Computerised Guidelines Implementation: Obtaining Feedback for Revision of Guidelines, Clinical Data Model and Data Flow

摘要

In this paper we describe a module that allows to collect (a) motivations for non-compliance to guidelines, (b) motivations for poor data entry into the electronic patient record, and (c) comments on medical aspects of guideline recommendations, on their formalisation into computerised rules, and on the guideline integration into the computerised clinical chart. We organised a well-structured taxonomy of non-compliance motivations in such a way that the main hierarchical levels correspond to different medical or technical roles suitable for feedback managing. We analysed about 400 consecutive cases of patients with ischemic stroke. About 40 non-compliances, as well as several incomplete data forms have been identified and motivated.