Va Decision Support Seminars 2009


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Overview of VA electronic record and functionality that supports clinical decision support

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Va Decision Support Seminars 2009

  1. 1. Decision Support in VA Clinical Information Systems James L. Breeling, MD March 18, 2009 BU Informatics Series
  2. 3. Diffusion of Innovations <ul><li>Classical diffusion theory assumes that innovations are sufficiently well defined for individuals to assess their relative advantage, risk and cost. </li></ul><ul><li>In reality, innovations carry uncertainty for individuals and therefore delay in adoption </li></ul><ul><li>Adoption of medical innovation in particular is slower and less predictable </li></ul>
  3. 4. Clinical Knowledge is a Special Case <ul><li>Physician expertise is built through </li></ul><ul><ul><li>Acquiring specific scientific knowledge </li></ul></ul><ul><ul><li>Learning-by-doing </li></ul></ul><ul><li>Practice Communities tend to be local “closed” systems despite links to international knowledge </li></ul><ul><li>General trends in local communities are shaped by opinion leaders </li></ul>
  4. 5. Unexplained Practice Variation
  5. 6. Business Drivers for Evidence Based Medicine <ul><li>Employers and consumers are now paying for performance </li></ul><ul><li>Institute of Medicine report on medical errors </li></ul><ul><li>Prescribing datasets suggest that 5-10% of medication prescriptions lead to preventable, anticipatable adverse events </li></ul>
  6. 7. Guideline Implementation VHA ORD HSR&D Blueprint for Change Jan 26, 2000 Practices or Strategies Definition Organizational & Administrative Changes in Leadership, responsibility, policy, decision making, culture, knowledge management, communication and coordination Technology & Infrastructure Changes in information technology, data management, feedback, physical plant and equipment Care Delivery Changes in care delivery process, patient interactions, patient education, clinical programs and treatment analysis Staff Resources & Development Changes in resource allocation, increased awareness and knowledge, skill building, influence provider attitude, behavior changes.
  7. 8. Expansion of Medical Knowledge <ul><li>“ The surge of new knowledge in medicine has created a tremendous problem for the student and for the practitioner. The periodical literature, for a long time unwieldy, has now become impossible to handle…” </li></ul><ul><ul><li>Arthur L. Bloomfield, MD, “A Bibliography of Internal Medicine” 1957 </li></ul></ul>
  8. 9. Clinical Decision Support Challenges <ul><li>Meaningful decision support should improve quality of care for patient </li></ul><ul><li>Meaningful decision support should improved quality of clinician interaction with electronic record </li></ul><ul><li>Meaningful decision support will be based on highest quality knowledge base in a timely fashion (“don’t be the first or the last to prescribe a new drug”) </li></ul>
  9. 10. Facets of Clinical Decision Support <ul><li>Quality & Performance </li></ul><ul><ul><li>Evidence based </li></ul></ul><ul><ul><li>Safety based </li></ul></ul><ul><ul><li>Regulatory based </li></ul></ul><ul><li>Patient Perspective </li></ul><ul><ul><li>Preferred agent </li></ul></ul><ul><ul><li>Preferred dosing </li></ul></ul><ul><ul><li>preferred route </li></ul></ul><ul><li>End User Experience </li></ul><ul><ul><li>End user role </li></ul></ul><ul><ul><li>Office workflow </li></ul></ul><ul><ul><li>Preferred workflow </li></ul></ul>
  10. 11. Pitfalls of Clinical Decision Support <ul><li>“ task-interference” as a method of guideline enforcement </li></ul><ul><ul><li>Make it difficult for clinician to complete a process unless minimum threshold met </li></ul></ul><ul><ul><li>Decision Support through interference with task </li></ul></ul><ul><li>“ task-facilitation” as a method of guideline enforcement </li></ul><ul><ul><li>Manage disease states through presentation of context sensitive rules, order sets, documentation templates </li></ul></ul><ul><ul><li>Decision support should facilitate goal – i.e. manage Diabetes for better glycemic control </li></ul></ul>
  11. 12. Knowledge Life-Cycle Proposed Guideline & Content Guideline Defined & Validated Functional Knowledge Specified for Encoding Engineered into Production Ongoing Revisions & Eventual Sunset
  12. 13. VISTA Clinical Reminder Package: Designing a Reminder <ul><li>Think of the clinical practice guideline as an algorithm </li></ul><ul><li>Think of the clinical reminder as a decision node in the algorithm </li></ul><ul><li>State in plain English the target population=“denominator” </li></ul><ul><li>State in plain English the action that resolves the reminder=“numerator” </li></ul>
  13. 14. VISTA Clinical Reminders: Findings <ul><li>Drug </li></ul><ul><li>Education topic </li></ul><ul><li>Exam </li></ul><ul><li>Health factor </li></ul><ul><li>Immunization </li></ul><ul><li>Laboratory test </li></ul><ul><li>Mental health instrument </li></ul><ul><li>Orderable item </li></ul><ul><li>Radiology procedure </li></ul><ul><li>Reminder computed finding </li></ul><ul><li>Reminder taxonomy </li></ul><ul><li>Reminder term </li></ul><ul><li>Skin test </li></ul><ul><li>VA drug class </li></ul><ul><li>VA generic </li></ul><ul><li>Vital measurement </li></ul><ul><li>Reminder location list </li></ul>
  14. 15. Boolean Logic: How Findings Are 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”
  15. 16. Importance of Denominators <ul><li>A finding that make a reminder not applicable for a patient, causes that patient to NOT be included in the denominator </li></ul><ul><ul><li>patient is not in the cohort </li></ul></ul><ul><li>A finding that satisfies or resolves the reminder leaves the patient in the denominator. </li></ul>
  16. 17. Two Difference Populations Receiving Pneumovax <ul><li>Age AND Sex OR High Risk </li></ul><ul><ul><li>satisfied by vaccine or refusal </li></ul></ul><ul><li>Age AND Sex OR High Risk AND NOT Refusal </li></ul><ul><ul><li>satisfied by vaccine </li></ul></ul>
  17. 18. Pneumovax Example: Denominators # Patients with Reminder Applicable Reminder Due ------------------- ------------ 1 Pneumovax 33 11 # Patients with Reminder Applicable Reminder Due ------------------- ------------ 2 Pneumovax 19 11 45 patients evaluated
  18. 19. Dialogs: What Is in the Programming Tool Box? <ul><li>Radio buttons </li></ul><ul><ul><li>one choice only from group of responses </li></ul></ul><ul><li>Check boxes </li></ul><ul><ul><li>multiple choices </li></ul></ul><ul><li>Hidden/visible items </li></ul><ul><li>Informational text </li></ul><ul><ul><li>no user entry </li></ul></ul><ul><li>Free text comment boxes </li></ul><ul><ul><li>user entry optional or required </li></ul></ul><ul><li>Forced YES/NO answers </li></ul><ul><li>Hyperlinks </li></ul>
  19. 20. Dialogs – Informatics Ergonomics <ul><li>Bad practices </li></ul><ul><ul><li>Too many mouse clicks per window to process dialog </li></ul></ul><ul><ul><li>Window scrolls down in seemingly unlimited fashion </li></ul></ul><ul><ul><li>Too many embedded windows appear in succession </li></ul></ul><ul><li>Good practices </li></ul><ul><ul><li>Present just enough useful options to user to process </li></ul></ul><ul><ul><li>Allows user to quickly process relevant information and then return main level </li></ul></ul>
  20. 21. Applications <ul><li>Performance improvement </li></ul><ul><li>Decision Support </li></ul><ul><li>Case Finding </li></ul><ul><li>Risk Profile </li></ul><ul><ul><li>PACT </li></ul></ul><ul><ul><li>MOVE </li></ul></ul><ul><li>Standards of Care </li></ul>
  21. 22. Patient Lists <ul><li>New in Clinical Reminders V.2.0 </li></ul><ul><li>Created as part of reminder extracts </li></ul><ul><ul><li>Patient lists can be built independently of extracts </li></ul></ul><ul><li>Uses Clinical Reminders Index </li></ul><ul><ul><li>Fast compiling </li></ul></ul><ul><li>Uses? </li></ul><ul><ul><li>Extracts, Health Summaries, Reminder Reports, Demographics, Patient Mailing Lists </li></ul></ul>
  22. 23. Clinical Reminders – Network Initiative and Governance <ul><li>Oversight of Clinical Reminders is by the Clinical Practice Guidelines committee </li></ul><ul><li>Every reminder must have a service line sponsor (administrative or clinical) </li></ul><ul><li>Every reminder must have an owner who is responsible for the content and for awareness of need for change </li></ul><ul><li>A subcommittee accepts proposals for new reminders, recommends priorities, may help develop prototypes and conduct alpha tests </li></ul><ul><li>An implementation group meets quarterly to roll out reminders or modifications on a uniform basis </li></ul>
  23. 24. Clinical Decision Support <ul><li>Point-of-care decision support </li></ul><ul><ul><li>Provides information to the clinician at the time of medical-decision-making </li></ul></ul><ul><li>More than clinical reminders </li></ul><ul><ul><li>More complex reasoning </li></ul></ul><ul><ul><li>Evidence-base for recommendations </li></ul></ul>
  24. 25. Clinical Decision Support <ul><li>Active systems </li></ul><ul><ul><li>Drug allergy alerts </li></ul></ul><ul><ul><li>Lab alerts </li></ul></ul><ul><ul><li>Abnormal x-ray findings </li></ul></ul><ul><li>Passive Systems </li></ul><ul><ul><li>Problem lists </li></ul></ul><ul><ul><li>Intelligent order sets based on evidence </li></ul></ul><ul><ul><li>Antibiotics listed for specific conditions </li></ul></ul><ul><ul><li>Social history specifics triggers social work consult </li></ul></ul><ul><ul><li>Family history suggests specific testing or screening </li></ul></ul>
  25. 26. Principle 1: If the Information Is Necessary, It Should Be Made Known Before Any Action <ul><li>Allergies should be listed in all med order screens </li></ul><ul><li>Renal function should be visible when ordering nephrotoxic drugs </li></ul><ul><li>formulary drugs for a given condition should be listed first </li></ul>
  26. 27. Principle 2: Intrusiveness is more tolerable when the situation is more complex <ul><li>Knowledge of renal dysfunction as related to co-morbidity of CHF or diabetes </li></ul><ul><li>Knowledge of HIV treatment regimen and drug-drug interactions and adverse drug events </li></ul><ul><li>Controversies over best diagnostic strategies for target condition </li></ul>
  27. 28. The CPR in US Industry: Gartner Group (1999) Functionality 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 Maturity Data Acquired Through Feeder Systems Document Care in Free Text Structured Documentation Spanning Episodes of Care Clinical Workflow Intervention Screening Decision Support Automated Generation Of Pathways and Workflow; Use by Consumers Now Third Generation: The Helper