Adapting Clinical Guidelines for the Digital Age

Diagram of HL7 implementation guide for the representation of clinical practice guideline recommendations in FHIR (“CPG-on-FHIR”)

In today’s hyperconnected world, delivering swift, accurate evidence to patients and providers saves lives. Efficient, effective, and reliable information transfer matters more than ever as the role of public health in national and global health care systems broadens and overlaps.

CDC leads the Adapting Clinical Guidelines for the Digital Age initiative through the Center for Surveillance, Epidemiology, and Laboratory Services (CSELS) Public Health Informatics Office (PHIO). This multi-stakeholder collaboration, which began as a CDC-wide workgroup in 2016, has expanded to involve many experts worldwide. This collaboration is helping standardize the way clinical guidelines are developed and implemented in the digital age.

Better Connection to Patient Care

Many CDC programs, directly or in partnership with other organizations, develop clinical guidelines, recommendations, or best practices. These evidence-based disease-specific “maps” help providers deliver optimal patient care.

CDC guidelines lead to many healthcare improvements—from faster adoption of discoveries made during outbreaks, to greater clarity in screening for cancer and chronic diseases, to appropriate immunization standards.

Even though CDC guidelines are useful, there are barriers to implementing this important information—including the way information is transmitted.

CDC’s Adapting Clinical Guidelines for the Digital Age initiative is one example of the agency’s ongoing efforts to help ensure quick and easy use of guidelines through standardization and automation.

Lost in Translation

Providers need access to clinical guidelines that are easy to understand and use. To fill that need, electronic health record (EHR) vendors, third-party app and content developers, and health system IT teams condense and translate guideline information into computer-based Clinical Decision Support (CDS).

But making guidelines easy to use can create opportunities for information to be incorrectly condensed or translated. What often happens is similar to the age-old game of telephone: Players hear, interpret, then pass along a message that changes as it moves down the line. With guideline information transfer, complex messages and nuanced information degrade with each translation of the guideline, losing the clarity of the initial guidance and leading to reduced adherence and potential medical errors.

What are Computable Guidelines?

Guidelines are being adapted for the digital age in pivotal ways. Adapting Clinical Guidelines for the Digital Age focuses on computable guidelines, a faithful representation of the narrative guidelines that computers can read, that can be implemented as electronic clinical quality measures (eCQMs), electronic case reports, and other information-delivery tools.

For example, Clinical Decision Support systems analyze EHR data and display the right information to the right people through the right channels in the right intervention formats at the right place in the workflow (Osheroff et al., 2012)1. CDS can deliver evidence-based recommendations in ways that help providers and patients make well-informed decisions and take actions to improve health.

Finding What Works

We need our information to get to the right people at the right time in the clearest, most useful way. Strategies, experience, and champions working together can help prevent or minimize message confusion, as they do in the telephone game.

In 2016, the Office of Public Health Scientific Services (OPHSS)2 initiated CDC’s Clinical Decision Support workgroup to help standardize and improve our approach to clinical decision support. Feedback at the time from stakeholders throughout CDC revealed that the agency’s biggest value-add to health care and public health would be to produce guidelines that could be more easily used in patient care settings.

Based on these findings, CDC’s original agency-wide CDS workgroup became the multi-stakeholder Adapting Clinical Guidelines for the Digital Age initiative.

Start of the Multi-Stakeholder Initiative, February 2018

The five-day Adapting Clinical Guideline for the Digital Age meeting gathered stakeholders responsible for different phases of guideline use, dissemination, and adoption to help them envision how each part of the process works, how the parts interact, and how the system can be improved. The group applied the “Kaizen” method—Japanese for “change for the better”—as the approach in this meeting and going forward in the initiative.

More details about the meeting can be found on the meeting page.

Ongoing Work in Adapting Clinical Guidelines for the Digital Age

Workgroups that formed at the meeting in 2018, continue to collaborate on areas of interest they identified during the Kaizen event.

  • Guideline Creation
  • Informatics
  • Translation and Implementation
  • Dissemination and Communication
  • Evaluation

Following the Kaizen event, the multi-stakeholder group partnered with subject matter experts in anthrax for a “pilot” project. This pilot helped identify the challenges involved and possible improvements based on the multi-stakeholder work done during the event.

Ongoing workgroup projects include the following:

  • An integrated process to develop and implement narrative and computable guidelines in parallel
  • A new standard for developing computable guidelines using Fast Healthcare Interoperability Resources (FHIR)
  • An evaluation framework for determining if the integrated process has improved the process, products, or outcomes of the guidelines
  • Partnership with the World Health Organization (WHO) to develop computable guidelines
  • Conference presentations

1 Osheroff, Teich, Levick, Saldana, Velasco, Sittig, Rogers, Jenders2012. Improving outcomes with CDS: an implementer’s guide, Second Edition.

2 Now known as the Deputy Director for Public Health Science and Surveillance (DDPHSS)

Page last reviewed: December 4, 2020