AHRQ Annual Meeting 09SEP08 HIT Asthma a tale of woe and enlightenment Yiscah Bracha, M.S. [email_address]
Project Objective: <ul><li>Demonstrate use of HIT to improve ambulatory asthma care </li></ul><ul><li>Two existing technol...
What we knew: <ul><li>For asthma, IAAP beats Epic in user and patient friendliness </li></ul><ul><li>Difficult for Epic us...
What we wanted to propose: <ul><li>Make IAAP available from within Epic-driven workflow </li></ul><ul><ul><li>Brings guide...
<ul><li>Existing IAAP based on guidelines released in 2002 </li></ul><ul><li>2007 guidelines soon to be released </li></ul...
What we actually proposed: <ul><li>Update  IAAP to be consistent with 2007 guidelines </li></ul><ul><li>Make  updated  IAA...
Expected challenges <ul><li>Accessing IAAP from Epic </li></ul><ul><ul><li>Pushes boundaries both technically & organizati...
3 months after project inception: <ul><li>IAAP-EHR interface: </li></ul><ul><ul><li>Technical boundaries identified </li><...
<ul><li>“It will be simple to update the existing IAAP to make it consistent with the new guidelines” </li></ul>Famous las...
Oops: <ul><li>Original IAAP contained: </li></ul><ul><ul><li>Out-of-date, unsupported version of Java </li></ul></ul><ul><...
The struggle: <ul><li>Clinicians try to convert guidelines directly into screens: </li></ul><ul><ul><li>They get trapped i...
Some concerns: <ul><li>Close scrutiny of guidelines reveals: </li></ul><ul><ul><li>Ambiguous and/or internally inconsisten...
More concerns: <ul><li>Even with close scrutiny, no answers to front-line clinical questions: </li></ul><ul><ul><li>What s...
And more struggles: <ul><li>Enormous effort required to communicate needs to software development company </li></ul><ul><l...
The tale of woe… <ul><li>We are failing at our most trivial task </li></ul><ul><ul><li>AHRQ will give up on us </li></ul><...
The tale of enlightenment: <ul><li>Bob* (unexpectedly) says: </li></ul><ul><ul><li>This is  very  interesting!  </li></ul>...
From:   Expert Panel Guidelines To: Electronic Clinical Decision Support:
What are the Primary Challenges? <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul>...
The Primary Challenges <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><li>Differ...
The human mind: <ul><li>Do I know this patient? </li></ul><ul><li>Is the patient already being treated? How aggressively? ...
The software mind…
More peaks into the software mind…
Human vs software “minds”: No tolerance for ambiguity Can tolerate ambiguity Precise meaning of words required Approximate...
The negotiation challenge: <ul><li>Clinicians must: </li></ul><ul><ul><li>Clearly explicate their thought processes </li><...
Software Development Challenges <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><...
From this….
 
…  to this
 
Combinatorial volume <ul><li>> 23,000 possible combinations of </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Step <...
Challenges posed by volume: <ul><li>Effort required to capture all possibilities </li></ul><ul><li>Likelihood of errors & ...
Software Development Challenges <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><...
Different words for same ideas: I thought my child would die ED visit Exacerbation My top number on the meter What you can...
Because of differing vocabulary: <ul><li>Text in guidelines doesn’t work on screen </li></ul><ul><ul><li>Guidelines:  “Ste...
Because of differing vocabulary: <ul><li>On-screen text for clinical users doesn’t work in asthma action plan. </li></ul><...
The challenge posed by vocabulary: <ul><li>Anticipating who the user/consumer is </li></ul><ul><li>Testing vocabulary with...
Some preliminary conclusions
Policy Qs the process reveals: <ul><li>At what point in guideline development should “codification” be considered? </li></...
Addl policy Qs the process reveals: <ul><li>What should the “update” process be? </li></ul><ul><ul><li>Reconvene expert pa...
Sustainability questions <ul><li>Who bears the costs of development? </li></ul><ul><ul><li>Original guidelines </li></ul><...
Our work continues: <ul><li>Conveying user requirements to software developers, where requirements include: </li></ul><ul>...
And: <ul><li>Sharing process & results with all of you! </li></ul>
Improving Asthma Care in an Integrated Safety Net through a Commercially Available Electronic Medical Record <ul><li>Prime...
…  and now, Bob Mayes our Task Order Officer
Upcoming SlideShare
Loading in...5
×

HIT Asthma: A Tale of Woe and Enlightenment

381

Published on

Describes challenges encountered in converting clinical practice guidelines for asthma into electronic decision support software. Presented at annual mtg of AHRQ, Sept 08.

Published in: Health & Medicine, Technology
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
381
On Slideshare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
8
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

HIT Asthma: A Tale of Woe and Enlightenment

  1. 1. AHRQ Annual Meeting 09SEP08 HIT Asthma a tale of woe and enlightenment Yiscah Bracha, M.S. [email_address]
  2. 2. Project Objective: <ul><li>Demonstrate use of HIT to improve ambulatory asthma care </li></ul><ul><li>Two existing technologies: </li></ul><ul><ul><li>Interactive Asthma Action Plan (IAAP) (developed by MN Dept of Health) </li></ul></ul><ul><ul><li>Commercially available electronic health record (EHR) (EpicSystems Inc.) </li></ul></ul>
  3. 3. What we knew: <ul><li>For asthma, IAAP beats Epic in user and patient friendliness </li></ul><ul><li>Difficult for Epic user to get to IAAP </li></ul><ul><li>Untapped potential to use EHR data to support QI </li></ul>
  4. 4. What we wanted to propose: <ul><li>Make IAAP available from within Epic-driven workflow </li></ul><ul><ul><li>Brings guidelines to the point of care </li></ul></ul><ul><li>Use IAAP database as asthma registry </li></ul><ul><ul><li>Evaluate effect of QI initiatives </li></ul></ul><ul><ul><li>Identify at-risk patients </li></ul></ul><ul><ul><li>Generate reports required by external agencies </li></ul></ul>
  5. 5. <ul><li>Existing IAAP based on guidelines released in 2002 </li></ul><ul><li>2007 guidelines soon to be released </li></ul><ul><li>Our project would link the EHR system to a soon-to-be-obsolete tool </li></ul>One small problem…
  6. 6. What we actually proposed: <ul><li>Update IAAP to be consistent with 2007 guidelines </li></ul><ul><li>Make updated IAAP available from within Epic-driven workflow </li></ul><ul><ul><li>Brings new guidelines to the point of care </li></ul></ul><ul><li>Use IAAP database as asthma registry </li></ul><ul><ul><li>Evaluate effect of QI initiatives </li></ul></ul><ul><ul><li>Identify at-risk patients </li></ul></ul><ul><ul><li>Generate reports required by external agencies </li></ul></ul>
  7. 7. Expected challenges <ul><li>Accessing IAAP from Epic </li></ul><ul><ul><li>Pushes boundaries both technically & organizationally </li></ul></ul><ul><li>Creating & using asthma registry </li></ul><ul><ul><li>Technology well-understood; organizational barriers to readiness </li></ul></ul><ul><li>Updating IAAP </li></ul><ul><ul><li>Trivial technically; no impact organizationally </li></ul></ul>
  8. 8. 3 months after project inception: <ul><li>IAAP-EHR interface: </li></ul><ul><ul><li>Technical boundaries identified </li></ul></ul><ul><ul><li>Organization is ready within those boundaries </li></ul></ul><ul><li>Registry </li></ul><ul><ul><li>Organizational barriers quickly overcome </li></ul></ul><ul><ul><li>Demanding to establish what fields to pull, but a well-understood task. </li></ul></ul><ul><li>Update IAAP …. </li></ul>
  9. 9. <ul><li>“It will be simple to update the existing IAAP to make it consistent with the new guidelines” </li></ul>Famous last words:
  10. 10. Oops: <ul><li>Original IAAP contained: </li></ul><ul><ul><li>Out-of-date, unsupported version of Java </li></ul></ul><ul><ul><li>Database not designed to support analysis </li></ul></ul><ul><ul><li>List of meds not designed to be updated </li></ul></ul><ul><li>“Update” of any kind not possible </li></ul><ul><ul><li>Radical shift in perspective from 2002 to 2007 </li></ul></ul><ul><ul><ul><li>FROM: Treating acute symptoms </li></ul></ul></ul><ul><ul><ul><li>TO: Managing chronic disease </li></ul></ul></ul>
  11. 11. The struggle: <ul><li>Clinicians try to convert guidelines directly into screens: </li></ul><ul><ul><li>They get trapped in logical circles from which they cannot escape </li></ul></ul><ul><li>Analytically-minded Project Director tries to display their thinking in flow diagrams </li></ul><ul><ul><li>Clinicians can’t follow the diagrams </li></ul></ul><ul><li>Many expressions of frustration exchanged! </li></ul>
  12. 12. Some concerns: <ul><li>Close scrutiny of guidelines reveals: </li></ul><ul><ul><li>Ambiguous and/or internally inconsistent recommendations: </li></ul></ul><ul><ul><ul><li>Inadequate dosing instructions for young children </li></ul></ul></ul><ul><ul><ul><li>Recommendations for formulations not available commercially </li></ul></ul></ul><ul><ul><li>Recommendations for off-label uses of drugs </li></ul></ul><ul><ul><ul><li>Drugs for young children not approved by FDA </li></ul></ul></ul>
  13. 13. More concerns: <ul><li>Even with close scrutiny, no answers to front-line clinical questions: </li></ul><ul><ul><li>What should the dosing instructions be in the “red zone” of the asthma action plan? </li></ul></ul><ul><ul><li>How can we determine the current treatment step for a new patient who is already receiving asthma care? </li></ul></ul>
  14. 14. And more struggles: <ul><li>Enormous effort required to communicate needs to software development company </li></ul><ul><li>Even with that effort, still uncertainty that they really understand what’s required </li></ul>
  15. 15. The tale of woe… <ul><li>We are failing at our most trivial task </li></ul><ul><ul><li>AHRQ will give up on us </li></ul></ul><ul><ul><li>We will disappoint the users whose expectations we have raised </li></ul></ul><ul><li>We have over-extended ourselves and our budget trying to cope with this </li></ul><ul><li>If we succeed, who will be responsible for harm that may arise because we delivered vague guidelines to the point of care? </li></ul>
  16. 16. The tale of enlightenment: <ul><li>Bob* (unexpectedly) says: </li></ul><ul><ul><li>This is very interesting! </li></ul></ul><ul><ul><li>Let’s reduce your anxiety … there are lots of ways to make lemonade here </li></ul></ul><ul><ul><li>We have an agency interest in alternative ways to disseminate guidelines </li></ul></ul><ul><ul><ul><li>Document these issues </li></ul></ul></ul><ul><ul><ul><li>Analyze them </li></ul></ul></ul><ul><ul><ul><li>Make recommendations to future expert panels </li></ul></ul></ul>* Bob Mayes, our AHRQ Task Order Officer
  17. 17. From: Expert Panel Guidelines To: Electronic Clinical Decision Support:
  18. 18. What are the Primary Challenges? <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><li>Different languages used by: </li></ul><ul><ul><li>Academic experts </li></ul></ul><ul><ul><li>Front-line clinicians with limited time </li></ul></ul><ul><ul><li>Patients responsible for self-management </li></ul></ul>
  19. 19. The Primary Challenges <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><li>Different languages used by: </li></ul><ul><ul><li>Academic experts </li></ul></ul><ul><ul><li>Front-line clinicians with limited time </li></ul></ul><ul><ul><li>Patients responsible for self-management </li></ul></ul>
  20. 20. The human mind: <ul><li>Do I know this patient? </li></ul><ul><li>Is the patient already being treated? How aggressively? Is the patient being treated the right way? </li></ul><ul><li>How is the patient doing? Is the therapy adequate? Is the patient using the therapy as prescribed? </li></ul><ul><li>What might happen if I changed the dose? </li></ul>
  21. 21. The software mind…
  22. 22. More peaks into the software mind…
  23. 23. Human vs software “minds”: No tolerance for ambiguity Can tolerate ambiguity Precise meaning of words required Approximate meanings of words OK Counterfactuals not possible Counterfactuals entertained Linear, step-by-step “ Gestalt” Series of nested and explicit if-then statements Fast, unarticulated thought processes Software Humans
  24. 24. The negotiation challenge: <ul><li>Clinicians must: </li></ul><ul><ul><li>Clearly explicate their thought processes </li></ul></ul><ul><ul><li>Force themselves to use precise vocabulary </li></ul></ul><ul><ul><li>Think linearly </li></ul></ul><ul><li>Software developers must: </li></ul><ul><ul><li>Obtain necessary initial values without burdening users </li></ul></ul><ul><ul><li>Replicate clinical “flow” </li></ul></ul>
  25. 25. Software Development Challenges <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><li>Bridging languages </li></ul><ul><ul><li>Academic medical expertise </li></ul></ul><ul><ul><li>Front-line clinicians with limited time </li></ul></ul><ul><ul><li>Patients responsible for self-management </li></ul></ul>
  26. 26. From this….
  27. 28. … to this
  28. 30. Combinatorial volume <ul><li>> 23,000 possible combinations of </li></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>Step </li></ul></ul><ul><ul><li>Preferred vs. alternative </li></ul></ul><ul><ul><li>Instructions for use </li></ul></ul><ul><ul><li>Brands </li></ul></ul><ul><li>Some combinations are impossible, or unsupported by evidence, or contradict FDA </li></ul><ul><li>Changing all the time </li></ul><ul><ul><li>New drugs </li></ul></ul><ul><ul><li>New delivery mechanisms </li></ul></ul><ul><ul><li>New evidence </li></ul></ul>
  29. 31. Challenges posed by volume: <ul><li>Effort required to capture all possibilities </li></ul><ul><li>Likelihood of errors & inconsistencies increase with volume </li></ul><ul><li>Deciding when to stop, when every month something new comes out </li></ul><ul><li>Responsibility for on-going maintenance </li></ul>
  30. 32. Software Development Challenges <ul><li>Logical complexity </li></ul><ul><li>Volume of therapeutic choices </li></ul><ul><li>Different languages used by: </li></ul><ul><ul><li>Academic medical experts </li></ul></ul><ul><ul><li>Front-line clinicians with limited time </li></ul></ul><ul><ul><li>Patients responsible for self-management </li></ul></ul>
  31. 33. Different words for same ideas: I thought my child would die ED visit Exacerbation My top number on the meter What you can and should be able to blow FEV 1 actual vs. predicted Purple inhaler Daily controller Long-acting beta agonist Ordinary: Clinical: Academic:
  32. 34. Because of differing vocabulary: <ul><li>Text in guidelines doesn’t work on screen </li></ul><ul><ul><li>Guidelines: “Step up one” </li></ul></ul><ul><ul><li>Clinician question: “What is the current step?” </li></ul></ul><ul><ul><li>(Patient question: What is a step?) </li></ul></ul>
  33. 35. Because of differing vocabulary: <ul><li>On-screen text for clinical users doesn’t work in asthma action plan. </li></ul><ul><ul><li>Drug example: </li></ul></ul><ul><ul><ul><li>Clinician: Fluticasone MDI (44 mcg/puff) </li></ul></ul></ul><ul><ul><ul><li>Patient: Fluticasone inhaler 44 mcg </li></ul></ul></ul><ul><ul><li>Condition example: </li></ul></ul><ul><ul><ul><li>Clinician: Best peak flow, predicted peak flow </li></ul></ul></ul><ul><ul><ul><li>Patient: Peak flow </li></ul></ul></ul>
  34. 36. The challenge posed by vocabulary: <ul><li>Anticipating who the user/consumer is </li></ul><ul><li>Testing vocabulary with users to make sure it works </li></ul><ul><li>Resolving conflicts between need for specificity among one group of users vs. need for simplicity among another </li></ul>
  35. 37. Some preliminary conclusions
  36. 38. Policy Qs the process reveals: <ul><li>At what point in guideline development should “codification” be considered? </li></ul><ul><ul><li>By the expert panel while deliberating? </li></ul></ul><ul><ul><li>After the text of the guidelines released? </li></ul></ul><ul><li>Who is responsible for resolving textual inconsistencies and ambiguities? </li></ul><ul><ul><li>Expert panel? </li></ul></ul><ul><ul><li>Software developers? </li></ul></ul><ul><ul><li>Front-line clinicians? </li></ul></ul>
  37. 39. Addl policy Qs the process reveals: <ul><li>What should the “update” process be? </li></ul><ul><ul><li>Reconvene expert panel every xxx years? </li></ul></ul><ul><ul><li>Regular software maintenance? </li></ul></ul><ul><li>Should users be enabled to maintain their own lists of therapeutic choices? </li></ul><ul><ul><li>Pros: Can be customized to site (e.g. locally supported formularies) </li></ul></ul><ul><ul><li>Cons: Induces site-to-site variability in dissemination of latest evidence </li></ul></ul>
  38. 40. Sustainability questions <ul><li>Who bears the costs of development? </li></ul><ul><ul><li>Original guidelines </li></ul></ul><ul><ul><li>Original software for guideline-based decision support </li></ul></ul><ul><li>Who bears the costs of maintenance? </li></ul><ul><ul><li>Guidelines </li></ul></ul><ul><ul><li>Software, especially when software and clinical expertise are seldom the same </li></ul></ul>
  39. 41. Our work continues: <ul><li>Conveying user requirements to software developers, where requirements include: </li></ul><ul><ul><li>Adherence to interpreted guidelines </li></ul></ul><ul><ul><li>“Smooth” & supportive clinical workflow </li></ul></ul><ul><li>Documenting issues we encounter in attempting to achieve that goal </li></ul><ul><li>Preparing our sites for implementation, albeit a year late </li></ul>
  40. 42. And: <ul><li>Sharing process & results with all of you! </li></ul>
  41. 43. Improving Asthma Care in an Integrated Safety Net through a Commercially Available Electronic Medical Record <ul><li>Prime contractor:  Denver Health and Hospital Association . </li></ul><ul><li>Subcontractor:  Minneapolis Medical Research Foundation. Project site: Hennepin County Medical Center, Mpls MN </li></ul><ul><li>AHRQ Contract No. HHSA290200600020, Task Order No. 5 </li></ul><ul><ul><li>Staff and contractors – Minneapolis Medical Research Foundation </li></ul></ul><ul><ul><li>Gail Brottman, MD (Chief, Pediatric Pulmonology, HCMC) </li></ul></ul><ul><ul><li>Kevin Larsen, MD (Chief Medical Informatics Officer, HCMC) </li></ul></ul><ul><ul><li>Yiscah Bracha, MS (Research Director, Center for Urban Health) </li></ul></ul><ul><ul><li>Cherylee Sherry, MPH (Project Manager, Pediatric Research & Advocacy HCMC ) </li></ul></ul><ul><ul><li>Touch Thouk (Administrative Manager, Center for Urban Health) </li></ul></ul><ul><ul><li>Angeline Carlson, PhD (Principle, Data Intelligence Inc.) </li></ul></ul><ul><ul><li>Staff – Denver Health and Hospital Association </li></ul></ul><ul><ul><li>Sheri Eisert, PhD (Director, Health Services Research) </li></ul></ul><ul><ul><li>Michael (Josh) Durfee (Research Projects Coordinator, Health Services Research) </li></ul></ul><ul><ul><li>Contributors of Ideas, Information & Effort: </li></ul></ul><ul><ul><li>Michael Barbouche (University of Wisconsin Medical Foundation); Robert Grundmeier, MD (Children’s Hospital of Philadelphia); Michael Kahn, MD, PhD (Denver Children’s Hospital) </li></ul></ul><ul><ul><li>Donald Uden, PharmD (University of Minnesota), Faith Dohman, RN (Hennepin Faculty Associates); Susan Ross, RN (Minnesota Department of Health) </li></ul></ul>
  42. 44. … and now, Bob Mayes our Task Order Officer
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×