TRANSFORMING A HIGH BLOOD PRESSURE CLINICAL

GUIDELINE INTO A CDSS

Difficulties in Understanding

Gustavo Marísio Bacelar-Silva

1,2

, Rong Chen

3,4

and Ricardo Cruz-Correia

1,2

Center for Research in Health Technologies and Information Systems, Porto, Portugal

Faculty of Medicine, University of Porto, Porto, Portugal

Department of Biomedical Engineering, Linköping University, Linköping, Sweden

Cambio Healthcare Systems, Stockholm, Sweden

Keywords: Guideline, Hypertension, JNC 7, Electronic health record, Clinical decision support system.

Abstract: Introduction. Due to the increasing use of Electronic Health Records there is a tendency to implement

clinical decision support system (CDSS) based on existing clinical guidelines. The Seventh Report of the

Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

(JNC 7) is well known and widely used worldwide guideline. Transforming published guidelines into CDSS

is a process that still needs to be improved. Aim. To describe the difficulties in understanding the guideline,

to recommend better suited descriptions for the contents. Methods. Systematic reading of the guideline for

the extraction of the main patient variables, processes and evaluation suggested. The issues were evaluated

considering the Domain 4 of the Appraisal of Guidelines for Research & Evaluation II Instrument. Results.

Several problems were identified considering whether the recommendations are specific and unambiguous,

the different options for management of the condition or health issue are clearly presented and key

recommendations are easily identifiable. Discussion. Some initiatives have been made, as the Guideline

Elements Models and the development of guideline model representations. This attempt to formalise the

JNC 7 guideline allowed to discover many ambiguities, concepts related to prior knowledge and issues

related to the distribution of the content presentation.

1 INTRODUCTION

It is a consensus that clinical guidelines should be

deployed through clinical information systems. Such

measure facilitates overcoming two obstacles to

guideline adherence, which are the awareness of the

document and the availability of its contents for the

healthcare professional at the moment of care.

Despite this, a major guideline implementation

problem is the difficulty to create a comprehensible

document, easy to convert it later into a useful

framework for EHR or a clinical decision support

system (CDSS). Some times the clinical guidelines

are logically incomplete and often employ concepts

that require background knowledge not contained in

the guideline document (Fox et al., 2009). Among

other definitions of what is desirable to a guideline,

the Appraisal of Guidelines for Research &

Evaluation II (AGREE II) Instrument highlights the

clarity of presentation, which involves the

assessment of specificity, unambiguity, clearly

presentation of different options for management

and easiness to identify key recommendations (The

AGREE Next Steps Consortium 2009).

The Seventh Report of the Joint National

Committee on the Prevention, Detection, Evaluation,

and Treatment of High Blood Pressure (JNC 7) was

published in 2003 and since then has been serving as

an important reference to the management of high

blood pressure (BP) worldwide. The JNC 7 updated

and introduced new concepts to hypertension

guidelines. The BP classification (i.e. normal,

prehypertension, hypertension) was simpler than

previous versions and each category should lead to

different approaches to hypertension management. It

also brought new epidemiologic data concerning the

risk of the BP levels, treatment and control rates and

how to apply the guideline concepts to public health

and in medical care practices (Chobanian et al.,

405

Bacelar-Silva G., Chen R. and Cruz-Correia R..

TRANSFORMING A HIGH BLOOD PRESSURE CLINICAL GUIDELINE INTO A CDSS - Difﬁculties in Understanding.

DOI: 10.5220/0003787804050408

In Proceedings of the International Conference on Health Informatics (HEALTHINF-2012), pages 405-408

ISBN: 978-989-8425-88-1

 2012 SCITEPRESS (Science and Technology Publications, Lda.)

2003). Transforming the JNC 7 to an electronically

readable format could bring many benefits to health

providers. It could improve the development of

electronic health records (EHR) and clinical decision

support system (CDSS) being a framework to a

more efficient clinical approach to prevent and

manage hypertension, a cardiac chronic condition

that affected nearly one billion people worldwide in

2000 and is expected to affect 1.56 billion by 2025

(Kearney et al., 2005).

The aim of this work is to assess the clarity of

presentation and describe the difficulties in

understanding patient evaluation items of JNC 7

clinical guideline and recommend better-suited

descriptions for its contents.

2 METHODS

The JNC 7 clinical guideline is available on the

Internet in two documents, an express edition and a

full report. There is also a quick reference card

available to download. We used the full report and

the quick reference card to perform the assessment

of the guideline.

The aspects considered to assess the guideline

were based on the AGREE II Instrument. This

instrument was developed by an independent body

established in 2004 to address the issue of variability

in guideline quality. Its purpose is to provide a

generic framework to (1) assess the quality, (2) serve

as a methodological strategy for the development of

guidelines and (3) inform what information and how

information ought to be reported in guidelines. The

instrument is composed of 23-item organized into

six domains. In order to assess the JNC 7 we used

the Domain 4, which is Clarity of Presentation. The

items that comprise this selected domain are

described as follows:

 The recommendations are specific and

unambiguous - A recommendation should provide a

concrete and precise description of which option is

appropriate in which situation and in what

population group, as informed by the body of

evidence.

 The different options for management of the

condition or health issue are clearly presented - A

guideline that targets the management of a disease

should consider the different possible options for

screening, prevention, diagnosis or treatment of the

condition it covers. These possible options should be

clearly presented in the guideline.

 Key recommendations are easily identifiable –

Users should be able to find the most relevant

recommendations easily. These recommendations

answer the main question(s) that have been covered

by the guideline and can be identified in different

ways. For example, they can be summarized in a

box, typed in bold, underlined or presented as flow

charts or algorithms.

Once we established a framework to consider for

analysis, a systematic reading of the guideline was

conducted. We focused on the extraction of the main

patient variables, processes and its evaluation

according to the AGREED II selected items. Several

new readings were made when it was necessary to

clarify the points considered in disagreement with

the Clarity of Presentation evaluation items. To

better visualize, we developed a diagram illustrating

the thinking processes within the content of the

guideline concerning the patient evaluation.

3 RESULTS

First will be presented the results of our evaluation,

addressing the three items of the selected AGREE II

domain, followed by suggestions on what could

have been done to improve the mentioned issues of

the guideline.

3.1 The Recommendations are Specific

and Unambiguous

 Lacks explanation of what is important to know

about the medical history evaluation. Some of this

information is cited in a different chapter, which

describes particular forms of identifiable

hypertension (e.g. Pheochromocytoma suspicion in

patients with labile hypertension or with paroxysms

of hypertension accompanied by headache,

palpitations, pallor, and perspiration). A list of signs

and symptoms should be presented with a correlated

suspicion.

 Prehypertension is not considered a disease

category, but the JNC 7 states that drug therapy

should be considered for individuals that also have

diabetes or kidney disease and BP levels higher than

130/80 mmHg after a trial of lifestyle modification.

Since these individuals are candidates for drug

therapy, the guideline lacks explaining whether the

physician should perform a more thorough clinical

evaluation besides BP measurement. The guideline

should indicate the clinical approach to this

situation.

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 Many vague recommendations linked to implicit

references of knowledge not contained in the

document (e.g. a thorough examination of the heart

and lungs). Although it may seem obvious for

physicians, it would be better to have these items

clearer explained or referenced to an external

content.

 Sometimes the guideline lacks explaining and/or

correlating the reasons patient evaluation items are

performed (e.g. lipid panel to evaluate

cardiovascular risk factor). Correlating patient

evaluation items with objectives would ease the

comprehension.

3.2 The Different Options for

Management of the Condition or

Health Issue are Clearly Presented

 The table that is supposed to contain the

concomitant disorders that may affect prognosis and

guide treatment actually describes the target organ

damage and is named “Cardiovascular risk factors”.

A new separate table should contain target organ

damage and another one should contain the

concomitant disorders that may affect prognosis and

guide treatment.

 Although referred in the Patient Evaluation

chapter, a list of the concomitant disorders that may

affect prognosis and guide treatment is described

only four chapters ahead (“Special Situations in

Hypertension Management”). It should be presented

in the “Patient Evaluation” chapter.

 Lifestyle evaluation items are not grouped, but

lifestyle modifications are grouped as a table in the

treatment chapter, including items not included

within the evaluation items (e.g. alcohol

consumption). The lifestyle evaluation items should

be described within medical history.

 The guideline is conducted through two paths,

the Objectives-oriented (evidence-based thinking)

and the Semiology-oriented (traditional medical

thinking) paths. The problem is that these paths are

rarely correlated. The establishment of a connection

between these two paths (e.g. subdividing the

semiology items according to the objectives of

patient evaluation) would improve the

comprehension of the guideline as a whole, allowing

the readers to know what is necessary to do and why

it is necessary to be done.

 Electrocardiography is presented as a routine

laboratory test, but it is not a laboratory test, it is a

diagnostic tool (Meek and Morris, 2002). A new

name, such as “Routine diagnostic procedures”

would be more appropriated.

 “Other diagnostic procedures” are not clearly

grouped. They are cited and start to be described in

the “Patient Evaluation” chapter but continue and

end in the next chapter (“Identifiable Causes of

Hypertension”). They are also referred as “additional

diagnostic procedures”. They should have been cited

before as a single term and completely described in

the chapter.

3.3 Key Recommendations are Easily

Identifiable

 Recommendations for patient follow-up

frequency according to BP measurements are

presented in the chapter named “Calibration,

Maintenance, and Use of Blood Pressure Devices”.

It would be better to present the recommended

approach after the patient has been classified.

 The Quick Reference Card contains the sections

“Diagnostic Workup of Hypertension”, “Assess risk

factors and comorbidities” and “Reveal identifiable

causes of hypertension” in a manner that they seem

to be different aspects to evaluate, but actually the

last two sections are items of the first one. “Assess

risk factors and comorbidities” and “Reveal

identifiable causes of hypertension” sections should

be presented in a different manner to demonstrate

they are within “Diagnostic Workup of

Hypertension”.

4 DISCUSSION

As already mentioned, the JNC 7 guideline is a very

important document, which has been cited over than

10,500 articles worldwide since 2003. But despite

the efforts of the medical informatics community,

this document, as many others, has several issues

that make it difficult to understand and convert it

into an EHR or CDSS.

Five years before the release of the JNC 7,

Douglas K. Owens (1998) published a paper about

the implementation of guidelines into the clinical

practice. The guidelines’ potential to improve

quality of healthcare and the increased benefit of

their integration to an EHR and CDSS were reported

and are well known today. But he also described the

two main reasons why guidelines were rarely used:

(1) the lack of computing infrastructure to support

computer-based guidelines; and (2) the substantial

technical challenges related to the guideline

development, which were the medical vocabularies

TRANSFORMING A HIGH BLOOD PRESSURE CLINICAL GUIDELINE INTO A CDSS - Difficulties in

Understanding

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insufficiently standardized and guideline produced

without precise enough recommendations.

The technology advances involving, for

example, wider access and use of Internet and

mobile devices have been allowing to address the

first reason.

But the second reason is not so easy. Some

initiatives have been made, as the Guideline

Elements Models (GEM) and development of

guideline model representations. The GEM is a

framework that uses tags and intends to promote

translation of natural language within guideline

documents into a format that can be electronically

processed by describing concepts, their attributes

and their relationships. However, GEM has some

limitations, such as its little potential to resolve the

ambiguities that are easily found in many guidelines

(Shiffman et al. 2000). Several different formalisms

have been developed by research teams to develop

guideline decision models. These models are

representations of guideline recommendations as a

plan, composed by decisions, actions, subplans and

their relationships. In order to facilitate future

updates, the model element is associated with the

guideline text using the GEM tags (Quaglini and

Ciccarese, 2006).

5 CONCLUSIONS

This attempt to formalise the JNC 7 guideline

allowed to discover many ambiguities, concepts

related to prior knowledge and issues related to the

distribution of the content presentation. Since the

date the JNC 7 was published many efforts were

made in order to put together the paper and machine-

readable versions of guidelines. The guideline

developers should consider during its developing

time to use the medical informatics tools to have, in

the end, both versions made. This would also

improve the quality and comprehension of the

guideline’s statements and meet the needs of

healthcare stakeholders to build a more affordable

and reliable practice. We expect that our suggestions

can help improving the future guidelines

development.

ACKNOWLEDGEMENTS

This work is funded by FEDER funds (Programa

Operacional Factores de Competitividade –

COMPETE) and by National funds (FCT –

Fundação para a Ciência e a Tecnologia) through

project SAHIB - Enhancing multi-institutional

health data availability through multi-agent systems

[PTDC/EIA-EIA/105352/2008].

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Chobanian, A. V. et al., 2003. Seventh Report of the Joint

National Committee on Prevention, Detection,

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Fox, J. et al., 2009. From practice guidelines to clinical

decision support: closing the loop. Journal of the

Royal Society of Medicine, 102(11), p.464-473.

Kearney, P. M. et al., 2005. Global burden of

hypertension: analysis of worldwide data. The Lancet,

365(9455), p.217-223.

Meek, S. and Morris, F., 2002. Introduction. I—Leads,

rate, rhythm, and cardiac axis. BMJ, 324(7334), p.415

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Owens, D., 1998. Use of medical informatics to

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Quaglini, S. and Ciccarese, P., 2006. Models for guideline

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Shiffman, R. N. et al., 2000. GEM: A Proposal for a More

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Available at: www.agreetrust.org/?o=1397.

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