Maintaining and incrementally revalidating a computer-based clinical guideline: a case study

The paper explores the issues involved in maintaining the logic within a complex computer-based clinical guideline, using as a case study IMM/Serve, an operational guideline whose domain is childhood immunization. For a period of more than a year and a half, we have maintained a log of (1) the national changes to the immunization recommendations, (2) the local customizations of IMM/Serve's logic, and (3) certain logic problems that arose in the process of accommodating these changes and customizations. We describe the nature of these changes, customizations, and problems. We also discuss how different types of domain knowledge might assist in the automated process of validating successive versions of the logic. The paper's goal is to use the immunization domain to provide specific examples of the issues and problems that arise in maintaining a computer-based clinical guideline.