Arden-history-context
Arden Syntax: Context and History
Computer-based clinical decision support (CDS) has been shown to improve the quality of health care treatment and the performance of health care professionals. Clinical decision support involves delivering knowledge to decision-makers in clinical settings in order to improve the quality of decisions and the outcomes to which they lead. CDS sometimes is described in terms of the Five Rights: Delivering the right knowledge to the right person at the right time in workflow in the right format via the right channel.
In order to provide computer-based CDS, the knowledge to be delivered must be represented in digital format. In this light, CDS can be divided into two broad classes: Services that facilitate delivery of knowledge and explicit, computable representations of the knowledge itself that can be shared via transfer and reuse. In the case of a knowledge delivery service, standards facilitate communication between electronic health record systems and other clinical software and knowledge sources, allowing connection of systems and sources from multiple vendors without having to negotiate and implement ad hoc methods for each connection. In the case of explicit knowledge encoding, standards facilitate sharing of knowledge by minimizing the changes necessary for the knowledge to be executed or used in different information systems.
The Health Level Seven International (HL7) Infobutton standard is an example of a knowledge delivery service standard. It facilitates queries from users of electronic health record systems in the context of particular care activities and particular patients, providing knowledge from knowledge sources that is pertinent to these contexts. By contrast, examples of explicit knowledge encoding include the HL7 GELLO, Order Set and Arden Syntax standards.
A knowledge representation formalism constitutes one part of an overall CDS system. Units of knowledge encoded using the formalism are stored in the knowledge base (KB), independent of but linked to the inference engine or event monitor that executes units of the KB in combination with patient data to produce tailored, context-specific knowledge-based interventions that then can be delivered to the appropriate recipient such as a clinician, patient or administrator.
A prominent example of a knowledge formalism for encoding units of knowledge in the KB is The Arden Syntax for Medical Logic Systems. This is a computable language for encoding medical knowledge. It was previously adopted as a standard by the American Society for Testing and Materials (ASTM) as document E 1460, under subcommittee E31.15 Health Knowledge Representation. Adopted in 1992, this became Arden Syntax Version 1.0
Beginning in 1998 sponsorship of this standard was moved to Health Level Seven International (HL7). Maintenance and further development of the standard is overseen by the Arden Syntax Work Group of HL7. Arden Syntax Version 2.0 was formally adopted by HL7 and the American National Standards Institute (ANSI) in August, 1999. Since then, the standard has evolved with addition of new features and functionality responding to the needs of users and vendors. At the time of this publication, the latest version of the standard, Version 2.9, was adopted by HL7 and certified by ANSI in March, 2013.
The unit of knowledge representation in the Arden Syntax is the medical logic module (MLM). Each MLM contains sufficient logic to make a single medical decision. MLMs have been used to generate clinical alerts, interpretations, diagnoses, screening for clinical research, quality assurance functions, and administrative support. With an appropriate computer program (known as an event monitor), MLMs run automatically, generating advice where and when it is needed.
This implementation guide describes the key features of the Arden Syntax and how it may be used in a variety of scenarios to deliver CDS.
References
Hripcsak G. Writing Arden Syntax medical logic modules. Computers in Biology and Medicine 1994;24(5):331-363.
Hripcsak G, Ludemann P, Pryor TA, Wigertz OB, Clayton PD. Rationale for the Arden Syntax. Computers and Biomedical Research 1994;27:291-324.
Jenders RA, Hripcsak G, Sideli RV, DuMouchel W, Zhang H, Cimino JJ, Johnson SB, Sherman EH, Clayton PD. Medical decision support: experience with implementing the Arden Syntax at the Columbia-Presbyterian Medical Center. Proc AMIA Symp 1995;:169-73.
Osheroff JA, Teich JM, Levick D, Saldana L, Velasco FT, Sittig DF, Rogers KM, Jenders RA. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide, Second Edition. Chicago: Healthcare Information and Management Systems Society, 2012.
Samwald M, Fehre K, de Bruin J, Adlassnig KP. The Arden Syntax standard for clinical decision support: experiences and directions. J Biomed Inform. 2012 Aug;45(4):711-8.
