Decision Support in VA Decision Support in VA Clinical Information Clinical Information
SystemsSystems
James L. Breeling, MDJames L. Breeling, MD
March 18, 2009March 18, 2009
BU Informatics SeriesBU Informatics Series
Diffusion of InnovationsDiffusion of Innovations
Classical diffusion theory assumes that Classical diffusion theory assumes that innovations are sufficiently well defined for innovations are sufficiently well defined for individuals to assess their relative individuals to assess their relative advantage, risk and cost. advantage, risk and cost.
In reality, innovations carry uncertainty for In reality, innovations carry uncertainty for individuals and therefore delay in adoptionindividuals and therefore delay in adoption
Adoption of medical innovation in Adoption of medical innovation in particular is slower and less predictableparticular is slower and less predictable
Clinical Knowledge is a Special Clinical Knowledge is a Special CaseCase
Physician expertise is built through Physician expertise is built through Acquiring specific scientific knowledgeAcquiring specific scientific knowledge Learning-by-doingLearning-by-doing
Practice Communities tend to be local Practice Communities tend to be local “closed” systems despite links to “closed” systems despite links to international knowledgeinternational knowledge
General trends in local communities are General trends in local communities are shaped by opinion leadersshaped by opinion leaders
Unexplained Practice VariationUnexplained Practice Variation
Business Drivers for Evidence Business Drivers for Evidence Based MedicineBased Medicine
Employers and consumers are now paying Employers and consumers are now paying for performancefor performance
Institute of Medicine report on medical Institute of Medicine report on medical errorserrors
Prescribing datasets suggest that 5-10% Prescribing datasets suggest that 5-10% of medication prescriptions lead to of medication prescriptions lead to preventable, anticipatable adverse eventspreventable, anticipatable adverse events
Guideline ImplementationGuideline ImplementationPractices or Practices or StrategiesStrategies
DefinitionDefinition
Organizational & Organizational & AdministrativeAdministrative
Changes in Leadership, responsibility, policy, Changes in Leadership, responsibility, policy, decision making, culture, knowledge management, decision making, culture, knowledge management, communication and coordinationcommunication and coordination
Technology & Technology & InfrastructureInfrastructure
Changes in information technology, data Changes in information technology, data management, feedback, physical plant and management, feedback, physical plant and equipmentequipment
Care DeliveryCare Delivery Changes in care delivery process, patient Changes in care delivery process, patient interactions, patient education, clinical programs and interactions, patient education, clinical programs and treatment analysistreatment analysis
Staff Resources & Staff Resources & DevelopmentDevelopment
Changes in resource allocation, increased awareness Changes in resource allocation, increased awareness and knowledge, skill building, influence provider and knowledge, skill building, influence provider attitude, behavior changes.attitude, behavior changes.
VHA ORD HSR&D Blueprint for Change Jan 26, 2000
Expansion of Medical KnowledgeExpansion of Medical Knowledge
““The surge of new knowledge in medicine The surge of new knowledge in medicine has created a tremendous problem for the has created a tremendous problem for the student and for the practitioner. The student and for the practitioner. The periodical literature, for a long time periodical literature, for a long time unwieldy, has now become impossible to unwieldy, has now become impossible to handle…”handle…” Arthur L. Bloomfield, MD, “A Bibliography of Arthur L. Bloomfield, MD, “A Bibliography of
Internal Medicine” 1957Internal Medicine” 1957
Clinical Decision Support Clinical Decision Support ChallengesChallenges
Meaningful decision support should Meaningful decision support should improve quality of care for patientimprove quality of care for patient
Meaningful decision support should Meaningful decision support should improved quality of clinician interaction improved quality of clinician interaction with electronic recordwith electronic record
Meaningful decision support will be based Meaningful decision support will be based on highest quality knowledge base in a on highest quality knowledge base in a timely fashion (“don’t be the first or the last timely fashion (“don’t be the first or the last to prescribe a new drug”)to prescribe a new drug”)
Facets of Clinical Decision Support Facets of Clinical Decision Support Quality & Performance
•Evidence based•Safety based•Regulatory based
Patient Perspective•Preferred agent•Preferred dosing•preferred route
End User Experience•End user role•Office workflow•Preferred workflow
Pitfalls of Clinical Decision SupportPitfalls of Clinical Decision Support
““task-interference” as a method of guideline task-interference” as a method of guideline enforcementenforcement Make it difficult for clinician to complete a process Make it difficult for clinician to complete a process
unless minimum threshold metunless minimum threshold met Decision Support through interference with taskDecision Support through interference with task
““task-facilitation” as a method of guideline task-facilitation” as a method of guideline enforcementenforcement Manage disease states through presentation of Manage disease states through presentation of
context sensitive rules, order sets, documentation context sensitive rules, order sets, documentation templatestemplates
Decision support should facilitate goal – i.e. manage Decision support should facilitate goal – i.e. manage Diabetes for better glycemic controlDiabetes for better glycemic control
Knowledge Life-CycleKnowledge Life-Cycle
Proposed Guideline & Content
Guideline Defined & Validated
Functional Knowledge Specified for Encoding
Engineered into Production
Ongoing Revisions&
Eventual Sunset
VISTA Clinical Reminder Package: VISTA Clinical Reminder Package: Designing a ReminderDesigning a Reminder
Think of the clinical practice guideline as Think of the clinical practice guideline as an algorithman algorithm
Think of the clinical reminder as a decision Think of the clinical reminder as a decision node in the algorithmnode in the algorithm
State in plain English the target State in plain English the target population=“denominator”population=“denominator”
State in plain English the action that State in plain English the action that resolves the reminder=“numerator”resolves the reminder=“numerator”
VISTA Clinical Reminders: FindingsVISTA Clinical Reminders: Findings
DrugDrug Education topicEducation topic ExamExam Health factorHealth factor ImmunizationImmunization Laboratory testLaboratory test Mental health instrumentMental health instrument Orderable itemOrderable item Radiology procedureRadiology procedure
Reminder computed Reminder computed findingfinding
Reminder taxonomyReminder taxonomy Reminder termReminder term Skin testSkin test VA drug classVA drug class VA genericVA generic Vital measurementVital measurement Reminder location listReminder location list
Boolean Logic: How Findings Boolean Logic: How Findings Are Used to Define PopulationsAre Used to Define Populations
A AND NOT B
A B
A AND B
A B
A OR B
A B
The negation of “A or B” is “Not A and not B”
The negation of “A and B” is “Not A or not B”
Importance of DenominatorsImportance of Denominators
A finding that make a reminder not A finding that make a reminder not applicable for a patient, causes that applicable for a patient, causes that patient to NOT be included in the patient to NOT be included in the denominatordenominator patient is not in the cohortpatient is not in the cohort
A finding that satisfies or resolves the A finding that satisfies or resolves the reminder leaves the patient in the reminder leaves the patient in the denominator.denominator.
Two Difference Populations Two Difference Populations Receiving PneumovaxReceiving Pneumovax
1 Age AND Sex OR High RiskAge AND Sex OR High Risk satisfied by vaccine or refusalsatisfied by vaccine or refusal
2 Age AND Sex OR High Risk Age AND Sex OR High Risk AND NOT Refusal AND NOT Refusal
satisfied by vaccinesatisfied by vaccine
Pneumovax Example:Pneumovax Example:DenominatorsDenominators
# Patients with# Patients with Reminder Applicable Reminder Due Reminder Applicable Reminder Due ------------------- ------------ ------------------- ------------
1 Pneumovax 33 111 Pneumovax 33 11
# Patients with# Patients with Reminder Applicable Reminder Due Reminder Applicable Reminder Due ------------------- ------------ ------------------- ------------
2 Pneumovax 19 112 Pneumovax 19 11
45 patients evaluated45 patients evaluated
Dialogs: What Is in the Dialogs: What Is in the Programming Tool Box?Programming Tool Box?
Radio buttonsRadio buttons one choice only from group of responsesone choice only from group of responses
Check boxesCheck boxes multiple choicesmultiple choices
Hidden/visible itemsHidden/visible items Informational textInformational text
no user entryno user entry Free text comment boxesFree text comment boxes
user entry optional or requireduser entry optional or required Forced YES/NO answersForced YES/NO answers HyperlinksHyperlinks
Dialogs – Informatics Dialogs – Informatics ErgonomicsErgonomics
Bad practicesBad practices Too many mouse Too many mouse
clicks per window to clicks per window to process dialogprocess dialog
Window scrolls down Window scrolls down in seemingly unlimited in seemingly unlimited fashionfashion
Too many embedded Too many embedded windows appear in windows appear in successionsuccession
Good practicesGood practices Present just enough Present just enough
useful options to user useful options to user to processto process
Allows user to quickly Allows user to quickly process relevant process relevant information and then information and then return main levelreturn main level
ApplicationsApplications
Performance improvementPerformance improvement Decision SupportDecision Support Case FindingCase Finding Risk ProfileRisk Profile
PACTPACT MOVEMOVE
Standards of CareStandards of Care
Patient ListsPatient Lists
New in Clinical Reminders V.2.0New in Clinical Reminders V.2.0 Created as part of reminder extractsCreated as part of reminder extracts
Patient lists can be built independently of extractsPatient lists can be built independently of extracts
Uses Clinical Reminders IndexUses Clinical Reminders Index Fast compilingFast compiling
Uses?Uses? Extracts, Health Summaries, Reminder Reports, Extracts, Health Summaries, Reminder Reports,
Demographics, Patient Mailing ListsDemographics, Patient Mailing Lists
Clinical Reminders – Network Clinical Reminders – Network Initiative and GovernanceInitiative and Governance
Oversight of Clinical Reminders is by the Clinical Practice Oversight of Clinical Reminders is by the Clinical Practice Guidelines committeeGuidelines committee
Every reminder must have a service line sponsor Every reminder must have a service line sponsor (administrative or clinical)(administrative or clinical)
Every reminder must have an owner who is responsible for Every reminder must have an owner who is responsible for the content and for awareness of need for changethe content and for awareness of need for change
A subcommittee accepts proposals for new reminders, A subcommittee accepts proposals for new reminders, recommends priorities, may help develop prototypes and recommends priorities, may help develop prototypes and conduct alpha testsconduct alpha tests
An implementation group meets quarterly to roll out An implementation group meets quarterly to roll out reminders or modifications on a uniform basisreminders or modifications on a uniform basis
Clinical Decision SupportClinical Decision Support
Point-of-care decision support Point-of-care decision support Provides information to the clinician at the Provides information to the clinician at the
time of medical-decision-makingtime of medical-decision-making More than clinical remindersMore than clinical reminders
More complex reasoningMore complex reasoning Evidence-base for recommendationsEvidence-base for recommendations
Clinical Decision SupportClinical Decision Support
Active systemsActive systems Drug allergy alertsDrug allergy alerts Lab alertsLab alerts Abnormal x-ray Abnormal x-ray
findingsfindings
Passive SystemsPassive Systems Problem listsProblem lists Intelligent order sets Intelligent order sets
based on evidencebased on evidence Antibiotics listed for Antibiotics listed for
specific conditionsspecific conditions Social history specifics Social history specifics
triggers social work triggers social work consultconsult
Family history Family history suggests specific suggests specific testing or screeningtesting or screening
Principle 1: If the Information Is Principle 1: If the Information Is Necessary, It Should Be Made Necessary, It Should Be Made
Known Before Any ActionKnown Before Any Action Allergies should be listed in all med Allergies should be listed in all med
order screensorder screens Renal function should be visible when Renal function should be visible when
ordering nephrotoxic drugsordering nephrotoxic drugs formulary drugs for a given condition formulary drugs for a given condition
should be listed firstshould be listed first
Principle 2: Intrusiveness is Principle 2: Intrusiveness is more tolerable when the more tolerable when the
situation is more complexsituation is more complex
Knowledge of renal dysfunction as Knowledge of renal dysfunction as related to co-morbidity of CHF or related to co-morbidity of CHF or diabetesdiabetes
Knowledge of HIV treatment regimen Knowledge of HIV treatment regimen and drug-drug interactions and adverse and drug-drug interactions and adverse drug eventsdrug events
Controversies over best diagnostic Controversies over best diagnostic strategies for target conditionstrategies for target condition
The CPR in US Industry: The CPR in US Industry: Gartner Group (1999)Gartner Group (1999)
Fun
ctio
nali
ty
First Generation:The Collector
1993 1998 2003 2008 2012+
Second Generation: The Document
Fourth Generation: The Partner
Fifth Generation: The Mentor
Minimal
Full
Predicted Marketplace Predicted Marketplace MaturityMaturity
Data Acquired Through Feeder Systems
Document Care in Free Text
Structured DocumentationSpanning Episodes of Care
Clinical WorkflowIntervention ScreeningDecision Support
Automated GenerationOf Pathways and Workflow; Use by Consumers
Now
Third Generation: The Helper