DR ANTHONY MADDEN Consultant Anaesthetist & ACIS Programme Director North Bristol NHS Trust

1. CLINICAL DECISION SUPPORT AND PROGRAMMING IN ARDEN SYNTAX DR ANTHONY MADDEN Consultant Anaesthetist & ACIS Programme Director North Bristol NHS Trust

2. AIMS • to explain the term ‘Clinical Decision Support' in the context of EPR/EHR • to explain why we need CDS • to explain what Arden Syntax is • to introduce programming medical logic modules in Arden Syntax

3. Clinical Decision Support • Why we need CDS • Arden Syntax • Programming ‘medical logic modules’ in Arden Syntax

4. CLINICAL DECISION SUPPORT “Pull Technology” • Medline • Embase • NELH • Internet • WeBNF

7. CLINICAL DECISION SUPPORT “Push Technology” • Notes • Order sets • Care pathways • Expert systems • Arden Syntax

10. Clinical Decision Support • Why we need CDS • Arden Syntax • Programming ‘medical logic modules’ in Arden Syntax

11. CLINICIANS NEED INFORMATION AT THE POINT OF CARE “If we managed travel like we manage healthcare then travel agents would book flights on the basis of the flight schedules they could remember" Lawrence L Weed

12. HOSPITAL FATALITY RATE “In the USA medical error results in 44,000-98,000 unnecessary deaths each year and 1,000,000 excess injuries” Epidemiology of medical error BMJ 18 March 2000

13. EFFECTIVENESS OF CDSS Perioperative Antibiotic Administration • Intervention : reminder re timing and type of antibiotic • Period : 1988 - 1994 • Result : perioperative wound infections declined from 1.8% to 0.9% • average # doses : 19 to 5.3 • antibiotic cost per patient: $123 to $52 (Pestotnik, LDS Hospital: Ann Intern Med 1996;124(10):884-90)

14. Clinical Decision Support • Why we need CDS • Arden Syntax • Programming ‘medical logic modules’ in Arden Syntax

15. MEDICAL LOGIC MODULE • Each MLM contains maintenance information, links to other sources of knowledge, and enough logic to make a single health decision • The Medical Logic Module (MLM) is a stream of text stored in an ASCII file in statements called slots

16. ARDEN SYNTAX - DEFINITION • Arden Syntax is an HL7/ANSI standard specification for defining and sharing medical logic. It is a programming language. • Current approved version is 2.1

17. ARDEN SYNTAX - HISTORY HELP LDS Hospital Salt Lake City, UT CARE Regenstrief Institute Indianapolis, IN Arden Syntax Retreat at Arden Homestead, Harriman, NY 1989

18. Arden Syntax • Version 1: 1992 ASTM document 1460 • Version 2: 1999 HL7/ANSI • Version 2.1 : 2002 HL7/ANSI

19. Eclipsys / iSoft McKessonHBOC Siemens Cerner IBM SMS Epic Systems Micromedex SUPPORT FOR ARDEN SYNTAX

20. Arden: New Initiatives • Structured Write statement: - XML DTD • Representing MLMs in XML • Data Model: Fuzzy logic, standard expression language, etc

21. Clinical Decision Support • Why we need CDS • Arden Syntax • Programming ‘medical logic modules’ in Arden Syntax

22. MLM - Structure Categories & Slots maintenance: slotname: slot-body;; library: slotname: slot-body;; knowledge: slotname: slot-body;; end:

23. Maintenance Category Slots (9) • Title • Mlmname (formerly called filename) • Arden • Version • Institution • Author • Specialist • Date • Validation

24. Library Category Slots (5) • Purpose • Explanation • Keywords • Citations (optional) • Links (optional)

25. Knowledge Category Slots (7) • Type • Data* • Priority • Evoke • Logic* • Action • Urgency

26. Data Slot • Terms in the medical logic module must be mapped to a database • Use of curly braces { } allows flexibility in mapping to the institution’s local database • Mapping terms in this way separates the logic in the MLM from institution-specific information

27. Logic Slot • Logical algorithm ‘If…….then…..’ • Ends with a “conclude statement” conclude true; or conclude false;

28. Conclude Statement • conclude true; terminates the rule go to the action slot • conclude false; terminates the rule do not go to the action slot go to end;;

30. PLAYTIME!