Living Practice Guidelines Require Robust and Continuous Iteration and Uptake
Authors: Tianjing Li; Maria Michaels
Year: 2022

R igorously developed, disseminated, and implemented practice guidelines promote health, prevent harm, encourage best practice, and reduce practice variation. Incorporation of the latest, relevant research evidence as soon as it is available can bolster guideline quality. Although the concept for accumulating evidence for guiding practice has existed for decades, the COVID-19 pandemic has shown that living guidelines are not only desirable but also possible, even during a time characterized by an explosion of research (1, 2). In their article, El Mikati and colleagues (3) present a framework for developing living practice guidelines in health care. The framework includes 4 integrated steps— planning, production, reporting, and dissemination. In each step, the authors highlight considerations specific to living guidelines. The authors developed the framework on the basis of comprehensive reviews of literature, an online survey, and online discussions with an international multidisciplinary group. Of note, the framework is not intended to address the important step of implementation. For living guidelines to be successful, there needs to be a seamless translation from living recommendations to patient care. That is, guideline implementation should be living as well. In a multidisciplinary, multiorganizational initiative on Adapting Clinical Guidelines for the Digital Age led by the Centers for Disease Control and Prevention (4), implementation challenges were among the reasons noted by participants for lower uptake of guideline recommendations. The desire to overcome these challenges earlier in the development led to the creation of an iterative, integrated process for coproducing written and computable guidelines (including living guidelines), a Fast Healthcare Interoperability Resources (FHIR)–based health information technology standard, and an evaluation framework to assess the guideline process, products, and outcomes. FHIR Clinical Guidelines, also known as “Clinical Practice Guidelines (CPG)-on-FHIR,” is the health information technology standard developed for representing guideline recommendations in computable format that incorporates the integrated process and evaluation framework in its approach and methodology (5). We encourage users of the living guideline framework to consider codeveloping digital solutions for living guidelines to facilitate the application of evidence to patient care more easily, quickly, accurately, and consistently. Furthermore, meaningful inclusion of all relevant perspectives and stakeholders throughout the living guideline production cycle could help guideline developers understand challenges, account for health equity factors, and secure buy-in from various stakeholders. For example, although El Mikati and colleagues address organizational planning in living guidelines, the iterative incorporation of input from end-users, for example, clinicians and patients, is also needed throughout the guideline development and implementation process to facilitate guideline adherence. The American College of Emergency Physicians' COVID-19 Severity Classification case study is an example of this iterative methodology (6). The COVID-19 Digital Guideline Working Group of guideline authors, informaticians, implementers, end-users, and others collaborated to codevelop a living and computable guidance. In addition to the traditional written format for dissemination, codeveloping and distributing computable guidelines can be considered given the modular nature of living guidelines. Computable guidelines can be used to create clinical decision support that applies algorithms and data from the patient's context to support clinical decision making, clinical quality measures that help monitor quality of care, case reports that provide conditionspecific information to entities such as public health agencies or medical societies, and similar digital tools to support implementation andmonitoring of the adherence to guideline recommendations in practice. One noteworthy example of how to distribute computable guidelines is the Agency for Healthcare Research and Quality's Clinical Decision Support Connect program, which aims to help health care providers move patient-centered outcomes research evidence into practice through developing clinical decision support tools that are shareable, standardsbased, publicly available, and patient-centered (7). Digital derivatives from living guidelines, such as clinical decision support tools, necessitate the involvement of relevant experts, for example, communication specialists and health information technology developers. There are unique considerations of living public health guidelines that go beyond those noted by El Mikati and colleagues. Some distinctive challenges with public health guidelines include the need to include different study designs leading to increased methodological heterogeneity, a wide range of outcomes with potentially inconsistent definitions, and complex interventions made up of several components (8). Implementing public health guidelines beyond the clinical setting—for example, with community partners—requires interdisciplinary approaches. Moreover, the need to consider the whole “client” (for example, individuals, families or significant others, groups, communities, and populations) and their lived experiences requires insights from a broader set of perspectives for public health interventions than those intended for clinical settings. Finally, it is imperative that the efforts to develop living guidelines be coordinated. Several living guideline teams have noted that massive resource requirements and strong project management plans are needed for living guidelines to be successful (9). Coordination on guideline efforts can reduce waste from activities like duplicating research, developing several guidelines on the same topic, or replicating similar digital tools at several clinical