Clinical Decision Support at Clinical Decision Support at Partners HealthcarePartners HealthcareBlackford Middleton, MD, MPH, MSc Blackford Middleton, MD, MPH, MSc

Corporate Director, Clinical Informatics R&DCorporate Director, Clinical Informatics R&DChairman, Center for IT LeadershipChairman, Center for IT Leadership

Partners Healthcare SystemPartners Healthcare SystemHarvard Medical SchoolHarvard Medical School

Harvard School of Public HealthHarvard School of Public Health

Overview: Overview: CDS DimensionsCDS Dimensions

Provider workflowProvider workflow– LookupLookup

– Alert Alert

– Interrupt Interrupt

– ActionableActionable

– Documentation-centricDocumentation-centric

– Population (Cohort)Population (Cohort)

Patient RelevancePatient Relevance– Non-specificNon-specific

– Specific/tailoredSpecific/tailored

ConsumerConsumer– LookupLookup

– AlertAlert

– Population (Cohort)Population (Cohort)

MethodsMethods– Inference methods (rules, etc.)Inference methods (rules, etc.)

– Temporal reasoning Temporal reasoning (protocols/pathways)(protocols/pathways)

– Values/Utilities (preferences: Values/Utilities (preferences: pt/provider)pt/provider)

5*2*3*3 = a minimum of 90 different approaches to CDS!5*2*3*3 = a minimum of 90 different approaches to CDS!

Partners CDSPartners CDS

CPOECPOE Alerts & RemindersAlerts & Reminders Actionable CDSActionable CDS Documentation-centric CDSDocumentation-centric CDS Population/cohortPopulation/cohort Patient-directed CDSPatient-directed CDS

Medication ordering -- Medication ordering -- main screenmain screen

KnowledgeLink in the Workflow

Secure Messaging

Task Management

PopulationManagement

Clinical Alerts

Schedule

Patient Lists

KnowledgeLinks

CAD/DM Smart FormCAD/DM Smart Form

Smart View: Data Display

Smart View: Data Display

Smart Assessment, Orders, and Plan

Smart Assessment, Orders, and Plan

Assessment and recommendations generated from rules engine

Assessment and recommendations generated from rules engine

Smart Documentation

Smart Documentation

• Lipids• Anti-platelet therapy• Blood pressure• Glucose control• Microalbuminuria• Immunizations• Smoking • Weight• Eye and foot examinations

• Lipids• Anti-platelet therapy• Blood pressure• Glucose control• Microalbuminuria• Immunizations• Smoking • Weight• Eye and foot examinations

CAD/DM Smart FormCAD/DM Smart Form

Medication OrdersMedication Orders

Lab OrdersLab Orders

ReferralsReferrals

Handouts/EducationHandouts/Education

CAD Quality DashboardCAD Quality Dashboard

Targets are 90th percentile for HEDIS or for Partners providers

Targets are 90th percentile for HEDIS or for Partners providers

Zero defect care: • Aspirin• Beta-blockers• Blood pressure• Lipids

Zero defect care: • Aspirin• Beta-blockers• Blood pressure• Lipids

Red, yellow, and green indicators show adherence with targets

Red, yellow, and green indicators show adherence with targets

Discrepancy

Details

Serious Medication Error Serious Medication Error Rates Before and After CPOERates Before and After CPOE

Bates et. al. JAMA 1998.

Preliminary Results: Preliminary Results: Smart Form On Treatment AnalysisSmart Form On Treatment Analysis

<0.001

<0.001

<0.001

<0.001

<0.001

0.05

0.004

0.006

Patient Journal CausesPatient Journal CausesProvider Activation Provider Activation

Grant RW et al. Practice-linked Online Personal Health Records for Type 2 Diabetes: A Randomized Controlled Trial. Arch Intern Med. 2008 Sep 8;168(16):1776-82. .

More medication changes in visits after diabetes journal submission:

An external repository of clinical An external repository of clinical content with web-based viewercontent with web-based viewer

Search CriteriaSearch CriteriaContent Type…Content Type…

SpecialtySpecialty

Community (”Crowd”)Medical Professional

Personal Health

Information NetworkScience

Rule builder

Knowledge

respository

Rule engine

Clin. Inf. System

Petter K. RisøeHSPH HPM512 2009

’’Crowdsourcing’ Crowdsourcing’ Knowledge EngineeringKnowledge Engineering

Patient

“I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.”

Clem McDonald, MD NEJM 1976

Thank you!Blackford Middleton, MDbmiddleton1@partners.orgwww.partners.org/cirdwww.citl.org

Where are we?Where are we?