GEM: A Proposal for a More Comprehensive Guideline Document Model Using XML

Richard N. Shiffman, MD, MCIS, Bryant T. Karras, MD, Abha Agrawal, MD, Roland Chen, MD, Luis Marenco, MD and Sujai Nath, MD

Affiliation of the authors: Yale University, New Haven, Connecticut.

Correspondence and reprints: Richard N. Shiffman, MD, Center for Medical Informatics, P.O. Box 208009, New Haven, CT 06520-8009; e-mail: <richard.shiffman@yale.edu>.

Abstract Objective: To develop a guideline document model that includes a sufficiently broad set of concepts to be useful throughout the guideline life cycle.

Design: Current guideline document models are limited in that they reflect the specific orientation of the stakeholder who created them; thus, developers and disseminators often provide few constructs for conceptualizing recommendations, while implementers de-emphasize concepts related to establishing guideline validity. The authors developed the Guideline Elements Model (GEM) using XML to better represent the heterogeneous knowledge contained in practice guidelines. Core constructs were derived from the Institute of Medicine's Guideline Appraisal Instrument, the National Guideline Clearinghouse, and the augmented decision table guideline representation. These were supplemented by additional concepts from a literature review.

Results: The GEM hierarchy includes more than 100 elements. Major concepts relate to a guideline's identity, developer, purpose, intended audience, method of development, target population, knowledge components, testing, and review plan. Knowledge components in guideline documents include recommendations (which in turn comprise conditionals and imperatives), definitions, and algorithms.

Conclusion: GEM is more comprehensive than existing models and is expressively adequate to represent the heterogeneous information contained in guidelines. Use of XML contributes to a flexible, comprehensible, shareable, and reusable knowledge representation that is both readable by human beings and processible by computers.