Breaking the Cycle: The Case for Iterative Guideline Development
Have you ever sent a procedure or guideline out for consultation and then received essentially no feedback on it? Or even worse, have you ever received a document packed with tracked changes from someone who hasn’t worked in a clinical role for a long time, and then had to delicately say, “that’s not actually going to happen in practice”?
It happens to everyone, and I think there are a few core reasons for it:
1. Describing and making recommendations for complex clinical processes is a big undertaking.
Let’s say you had to write a VTE prophylaxis guideline from scratch. You need to give people tools to risk assess for bleeding, risk assess for thrombosis, differentiate clinical conditions, and dose according to patient characteristics (and much more). Each of these things is context-specific and dangerous if you get them wrong. Your document will quickly swell into a 30-page document (and this is needed to cover all bases), but all of a sudden nobody has time to read and review it...
2. The people who really know the process probably don’t have any capacity to comment on it.
There are plenty of very good clinicians out there who have a bursting email inbox because they are focused on spending time on the hospital floor. It’s not a bad thing; they got into healthcare to help people, and they are working where they are needed. Competing for their bandwidth, especially getting them to read and comment on a large document, is very difficult.
3. The people who do have the time to comment don’t necessarily know the day-to-day processes very well.
It tends to be people in full-time desk jobs who have the time to read through large documents and provide comments. It’s great to have them, but they have often been out of practice for a while and may not make the most practical recommendations.
Healthcare is complex, and people are busy. Lumping a huge review process on them every few years is bound to fail.
When it comes to our own software, I am a strong advocate for iterative development. You often don’t fully know what problems you need to solve until you start using something for a few months. You also won’t know how something should work until you really start stress testing it and find out how things break under pressure.
I think procedure and guideline review should be the same. It is often not until you encounter that 1 in 1000 weird patient and check the guideline that you think, “actually, this guideline doesn’t apply to my patient very well". What’s worse is when you are knee-deep in clinical reviews and statistically most likely to identify a problem, that is the point when you are least likely to provide feedback on a procedure or guideline.
Even if you manage to make a good clinical recommendation to the authors, often it will be lost in the ether, as the guideline won’t be up for review for another 2 or 3 years. This is why I think procedure and guideline development should be performed iteratively rather than periodically.
But how could that even be possible, you might ask?
It would mean the authors would need to be working full time, making regular, tiny adjustments to their procedures and guidelines 365 days a year. That would never happen in a public health service!
Well, it can!
And it can be done with no changes to staffing.
There is a massive amount of duplication across government health services. For example, every service has a pneumonia guideline because every service gets cases of pneumonia. Some services recommend interhospital transfer at a certain threshold; others will treat for unique microbes found in their area, but they all do the same thing: they assess the severity, check the patient characteristics and history, and then recommend a treatment +/- referral.
Now, I am certainly not saying that every health service could share the same pneumonia guideline. The way we currently manage procedures and guidelines we all legitimately need a separate pneumonia guideline to describe how we manage it at our own service. This means this document must go out for consultation every few years, and every health service needs to spend considerable time reviewing this document. Now multiply that by every guideline maintained across each service... The administrative costs are enormous...
The way we manage healthcare procedures is not sustainable. It puts a lot of pressure on thinly stretched clinicians and promotes the use of out of date material.
The Sales Pitch
This blog post was never intended to be a sales pitch, but seeing as this is one of the core purposes of Clinical Branches, it would be a sad ending if I didn’t describe what we have been building.
What we have done is develop a tool that allows the development of a central clinical framework that describes the shared logic that is used by all health services for a given procedure (as a branching decision tree). They can then take these branches and make small ‘site-specific variations’ so that when their clinicians view the mobile or desktop version of the application for their site, it makes recommendations appropriate to their own context while still following the same overall decision pattern as their peers.
By abstracting the procedure this way the review of the procedure's core logic can be performed collectively across multiple jurisdictions while still accommodating for each area’s site-specific needs. This means no more review request emails! All clinicians across multiple health services can review the “clinical branches” developed for that procedure and comment on it immediately when they notice an improvement to be made. This allows iterative improvement to the procedure rather than doing a giant 3-yearly review!
Meanwhile, comments made can be upvoted or downvoted to ensure they are peer-reviewed by the people who use the procedure, ensuring it is fit for purpose. People even get ‘clinical credit’ points for contributing to good clinical discussions.
I’m not sure there is a person out there who would disagree with me, the way we are providing procedures and guidelines to clinicians is not sustainable. Medicine is only getting more complicated, guidelines are only becoming more bloated, and clinicians are being stretched more thinly.
If you are interested in trying out Clinical Branches for yourself, please get in touch.
Written by John Shanks - Antimicrobial Stewardship Pharmacist and Software Developer at Kraken Coding