MN HSR Conference March 3, 2009 Bringing Clinical Guidelines to the Point of Care with HIT  Intelligent Designers & Adapti...
The issue: <ul><li>Medical care delivered ≠ medical care recommended in evidence-based guidelines </li></ul><ul><li>Is thi...
Reasons identified empirically: <ul><li>Information overload </li></ul><ul><ul><li>Too many guidelines </li></ul></ul><ul>...
Reason 1:  Info overload <ul><li>Assumptions :  Docs want to use guidelines, but don’t know what they are </li></ul><ul><u...
Reason 2. Limited resources <ul><li>Assumptions:   Docs want to use guidelines, know what they are, but cannot implement t...
Reason 3. Not useful or relevant <ul><li>Assumptions : Contested! </li></ul><ul><ul><li>Epistemic legitimacy:   Biomedicin...
Using HIT as soln to info overload: Experience: HIT Tool: “ The final frontier” Modifying therapy over time Initiating the...
A Vision of the Future <ul><li>Individual practice sites will have up-to-date electronic decision support tools. </li></ul...
(assumptions behind the vision) <ul><li>Material resources are adequate </li></ul><ul><li>Contests over legitimacy & autho...
Current HIT work leading to vision: <ul><li>Intelligent Designers </li></ul><ul><ul><li>Practiced by subgroup in academic ...
Intelligent Designers <ul><li>Situated at:   Source of guidelines </li></ul><ul><li>Looking towards:   Universe of practit...
Adaptive Agents Healthcare product marketplace Communication mechanisms: Relationships w. EHR vendors Use whatever is avai...
Properties of developed tools: Current Efforts By: Depends on installation Intended to be minor Local  Use Effort Depends ...
HIT Asthma Project: An Adaptive Agent Example Project supported by the  Agency for Health Research and Quality .  Contract...
HIT Asthma Tool Supports: <ul><li>Assessment & documentation: </li></ul><ul><ul><li>Asthma severity for untreated patients...
 
HIT Asthma Tool: Properties <ul><li>Coding language:   Java applet </li></ul><ul><li>Installation mechanism:   Hyperlink o...
EHR Data Repository Information for Populations Local EHR Information for Individual Patients HIT Asthma Data Model for EHR
EHR Data Repository Information for Populations Local EHR Information for Individual Patients ASTHMA APPLET   Asthma info ...
EHR Data Repository Information for Populations Local EHR Information for Individual Patients ASTHMA APPLET   Asthma info ...
EHR Data Repository Information for Populations Local EHR Information for Individual Patients ASTHMA CIG*   Asthma info fo...
Both designers & adaptive agents: <ul><li>Face challenges: </li></ul><ul><ul><li>Converting natural language narrative int...
Proposed Solutions vs. Adaptations: Adaptation:  Contest or accept  epistemic assumptions. Proposed Solution: Standards Co...
Conclusions: Role of HIT <ul><li>HIT can encourage guideline-based care </li></ul><ul><ul><li>Addresses information overlo...
Predicted response to challenges: <ul><li>Dispersed, creative, adaptive efforts will continue: </li></ul><ul><ul><li>If re...
Thank You For more information: Yiscah Bracha.  [email_address]
 
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Bringing Clinical Guidelines to the Point of Care with HIT

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Compares two approaches for bringing up-to-date electronic decision support to the point of care, for docs using electronic health records systems. One approach taken by "intelligent designers", the other emerging from collective actions of "adaptive agents". Presented at MN HSR conference, Mar 09.

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Bringing Clinical Guidelines to the Point of Care with HIT

  1. 1. MN HSR Conference March 3, 2009 Bringing Clinical Guidelines to the Point of Care with HIT Intelligent Designers & Adaptive Agents Compared Yiscah Bracha, MS Minneapolis Medical Research Foundation Gail Brottman, MD Hennepin County Medical Center Kevin Larsen, MD Hennepin County Medical Center Robert Grundmeier The Children’s Hospital of Philadelphia Angeline Carlson, PhD Data Intelligence, Inc.
  2. 2. The issue: <ul><li>Medical care delivered ≠ medical care recommended in evidence-based guidelines </li></ul><ul><li>Is this a “problem”? </li></ul><ul><ul><li>Health policy: It is a problem. Docs not following guidelines, pts don’t get best care. </li></ul></ul><ul><ul><li>Docs: Construction as “problem” depends on reason for differences </li></ul></ul>
  3. 3. Reasons identified empirically: <ul><li>Information overload </li></ul><ul><ul><li>Too many guidelines </li></ul></ul><ul><ul><li>Unaware of specific recommendation </li></ul></ul><ul><ul><li>Need info in the moment of delivering care </li></ul></ul><ul><li>Limited resources for implementation. </li></ul><ul><ul><li>Docs don’t have time or staff </li></ul></ul><ul><ul><li>No reimbursement </li></ul></ul><ul><li>Recommendations not useful or relevant </li></ul>
  4. 4. Reason 1: Info overload <ul><li>Assumptions : Docs want to use guidelines, but don’t know what they are </li></ul><ul><ul><li>Source of the problem: Limits to human cognitive capacity </li></ul></ul><ul><ul><li>Solution to the problem: Use information technology to enhance human cognitive capacity </li></ul></ul>
  5. 5. Reason 2. Limited resources <ul><li>Assumptions: Docs want to use guidelines, know what they are, but cannot implement them with existing resources (e.g. time, staff) </li></ul><ul><ul><li>Source of the problem: Inadequate material resources </li></ul></ul><ul><ul><li>Solution to the problem: Change reimbursement systems. </li></ul></ul>
  6. 6. Reason 3. Not useful or relevant <ul><li>Assumptions : Contested! </li></ul><ul><ul><li>Epistemic legitimacy: Biomedicine vs. epidemiology </li></ul></ul><ul><ul><li>Source of authority: Front-line clinicians vs. university-based researchers </li></ul></ul><ul><ul><li>Credible “evidence”: Clinical practice vs. controlled experiments </li></ul></ul><ul><li>Problem? Contested! </li></ul>
  7. 7. Using HIT as soln to info overload: Experience: HIT Tool: “ The final frontier” Modifying therapy over time Initiating therapy Tools exist. Varied effect on doc behavior. Pt outcomes unknown Diagnostic tests to use Electronic clinical decision support tools for: “ Alert fatigue”. Pop-up reminders and alerts Clinicians don’t access it PDF of guideline on screen
  8. 8. A Vision of the Future <ul><li>Individual practice sites will have up-to-date electronic decision support tools. </li></ul><ul><li>Tools based on guidelines’ recommendations </li></ul><ul><li>Recommendations based on evidence </li></ul><ul><li>Tools integrated into EHR systems. </li></ul><ul><li>Tool updates disseminated electronically </li></ul>
  9. 9. (assumptions behind the vision) <ul><li>Material resources are adequate </li></ul><ul><li>Contests over legitimacy & authority resolved. </li></ul>
  10. 10. Current HIT work leading to vision: <ul><li>Intelligent Designers </li></ul><ul><ul><li>Practiced by subgroup in academic medical informatics community </li></ul></ul><ul><ul><li>Supported by govt grants & contracts to universities </li></ul></ul><ul><ul><li>Current efforts guided by vision of future </li></ul></ul><ul><li>Adaptive Agents </li></ul><ul><ul><li>Practiced by vendors & their healthcare customers </li></ul></ul><ul><ul><li>Supported by market forces </li></ul></ul><ul><ul><li>Current efforts guided by immediate needs </li></ul></ul>
  11. 11. Intelligent Designers <ul><li>Situated at: Source of guidelines </li></ul><ul><li>Looking towards: Universe of practitioners </li></ul><ul><li>Concept: Convert guidelines into executable code; disseminate code to practice sites. </li></ul><ul><li>Implementation: Standards (to help local implementation) adopted by: </li></ul><ul><ul><li>Guideline developers </li></ul></ul><ul><ul><li>EHR systems </li></ul></ul><ul><ul><li>Guideline coders. </li></ul></ul><ul><li>Information channels: Academic conferences & peer-reviewed journals </li></ul>
  12. 12. Adaptive Agents Healthcare product marketplace Communication mechanisms: Relationships w. EHR vendors Use whatever is available Implementation concept: Develop tools that meet local needs Find tools that meet local needs Development concept: Universe of potential sites Universe of potential tools Looking towards: Tool Developers Practitioner sites Situated at:
  13. 13. Properties of developed tools: Current Efforts By: Depends on installation Intended to be minor Local Use Effort Depends on local environment Extensive Local Install Effort Modest Extensive. Development effort Narrow – single clinical condition or issue Broad – all guidelines thru entire lifecycle Scope Support - clinical decision making & administrative documentation. Language – can represent guidelines as executable code Content Adaptive agents Intelligent Designers Properties: Single tool
  14. 14. HIT Asthma Project: An Adaptive Agent Example Project supported by the Agency for Health Research and Quality . Contract No. HHSA290200600020 Task Order No. 5 The findings and conclusions are the responsibility of the authors, not the AHRQ.
  15. 15. HIT Asthma Tool Supports: <ul><li>Assessment & documentation: </li></ul><ul><ul><li>Asthma severity for untreated patients </li></ul></ul><ul><ul><li>Asthma control for treated patients </li></ul></ul><ul><li>Selection of age-specific therapy: </li></ul><ul><ul><li>Initial therapy for untreated patients </li></ul></ul><ul><ul><li>Modified therapy for treated patients </li></ul></ul><ul><li>Production of: </li></ul><ul><ul><li>Asthma progress note for patient’s chart </li></ul></ul><ul><ul><li>List of selected meds & instructions for use </li></ul></ul><ul><ul><li>Patient-friendly Asthma Action Plan. </li></ul></ul>
  16. 17. HIT Asthma Tool: Properties <ul><li>Coding language: Java applet </li></ul><ul><li>Installation mechanism: Hyperlink opens applet on delivery site’s Intranet. </li></ul><ul><li>System  tool data exchange : Encrypted data in URL of hyperlink </li></ul><ul><li>Tool  system data exchange: </li></ul><ul><ul><li>Individual patient record : Doc opens applet in read-only mode to get asthma-specific hx. </li></ul></ul><ul><ul><li>Aggregate records: Merge data extracted from EHR & data generated by applet </li></ul></ul>
  17. 18. EHR Data Repository Information for Populations Local EHR Information for Individual Patients HIT Asthma Data Model for EHR
  18. 19. EHR Data Repository Information for Populations Local EHR Information for Individual Patients ASTHMA APPLET Asthma info for Individual patients ASTHMA REGISTRY Asthma info for Populations Asthma Summary Read-only invocation tool Patient & user context HIT Asthma Data Exchange Model
  19. 20. EHR Data Repository Information for Populations Local EHR Information for Individual Patients ASTHMA APPLET Asthma info for Individual patients HIV APPLET HIV info for Individual Patients ASTHMA REGISTRY Asthma info for Populations HIV REGISTRY HIV info for Populations Asthma Summary Read-only invocation tool Read-only invocation tool HIV Summary Patient & user context Patient & user context Evolutionary Emergence:
  20. 21. EHR Data Repository Information for Populations Local EHR Information for Individual Patients ASTHMA CIG* Asthma info for Individual patients HIV CIG* HIV info for Individual Patients ASTHMA REGISTRY Asthma info for Populations HIV REGISTRY HIV info for Populations Intelligent Design * Computer-Interpretable Guideline interface engine interface engine
  21. 22. Both designers & adaptive agents: <ul><li>Face challenges: </li></ul><ul><ul><li>Converting natural language narrative into computer-executable code </li></ul></ul><ul><ul><li>Implementing uniform code into widely disparate local systems </li></ul></ul><ul><li>Respond to challenges: </li></ul><ul><ul><li>Designers: Design global solutions </li></ul></ul><ul><ul><li>Adaptive agents: Locally adapt </li></ul></ul>
  22. 23. Proposed Solutions vs. Adaptations: Adaptation: Contest or accept epistemic assumptions. Proposed Solution: Standards Conversion challenge Adaptation: Whatever works Proposed Solution: Standards Implementation challenge Meet immediate needs Convert narratives to CIGs, disseminate to local sites electronically Goal Sites  products; Product developers  sites Disparate local delivery sites View Healthcare delivery sites & vendors meeting their needs Guideline developers & researchers Perspective Adaptive Agents Intelligent Designers
  23. 24. Conclusions: Role of HIT <ul><li>HIT can encourage guideline-based care </li></ul><ul><ul><li>Addresses information overload </li></ul></ul><ul><ul><li>Does not address: </li></ul></ul><ul><ul><ul><li>Material resources </li></ul></ul></ul><ul><ul><ul><li>Contested assumptions </li></ul></ul></ul>
  24. 25. Predicted response to challenges: <ul><li>Dispersed, creative, adaptive efforts will continue: </li></ul><ul><ul><li>If regulatory & reimbursement systems create needs </li></ul></ul><ul><ul><li>Successful adaptations will spread </li></ul></ul><ul><li>Global design efforts will continue </li></ul><ul><ul><li>If grant funding continues </li></ul></ul><ul><ul><ul><li>Convergence towards standard representation language </li></ul></ul></ul><ul><ul><ul><li>No convergence towards standard implementation </li></ul></ul></ul><ul><li>Standards: May assist locally adaptive agents </li></ul><ul><li>Vision will manifest (if at all) by evolution, not design </li></ul><ul><ul><li>Loosely coupled data exchange </li></ul></ul><ul><ul><li>No one in control </li></ul></ul><ul><ul><li>Messy, but will bring more guidelines to more points of care. </li></ul></ul>
  25. 26. Thank You For more information: Yiscah Bracha. [email_address]
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