hitasthma: a tale of woe and enlightenment
Post on 18-Dec-2014
209 Views
Preview:
DESCRIPTION
TRANSCRIPT
www.CenterForUrbanHealth.org
AHRQ Annual Meeting09SEP08
HIT Asthmaa tale of woe and enlightenment
Yiscah Bracha, M.S.ybracha@CenterForUrbanHealth.org
www.CenterForUrbanHealth.org
Project Objective:
• Demonstrate use of HIT to improve ambulatory asthma care
• Two existing technologies:1. Interactive Asthma Action Plan (IAAP)
(developed by MN Dept of Health)2. Commercially available electronic
health record (EHR) (EpicSystems Inc.)
www.CenterForUrbanHealth.org
What we knew:
• For asthma, IAAP beats Epic in user and patient friendliness
• Difficult for Epic user to get to IAAP• Untapped potential to use EHR data
to support QI
www.CenterForUrbanHealth.org
What we wanted to propose:
• Make IAAP available from within Epic-driven workflow Brings guidelines to the point of care
• Use IAAP database as asthma registry Evaluate effect of QI initiatives Identify at-risk patients Generate reports required by external
agencies
www.CenterForUrbanHealth.org
• Existing IAAP based on guidelines released in 2002
• 2007 guidelines soon to be released• Our project would link the EHR
system to a soon-to-be-obsolete tool
One small problem…
www.CenterForUrbanHealth.org
What we actually proposed:
• Update IAAP to be consistent with 2007 guidelines
• Make updated IAAP available from within Epic-driven workflow Brings new guidelines to the point of care
• Use IAAP database as asthma registry Evaluate effect of QI initiatives Identify at-risk patients Generate reports required by external agencies
www.CenterForUrbanHealth.org
Expected challenges
• Accessing IAAP from Epic Pushes boundaries both technically &
organizationally
• Creating & using asthma registry Technology well-understood;
organizational barriers to readiness
• Updating IAAP Trivial technically; no impact
organizationally
www.CenterForUrbanHealth.org
3 months after project inception:
• IAAP-EHR interface: Technical boundaries identified Organization is ready within those
boundaries
• Registry Organizational barriers quickly overcome Demanding to establish what fields to
pull, but a well-understood task.
• Update IAAP ….
www.CenterForUrbanHealth.org
• “It will be simple to update the existing IAAP to make it consistent with the new guidelines”
Famous last words:
www.CenterForUrbanHealth.org
Oops:
• Original IAAP contained: Out-of-date, unsupported version of Java Database not designed to support
analysis List of meds not designed to be updated
• “Update” of any kind not possible Radical shift in perspective from 2002 to
2007 FROM: Treating acute symptoms TO: Managing chronic disease
www.CenterForUrbanHealth.org
The struggle:
• Clinicians try to convert guidelines directly into screens: They get trapped in logical circles from
which they cannot escape
• Analytically-minded Project Director tries to display their thinking in flow diagrams Clinicians can’t follow the diagrams
• Many expressions of frustration exchanged!
www.CenterForUrbanHealth.org
Some concerns:
• Close scrutiny of guidelines reveals: Ambiguous and/or internally
inconsistent recommendations: Inadequate dosing instructions for young
children Recommendations for formulations not
available commercially
Recommendations for off-label uses of drugs Drugs for young children not approved by
FDA
www.CenterForUrbanHealth.org
More concerns:
• Even with close scrutiny, no answers to front-line clinical questions: What should the dosing instructions be
in the “red zone” of the asthma action plan?
How can we determine the current treatment step for a new patient who is already receiving asthma care?
www.CenterForUrbanHealth.org
And more struggles:
• Enormous effort required to communicate needs to software development company
• Even with that effort, still uncertainty that they really understand what’s required
www.CenterForUrbanHealth.org
The tale of woe…
• We are failing at our most trivial task AHRQ will give up on us We will disappoint the users whose
expectations we have raised
• We have over-extended ourselves and our budget trying to cope with this
• If we succeed, who will be responsible for harm that may arise because we delivered vague guidelines to the point of care?
www.CenterForUrbanHealth.org
The tale of enlightenment:
• Bob* (unexpectedly) says: This is very interesting! Let’s reduce your anxiety … there are lots
of ways to make lemonade here We have an agency interest in alternative
ways to disseminate guidelines Document these issues Analyze them Make recommendations to future expert
panels
* Bob Mayes, our AHRQ Task Order Officer
www.CenterForUrbanHealth.org
From: Expert Panel Guidelines
To:
Electronic Clinical Decision Support:
www.CenterForUrbanHealth.org
What are the Primary Challenges?
• Logical complexity• Volume of therapeutic choices• Different languages used by:
Academic experts Front-line clinicians with limited time Patients responsible for self-
management
www.CenterForUrbanHealth.org
The Primary Challenges
• Logical complexity• Volume of therapeutic choices• Different languages used by:
Academic experts Front-line clinicians with limited time Patients responsible for self-
management
www.CenterForUrbanHealth.org
The human mind:
• Do I know this patient?• Is the patient already being treated?
How aggressively? Is the patient being treated the right way?
• How is the patient doing? Is the therapy adequate? Is the patient using the therapy as prescribed?
• What might happen if I changed the dose?
www.CenterForUrbanHealth.org
The software mind…1. System displays all known values, as
shown on UI screen.
2. User accepts or changes value for weight
3a. User accepts value
for weight
4b. System changes value for date of last weight to current date.
5. User accepts or changes value for height.
7b. System changes value for date of last height to current date. System
changes value of predicted peak flow.
3b. User changes value
for weight
6a. User accepts value
for height
6b. User changes value
for height
www.CenterForUrbanHealth.org
More peaks into the software mind…
10.System transfers user to
‘Determine Control’ interface.
1.IAAP Screen_03_01. (User Interface_03_01)
User opts to establish asthma control or severity.User opts to infer level, or to enter known level.
To User Interface_03_01
8. System check: If neither current
treatment step nor pharmacy order for
asthma meds available, then
POPUP
6. USER CHOOSES:ASSESS CONTROL
3a. USER CHOOSES:Infer severity from
symptoms
3b. USER CHOOSES:Enter severity level
as known.
4a.System transfers user to process that classifies
severity from symptoms
4b.System calculates [step_recommend],
based on severity and patient age.
To Pop-Up_03_02To Process Flow_04S
To Process Flow_04CTo Function_04. Step recommend.
Clinicians: How do you want to
handle this choice and/or this screen
if there is an existing value for
severity in the system?
www.CenterForUrbanHealth.org
Human vs software “minds”:
Humans Software
Fast, unarticulated thought processes
Series of nested and explicit if-then statements
“Gestalt” Linear, step-by-step
Counterfactuals entertained
Counterfactuals not possible
Approximate meanings of words OK
Precise meaning of words required
Can tolerate ambiguity
No tolerance for ambiguity
www.CenterForUrbanHealth.org
The negotiation challenge:
• Clinicians must: Clearly explicate their thought processes Force themselves to use precise
vocabulary Think linearly
• Software developers must: Obtain necessary initial values without
burdening users Replicate clinical “flow”
www.CenterForUrbanHealth.org
Software Development Challenges
• Logical complexity• Volume of therapeutic choices• Bridging languages
Academic medical expertise Front-line clinicians with limited time Patients responsible for self-
management
www.CenterForUrbanHealth.org
From this….
www.CenterForUrbanHealth.org
www.CenterForUrbanHealth.org
… to this
www.CenterForUrbanHealth.org
www.CenterForUrbanHealth.org
Combinatorial volume
• > 23,000 possible combinations of Age Step Preferred vs. alternative Instructions for use Brands
• Some combinations are impossible, or unsupported by evidence, or contradict FDA
• Changing all the time New drugs New delivery mechanisms New evidence
www.CenterForUrbanHealth.org
Challenges posed by volume:
• Effort required to capture all possibilities
• Likelihood of errors & inconsistencies increase with volume
• Deciding when to stop, when every month something new comes out
• Responsibility for on-going maintenance
www.CenterForUrbanHealth.org
Software Development Challenges
• Logical complexity• Volume of therapeutic choices• Different languages used by:
Academic medical experts Front-line clinicians with limited time Patients responsible for self-
management
www.CenterForUrbanHealth.org
Different words for same ideas:
Academic: Clinical: Ordinary:
Long-acting beta agonist
Daily controller
Purple inhaler
FEV1 actual vs. predicted
What you can and should be able to blow
My top number on the meter
Exacerbation ED visitI thought my child would die
www.CenterForUrbanHealth.org
Because of differing vocabulary:
• Text in guidelines doesn’t work on screen Guidelines: “Step up one” Clinician question: “What is the current
step?” (Patient question: What is a step?)
www.CenterForUrbanHealth.org
Because of differing vocabulary:
• On-screen text for clinical users doesn’t work in asthma action plan. Drug example:
Clinician: Fluticasone MDI (44 mcg/puff) Patient: Fluticasone inhaler 44 mcg
Condition example: Clinician: Best peak flow, predicted peak
flow Patient: Peak flow
www.CenterForUrbanHealth.org
The challenge posed by vocabulary:
• Anticipating who the user/consumer is
• Testing vocabulary with users to make sure it works
• Resolving conflicts between need for specificity among one group of users vs. need for simplicity among another
Some preliminary conclusions
www.CenterForUrbanHealth.org
Policy Qs the process reveals:
• At what point in guideline development should “codification” be considered? By the expert panel while deliberating? After the text of the guidelines released?
• Who is responsible for resolving textual inconsistencies and ambiguities? Expert panel? Software developers? Front-line clinicians?
www.CenterForUrbanHealth.org
Addl policy Qs the process reveals:
• What should the “update” process be? Reconvene expert panel every xxx years? Regular software maintenance?
• Should users be enabled to maintain their own lists of therapeutic choices? Pros: Can be customized to site (e.g.
locally supported formularies) Cons: Induces site-to-site variability in
dissemination of latest evidence
www.CenterForUrbanHealth.org
Sustainability questions
• Who bears the costs of development? Original guidelines Original software for guideline-based
decision support
• Who bears the costs of maintenance? Guidelines Software, especially when software and
clinical expertise are seldom the same
www.CenterForUrbanHealth.org
Our work continues:
• Conveying user requirements to software developers, where requirements include: Adherence to interpreted guidelines “Smooth” & supportive clinical workflow
• Documenting issues we encounter in attempting to achieve that goal
• Preparing our sites for implementation, albeit a year late
www.CenterForUrbanHealth.org
And:
• Sharing process & results with all of you!
www.CenterForUrbanHealth.org
Improving Asthma Care in an Integrated Safety Net through a Commercially Available Electronic Medical
Record
Prime contractor: Denver Health and Hospital Association. Subcontractor: Minneapolis Medical Research Foundation. Project site: Hennepin County Medical Center, Mpls MN
AHRQ Contract No. HHSA290200600020, Task Order No. 5
Staff and contractors – Minneapolis Medical Research FoundationGail Brottman, MD (Chief, Pediatric Pulmonology, HCMC)Kevin Larsen, MD (Chief Medical Informatics Officer, HCMC)Yiscah Bracha, MS (Research Director, Center for Urban Health)Cherylee Sherry, MPH (Project Manager, Pediatric Research & Advocacy HCMC )Touch Thouk (Administrative Manager, Center for Urban Health)Angeline Carlson, PhD (Principle, Data Intelligence Inc.)
Staff – Denver Health and Hospital AssociationSheri Eisert, PhD (Director, Health Services Research)Michael (Josh) Durfee (Research Projects Coordinator, Health Services Research)
Contributors of Ideas, Information & Effort:Michael Barbouche (University of Wisconsin Medical Foundation); Robert Grundmeier, MD (Children’s Hospital of Philadelphia); Michael Kahn, MD, PhD (Denver Children’s Hospital)Donald Uden, PharmD (University of Minnesota), Faith Dohman, RN (Hennepin Faculty Associates); Susan Ross, RN (Minnesota Department of Health)
www.CenterForUrbanHealth.org… … and now, Bob and now, Bob Mayes our Task Order Mayes our Task Order
OfficerOfficer
top related