Distributed Application of Guideline-Based Decision Support through Mobile Devices: Implementation and Evaluation

Traditionally Guideline(GL)based Decision Support Systems (DSSs) use a centralized infrastructure to generate recommendations to care providers. However, managing patients at home is preferable, reducing costs and empowering patients. We aimed to design, implement, and demonstrate the feasibility of a new architecture for a distributed DSS that provides patients with personalized, context-sensitive, evidence based guidance through their mobile device, and increases the robustness of the distributed application of the GL, while maintaining access to the patient longitudinal record and to an up to date evidence based GL repository. We have designed and implemented a novel projection and callback (PCB) model, in which small portions of the evidence based GL procedural knowledge, adapted to the patient preferences and to their current context, are projected from a central DSS server, to a local DSS on the patient mobile device that applies that knowledge. When appropriate, as defined by a temporal pattern within the projected plan, the local DSS calls back the central DSS, requesting further assistance, possibly another projection. Thus, the GL specification includes two levels: one for the central DSS, one for the local DSS. We successfully evaluated the PCB model within the MobiGuide EU project by managing Gestational Diabetes Mellitus patients in Spain, and Atrial Fibrillation patients in Italy. Significant differences exist between the two GL representations, suggesting additional ways to characterize GLs. Mean time between the central and local interactions was quite different for the two GLs: 3.95 days for gestational diabetes, 23.80 days for atrial fibrillation. Most interactions, 83%, were due to projections to the mDSS. Others were data notifications, mostly to change context. Robustness was demonstrated through successful recovery from multiple local DSS crashes.