Bringing Clinical Knowledge to Bringing Clinical Knowledge to the Point of Care and to Patientsthe Point of Care and to Patients

Jonathan TeichJonathan Teich

Patti AbbottPatti Abbott

Bill HershBill Hersh

Molly MettlerMolly Mettler

Eduardo OrtizEduardo Ortiz

Marc OverhageMarc Overhage

Nick BeardNick Beard

TopicsTopics

Clinical decision support: examples, Clinical decision support: examples, value, best practicesvalue, best practices

Finding and using knowledge Finding and using knowledge resourcesresources

Turning clinical goals into computer Turning clinical goals into computer interventionsinterventions

CDS as a “team sport” – nurses, CDS as a “team sport” – nurses, patients, and morepatients, and more

Clinical Decision Support and the Clinical Decision Support and the Quality of CareQuality of Care

Jonathan Teich, MD, PhDJonathan Teich, MD, PhD

SVP and Chief Medical OfficerSVP and Chief Medical Officer

HealthvisionHealthvision

Asst. Prof. of Med., Harvard Asst. Prof. of Med., Harvard Univ.Univ.

““Providing clinicians or patients Providing clinicians or patients with clinical knowledge and with clinical knowledge and patient-related information, patient-related information,

intelligently filtered and intelligently filtered and presented at appropriate times, presented at appropriate times,

to enhance patient care”to enhance patient care”

The GoalThe Goal

Patient SafetyPatient Safety

Improved QualityImproved Quality

Improved CommunicationImproved Communication

Adherence to Best PracticesAdherence to Best Practices

Improved Access to Improved Access to Knowledge/EvidenceKnowledge/Evidence

Better Financial PerformanceBetter Financial Performance

Substitution alertsSubstitution alerts

Consequent (corollary) ordersConsequent (corollary) orders

Impact studies - Excessive Impact studies - Excessive dosesdoses

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0.5

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1.5

2

2.5

Pre-OE Post-OE Year 1 Year 2 Year 3

% o

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Use of recommended H2 Use of recommended H2 blockerblocker

0102030405060708090

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-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8

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Ambulatory errorsAmbulatory errors

Reported in 5% to 18% of encountersReported in 5% to 18% of encounters1 per 20 patient-years, 40% very serious1 per 20 patient-years, 40% very seriousLeapfrog and IOM new reports on Leapfrog and IOM new reports on ambulatory errorsambulatory errorsAllergies and DDI‘s, drug-food and drug-Allergies and DDI‘s, drug-food and drug-OTCOTCDrug monitoring, especially CoumadinDrug monitoring, especially CoumadinPoor protocol follow-throughPoor protocol follow-throughPoor test follow-upPoor test follow-upBetween-visit condition changesBetween-visit condition changesPatient misinterpretationPatient misinterpretation

Ambulatory Clinical Decision Ambulatory Clinical Decision SupportSupport

Drug allergy, DDIDrug allergy, DDIDrug substitution and preconditionsDrug substitution and preconditionsAppropriate utilization of testsAppropriate utilization of testsOrder sets and care plans Order sets and care plans (algorithms)(algorithms)Asynchronous warnings and alertsAsynchronous warnings and alertsHealth maintenance remindersHealth maintenance remindersPrescribable educationPrescribable educationJust-in-time reference informationJust-in-time reference information

Formulary CheckingFormulary Checking

www.himss.org/cdsworkbook

Opportunities for CDSOpportunities for CDS

Six steps to successful CDSSix steps to successful CDS

Determine the CDS program’s goals and Determine the CDS program’s goals and clinical objectivesclinical objectives

Catalog your information systems’ capabilities Catalog your information systems’ capabilities to help achieve those targetsto help achieve those targets

Select the best interventions and Select the best interventions and opportunities to achieve specific interventionsopportunities to achieve specific interventions

Review and vet interventions with Review and vet interventions with stakeholdersstakeholders

Monitor how it is workingMonitor how it is working

Turning Decision Support Goals Turning Decision Support Goals into Interventionsinto Interventions

Patricia A. AbbottPatricia A. Abbott

Assistant Professor & Director of Assistant Professor & Director of the WHO/PAHO Center for the WHO/PAHO Center for

Information Systems in Nursing Information Systems in Nursing CareCare

Johns Hopkins University School Johns Hopkins University School of Nursingof Nursing

People – The Key to SuccessPeople – The Key to Success

CDS impact on behaviorCDS impact on behaviorHumans do not like cheese movedHumans do not like cheese moved

Identify key stakeholders/opinion leadersIdentify key stakeholders/opinion leadersInterdisciplinaryInterdisciplinaryKey Success FactorsKey Success Factors11

Deep executive support & belief in ITDeep executive support & belief in ITHistory of successful clinical ITHistory of successful clinical ITExcellent communication to stakeholdersExcellent communication to stakeholdersInvolvement of key users & championsInvolvement of key users & championsStrong support from IT staff for problem resolution Strong support from IT staff for problem resolution – before, during and after implementation– before, during and after implementation

1. Osheroff, Pifer, Sittig, Jenders & Teich (2004). Clinical Decision Support Implementers Workbook.

Identifying the Achievable GoalIdentifying the Achievable Goal

Goals determined in collaborative Goals determined in collaborative fashionfashion

Evaluate current effortsEvaluate current efforts• Case managementCase management• Process redesignProcess redesign

Identify fertile areas of importanceIdentify fertile areas of importance

Consider goals individually and collectivelyConsider goals individually and collectively

Focused, measurable, and realisticFocused, measurable, and realistic

From Goal to ActionFrom Goal to Action

High level Goal High level Goal

Focused GoalFocused Goal

Clinical GoalClinical Goal

Clinical ActionClinical Action

ProgramProgram

GoalsGoals

ObjectivesObjectives

Objective ClassesObjective Classes

InterventionsInterventions

ParametersParameters

ExampleExample

High-level goal / programHigh-level goal / program: : Support Disease Mgmt. Support Disease Mgmt. Programs that measurably improve care & outcomesPrograms that measurably improve care & outcomes

Focused GoalFocused Goal:: Diabetes Mellitus Disease Mgmt. ProgramDiabetes Mellitus Disease Mgmt. Program• Clinical GoalClinical Goal: Prevent Diabetic Retinopathy: Prevent Diabetic Retinopathy

– Clinical ActionClinical Action - Increase regular Ophthalmology f/u - Increase regular Ophthalmology f/u– Clinical ActionClinical Action - Perform annual funduscopic exam - Perform annual funduscopic exam

• Clinical Goal:Clinical Goal: Decrease complications of diabetic neuropathy Decrease complications of diabetic neuropathy– Clinical ActionClinical Action – Increase regular podiatry follow-up – Increase regular podiatry follow-up

• Clinical Goal:Clinical Goal: Prevent diabetic nephropathy Prevent diabetic nephropathy– Clinical ActionClinical Action – Increase regular measurement of – Increase regular measurement of

microalbuminmicroalbumin

Osheroff, Pifer, Sittig, Jenders & Teich (2004). Clinical Decision Support Implementers Workbook.

Selecting Interventions – CDS TypesSelecting Interventions – CDS Types

• Forms and templates (encounter Forms and templates (encounter documentation)documentation)

• Relevant data presentation (flowsheets, CPM)Relevant data presentation (flowsheets, CPM)

• Order setsOrder sets

• Integrated guidelines (active guidelines) Integrated guidelines (active guidelines) 

• Reference information (links/Infobuttons)Reference information (links/Infobuttons)

• Reactive/unsolicited alerts (drug interactions)Reactive/unsolicited alerts (drug interactions)

Finding and Using Knowledge Finding and Using Knowledge ResourcesResources

William Hersh, MDWilliam Hersh, MDProfessor and ChairProfessor and Chair

Department of Medical Informatics & Clinical Department of Medical Informatics & Clinical EpidemiologyEpidemiology

Oregon Health & Science UniversityOregon Health & Science Universityhersh@ohsu.eduhersh@ohsu.edu

The life-cycle of medical (scientific) The life-cycle of medical (scientific) knowledgeknowledge

Originalresearch

Write upresults

Submit forpublication

Publish

Secondarypublications

Peerreview

Public datarepository

Relinquishcopyright

Revise

Reject

Accept

The hierarchy of evidenceThe hierarchy of evidence(Haynes, 2001)(Haynes, 2001)

Studies – original articles published in journals

Syntheses – systematic reviewsand evidence reports

Synopses – evidence-based abstractions

Systems –computerized

decision support

Knowledge resourcesKnowledge resources

Studies

Syntheses

Synopses

Systems

MEDLINE Journalarticles

Textbooks, compendia, guidelines

Guidelines, rules

Databases of systematic reviews

Finding studiesFinding studies

pubmed.gov www.bmj.com

Finding synthesesFinding syntheses

www.cochrane.org http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books

Finding synopsesFinding synopses

www.guideline.gov www.clinicalevidence.com

Challenges in knowledge Challenges in knowledge generation,generation,

access, and useaccess, and use

Generation – development of Generation – development of syntheses, synopses, and systems syntheses, synopses, and systems for use at point of carefor use at point of care

Access – open access, Access – open access, interoperability, licensinginteroperability, licensing

Use – how to apply in the clinical Use – how to apply in the clinical settingsetting

Using knowledge resources at the Using knowledge resources at the point of care – some general point of care – some general

pointerspointersClinicians need the appropriate amount of the right Clinicians need the appropriate amount of the right information at the right timeinformation at the right time

Systems and synopses at point of careSystems and synopses at point of careSyntheses and studies when have more time or need more Syntheses and studies when have more time or need more detaildetail

Interesting research coming down the pikeInteresting research coming down the pikeInfobuttons – Cimino et al. and othersInfobuttons – Cimino et al. and othersMaintaining user “context,” i.e., allowing user to drill down to Maintaining user “context,” i.e., allowing user to drill down to more information at a later pointmore information at a later point

What about different devices, e.g., PDAs and tablets?What about different devices, e.g., PDAs and tablets?Each has benefits and drawbacks; ideal solution is allow use of Each has benefits and drawbacks; ideal solution is allow use of anyanyAs with EHR, need standards for display, query, rights As with EHR, need standards for display, query, rights management, etc.management, etc.

CDS as a Team Sport:CDS as a Team Sport:The Role of Nurses, Allied Health The Role of Nurses, Allied Health

and Consumersand Consumers

Molly MettlerMolly Mettler

Senior VPSenior VP

HealthwiseHealthwise

CDS that Supports CDS that Supports Interdisciplinary CareInterdisciplinary Care

Evidence Based Practice depends on coordination Evidence Based Practice depends on coordination of all providers, including nurses, allied health, of all providers, including nurses, allied health, social work, & physicianssocial work, & physicians

““Domino” EffectDomino” Effect

Easy to use by busy cliniciansEasy to use by busy clinicians

Fits into workflowFits into workflow

Use of guidelines & documentation as natural Use of guidelines & documentation as natural process process

Focused, nimble, sensible, & vetted by Focused, nimble, sensible, & vetted by users/consumersusers/consumers

Patient-Centered InformaticsPatient-Centered Informatics

Include the patient Include the patient

Facilitate Facilitate patient/provider patient/provider conversationsconversations

Support shared-Support shared-decision makingdecision making

Support patient follow-Support patient follow-throughthrough

Information TherapyInformation Therapy::A Patient-Centered SolutionA Patient-Centered Solution

The The prescriptionprescription of : of : specific evidence-based medical informationspecific evidence-based medical information

to a specific patient, caregiver, or consumer to a specific patient, caregiver, or consumer

at just the right time to help them make a specific at just the right time to help them make a specific health decision or behavior changehealth decision or behavior change

asas part of the process of care part of the process of care

Diabetes Self-Management: Diabetes Self-Management: The Consumer’s POVThe Consumer’s POV

DietDietExerciseExerciseMedicationsMedicationsEye/Foot CareEye/Foot CareInsulin MonitoringInsulin MonitoringDepressionDepressionNerve damageNerve damageEtc., etc., etc.Etc., etc., etc.

Using a plate format for people with diabetes

The Ideal Application of CDS/CDAThe Ideal Application of CDS/CDA

From electronic medical record… to patient portal

Easy to Use ● Focused and Specific ● Documented