our evolving journey with clinical decision support · 2018-02-14 · 5 helping more people in more...

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Our Evolving Journey with Clinical Decision SupportSession 53, March 6, 2018

Connie L. Saltsman, Pharm.D., MBA, CPHIMS; AVP, Clinical Pharmacy Informatics

Risa C. Rahm, Pharm.D., CPHIMS; Director, Clinical Pharmacy Informatics

HCA Healthcare, Nashville, TN

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Connie L. Saltsman, Pharm.D., MBA, CPHIMS

Risa C. Rahm, Pharm.D., CPHIMS

Have no real or apparent conflicts of interest to report.

Conflict of Interest

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Agenda• Which CDS Should be Developed

• Project Management-Driven Process

• Monitoring & Metrics

• Clinical Data Warehouses

• Influencing Factors

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Learning Objectives• Describe a process to evaluate and prioritize potential clinical

decision support (CDS) tools for development

• Discuss the use of cross functional diagrams and project management to best design and develop CDS for minimal disruption to clinicians’ workflow

• Assess various monitoring methods to analyze the outcome and usage of a CDS, including the use of a Clinical Data Warehouse

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Helping more people in more places

Our hospitals care for

27M+ patients annually

• Admissions – 1,800,000

• Deliveries – 210,000

• ER visits – 7,500,000

• Physician Clinic Visits –

8,000,000

• Surgeries – 1,400,000

170+ Hospitals in the

U.S. and 6 in the U.K.

118 Ambulatory Surgery

Centers

51 Freestanding ERs

241,000 employees

• 79,000 nurses

• 47,000 allied health

professionals

• 37,000 affiliated physicians

• 3,100 employed physicians

& 1,000 practitioners

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What is the current status of your CDS development process?

(Choose the response which is used most often at your facility/system)

• Not developing at this time

• Based on who yells the loudest or who has most power

• Evaluation with one group only (pharmacy, nursing or providers)

• Evaluation with a multi-disciplinary team

• Evaluation with a structured matrix

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Alert Fatigue

• Major unintended consequence of the computerization of health care

• Significant patient safety hazard

• Study: CPOE systems generated warnings for 3-6% of all orders entered

Alert Fatigue Patient Safety Primer. AHRQ PSNet.

https://psnet.ahrq.gov/primers/primer/28/alert-fatigue. Last Accessed 12/16/17

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Which CDS Should Be Developed?

• Who should get the CDS?

• What prioritization should it get?

• Where does it present in the clinicians’ workflow?

• When do you choose to provide evidence-based practice information vs concerns with alert fatigue?

• Why is the CDS being requested?

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Case Study: Metformin

• Why: Black Box Warning

• What is the prioritization?

• Who should receive the CDS?

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Prioritization: CDS Matrix

• Variety of factors to consider

• Clinical

• Technical

• Structured format

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Clinical Factors to Evaluate

• Failure Mode Effect Analysis (FMEA)

• ISMP Error Reduction Strategies: Automation & Computerization

• Usability & Interface Design

• Strategic Placement in Workflow

• Meaningful Use

• Core Measures

• Regulatory Standards: TJC / CMS

• Federal & State Laws

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Technical Factors to Evaluate

• Developing & Programming Time

• Testing Time

• Deployment

• Maintenance

• Sensitivity & Specificity

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CDS Matrix

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Who Gets the CDS?

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Case Study: Metformin

• Why: Black Box Warning

• Who is involved & workflow:

• Provider: order entry

• Pharmacist: clinical order review and entry/verification

• Nurse: order acknowledgement and administration

• Who should receive the CDS?

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Design: Who, What & Where

Who should receive the CDS?

What alerts should be provided to the clinician(s)?

Where should the alerts be in the clinician’s workflow?

– Cross functional diagram (swim lanes)

– Multi-disciplinary input

– End-user evaluation prior to development

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Swim Lanes

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Who Should Receive the CDS?

A. Provider

B. Pharmacist

C. Nurse

D. A & B

E. A & C

F. All of the Above

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Who, What & Where: What did we do?

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Projects Collected CSG Informatics Group Research and Review

IPAB ReviewFeedback

Prioritization

Projects Approved Additional CSGInformatics Group

Research and Review

Requirements, clinical content, enhancements, and background

submitted to IT&S

IT&S Develop RequirementsPeer Review

Mock up

IT&S Developer proposal and project specs estimated

Approval by team to allow project to begin development

CSG / IT&SDevelopment Walkthrough

Demo

Final CSG approval Pilot at voluntary site

Test Enviroment

Live Enviroment

2

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Materials pushed enterprise wide

Open communication with sites

Project approved for enterprise deployment

New FunctionalityField Request

IPAB SuggestionsIdentified Best Practice

Enhancement

Request for more information Additional approval if major

impact to non-pharmacy professionals

Project Denied IT&S requires research or more information

CSG feedback

Project Denied

Feedback

Education developed

CSG / IT&S Requirements Walkthrough

IT&S DevelopmentQA Testing

Project Management-Driven Process

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Projects Collected CSG Informatics Group Research and Review

IPAB ReviewFeedback

Prioritization

Projects Approved Additional CSGInformatics Group

Research and Review

Requirements, clinical content, enhancements, and background

submitted to IT&S

IT&S Develop RequirementsPeer Review

Mock up

IT&S Developer proposal and project specs estimated

Approval by team to allow project to begin development

CSG / IT&SDevelopment Walkthrough

Demo

Final CSG approval Pilot at voluntary site

Test Enviroment

Live Enviroment

2

1

Materials pushed enterprise wide

Open communication with sites

Project approved for enterprise deployment

New FunctionalityField Request

IPAB SuggestionsIdentified Best Practice

Enhancement

Request for more information Additional approval if major

impact to non-pharmacy professionals

Project Denied IT&S requires research or more information

CSG feedback

Project Denied

Feedback

Education developed

CSG / IT&S Requirements Walkthrough

IT&S DevelopmentQA Testing

23

Projects Collected CSG Informatics Group Research and Review

IPAB ReviewFeedback

Prioritization

Projects Approved Additional CSGInformatics Group

Research and Review

Requirements, clinical content, enhancements, and background

submitted to IT&S

IT&S Develop RequirementsPeer Review

Mock up

IT&S Developer proposal and project specs estimated

Approval by team to allow project to begin development

CSG / IT&SDevelopment Walkthrough

Demo

Final CSG approval Pilot at voluntary site

Test Enviroment

Live Enviroment

2

1

Materials pushed enterprise wide

Open communication with sites

Project approved for enterprise deployment

New FunctionalityField Request

IPAB SuggestionsIdentified Best Practice

Enhancement

Request for more information Additional approval if major

impact to non-pharmacy professionals

Project Denied IT&S requires research or more information

CSG feedback

Project Denied

Feedback

Education developed

CSG / IT&S Requirements Walkthrough

IT&S DevelopmentQA Testing

24

Projects Collected CSG Informatics Group Research and Review

IPAB ReviewFeedback

Prioritization

Projects Approved Additional CSGInformatics Group

Research and Review

Requirements, clinical content, enhancements, and background

submitted to IT&S

IT&S Develop RequirementsPeer Review

Mock up

IT&S Developer proposal and project specs estimated

Approval by team to allow project to begin development

CSG / IT&SDevelopment Walkthrough

Demo

Final CSG approval Pilot at voluntary site

Test Enviroment

Live Enviroment

2

1

Materials pushed enterprise wide

Open communication with sites

Project approved for enterprise deployment

New FunctionalityField Request

IPAB SuggestionsIdentified Best Practice

Enhancement

Request for more information Additional approval if major

impact to non-pharmacy professionals

Project Denied IT&S requires research or more information

CSG feedback

Project Denied

Feedback

Education developed

CSG / IT&S Requirements Walkthrough

IT&S DevelopmentQA Testing

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CDS Monitoring - Why?

• Active in the production environment

• Providing useful, pertinent information to the clinician

• Clinical workflow is positively impacted

• Sensitive and specific to the problem at hand

• Future enhancements are identified

• Support current regulations / best practices

• Remove if no longer needed

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How to Monitor & Measure

• Surveys to clinicians for impact and future enhancements

• Chart reviews

• Enhancement requests from clinicians

• Complaints from clinicians

• Help desk calls

• Reports from EHR

• Clinical Data Warehouse reports

• Dashboards

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Case Study: Metformin

• Original CDS

• Lesson Learned

• Enhanced CDS

• Regulatory Update & Enhancements

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Clinical Data Warehouse

• Clinical Data Warehouse (CDW)

• Enterprise Data Warehouse (EDW)

• Data Warehouse (DW)

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Clinical Data Warehouse• I have a CDW and use it for all of my data analysis needs

• I have a CDW and am just beginning to use it

• I don’t know

• I don’t have one

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Considerations with CDW & CDS

• Disconnect between clinicians, informaticists and data analysists

• Garbage in = Garbage out

• Mapping

• Dashboard software

• Access

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Clinical Data Warehouse

Review key informatics projects

for data points

Collect list of data points

Review data points with analysis team

Review data points against current CDW

Request additional data points to be

added to CDW

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Influencing Factors

Proponents of Success:• Multi-disciplinary

• Constant feedback

• Establishing workflow

• Leadership support

• Project prioritization

• Project management

• New functionalities

Barriers to Success:• Regulatory changes

• Clinical Updates

• Team turnover

• Funding

• System limitations

• Variation from standards

• New functionalities

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Future

• Data to identify the issues that CDS can fix and help in the prioritization

• Pulling data from the CDW to prompt CDS in the EHR

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Questions

• Connie Saltsman (Connie.Saltsman@hcahealthcare.com)

• Risa Rahm (Risa.Rahm@hcahealthcare.com)

• Please don’t forget to complete the online session evaluation