mie2009 keynote address: clinical decision support

Download MIE2009 Keynote Address: Clinical Decision Support

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Dr. Blackford Middleton keynote address at MIE2009 in Sarajevo, Bosnia-Herzogovina, Sept. 1, 2009.

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  • 1. BlackfordMiddleton,MD,MPH,MSc,FACP,FACMI,FHIMSS Chairman,CenterforInformationTechnologyLeadership CorporateDirector,ClinicalInformaticsResearch&Development PartnersHealthcareSystem HarvardMedicalSchool HarvardSchoolofPublicHealth
  • 2. WhatisClinicalDecisionSupport? TheEvidenceForandAgainstCDS CurrentexamplesandR&DProjectsfromPartners TheClinicalDecisionSupportConsortium
  • 3. Whatinformationconsumes isratherobvious:it consumestheattentionofits recipients. Henceawealthofinformation createsapovertyofattention, andaneedtoallocatethat attentionefCicientlyamongthe overabundanceofinformation sourcesthatmightconsumeit. Changingclinicianroles: FromOmniscientOracleto KnowledgeBroker.
  • 4. acted upon analyzed compiled After B Blum, 1984
  • 5. Medicalliteraturedoublingevery19years Doublesevery22monthsforAIDScare 2Millionfactsneededtopractice CovellstudyofLAInternists: 2unansweredclinicalquestionsforevery3pts 40%weredescribedasquestionsoffact, 44%werequestionsofmedicalopinion, 16%werequestionsofnonmedicalinformation. Covell DG, Uman GC, Manning PR. Ann Intern Med. 1985 Oct;103(4):596-9
  • 6. Generally,withdirectobservation,orinterview immediatelyafterclinicalencounters,physicianshave approximatelyonequestionforevery12patients Independentestimates:0.6,and0.62Q/pt HoldsacrossPCPandspecialtycare Holdsacrossurbanandrural Gorman, 1995 Gorman and Helfand 1995
  • 7. An objective measure of the amount of literature generated by medical scientists annually
  • 8. Originalresearch Negative 18% variable results Dickersin,1987 Submission 46% 0.5year Kumar,1992 17 years Acceptance 14% of to apply Koren,1989 Negative results 0.6year research knowledge Kumar,1992 Publication 17:14 35%to patient care! 0.3year Poyer,1982 Balas,1995 Lackof numbers Bibliographicdatabases 50% 6.013.0years Antman,1992 Poynard,1985 Reviews,guidelines,textbook Inconsistent 9.3years indexing PatientCare BalasYearbookMedicalInformatics2000gtre4,courtesyMOverhage
  • 9. "...The curse of medical education is the excessive number of schools. The situation can improve only as weaker and superfluous schools are extinguished." Society reaps at this moment but a small fraction of the advantage which current knowledge has the power to confer. AbrahamFlexner, MedicalEducationintheUnitedStatesandCanada. Boston:MerrymountPress,1910
  • 10. Insteadofteaching doctorstobeintelligent mapreaders,wehave triedtoteacheveryone tobeacartographer. Wepracticehealthcare asifweneverwrote anythingdown.Itisa spectacleoffragmented intention. LarryWeed,M.D. (fatherofS.O.A.P.note)
  • 11. Pronetoerror Lotsofinformationbutnodata Limiteddecisionsupport,orqualitymeasurement DoesnotintegratewitheHealthcare Willnottransformhealthcare
  • 12. Medicalerror,patientsafety,andqualityissues 98,000deathsrelatedtomedicalerror 40%ofoutpatientprescriptionsunnecessary Patientsreceiveonly54.9%ofrecommendedcare Fracturedhealthcaredeliverysystem Medicarebenegiciariessee1.313.8uniqueproviders annually,onaverage6.4differentproviders/yr Patientsmultiplerecordsdonotinteroperate Anunwiredsystem 90%ofthe30BhealthcaretransactionsintheUSeveryyear areconductedviamail,fax,orphone
  • 13. driven primarily by local norms that tend towards heavier TEXAS use of discretionary services El Paso such as diagnostic testing and surgical versus less invasive interventions for which there are no clear clinical guidelines. 790 mi., Peter Orszag, OMB Blog 1271 km http://www.whitehouse.gov/omb/ blog/ McAllen http://tr.im/sVLA
  • 14. AknowledgebasedsystemisanAIprogramwhose performancedependsmoreontheexplicitpresenceof alargebodyofknowledgethanonthepresenceof ingeniouscomputationalprocedures Duda RO, Shortliffe EH. Expert systems research. Science. 1983 Apr 15;220(4594):261-8.
  • 15. Algorithmic Inference Engine Statistical PatternMatching Knowledge Base Rulebased(Heuristic) Metaheuristic Fuzzysets Neuralnets Bayesian
  • 16. A B BloisMS.Clinicaljudgmentandcomputers. NEnglJMed.1980Jul24;303(4):1927.
  • 17. Formatting Resultsreview,pocketroundsreports Interpreting EKG,PFTs,Pap,ABG Consulting QMR,DxPlain,Iliad,Meditel,AbdPain,MIrisk Monitoring Alerts:Criticallabs,ABx/Surgery,ADEs Critiquing Ventmgmt,anesthesiamgmt,HTNRx,Radiologytest selection,Bloodproductsordering Kuperman GJ et al. J Hlth Info Mgmt (13)2, pg 81-96
  • 18. CDSyieldsincreasedadherencetoguidelinebasedcare,enhanced surveillanceandmonitoring,anddecreasedmedicationerrors (Chaudhryetal.,2006) CDS,atthetimeoforderentryinacomputerizedproviderorderentry systemcanhelpeliminateoveruse,underuse,andmisuse. (Batesetal.,2003;Austinetal.,1994;Linder,BatesandLee,2005;Tierney etal.,2003) Forexpensiveradiologictestsandproceduresthisguidanceatthepointof orderingcanguidephysicianstowardorderingthemostappropriateand costeffective,radiologictests. (Batesetal.,2003;Khorasanietal.,2003) Showingthecumulativechargedisplayforalltestsordered,reminding aboutredundanttestsordered,providingcounterdetailingduringorder entry,andremindingaboutconsequentorcorollaryordersmayalsoimpact resourceutilization (BatesandGawande,2003;Bates,2004;McDonaldetal.,2004).
  • 19. Savingspotential:$44billion reducedmedication,radiology,laboratory,and ADErelatedexpenses AdvancedCDSsystems SavingspotentialonlywithadvancedCDS costgivetimesasmuchasbasicCDS generate12timesgreaterginancialreturn Apotentialreductionofmorethan2millionadverse drugevents(ADEs)annually http://www.citl.org Johnston et al., 2003