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Writing to the Rules

March 1, 1998
by Charlene Marietti
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A STANDARD LANGUAGE for defining clinical decision rules, the Arden Syntax is fast gathering proponents. The Arden Syntax presents a standardized and relatively simple rules format as well as an opportunity to incorporate medical knowledge from many diverse sources into the information system. Whether the rules are downloaded from an Internet site, exchanged with another organization, written in-house or purchased, Arden-compliant rules will operate with minimal customization and without interface building. Operative over the past few years in a handful of academic institutions in the U.S. and Europe, it has demonstrated support for a range of clinical functions including alerts and reminders, interpretations, diagnoses research screening and quality assurance.

The current chairman of the Arden Syntax, Harm Scherpbier, MD, physician consultant and manager of clinical decision support development, SMS Corp., Malvern, Penn., believes adoption of Arden is key to widespread use of clinical decision support systems in healthcare. Toward that end, his goal is to make Arden Syntax a generally accepted industry standard.

Moving into the mainstream

Originally developed in academia to facilitate medical knowledge-sharing, the American Society of Testing and Materials first oversaw the standard. Now in transition, Arden will join Health Level Seven where it can take advantage of greater industry support. At present, three main groups are showing interest in the standard: vendors, health maintenance organizations and healthcare providers who recognize the need for clinical decision support and are looking for a starting point.

According to Scherpbier, vendors are approaching Arden somewhat differently, with some providing software and others, both the software and the medical knowledge. Companies including HBO & Company, SMS, HealthVISION, IDX, Eclipsys and IBM have Arden Syntax projects under way, although in varying stages of commercialization. Some have products available now; others are in development. Knowledge-provider vendors such as Micromedex (with perhaps the first commercial product) are building knowledge rules that will run on any Arden-compliant system, be it built by HBOC, SMS or IDX. "Overall," he says, "I think that the healthcare market is too big and too complex for a single software vendor to supply all the medical knowledge. The knowledge should come from multiple sources."

Implementation bumps

Although promising, there are barriers to Arden implementation. One is data--or rather, the lack thereof. Few organizations capture structured, coded data in databases for use with a clinical decision support system. At a minimum, says Scherpbier, organizations must collect patient demographics, patient lab results and medications.

Although Arden helps standardize the method for adding knowledge to the system, adding the knowledge rules can be a slow process. Adopted rules, particularly those downloaded from an Internet site or borrowed from another institution, must be validated for local use. Commercialization may offer healthcare organizations some important advantages including consistency as well as important support and maintenance updates to keep the knowledge current.

With all the barriers to implementation, Scherpbier reports that a frequent criticism of Arden is that it is too simplistic. It’s a valid comment, he says, but Arden is simple by design. It is a starting point, not intended to meet all the needs of the clinical decision support system. Like other standards, Arden Syntax will mature over time. "A standard is never intended to limit," he notes, "only to simplify implementations."

Charlene Marietti is senior technology writer at Healthcare Informatics.