AN EXPERT-SYSTEM FOR PERFORMANCE-BASED DIRECT DELIVERY OF PUBLISHED CLINICAL-EVIDENCE

Objective: To develop a system for clinical performance improvement th rough rule-based analysis of medical practice patterns and individuali zed distribution of published scientific evidence. Methods: The Qualit y Feedback Expert System (QFES) was developed by applying a Level-5 ex pert system shell to generate clinical direct reports for performance improvement. The system comprises three data and knowledge bases: 1) a knowledge base of measurable clinical practice parameters; 2) a pract ice pattern database of provider-specific numbers of patients and clin ical activities; and 3) a management rule base comprising ''redline ru les'' that identify providers whose practice styles vary significantly . Clinical direct reports consist of a table of practice data highligh ting individual utilization vs recommendation and selected pertinent s tatements from medical literature. Results: The QFES supports integrat ion of recommendations from several guidelines into a comprehensive an d measurable quality improvement plan, analysis of actual practice pat terns and comparison with accepted recommendations, and generation of a confidential individualized direct report to those who significantly deviate from clinical recommendations. The feasibility of the practic e pattern analysis by the QFES was demonstrated in a sample of 182 uri nary tract infection cases from a primary care clinic. In a set of cli nical activities, four questions/procedures were associated with signi ficant (p < 0.001) and unexplained variation. Conclusion: The QFES pro vides a flexible tool for the implementation of clinical practice guid elines in diverse and changing clinical areas without the need for spe cial program development. Preliminary studies indicate utility in the analysis of clinical practice variation and deviations. Using data obt ained through a retrospective chart audit, the QFES was able to detect overutilization, and to identify nonrandom differences in practice pa tterns.