In the corner of my office sits a pile of clinical guidelines 18 inches high, collected over a period of five years as chairman of the Trust's medical audit committee.
Some of these guidelines are evidence based, whereas others represent the opinions of individual doctors. Many are out of date and a few of these have been replaced, although it is not immediately obvious which are obsolete.
There are four different guidelines for the treatment of deep venous thrombosis, recommending wildly different regimens for similar groups of patients. They take the form of bullet points, diagrams, free text or combinations of these different styles and many, though not all, are adequately referenced.
This heterogeneous group of documents does, however, share some common characteristics. They were all written by dedicated doctors with the best intentions, and have been recommended for use in our organisation, and very few are easily available to clinicians.
Two years ago I was asked to develop a method of delivering high-quality, consistent, up-to-date, evidence-based guidelines to all clinical areas of the Trust.
The solution was slow in coming and evolved over time with contributions from many of my colleagues. We have now constructed a simple, cheap and effective system for distributing guidelines based on internet and world wide web technology.
It is currently delivered throughout the Trust via our local network (intranet) and could equally well be used in primary care using the NHS net and internet connections.
The prerequisites for utilising internet technology in this way are:
- A computer network, such as those used for patient information systems in most hospitals and the NHS network
- Computers running an operating system equipped with web browsing tools capable of interpreting and displaying web pages.
As the Trust was already able to meet these requirements, we decided to use this technology to distribute the guidelines.
A committee was established to review and categorise guidelines according to their evidence base. Clinicians were invited to submit guidelines with relevant documentation for approval. Approval was granted for a period of one year.
Guidelines were categorised as A (based on randomised clinical trials), B (based on good observational studies) or C (based on respected opinion). All other guidelines were rejected or returned for modification.
The committee endeavoured to ensure that similar guidelines were clinically consistent and were based on the most recent evidence. We also tried to encourage uniformity of style.
Approved guidelines were stored on a computer as HTML files. All commercially available web browsing tools such as Internet Explorer and Netscape Navigator interpret HTML files in order to display web pages.
Summary guideline information (e.g. expiry date, guideline author and relevant clinical specialty) was stored in a database on the same computer. The project then required the construction of a web site to serve the guidelines pages and provide information to the Trust.
The web site was constructed (by Roberta Roberts) using Microsoft Front Page, a cheap and simple web authoring software package. The site can be 'seen' from any computer connected to the Trust's network. If we wished, any computer connected to the NHS net or world wide web could view the site.
Users are able to search for clinical guidelines by key word, specialty or author, using the standard internet 'point and click' interface. Even the most hardened technophobes have found the system intuitive and easy to master.
One major advantage is that outdated guidelines can be removed and replaced very easily, leaving no reason for obsolete guidelines to circulate in the Trust (Figure 1).
|Figure 1: Page from website showing ease of access to updated guidelines|
It is also possible for clinicians to view all guidelines that have been added or updated since they last visited the site. Links are provided to other evidence-based medicine sites on the internet, so there is no excuse for practising out-of-date medicine.
This approach to the distribution of up-to-date evidence-based guidelines has proved to be cheap, efficient and reliable. I believe that the use of this technology will become the standard method for delivering guidelines to all doctors in the future.