Among five guideline development panels sponsored by two different professional organizations there was substantial agreement that use of BRIDGE-Wiz could promote quality, clarity, transparency, and implementability. In addition, BRIDGE-Wiz supports a process that was considered to be useful and usable. Employing a wizard design, the BRIDGE-Wiz program formalizes a process for propounding guideline recommendations in a systematic manner. Using a controlled natural language approach, the program creates and populates a template for recommendation statements. The use of BRIDGE-Wiz promotes overall guideline quality by incorporating the COGS checklist of criteria.40
By prompting the developers to address each of the COGS parameters, a more comprehensive, usable, and valid guideline document is created.
The use of BRIDGE-Wiz enhances clarity of recommendations by promoting the use of transitive verbs and active voice. The performer of the action is clearly designated, rather than hidden as is the case with passive voice statements. In addition, the developer panel is asked to examine explicitly the decidability of each condition and the executability of each proposed action. The program restricts the use of Boolean connectors that link conditions and actions because ambiguity may be introduced when clauses that are ANDed are combined with clauses that are ORed.
BRIDGE-Wiz enhances the transparency of each recommendation by requiring and documenting a systematic appraisal of evidence quality and weighing of anticipated benefits, risks, harms, and costs that contribute to recommendation strength. In addition, the evidence profile produced as output by the program incorporates slots to describe the values applied in judging the balance of benefits and harms, the role of patient preference in how the recommendation should be implemented, and the reason any conditions or actions might be deliberately vague or underspecified (eg, incomplete or controversial evidence, inability to reach consensus, unwillingness to set a legal standard of care).
BRIDGE-Wiz promotes the implementability of recommendation statements in a number of ways. The program suggests an appropriate standardized deontic operator and defines a strength of recommendation for each statement. This helps to communicate to implementers the level of obligation that the developers intend. This deontic determination is particularly important for developers of computer-mediated decision support who can use this information to design interfaces for particular rules that range from full-stop to simply advisory. Also, limitation on the use of the verb ‘consider’ increases the likelihood that adherence to a recommendation will be measurable. Finally, the output of the program includes a pseudocode ‘rule’ in IF–THEN format.
The panelists agreed that use of BRIDGE-Wiz had a salutary effect on the process of guideline development. Displaying the sequence of prompts provided by the program on a projection screen focuses the attention of the developer panel and diminishes distraction. On several occasions when the discussion became tangential, we observed that a panelist pointed to the screen and directed the group to address the issue at hand.
- Use of a regimented system for guideline development will be resisted by some guideline authors. Support for the BRIDGE-Wiz approach by the sponsoring organization and the panel chairperson and a demonstration of how the software works in developing a typical recommendation is critical to overcome these concerns.
- BRIDGE-Wiz has only been tested at two professional organizations. Although these organizations represented the ends of a spectrum from primary care to subspecialty surgery, the wide variety of development methodologies and organizational cultures extant may limit acceptance of the program by some organizations.
- Although BRIDGE-Wiz incorporates three different systems for grading evidence quality and recommendation strength, the program has only been evaluated with a single grading system.
- Complex recommendation statements—in which a single recommendation statement is associated with more than one evidence quality indicator or recommendation strength indicator—are not supported.
- Because BRIDGE-Wiz defines knowledge in a declarative manner, procedural details—as might be displayed best in a flowchart—are not well supported.48
- The output of BRIDGE-Wiz is a structured, natural language recommendation in IF–THEN format. Before implementation in a clinical decision support system is possible, the recommendation will need to undergo coding of its concepts in standardized vocabularies, selection of an appropriate decision support modality, user interface design, and integration with clinical workflow.4