [5]:• General medical societies• Subspecialty medical societies• Government agencies• Others (including individuals, insurers, andprivate organizations)Some electronic medical records and standaloneelectronic products have embedded guidelineswhich, at most, allow modification of parametersthat affect the guideline but in only limited waysthe logic of the guideline.At the Guideline Sharing Workshop, March 3-4,2000, Edward H. Shortliffe stated that guidelinescan be represented at any of three levels [6]:• Developer/viewer level• Abstract machine levels• Integration into application environmentsMICROMEDEX is synthesizing guidelines developedby trusted organizations and representingthem in Arden Syntax so that they can be integratedinto applications that customers can use.What makes the MICROMEDEX service unique isthat it addresses the abstract machine level andenables easier integration of medical knowledgeinto application environments.DiscussionImplementation of guidelines into practice hasbeen one of the most difficult problems, if notthe most difficult problem, related to guidelinedissemination. Hospitals and other healthcareenterprises, such as HMOs, have authored textbasedguidelines for physicians, nurses and pharmaciststo use in patient care, but the use ofthese guidelines in actual practice has been limitedby lack of clinician awareness. Putting analert or reminder directly into the workflowincreases the clinician’s awareness of the existenceof the guideline and enhances compliance.Guideline development requires considerableeffort. Hospitals and other healthcare enterpriseswill continue to develop local guidelines.However, there is considerable interest in takingguidelines developed by medical societies, governmentagencies and private organizations andimplementing those guidelines exactly as developed,or with only a few local modifications.MICROMEDEX has taken accepted guidelinesfrom trusted sources and expressed those guidelinesin Arden Syntax. In so doing, MICROMEDEXhas enabled hospitals and other healthcare enterprisesto implement those guidelines more quicklyand with less effort. But the greatest benefit tohealthcare enterprises will be in the maintenanceof the medical logic modules by MICROMEDEXwhen guidelines are updated.While there have been national efforts to gatherand centralize the available guidelines such asthe website for National GuidelineClearinghouse, there is still a need to synthesizethese guidelines and translate them into amachine-readable form. Development and maintenanceof any knowledge base is a formidabletask but is essential if the knowledge base is tohave and maintain relevance and validity. Makingguidelines available at the point of care whereand when they are needed will still require keenediting and implementation skills. One methodof doing this is by using a rules engine.A rules engine is a type of computer applicationthat applies rules to data to generate alerts andreminders for healthcare workers to followguidelines. Knowledge vendors are still neededto edit and translate guidelines into a format ofknowledge representation that can be used withrules engines in healthcare information systems.MICROMEDEX takes published guidelines andtranslates them for use within rules engines thatcan interpret Arden Syntax.Software vendors are reluctant to develop contentfor clinical decision support products. Theyview the development of content for clinicaldecision support a risky proposition, and outsidethe realm of their core competencies.MICROMEDEX has been developing knowledgebases and content for clinical decision support foryears with POISINDEX ® , DRUGDEX ® , and manyother products to support the clinical care ofpatients. It is a natural extension ofMICROMEDEX expertise to develop MedicalLogic Modules in Arden Syntax.
MICROMEDEX ®MEDICAL LOGIC MODULESMICROMEDEX currently offers three differentpackages of medical logic modules [7]. There is agold package, starter package, and a package ofwellness rules.Starter package (7 topics):• Lean Body Weight Calculator• Body Mass Index Calculator• Body Surface Area Calculator• Body Fluid Volumes Calculator• Creatinine Clearance Calculator/Monitor• Basal Energy Expenditure Calculator• Serum Osmolality CalculatorGold package (22 topics):• ANC Monitoring for Filgrastim (Neupogen)Therapy• Digoxin and Electrolytes• Dosing of Renally-Excreted Aminoglycosides• Dosing of Renally-Excreted Antivirals• Dosing of Renally-Excreted Betalactams• Dosing of Renally-Excreted Cephalosporins• Dosing of Renally-Excreted Fluoroquinolones• Dosing of Renally-Excreted Glycopeptides• Heparin Dosage Adjustment Suggestionsfor IV Infusion• Heparin Initial Dosage Suggestionsfor IV Infusion• Hypertensive Disease Management /Clinical Practice Guidelines• Antifungals IV-to-PO Conversion• Drug-Induced Hyperkalemia• Drug-Induced Hypokalemia• Drug-Induced Nephrotoxicity• Drug-Induced Thrombocytopenia• Drug-Induced Liver Injury• Fluoroquinolones IV-to-PO Conversion• H2-Receptor Antagonist IV to PO Conversion• IV-to-PO Cephalosporins Conversion• Appropriate Use of SupplementalIV Magnesium• Appropriate Use of SupplementalIV PotassiumWellness and Screening Package (9 topics):• Colorectal cancer screening• Breast cancer screening• Influenza screening• Cervical cancer screening• Pneumococcal immunization screening• High blood pressure screening• Cholesterol screening• Tetanus/diphtheria screening• Measles, mumps & rubella screeningThese sets range in complexity from the starterset, with relatively straightforward monitoringand screening, to rules for renal dosing of medicationswith complex absorption, bioavailabilityand excretion characteristics and narrow therapeuticindices. The development of the complexrules in the gold package draws on the expertisefor which MICROMEDEX is known. Most healthcareorganizations would not have the time ordepth of resources to create and maintain suchcomplex rules.One example of the forethought given to theMLM implementation process is the rule for creatinineclearance. The rule gives the user six differentformulas for creatinine clearance calculationfrom which to choose.Development and MaintenancePresently, the most common method of developmentof knowledge bases is through consensuspanels. These consensus panels serve as editorialboards that must determine when new knowledgerises to the level that a change must bemade to the knowledge base. MICROMEDEXdraws upon their clinical experts to contribute totheir editorial board.
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