1. Guidance MS launch History of the Guidance project Prof Graham Brown Nossal Institute Global Health University of Melbourne

2. Project History (mid 1990’s) Computer use pervades private industry, banking, and basic science Algorithms and programmes arising in clinical practice. Less in public hospitals Requirement to link data bases. Hospital cannot provide a single form for Pathology June 1998 Letter to Dr H Buchan, Assistant Director, Quality, Acute Health Services

3. “Computer-assisted Decision Support Systems for Antibiotic prescribing in hospital: a strategy for cost-effective, evidence-based clinical practice” The first proposal in 1998

4. Request for funding Major contributor Dr Raina McIntyre Develop computer-assisted decision support system for antibiotic use Test in ICU at RMH Aims include: –Reduction in rise of antimicrobial resistance by restriction of unnecessary use of broad-spectrum antibiotics –Reduction in prescribing errors –Reduction in adverse reactions –Evidence-based prescribing

5. Methods Design of software Develop data linkage systems- rejecting approach of Intermountain Health requiring development of single data repository Test in ICU Wider testing of system “Possible collaborations with Therapeutic Guidelines Limited “who are currently developing a CD-ROM version of Therapeutic Guidelines for antibiotics”

6. Methods (Contd) Clinical algorithms and decision trees (“Research Registrar” Dr Kas Thursky, Dr Alan Street) Multiple inputs, alternate scenarios Jonathan Dartnell and Rob Moulds.. Input and check for consistency with guidelines Data abstraction layer to interface with multiple systems that store data Expert systems designed independently of data storage systems

7. Reactions “You can’t do it”.. No-one has! “Current IT service providers won’t let you do it” Y2K is consuming all thoughts and time Statement in grant re “Obstacles” –Inefficient IT systems in Northwestern Network, duplicated systems, lack of timely data delivery –“No assistance from NW Network Information Services Department” –“Privatization of departments and services” –High cost –Clinician acceptability

8. Timeline June 1998 Submission to DHS Other submissions for funding December 1998 “Still being considered” by Quality branch December 1999 Contract sent 1998 Contract with Hugo Stephenson (Health Research Solutions) Medseed team (developers Hugo and Ryan, managers Lior and Russell) Cracking into Kestral to improve interfaces with constant update of information

9. 2001 Phase 1 Useability analysis completed System needed to be easy to use, save time, educational, flexible, “real-time” Knowledge base starting with “bug to drug”, of known or unknown sensitivity User interface developed but problems with linkage to Pathology data, allowing code for data extraction but not access to “back-end data bases”, need “real time” Pre-implementation data being analyzed 2001 “Users Guide to ADVISE” Kas Thursky Developing electronic antibiotic approval system esp. Mike Richards, Marion Robertson

10. Other Challenges Sustainability Recognized excellence of the product when presented locally or internationally but challenge for clinicians to make it more widely available Creating an “algorithm builder” so local rules can be applied (Jim Black) “Syndrome to initial therapy” eg Pneumonia Long-term projects, even commercial, are of low priority

11. Victorian Public Health Care Award Outside recognition

12. Lessons learned “I learn to help the sick” (RMH motto) Persistence with good ideas is a worthwhile venture CCREID was enormously helpful for partial salary supports Marvellous collaborations e.g. Pharmacy (Marion), Pharmacy College (Tabish), DHS Value of passionate people who want to make a difference eg Renu and Arti (developers), project officers Susan and Tseng, Kirsty and Jim (added ideas for robust systems, starting with needs of users) Many Registrars, now Nadia and Lydia, have learned and contributed Infection control - a mix of Acute and Public Health