The Partnership for Policy Implementation (PPI), initiated in June 2005 by the American Academy of Pediatrics (AAP), aims to create fundamental paradigm shifts in how policy statements, clinical reports, technical reports, and clinical guidelines are both written and ultimately integrated into care. These statements, designed to summarize current standards of care, have become a critical resource in disseminating “best practices” to health care providers. However, their acknowledged shortcomings in truly changing clinician behavior are well documented.

A growing body of research continues to demonstrate the distinct role of health information technology (HIT) in facilitating quality improvement efforts and putting standards of care into practice. It is the AAP’s belief that in order to meet this growing trend, AAP statements must be “operationalized” to provide HIT standard-developing groups and software designers with specific, unambiguous content. The PPI aims to ensure that HIT implementations are designed to meet the specific needs of child health professionals by facilitating creation of some of the fundamental building blocks of electronic health record (EHR) systems during the process of statement development. There are currently many national efforts to develop these functional and technical standards, but these efforts are currently independent of the statement development process. The AAP believes that integrating these groups together will allow both to inform each other’s work. In the process, statements written within this framework will also provide more straightforward guidance for all pediatric health care providers, even those who continue to use paper records.

Members of the PPI team (one pediatric-trained medical informatician and one primary care implementation expert per statement) will consult directly with statement authors during the production of either a new or a revision to a preexisting statement. During the pilot period, the explicit goal is to produce 6-8 published examples of statements written within this framework, which will both serve as substrate for HIT standards development and illustrate ways to alleviate many common shortcomings of such standard-of care statements:

Disambiguation: Often, non-specific language is used within statements, making it difficult for HIT developers to create data that’s useful within an information system. For example, the use of the word “infant” (what’s the age range for an infant? or the phrase “low maternal education” are ambiguities that are difficult to encod within a system. Such language also leads to differences in interpretation of a statement’s recommendations by health care providers.

Clear Definitions: Given that domain experts are most commonly authors of policy statements, clinical reports, technical reports, and clinical guidelines, statements are sometimes written with unclear or unmentioned definitions of concepts. For example, when providers are asked to perform developmental surveillance at every visit, a full explicit definition of the meaning of surveillance should be included.

Clearly Defined Logic: When provider action is prescribed, it needs to both be explicit, and detail all potential possibilities. By clearly and completely defining the logic, HIT developers can build alerts, reminders, and decision support tools to facilitate task completion by clinicians.

Implementation Techniques: Statements of standard-of-practice have an opportunity to define exactly how actions and behaviors should be performed, and explicitness in acceptable implementation techniques is crucial. For example, can developmental screening be conducted with a standardized instrument before a visit, or does it need to be done by a provider directly? By providing this specific information, functional standards for electronic health record (EHR) software can be established and disseminated to developers.

Action-Oriented: Often times, statement authors intend to communicate how clinicians should behave, but this guidance is often buried in the text and is not “user-friendly”. By focusing statement authors on being action-oriented throug the use of tools such as clinical algorithms, clinicians as well as technology developers will better understand both how to fulfill the intent of the statement and how they can interact with HIT.

Transparency: Statements often prescribe specific clinical actions, but don’t consistently provide documentation of the rationale for this guidance. Additionally, content experts during the course of writing statements sometimes avoid providing explicit guidance altogether because of an insufficient evidence base, even though there’s strong consensus. By clearly defining the level of evidence supporting each course of action, the provider is given the tools by which to use professional judgement to make a decision at the point of care.

HIT Standard Development: Once clear, more concise statements are created, they have to be “matched” to the various vocabulary, logical, and functional HIT standards (eg, LOINC, SNOMED, RxNorm, etc). This process will ultimately lead to a common pediatric language for information-management systems. These public domain products allow HIT systems to be integrated and interoperable with each other. These efforts also assure that the national HIT framework supports the medical home approach to pediatric care, enabling the provision of coordinated, comprehensive care to all children and their families – a strategic priority of the Academy.

A strategic planning meeting to be held December 1-2, 2005 will determine how to best integrate PPI methodology as a standard into all future AAP policy writing processes and will identify methods to assess the impact of the project. This meeting will also define future work that will come from the completion of these new statements.