Development and evaluation of a computer-interpretable guideline for depression screening and initial management in primary care

Abstract

Purpose: Clinical practice guidelines (CPGs) are designed to improve the quality of care by promoting proven interventions and consistency of care. The overall goal of this study was to develop a web-based decision support system (DSS) for depression screening and initial management that would be perceived as easy to use and potentially useful by system end-users (Advance Practice Nurses [APNs]). Translation of a CPG into a computer-interpretable guideline (CIG) is an essential step. Methods: This study consisted of six phases: (1) analysis of the prevalence of depression in an APN Student Clinical Log and evaluation of the ability of standardized terminologies to represent CPG concepts; (2) identification of functional requirements for the web-based DSS; (3) translation of a CPG into Guideline Interchange Format (GLIF) to create a CIG and measurement of the CIG's level of accuracy and completeness including comparison with primary care experts (n=4) on 21 clinical simulations; (4) technical integration and debugging of the web-based DSS; (5) heuristic evaluation by usability experts (n=3) to identify user interface problems; and (6) description of end-users (n=5) perceptions of ease of use and potential usefulness using quantitative (survey) and qualitative (think aloud) techniques. Results: (1) Depression as an assessment diagnosis was found in 300 out of 9,864 encounters in the APN Student Clinical Log database. Concepts extracted from the depression CPG were adequately represented by three standardized terminologies. (2) Functional specifications were identified and formalized in Unified Modeling Language diagrams. (3) Proficiency and efficiency scores were 100% for the performance of the CIG on 21 scenarios run by the Guideline Execution Engine. (4) Web-based DSS was implemented. (5) The average severity ratings for all heuristics, except for User control and freedom (M=3.3---major usability problem) ranged from 0.7 to 2.3. (6) Perceptions of potential usefulness and ease of use were 1.6 and 1.4 respectively (1=strongly agree and 5=strongly disagree). All qualitative comments reflected cosmetic, rather than functional issues. Discussion: This study contributes to the body of knowledge regarding creation of CIGs and their implementation into DSSs and to the design and implementation of DSSs for APN practice in primary care.