Clinical Practice Guidelines: Supporting Decisions, Optimizing Care

  • Richard N. Shiffman
Part of the Health Informatics book series (HI)


Clinical practice guidelines (CPGs) are repositories of high quality medical knowledge. During the past decade and a half, as techniques for distilling clinical knowledge from basic research have improved, data may be gathered efficiently and transformed in a timely basis into useful summaries of the best available evidence. CPGs are the subject of considerable interest in clinical medicine and informatics. Clinicians look to guidelines for credible assistance in resolving problems they face in daily practice.

Informaticians view guidelines as a mechanism to overcome the “knowledge acquisition bottleneck,” i.e., the extraction of knowledge from experts in a format that can be processed by computers. Other problems in CPG dissemination include selection of the “best” guideline on a particular topic when “competing” documents for management of common conditions are developed1 and the high cost of CPG development (US guidelines cost on average $100,000–200,0002 and require periodic updating).


Clinical Practice Guideline Guideline Implementation Quality Improvement Tool Guideline Knowledge Knowledge Acquisition Bottleneck 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Bosson JL, Labarere J. Determining indications for care common to competing guidelines by using classification tree analysis: application to the prevention of venous thromboembolism in medical inpatients. Med Decis Mak. 2006;26(1):63–75.CrossRefGoogle Scholar
  2. 2.
    Burgers JS, Grol R, Klazinga NS, Makela M, Zaat J. Towards evidence-based clinical practice: an international survey of 18 clinical guideline programs. Int J Qual Health Care. 2003;15(1):31–45.PubMedCrossRefGoogle Scholar
  3. 3.
    Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Field MJ, Lohr KN, eds. Washington, DC: National Academy Press.Google Scholar
  4. 4.
    Peleg M, Boxwala AA, Tu S, et al. The InterMed approach to sharable computer-interpretable guidelines: a review. J Am Med Inform Assoc. 2004;11(1):1–10.PubMedCrossRefGoogle Scholar
  5. 5.
    Shaneyfelt TM M-SM, Rothwangl J. Are guidelines following guidelines? The methodological quality of clinical practice guidelines in the peer-reviewed medical literature. JAMA. 1999;281:1900–1905.PubMedCrossRefGoogle Scholar
  6. 6.
    Shiffman RN, Shekelle P, Overhage JM, Slutsky J, Grimshaw J, Deshpande AM. Standardized reporting of clinical practice guidelines: a proposal from the Conference on Guideline Standardization. Ann Intern Med. 2003;139(6):493–498.PubMedGoogle Scholar
  7. 7.
    AGREE Collaboration. Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project. Qual Saf Health Care. 2003;12(1):18–23.CrossRefGoogle Scholar
  8. 8.
    Shiffman RN, Dixon J, Brandt C, et al. The GuideLine Implementability Appraisal (GLIA): development of an instrument to identify obstacles to guideline implementation. BMC Med Inform Decis Mak. 2005;27(5):23.Google Scholar
  9. 9.
    Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282(15):1458–1465.PubMedCrossRefGoogle Scholar
  10. 10.
    Grilli R, Magrini N, Penna A, Mura G, Liberati A. Practice guidelines developed by specialty societies: the need for a critical appraisal. Lancet. 2000;355:103–106.Google Scholar
  11. 11.
    Matthews JC, Johnson ML, Koelling TM. The impact of patient-specific quality-of-care report cards on guideline adherence in heart failure. Am Heart J. 2007;154(6):1174–1183.PubMedCrossRefGoogle Scholar
  12. 12.
    Jimbo M, Nease DE Jr, Ruffin MT 4th, Rana GK. Information technology and cancer prevention. CA Cancer J Clin. 2006;56(1):26–36.PubMedCrossRefGoogle Scholar
  13. 13.
    Johnson KB, Feldman MJ. Medical informatics and pediatrics. Decision-support systems. Arch Pediatr Adolesc Med. 1995;149(12):1371–1380.PubMedGoogle Scholar
  14. 14.
    O'Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007;17;(4):CD000409.Google Scholar
  15. 15.
    Tierney WM, Overhage JM, Takesue BY, et al. Computerizing guidelines to improve care and patient outcomes: the example of heart failure. J Am Med Inform Assoc. 1995;2:316–322.PubMedGoogle Scholar
  16. 16.
    Institute of Medicine.. Setting Priorities for Clinical Practice Guidelines. Field MJ, ed. Washington, DC: National Academy Press; 1995.Google Scholar
  17. 17.
    de Clercq PA, Blom JA, Korsten HH, Hasman A. Approaches for creating computer-interpretable guidelines that facilitate decision support. Artif Intell Med. 2004;31(1):1–27.PubMedCrossRefGoogle Scholar
  18. 18.
    Svátek V, Ruzicka M. Step-by-step mark-up of medical guideline documents. Int J Med Inform. 2003;70(2–3):329–335.Google Scholar
  19. 19.
    Peleg M, Tu S, Bury J, et al. Comparing computer-interpretable guideline models: a case-study approach. J Am Med Inform Assoc. 2003;10(1):52–68.PubMedCrossRefGoogle Scholar
  20. 20.
    Shiffman RN, Michel G, Essaihi A, Thornquist E. Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation. J Am Med Inform Assoc. 2004;11(5):418–426.PubMedCrossRefGoogle Scholar
  21. 21.
    OpenClinical. OpenClinical: Knowledge Management for Health Care Website; 2008. Available at: Accessed June 5, 2008.
  22. 22.
    Kim S, Haug PJ, Rocha RA, Choi I. Modeling the arden syntax for medical decisions in XML. Int J Med Inform. 2008;77(10):650–656.PubMedCrossRefGoogle Scholar
  23. 23.
    Musen MA, Tu SW, Das AK, Shahar Y. EON: a component-based approach to automation of protocol-directed therapy. J Am Med Inform Assoc. 1996;3(6):367–388.PubMedGoogle Scholar
  24. 24.
    Terenziani P, Montani S, Bottrighi A, Torchio M, Molino G, Correndo G. The GLARE approach to clinical guidelines: main features. Stud Health Technol Inform. 2004;101:162–166.PubMedGoogle Scholar
  25. 25.
    De Clercq PA, Blom JA, Hasman A, Korsten HH. GASTON: an architecture for the acquisition and execution of clinical guideline-application tasks. Med Inform Internet Med. 2000;25(4):247–263.PubMedCrossRefGoogle Scholar
  26. 26.
    Patel VL, Allen VG, Arocha JF, Shortliffe EH. Representing clinical guidelines in GLIF: individual and collaborative expertise. J Am Med Inform Assoc. 1998;5(5):467–483.PubMedGoogle Scholar
  27. 27.
    Ciccarese P, Caffi E, Boiocchi L, Quaglini S, Stefanelli M. A guideline management system. Medinfo. 2004;2004:28–32.Google Scholar
  28. 28.
    Hagerty CG, Chang J, Pickens DS, Kulikowski CA, Sonnenberg FA. Semi-automated encoding of guidelines. Medinfo. 2004:1625.Google Scholar
  29. 29.
    Sutton DR, Taylor P, Earle K. Evaluation of PROforma as a language for implementing medical guidelines in a practical context. BMC Med Inform Decis Mak. 2006;6:20.PubMedCrossRefGoogle Scholar
  30. 30.
    Zynx Health; 2008. Available at: Accessed June 8, 2008.
  31. 31.
    Shiffman RN, Michel G, Essaihi A, Thornquist E. Bridging the guideline implementation gap: a systematic, document-centered approach to guideline implementation. J Am Med Inform Assoc. 2004;11(5):418–426.PubMedCrossRefGoogle Scholar
  32. 32.
    Yale University. Guideline Elements Model Website; 2008. Available at: edu/default.htm. Accessed June 5, 2008.
  33. 33.
    American Academy of Pediatrics. AAP Red Book Online; 2008. Available at: http:// Accessed June 5, 2008.
  34. 34.
    American Academy of Pediatrics. AAP Policy Website; 2008. Available at: http:// Accessed June 5, 2008.
  35. 35.
    American Academy of Pediatrics. Steering Committee on Quality Improvement and Management Steering Committee on Quality Improvement and Management Website; 2008. Available at: Accessed June 5, 2008.

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  • Richard N. Shiffman
    • 1
  1. 1.Yale Center for Medical InformaticsYale UniversityNew Haven

Personalised recommendations