BPM Roundtable
Eindhoven University of Technology
5/11/2012
Opportunities for Evidence-based Clinical Decision Support Systems:
An Application for Oncology
Dr. Yaron Denekamp
CMIO, Hospital Division, Clalit Health Services, Tel Aviv
Faculty of Medicine, Technion, Haifa
European BPM Roundtable
Eindhoven University of Technology
5/11/2012
oSpecialist in Internal Medicine
oMedical Informatics - fellowship and studies at Harvard MIT division of Health Sciences and Technology in Boston
oChief Medical Informatics Officer Hospital Division, Corporate Headquarters, Clalit Health Services, Tel Aviv
oFaculty of Medicine, Technion, Haifa
o Largest health care provider in Israel
o 4 Million Insured Members – over half of the population
o Second largest organization of its type in the world
o 14 hospitals, 1400 clinics
o 36,000 employees, 10,000 physicians
o Clinical IT systems
- Community- one EMR system
- Hospitals – mainly 2 EMR systems
- Several BI systems
Clalit Health Services Group Israel’s Leading Health Care Organization
Hospitals across Israel
• Community outreach • National centers of excellence
• Children’s Hospital • Cancer center • Organ transplant center
• Rehabilitation centers
5
I. Why do we need to support clinical
decisions and processes?
II. Types and examples of clinical decision support systems (CDSS)
III. Opportunities and challenges of implementing CDSS
oPreventable <> side effects
oMedication – allergy, dosages, drug-drug interactions etc.
oMisdiagnosis
oTreatment – medical and surgical
Covell study of LA Internists, Ann Intern Med 1985
2 unanswered clinical questions for every 3 pts
o Holds across PCPs and specialty care
o Holds across urban and rural
Gorman, Medical Decision Making 1995, Gorman, Medinfo 2001
o 30% of questions were pursued
o 70% of information needs were not-pursued!
o Too busy, no immediate access to resources, or office materials (books, journals, etc.) in disarray or out-of-date
Some outcomes -
Overuse
o 30% of children receive excessive antibiotics for ear infection
o 20-40% of surgical procedures unnecessary
o 50% of back pain x-rays unnecessary
Underuse
o 50% of elderly patients don’t get the necessary immunizations
in winter
o> 20,000 journals published
o17,000 new books per year
oSize doubles every 10-15 years
o2 Million facts needed to practice
Medical School
Conferences, CME, Lectures
Clinical Reports
Medical
Record
Books, Journals
Guidelines
Administrative Issues
Decisions, Decisions, Decisions
Curbside Consultation
o A constellation of psychological studies converging to a description of human decision making under uncertainty
o It was awarded the Nobel Prize of Economics (2002)
o Main points: o People use a few simple heuristics when
making judgments under uncertainty
o These heuristics sometimes are useful and other times lead to severe and systematic errors
oCurrent Approach
- Professional autonomy drives variability - Decision making is based on training and experience
oNew Rules - Knowledge is shared and information flows freely - Decision making is evidence-based
Richardson, William C. IOM 2001 Crossing the Quality Chasm, pg. 71
Active knowledge systems which use two or more
items of patient data to generate case-specific advice
Support <> Replace
link health observations with health knowledge to influence health decisions by clinicians for improved health care processes
Evidenced Based Medicine
o High quality level studies – ranking for quality of
research, level of evidence
Clinical practice guidelines
o Developed by professional organizations, HMO’s,
Ministry of health
Problems –
- Physicians are not aware to that knowledge
- Time constraints to read and follow
- Compliance
oMedications – prescribing, ordering
oTreatments – most useful cost effective alternatives
oDiagnostic – complex multi step process
o Institutional administrative processes – duplicated testing, consultations, transferring labs specimens to the labs etc.
o Alerting - when a clinical data is abnormal
or a clinical guideline is not followed
o Critiquing – when ordering a medication or a test
o Reminders – reminding the clinician to follow desired practice guidelines and policies
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More challenging -
o Computer-interpretable guidelines
o Expert systems
Drug-Drug
Interaction
Screening
Dosages Renal and Hepatic
function
Duplicate Therapy
Checking
Drug Food
Interactions
Drug Allergy
Checking
Drug Indications Drug Side Effects
Drug Disease
Contraindication
Checking
Paediatric
Precautions Patient Education
Inference methods
o Algorithmic
o Statistical
o Pattern Matching
o Rule-based (Heuristic)
o Fuzzy sets
o Neural nets
o Bayesian
Knowledge
Base
Inference Engine
o Awareness to the need, also from the perspective of claims and risk management
o Platforms – EMR systems are increasingly used including CPOE
cannot be a standalone system
o Standards of clinical data and information
More standards are used for diagnoses, medications, clinical information model
o Less reluctance of healthcare workers
o More evidence that it works
o Documentation of the processes in EMR systems enables process mining to discover improved workflows
o Workflow integration on top of the EMR system - naturally fit into the process of care
o Representing and maintaining medical knowledge and process models
o Complexity of modeling time oriented data
o Need for flexibility – supporting process, not replacing the professionals
o Dealing with ambiguity
o Mechanisms to avoid the alert fatigue phenomena
o UI – simple interface directed by the user
oImproved patient safety - reduced medication errors and adverse events
- improved medication and test ordering
oImproved quality of care - increased application of clinical guidelines, facilitating the use
of up-to-date clinical evidence
oImproved efficiency in health care delivery - reductions in test duplication - decreased adverse events - changed patterns of drug prescribing favoring cheaper but equally effective generic brands