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.

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.

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

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. 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. 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.

18. EHR Data Repository Information for Populations Local EHR Information for Individual Patients HIT Asthma Data Model for EHR

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

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:

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

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

26. Thank You For more information: Yiscah Bracha. [email_address]