education and clinical decision support: reuniting twins separated at birth
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Education and Clinical Decision Support: Reuniting Twins Separated at Birth. Jerry Osheroff, M.D. Thomson Healthcare University of Pennsylvania. Objectives. Outline the need for a joint model for education and clinical decision support - PowerPoint PPT PresentationTRANSCRIPT
Education and Education and Clinical Decision Support:Clinical Decision Support:
Reuniting Twins Separated at BirthReuniting Twins Separated at Birth
Jerry Osheroff, M.D.Jerry Osheroff, M.D.
Thomson HealthcareThomson Healthcare
University of PennsylvaniaUniversity of Pennsylvania
ObjectivesObjectives
Outline the need for a joint model for Outline the need for a joint model for education and clinical decision education and clinical decision supportsupport
Describes how the two can be used Describes how the two can be used together to achieve outstanding care together to achieve outstanding care delivery and outcomes.delivery and outcomes.
Healthcare is BrokenHealthcare is BrokenSafetySafety 1 medication error/inpatient/day 1 medication error/inpatient/day – IOM– IOM >500K preventable ADE deaths/injuries (outpt) >500K preventable ADE deaths/injuries (outpt) – IOM– IOM
QualityQuality 55% chance of appropriate care 55% chance of appropriate care – McGlynn/NEJM– McGlynn/NEJM 17 years: effective treatment ->routine 17 years: effective treatment ->routine – Balas/IMIA– Balas/IMIA
Affordability Affordability $ 44 billion waste recoverable w/CPOE (outpt) $ 44 billion waste recoverable w/CPOE (outpt) - CITL- CITL $ 3.5 billion from inpatient ADEs $ 3.5 billion from inpatient ADEs – IOM– IOM
Education
“What should I know and do?”
Clinical Decision Support
“What should I do now?”
Part of the SolutionPart of the Solution
Orthopedic Surgery VTE prophylaxis schema for Orthopedic Surgery VTE prophylaxis schema for hip and knee arthroplasty and hip fracture surgeryhip and knee arthroplasty and hip fracture surgery
Any CONTRAINDICATIONS to pharmacologic prophylaxis?
High risk of bleeding Active bleeding
Systemic anticoagulation INR ≥ 1.5 or aPTT ratio ≥ 1.3
Platelet count < 50,000
Yes
Use TEDs/SCDs until contraindication no longer present. Consider serial duplex surveillance
or vena caval filter in high-risk orthopedic patients (Hip or knee arthroplasty-particularly with VTE risk
factors, Hip fracture surgery, major trauma, spine surgery with risk factors)
No Creatinine clearance < 30 ml/min
No
Hip surgery with VTE risk factors? Previous DVT/PE
CancerThrombophiliaMajor trauma
Fondaparinux 2.5 mg sc qday X 14 days(Start ≥ 6 hours post-op)
Enoxaparin 30 mg sc q12h X 14 days(Start 12-24 hours post-op; PREFERRED enoxaparin regimen)
Enoxaparin 40 mg sc qday X 14 days(Start 12 hours pre-op, next dose at least 12 hours post-op)
Warfarin 5 mg po qday (adjust to INR2-3)(Begin day of surgery)
(Use 2.5 mg for age>75, CHF or liver disease, interacting meds)
Consider extended prophylaxis for 28 days post-op with
Fondaparinux 2.5 mg sc qDay or Enoxaparin 40 mg sc qDay or
Warfarin (INR 2-3)(with at least weekly INR)
Yes
Complete 14 days of prophylaxis
No
Yes
Yes
Enoxaparin 30 mg sc q24h X 14 days(Start 12-24 hours post-op)
Warfarin 5 mg po qday (adjust to INR2-3)
(Begin day of surgery)(Use 2.5 mg for age>75, CHF or liver disease, interacting meds)
May addSCDs Foot pumps
Hip surgery with VTE risk factors? Previous DVT/PE
CancerThrombophiliaMajor trauma
Complete 14 days of prophylaxis
Consider extended prophylaxis for 28 days post-op with
Warfarin (INR 2-3)(with at least weekly INR)
Yes
No
Not in order set
Goal of EducationGoal of Education
Existing knowledge Exis
ting k
now
ledge
New knowledge
Provide cognitive framework, skills, and beliefs necessary for practice.
Tools of EducationTools of Education
DIDACTIC EXPERIENTIAL
Information Case PracticeBased Based Based
-Informational -Fictional -Apprenticeship
text & graphics or real -Quality -Books cases Improvement -Lectures -Virtual -Point of care
patients
Goals of CDSGoals of CDS
““Providing clinicians or patients with Providing clinicians or patients with clinical knowledgeclinical knowledge and patient-related and patient-related information, intelligently filtered or presented information, intelligently filtered or presented at appropriate times, at appropriate times, to enhance patient to enhance patient carecare.” .”
Includes and builds on what’s already being done Includes and builds on what’s already being done on a daily basis in healthcare organizations…on a daily basis in healthcare organizations…
NOTNOT just rules and alerts… just rules and alerts…
Tools of CDSTools of CDS
Documentation templates: Documentation templates: pt hx, visit notept hx, visit note
Relevant data presentation: Relevant data presentation: flowsheets, auditsflowsheets, audits
Order creation facilitators: Order creation facilitators: order setsorder sets
Protocol support: Protocol support: pathwayspathways
Reference information: Reference information: infobuttonsinfobuttons
Unsolicited alerts: Unsolicited alerts: proactive warningsproactive warnings
Must do items clearly identified
Help with order selection, core measures identified
Links to drug info from every medication orderC
Acute MI Order Set
Drug information at a glance
Knowledge NeedsKnowledge Needs
What I know that I What I know that I don’t knowdon’t know
(Recognized need)(Recognized need)
What I know that I What I know that I knowknow
What I don’t know What I don’t know that I don’t knowthat I don’t know
(Unrecognized need)(Unrecognized need)
What I don’t know What I don’t know that I knowthat I know
COMPETENCE
CO
NS
CIO
US
NES
S
Links to synoptic disease information
Reunion DriversReunion Drivers CME Accreditation changesCME Accreditation changes
• Improve physician competence, performance, patient outcomes* Improve physician competence, performance, patient outcomes* • Continuous improvement: knowledge, strategies, and Continuous improvement: knowledge, strategies, and
performance-in-practice**performance-in-practice**
Point of care learningPoint of care learning• Leverages decision support tools and adds reflective componentLeverages decision support tools and adds reflective component• Responds to learning needs from patients’ clinical problems ***Responds to learning needs from patients’ clinical problems ***
Quality improvementQuality improvement• Broader examination of quality gapsBroader examination of quality gaps• Integrated into Maintenance of CertificationIntegrated into Maintenance of Certification
* * ACCME, Updated Accreditation Citeria, 2006ACCME, Updated Accreditation Citeria, 2006
** Regnier et al., JCEHP 2005** Regnier et al., JCEHP 2005
*** Davis and Willis, JCEHP 2004*** Davis and Willis, JCEHP 2004
5 ‘Rights’: Joint Model for Education and CDS5 ‘Rights’: Joint Model for Education and CDS
CDS and Education should provide:CDS and Education should provide:
• the right the right informationinformation (ebm),(ebm),
• to the right to the right personperson (clinicians (clinicians andand patients…), patients…),
• in the right intervention in the right intervention format or activityformat or activity (alert, (alert, answer, virtual patient, assessment, reflection),answer, virtual patient, assessment, reflection),
• at the right point in at the right point in timetime (relative to workflow and other (relative to workflow and other interventions)interventions)
• through the right through the right systemssystems and and peoplepeople (cds and (cds and education professionals, multimodal solutions)education professionals, multimodal solutions)
to improve health care delivery and outcomesto improve health care delivery and outcomes. .
Keys to Joint ModelKeys to Joint Model
Comprehensive user needs assessmentComprehensive user needs assessment
Diverse development team (clinical Diverse development team (clinical experts, informaticians, educators)experts, informaticians, educators)
Multiple interventions and modalitiesMultiple interventions and modalities
IntegratedIntegrated perspective/action perspective/action
A Question
in Practice
Physician Performance
In Practice
PhysicianCompetence
Strategy
Wisdom
Judgment
Information
Analysis
Data
Syn
thesis
Kno
wle
dge
Regnier et al, JCEHP, Fall 2005
Assessment
Education
Decision Support
= Added
Continuing Professional Development
Implementing the Joint ModelImplementing the Joint Model
Work with colleagues in CDS Work with colleagues in CDS or Educationor Education
Understand the tools Understand the tools availableavailable
Look at clinical systems for Look at clinical systems for needs assessment dataneeds assessment data
Analyze root causes of poor Analyze root causes of poor performanceperformance
Create interventions fully Create interventions fully appropriate for needsappropriate for needs
Education + CDS =
Best Healthcare Outcomes
DiscussionDiscussion
Thank you!Thank you!
Comments? Questions?Comments? Questions?
Contact info:Contact info:• [email protected]@thomson.com• www.thomsonhealthcare.comwww.thomsonhealthcare.com