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E x t r a S lid e s                                   www.CenterForUrbanHealth.org• URL to live application demo• Why not ...
W h y n o t b u ild it in E p ic ?                                         www.CenterForUrbanHealth.org• Logical complexit...
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D is e a s e m a n a g e m e n t        c o mp o ne nt:     www.CenterForUrbanHealth.org
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T r e a t m e n t d a t a in A p p le t :                                 www.CenterForUrbanHealth.org
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Epic as a platform to launch clinical decision support tools

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  • Yiscah
  • Yiscah
  • Bob
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  • Bob. (Make point that we need to go beyond reminders & alerts)
  • Bob  Yiscah
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  • Yiscah, with support from Bob
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  • Bob (clicks get you all highlights)
  • Bob (clicks get you all highlights)
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  • Bob  Yiscah
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  • Yiscah & Bob
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  • Epic as a platform to launch clinical decision support tools

    1. 1. E p ic a s a P la t f o r m L a u n c h in g D e c is io n S u p p o r t T o o ls : www.CenterForUrbanHealth.orgIm p lic a t io n s f o r R e s e a r c h a n d P o p u la t io n QI Yiscah Bracha, MS Minneapolis Medical Research Foundation Robert Grundmeier, MD The Children’s Hospital of PhiladelphiaEpic Research Advisory Council MeetingApril 1, 2009
    2. 2. Im p r o v in g A s t h m a C a r e in a n In t e g r a t e dS a f e t y N e t t h r o u g h a C o m m e r c ia lly A v a ila b le E le c t r o n ic M e d ic a l R e c o r d www.CenterForUrbanHealth.org Prime contractor:  D e n v e r H e a l t h a n d H o s p i t a l A s s o c i a t i o n .Subcontractor:  M i n n e a p o l i s M e d i c a l R e s e a r c h F o u n d a t i o n . Project site: H e n n e p i n C o u n t y M e d ic a l C e n t e r , M p ls M N AHRQ Contract No. H H S A 2 9 0 2 0 0 6 0 0 0 2 0 , T a s k O r d e r N o . 5 Staff – Denver Health and Hospital Association Sherry Eisert, PhD (Director, Health Services Research) Michael (Josh) Durfee (Research Projects Coordinator, Health Services Research) Staff and contractors – Minneapolis Medical Research Foundation Gail Brottman, MD (Chief, Pediatric Pulmonology, HCMC) Kevin Larsen, MD (Chief Medical Informatics Officer, HCMC) Y i s c a h B r a c h a , M S (Research Director, Center for Urban Health) Cherylee Sherry, MPH (Project Manager, Pediatric Research & Advocacy HCMC ) Touch Thouk (Administrative Manager, Center for Urban Health) Angeline Carlson, PhD (Principle, Data Intelligence Inc.) Contributors of Ideas, Information & Effort: Michael Barbouche (University of Wisconsin Medical Foundation); R o b e r t G r u n d m e i e r , M D (Children’s Hospital of Philadelphia); Michael Kahn, MD, PhD (Denver Children’s Hospital) Donald Uden, PharmD (University of Minnesota), Faith Dohman, RN (Hennepin Faculty Associates), Susan Ross, RN (Minnesota Department of Health)
    3. 3. T h e P r o b le m : www.CenterForUrbanHealth.org• Docs practice within an information avalanche• Impossible for any human to keep up
    4. 4. W h a t is a b u s y p h y s ic ia n t o do? www.CenterForUrbanHealth.org
    5. 5. B e c o n f id e n t . www.CenterForUrbanHealth.org
    6. 6. B e c onc e rne d. www.CenterForUrbanHealth.org
    7. 7. B e o b liv io u s . www.CenterForUrbanHealth.org
    8. 8. M e d ic a l in f o r m a t ic s t o t h e re s c ue ! www.CenterForUrbanHealth.org• Provide decision support during care, while doc viewing pt electronic record• Developmental generation beyond:  URL to PDF of guidelines on screen (clinicians don’t go there)  Automatic reminders & alerts (clinicians suffer from “alert fatigue”)
    9. 9. T a s k -b a s e d d e c is io n s upport www.CenterForUrbanHealth.org• Types of support  Which diagnostic tests to use  How to initiate therapy  How to adjust therapy over time• Electronic data:  EHR data automatically populate decision algorithms  Results from algorithms automatically populate patient data record
    10. 10. D e c is io n S u p p o r t & E p ic : C urre nt mode l www.CenterForUrbanHealth.org EpicElectronic decision Electronic decision support for: Information on support for: interface interface engine Individual Patients engine Asthma Which diagnostic imaging tech? Clarity Information for ASTHMA Populations IMAGING REGISTRY REGISTRY Asthma info for Imaging info for Populations Populations
    11. 11. C u rre nt mo d e l a nd d a ta w a r e h o u s in g : www.CenterForUrbanHealth.org EpicElectronic decision Electronic decision support for: Information on support for: interface interface engine Individual Patients engine Asthma Which diagnostic imaging tech? Clarity ASTHMA REGISTRY Information for ASTHMA Asthma info for Populations IMAGING REGISTRY Populations REGISTRY Asthma info for Imaging info for Populations Populations
    12. 12. C u rre nt mo d e l a nd d a ta w a r e h o u s in g : www.CenterForUrbanHealth.org EpicElectronic decision Electronic decision support for: Information on support for: interface interface engine Individual Patients engine Asthma Which diagnostic imaging tech? ations Popul fo for Clarity Imagin g in RY REGIST Information for G IMAGIN Populations ASTHMA REGISTRY Asthma info for Populations
    13. 13. B u ild in g t h e W a r e h o u s e : www.CenterForUrbanHealth.org ations Popul fo for g in Imagin RY REGIST G IMAGIN ASTHMA REGISTRY Asthma info for Populations
    14. 14. Th e Wa re h o u s e D re a m : www.CenterForUrbanHealth.org HIV REGISTRY DIABETES REGISTRY COLONOSCOPY HIV info for Diabetes info for REGISTRY Populations Populations Colonoscopy info PopulationsASTHMA REGISTRY IMAGING REGISTRY STENT REGISTRY Asthma info for Imaging info for Stent info for Populations Populations Populations
    15. 15. T h e a n a ly t ic d r e a m : www.CenterForUrbanHealth.org HIV REGISTRY DIABETES REGISTRY COLONOSCOPY HIV info for Diabetes info for REGISTRY Populations Populations Colonoscopy info PopulationsASTHMA REGISTRY IMAGING REGISTRY STENT REGISTRY Asthma info for Imaging info for Stent info for Populations Populations Populations
    16. 16. O u r a n a ly t ic r e a lit y : www.CenterForUrbanHealth.org WHY? RY I ST R EG r ES fo T o BE inf ns IA es io D e t la t ab u Di Pop HI V RE GIS HIV TR Y Po info pu fo r la t ion s Ima P in IMA op g info g ula GIN tio for GR ns EG IST ASTHMA REGISTRY RY Asthma info for Populations
    17. 17. T h e p r o b le m w it h t h e c u r r e n t m o d e l: www.CenterForUrbanHealth.org EpicElectronic decision Electronic decision support for: Information on support for: interface interface engine Individual Patients engine Asthma Which diagnostic imaging tech? Clarity Information for ASTHMA Populations IMAGING REGISTRY REGISTRY Asthma info for Imaging info for Populations Populations
    18. 18. H a r d t o b u i l d …. www.CenterForUrbanHealth.org EpicElectronic decision Electronic decision support for: interface Information on interface support for: Individual Patients Asthma engine engine Which diagnostic imaging tech? Clarity Information for ASTHMA Populations IMAGING REGISTRY REGISTRY Asthma info for Imaging info for Populations Populations H a r d t o m a i n t a i n ….
    19. 19. S o m u c h e ffo rt fo c u s e d o n in t e r f a c e *: www.CenterForUrbanHealth.org Epic Electronic decision interface Information on interface Individual Patients Electronic decision support engine engine support for: for: Asthma Which diagnostic imaging tech? Clarity ASTHMA Information for IMAGING REGISTRY Populations REGISTRY Asthma info Imaging info for for Populations Populations* Building complex decision support within Epic isjust as much effort as interface
    20. 20. N o re s o u rc e s fo r d a ta mg mt: www.CenterForUrbanHealth.org R Y I ST EG SR fo r TE o BE inf ns IA es io D e t la t ab u Di Pop HI V RE GIS HIV TR Y Po info pu fo r la t ion s Ima P in IMA op g info g ula GIN tio for GR ns EG IST ASTHMA REGISTRY RY Asthma info for Populations
    21. 21. A lo w -c o s t a lt e r n a t iv e t o c u r r e n t m o d e l: www.CenterForUrbanHealth.org1. Support provided by external applet2. Applet invoked through Intranet hyperlink3. Hyperlink opens applet in new window4. Applet provides decision support5. Applet saves data to its own database6. User returns to Epic
    22. 22. E x a m p le : H IT A s t h m a P r o je c t www.CenterForUrbanHealth.org • Java Applet, called e-AAP, provides administrative & clinical decision support* • Invoked from Epic:  Create new Asthma Action Plan (procedure order)  View existing Asthma Action Plan  from Order Results  from asthma detail in problem list • Invocation sends @ 20 encrypted live Epic data elements to applet through URL • New asthma data saved to SQL server database* Support based on NAEPP-3 Guidelines, August 2007
    23. 23. e -A A P C lin ic a l D e c is io n S u p p o rt: www.CenterForUrbanHealth.org• For new asthma patients  Assess severity  Initiate treatment given age & severity• For currently treated asthma patients  Assess control  Modify treatment given age, control, current treatment, pt adherence  Step-based treatment  Supports user in calculating current step
    24. 24. e -A A P A d m in is t r a t iv e S u p p o rt: www.CenterForUrbanHealth.org• Document severity and/or control• Generate printable asthma action plan  Patient-specific  Patient-friendly (tested for literacy)  Records all JHACO-required data• Document production of AAP• Generate:  Template of asthma progress note that user can paste into patient’s chart  List of selected meds & instructions for use
    25. 25. La unc he d a s proc e dure o r d e r in E p ic : www.CenterForUrbanHealth.org Clicking here launches applet.. Highlighted data transferred in URL.
    26. 26. L iv e d a t a p a s s e d t o A p p le t in U R L : www.CenterForUrbanHealth.org Web link defined by print group Launches web browser with “garbled” pt data in URL
    27. 27. L in k in g c o d e r e q u ir e d : www.CenterForUrbanHealth.org Cache routine: Cache global:Delivers hyperlink Provides configuration
    28. 28. 1s t s c r e e n u s e r s e e s : www.CenterForUrbanHealth.org User automatically logged in; audit trail initiated; patient data transferred directly from Epic.
    29. 29. A p p le t g e n e r a t e s d a t a . Whe re d o the y g o ? www.CenterForUrbanHealth.org • Individual patient data:  Saved to underlying database  Applet generates asthma progress note that doc can paste into record • Population data:  All Applet data stored to underlying registry  Clarity data extracted & merged with Applet data in registry
    30. 30. In d iv id u a l p t d a t a : www.CenterForUrbanHealth.org Patient & user context thru URL EpicASTHMA APPLET Saved to SQL Information for server database Asthma info for Individual Patients Individual (registry) patients Clarity Information for ASTHMA Populations REGISTRY Asthma info for Populations
    31. 31. P o p u la t io n d a t a : www.CenterForUrbanHealth.org Patient & user context thru URL EpicASTHMA APPLET Relevant data Information for extracted from Asthma info for Individual Patients Individual Clarity, merged patients with Applet data in registry Clarity Information for ASTHMA Populations REGISTRY Asthma info for Populations
    32. 32. D e c is io n S u p p o r t & E p ic : A lt e r n a t iv e m o d e l www.CenterForUrbanHealth.org Patient & user context EpicASTHMA APPLET Information for Asthma info for Individual Patients Individual patients Clarity Information for ASTHMA Populations REGISTRY Asthma info for Populations
    33. 33. H o w a r e a p p le t d a t a r e t r ie v e d ? www.CenterForUrbanHealth.org• Individual patient data:  Previously created e-AAPs easily found & reviewed from Applet.  If user pasted asthma progress note, available in EHR.• Population data:  Extracted from underlying registry  Registry populated with Applet data and relevant data from Clarity
    34. 34. T o v ie w in d iv id u a l p t d a t a : www.CenterForUrbanHealth.org To see previous AAPs, user clicks here
    35. 35. P o p -u p a p p e a r s : www.CenterForUrbanHealth.org User clicks on desired PDF
    36. 36. H y p e r lin k o p e n s a p p le t : www.CenterForUrbanHealth.org
    37. 37. T o v ie w p o p u la t io n d a t a : www.CenterForUrbanHealth.org Patient & user context thru URL EpicASTHMA APPLET Information for Asthma info for Individual Patients Individual patients Clarity Information for ASTHMA Populations REGISTRY Asthma info for Populations
    38. 38. M u lt ip le s u c h r e g is t r ie s p o s s ib le : www.CenterForUrbanHealth.org Patient & user Patient & user context context EpicASTHMA APPLET Imaging Applet Information for Imaging info for Asthma info for Individual Patients Individual Individual Patients patients Clarity Information for ASTHMA Populations Imaging REGISTRY Registry Asthma info for Populations Imaging info for Populations
    39. 39. A lt e r n a t e m o d e l a n d d a t a w a r e h o u s in g : www.CenterForUrbanHealth.org Patient & user Patient & user context context EpicASTHMA APPLET Imaging Applet Information for Imaging info for Asthma info for Individual Patients Individual Individual Patients patients Clarity ASTHMA Information for ASTHMAREGISTRY Populations Imaging REGISTRY Registry Asthma info for Asthma infoPopulations for Populations HIV info for Populations
    40. 40. A lt e r n a t e m o d e l a n d d a t a w a r e h o u s in g : www.CenterForUrbanHealth.org Patient & user Patient & user context context Local EHRASTHMA APPLET Imaging Applet HIV APPLET Information for HIV info for Asthma info for Individual Patients Individual Individual Patients patients G IN Y EHR Data AG ISTR for IM G fo s Repository RE g in tion n a gi u l a Im Pop Information for ASTHMA Populations REGISTRY Asthma info for Populations
    41. 41. N o m a jo r in t e r f a c e t o b u ild o r m a in t a in ! www.CenterForUrbanHealth.org Patient & user Patient & user context context Local EHRASTHMA APPLET Imaging Applet interface Information for interface HIV info for Asthma info for Individual Patients Individual engine engine Individual Patients patients EHR Data Repository ASTHMA Imaging Information for REGISTRY Registry Populations Asthma info for Populations Imaging info for Populations
    42. 42. M a yb e w e c a n ! www.CenterForUrbanHealth.org HIV REGISTRY DIABETES REGISTRY COLONOSCOPY HIV info for Diabetes info for REGISTRY Populations Populations Colonoscopy info PopulationsASTHMA REGISTRY IMAGING REGISTRY STENT REGISTRY Asthma info for Imaging info for Stent info for Populations Populations Populations
    43. 43. Project supported by the Agency for Health Research and Quality. Contract No. HHSA290200600020, Task Order No. 5 www.CenterForUrbanHealth.org The findings and conclusions are the responsibility of the authors, not the AHRQ. Q u e s t io n s ?Clinical informatics at HCMC: Asthma details about applet: Dr. Kevin Larsen Dr. Gail Brottman (kevin.larsen@hcmed.org) (brott004@umn.edu) Invoking applet from Epic: Project direction & all other Qs: Dr. Robert Grundmeier Yiscah Bracha, MS (grundmeier@email.chop.edu) (shate001@umn.edu)
    44. 44. E x t r a S lid e s www.CenterForUrbanHealth.org• URL to live application demo• Why not build in Epic  Logical complexity  Volume of clinical material
    45. 45. W h y n o t b u ild it in E p ic ? www.CenterForUrbanHealth.org• Logical complexity  Existence of relevant data  Validity of relevant data  User choices  Patient age, adherence• Volume of up-to-date clinical info required  @37k med combos in guidelines  Guidelines contain @ 2% of all possibilities
    46. 46. e -A A P : H ig h -le v e l p r o c e s s 2. Identify patient f lo w : 3. Peak flow, triggers, weight. 4. Classify severity or assess control . 1. Classify Severity Live data transfer Live data transfer www.CenterForUrbanHealth.org Age 0-4 Age 5-11 Age 12+ from EHR & registry 4a. Existing record of severity 4b. No existing record of Registry & user (From EHR or registry , if exists ) severity Lookup in registry (From registry, if exists ) entry 2. Verify Level Of Severity 1. Authenticate 1. Assess Control BEGIN user Choose next Age 0-4 Age 5-11 Age 12+ step. Live data transfer from EHR No existing Log in by user & treatment record Existing treatment record system check. 3. Identify current Not 3. Validate meds in asthma meds validated record Validated . Return user to EHR system Closure END Return user to operating system Disease mgmt 4b. Current meds 4a. Current meds do not map to map to component recognized plan recognized plan 4. Choose next step. 1. Choose Treatment Plan New values of variables and PDF of AAP to registry Saves. New values of variables and PDF of AAP to registry 2. Choose daily controllers HIT Asthma.Model workflow for an outpatient asthma visit 3. Choose quick relievers Consistent with recommendations in 2007 NEAPP Guidelines. 2. View/Print Asthma Action Plan. 4. Choose burst meds EHR-compatible version 1. Next Visit Info Selected meds (for exacerbations) Desktop version Visit Summary
    47. 47. D is e a s e m a n a g e m e n t c o mp o ne nt: www.CenterForUrbanHealth.org
    48. 48. T r e a t m e n t d e c is io n s in g u id e lin e s : www.CenterForUrbanHealth.org
    49. 49. www.CenterForUrbanHealth.org
    50. 50. T r e a t m e n t d a t a in A p p le t : www.CenterForUrbanHealth.org
    51. 51. www.CenterForUrbanHealth.org
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