Computerizing clinical practice guidelines


Guidance in clinical work practice and implications for computerization

PhD-defence by Karen Marie Lyng



It is well described that hospitals have problems with sustaining high quality of care and expedient introduction of new medical knowledge. Clinical practice guidelines (CPGs) have been promoted as a remedy to deal with these problems. It is, however, also well described that application and compliance with CPGs in most areas of clinical practice are deficient. Computerization of CPGs has been brought forward as a method to disseminate and to support application of CPGs. Until now, CPG-computerization has focused on development of formal expressions of CPGs. The developed systems have, however, not gained any extensive application in clinical practice. The basic assumption in this thesis is that the scanty penetration is due to an inappropriate design process when designing computerized CPGs for clinical work practice.

This thesis examines the application of guidance within areas where CPG compliance is known to be prominent in order to determine demands on clinical guidance and characteristic features of applied guidance. The contributions of this thesis fall in two main areas:

  • An analysis of how guidance is applied in clinical practice, within areas where CPG compliance is known to be high. The analysis focuses on the emergence of general clinical work practice demands on guidance
  • An analysis of guidance demands from clinical work practice and business strategy, focusing on implications for the design of computerised CPGs.

The empirical basis of the thesis is comprised by fieldwork in three oncology departments and a case study of advanced life support. Although close to all patients within oncology are treated according to a CPG, I found limited application of physical CPGs and web-based CPG portals. However, I found comprehensive application of activity specific pre-printed forms and standard order sets embedded in the work practice and presenting guidance at the point of care. I have conceptualised the forms and standard order sets as second order guiding artefacts. Second order guiding artefacts were transformed from primary guiding artefacts (protocols and CPGs) according to a standard operating procedure. Based on a participatory design approach, prototypes for computerization of CPGs have been developed and applied for clarification of demands on computerized CPGs.

Assessment Committee:

Chairman: Professor Jørgen P. Bansler, Department of Computer Science, University of Copenhagen
Associate professor Silvana Quaglini, University of Pavia, Italy

Professor Anders Grimsmo, Norwegian University of Science and Technology

Academic supervisor:

Professor Finn Kensing, Center for IT Innovation, University of Copenhagen

For an electronic copy of the thesis, please contact Jette Giovanni Møller,