bringing clinical knowledge to the point of care and to patients jonathan teich patti abbott bill...
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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
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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
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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.
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““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”
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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
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Substitution alertsSubstitution alerts
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Consequent (corollary) ordersConsequent (corollary) orders
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Impact studies - Excessive Impact studies - Excessive dosesdoses
0
0.5
1
1.5
2
2.5
Pre-OE Post-OE Year 1 Year 2 Year 3
% o
f o
rder
s
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Use of recommended H2 Use of recommended H2 blockerblocker
0102030405060708090
100
-7 -6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6 7 8
Week
% o
f o
rder
s
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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
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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
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Formulary CheckingFormulary Checking
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www.himss.org/cdsworkbook
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Opportunities for CDSOpportunities for CDS
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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
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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
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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.
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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
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From Goal to ActionFrom Goal to Action
High level Goal High level Goal
Focused GoalFocused Goal
Clinical GoalClinical Goal
Clinical ActionClinical Action
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ProgramProgram
GoalsGoals
ObjectivesObjectives
Objective ClassesObjective Classes
InterventionsInterventions
ParametersParameters
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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.
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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)
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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 [email protected]@ohsu.edu
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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
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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
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Knowledge resourcesKnowledge resources
Studies
Syntheses
Synopses
Systems
MEDLINE Journalarticles
Textbooks, compendia, guidelines
Guidelines, rules
Databases of systematic reviews
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Finding studiesFinding studies
pubmed.gov www.bmj.com
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Finding synthesesFinding syntheses
www.cochrane.org http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=Books
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Finding synopsesFinding synopses
www.guideline.gov www.clinicalevidence.com
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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
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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.
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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
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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
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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
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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
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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.
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Using a plate format for people with diabetes
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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