H IT A s t h m a www.CenterForUrbanHealth.org a t a l e o f wo e a n d e n l ig h t e n me n t Yiscah Bracha, M.S. ybracha@CenterForUrbanHealth.orgAHRQ Annual Meeting09SEP08
P r o je c t O b je c t iv e : www.CenterForUrbanHealth.org• Demonstrate use of HIT to improve ambulatory asthma care• Two existing technologies: Interactive Asthma Action Plan (IAAP) (developed by MN Dept of Health) Commercially available electronic health record (EHR) (EpicSystems Inc.)
Wha t w e k ne w : www.CenterForUrbanHealth.org• For asthma, IAAP beats Epic in user and patient friendliness• Difficult for Epic user to get to IAAP• Untapped potential to use EHR data to support QI
Wha t w e w a nte d to propos e : www.CenterForUrbanHealth.org• Make IAAP available from within Epic- driven workflow Brings guidelines to the point of care• Use IAAP database as asthma registry Evaluate effect of QI initiatives Identify at-risk patients Generate reports required by external agencies
O n e s m a ll p r o b le m … www.CenterForUrbanHealth.org• Existing IAAP based on guidelines released in 2002• 2007 guidelines soon to be released• Our project would link the EHR system to a soon-to-be-obsolete tool
W h a t w e a c t u a lly propos e d: www.CenterForUrbanHealth.org• Update IAAP to be consistent with 2007 guidelines• Make updated IAAP available from within Epic- driven workflow Brings new guidelines to the point of care• Use IAAP database as asthma registry Evaluate effect of QI initiatives Identify at-risk patients Generate reports required by external agencies
E x p e c t e d c h a lle n g e s www.CenterForUrbanHealth.org• Accessing IAAP from Epic Pushes boundaries both technically & organizationally• Creating & using asthma registry Technology well-understood; organizational barriers to readiness• Updating IAAP Trivial technically; no impact organizationally
3 m o n t h s a f t e r p r o je c t in c e p t io n : www.CenterForUrbanHealth.org• IAAP-EHR interface: Technical boundaries identified Organization is ready within those boundaries• Registry Organizational barriers quickly overcome Demanding to establish what fields to pull, but a well-understood task.• Update IAAP ….
F a m o u s la s t w o r d s : www.CenterForUrbanHealth.org• “It will be simple to update the existing IAAP to make it consistent with the new guidelines”
Oops : www.CenterForUrbanHealth.org• Original IAAP contained: Out-of-date, unsupported version of Java Database not designed to support analysis List of meds not designed to be updated• “Update” of any kind not possible Radical shift in perspective from 2002 to 2007 FROM: Treating acute symptoms TO: Managing chronic disease
T h e s t r u g g le : www.CenterForUrbanHealth.org• Clinicians try to convert guidelines directly into screens: They get trapped in logical circles from which they cannot escape• Analytically-minded Project Director tries to display their thinking in flow diagrams Clinicians can’t follow the diagrams• Many expressions of frustration exchanged!
S ome c onc e rns : www.CenterForUrbanHealth.org• Close scrutiny of guidelines reveals: Ambiguous and/or internally inconsistent recommendations: Inadequate dosing instructions for young children Recommendations for formulations not available commercially Recommendations for off-label uses of drugs Drugs for young children not approved by FDA
More c onc e rns : www.CenterForUrbanHealth.org• Even with close scrutiny, no answers to front-line clinical questions: What should the dosing instructions be in the “red zone” of the asthma action plan? How can we determine the current treatment step for a new patient who is already receiving asthma care?
A n d m o r e s t r u g g le s : www.CenterForUrbanHealth.org• Enormous effort required to communicate needs to software development company• Even with that effort, still uncertainty that they really understand what’s required
T h e t a le o f w o e … www.CenterForUrbanHealth.org• We are failing at our most trivial task AHRQ will give up on us We will disappoint the users whose expectations we have raised• We have over-extended ourselves and our budget trying to cope with this• If we succeed, who will be responsible for harm that may arise because we delivered vague guidelines to the point of care?
T h e t a le o f e n lig h t e n m e n t : www.CenterForUrbanHealth.org • Bob* (unexpectedly) says: This is very interesting! Let’s reduce your anxiety … there are lots of ways to make lemonade here We have an agency interest in alternative ways to disseminate guidelines Document these issues Analyze them Make recommendations to future expert panels* Bob Mayes, our AHRQ Task Order Officer
www.CenterForUrbanHealth.org F r o m: E x p e r t P a n e l G u id e lin e s To :E le c t r o n ic C lin ic a l D e c is io n S u p p o rt:
W h a t a r e t h e P r im a r y C h a lle n g e s ? www.CenterForUrbanHealth.org• Logical complexity• Volume of therapeutic choices• Different languages used by: Academic experts Front-line clinicians with limited time Patients responsible for self-management
T h e P r im a r y C h a lle n g e s www.CenterForUrbanHealth.org• Logical complexity• Volume of therapeutic choices• Different languages used by: Academic experts Front-line clinicians with limited time Patients responsible for self-management
T h e h u m a n m in d : www.CenterForUrbanHealth.org• Do I know this patient?• Is the patient already being treated? How aggressively? Is the patient being treated the right way?• How is the patient doing? Is the therapy adequate? Is the patient using the therapy as prescribed?• What might happen if I changed the dose?
T h e s o f t w a r e m in d … www.CenterForUrbanHealth.org 1. System displays all known values , as shown on UI screen. 2. User accepts or changes value for weight 3a. 3b. 4b. System changes value for date ofUser accepts value User changes value last weight to current date. for weight for weight 5. User accepts or changes value for height. 6a. 6b. 7b. System changes value for date ofUser accepts value User changes value last height to current date. System for height for height changes value of predicted peak flow .
M o r e p e a k s in t o t h e s o f t w a r e m in d … www.CenterForUrbanHealth.org 1. IAAP Screen_03_01. (User Interface_03_01) User opts to establish asthma control or severity. User opts to infer level, or to enter known level. To User Interface _03_01 Clinicians : How do you want to handle this choice and/or this screen if there is an existing value for 3b. USER CHOOSES: severity in the3a. USER CHOOSES: 6. USER CHOOSES: Enter severity level system? Infer severity from ASSESS CONTROL as known. symptoms 8. System check: If neither current treatment step nor pharmacy order for 4b. 10. asthma meds 4a. System calculates System transfers user to available, thenSystem transfers user to [step_recommend], ‘Determine Control ’ POPUP process that classifies based on severity and interface.severity from symptoms patient age. To Pop-Up_03_ To Process Flow_04S To Function_04. Step recommend. To Process Flow_04C
H u m a n vs s o ftw a re “ m in d s ” : www.CenterForUrbanHealth.org Huma ns S o ftw a reFast, unarticulated Series of nested andthought processes explicit if-then statements“Gestalt” Linear, step-by-stepCounterfactuals Counterfactuals notentertained possibleApproximate Precise meaning of wordsmeanings of words OK requiredCan tolerate ambiguity No tolerance for ambiguity
T h e n e g o t ia t io n c h a lle n g e : www.CenterForUrbanHealth.org• Clinicians must: Clearly explicate their thought processes Force themselves to use precise vocabulary Think linearly• Software developers must: Obtain necessary initial values without burdening users Replicate clinical “flow”
S o f t w a r e D e v e lo p m e n t C h a lle n g e s www.CenterForUrbanHealth.org• Logical complexity• Volume of therapeutic choices• Bridging languages Academic medical expertise Front-line clinicians with limited time Patients responsible for self-management
F r o m t h is …. www.CenterForUrbanHealth.org
C o m b in a t o r ia l v o lu m e www.CenterForUrbanHealth.org• > 23,000 possible combinations of Age Step Preferred vs. alternative Instructions for use Brands• Some combinations are impossible, or unsupported by evidence, or contradict FDA• Changing all the time New drugs New delivery mechanisms New evidence
C h a lle n g e s p o s e d b y v o lu m e : www.CenterForUrbanHealth.org• Effort required to capture all possibilities• Likelihood of errors & inconsistencies increase with volume• Deciding when to stop, when every month something new comes out• Responsibility for on-going maintenance
S o f t w a r e D e v e lo p m e n t C h a lle n g e s www.CenterForUrbanHealth.org• Logical complexity• Volume of therapeutic choices• Different languages used by: Academic medical experts Front-line clinicians with limited time Patients responsible for self-management
D if f e r e n t w o r d s f o r s a m e id e a s : www.CenterForUrbanHealth.orgA c a d e m ic : C lin ic a l: O r d in a r y :Long-acting Daily controller Purple inhalerbeta agonist What you canFEV1 actual vs. My top number and should bepredicted on the meter able to blow I thought myExacerbation ED visit child would die
B e c a u s e o f d if f e r in g v o c a b u la r y : www.CenterForUrbanHealth.org• Text in guidelines doesn’t work on screen Guidelines: “Step up one” Clinician question: “What is the current step?” (Patient question: What is a step?)
B e c a u s e o f d if f e r in g v o c a b u la r y : www.CenterForUrbanHealth.org• On-screen text for clinical users doesn’t work in asthma action plan. Drug example: Clinician: Fluticasone MDI (44 mcg/puff) Patient: Fluticasone inhaler 44 mcg Condition example: Clinician: Best peak flow, predicted peak flow Patient: Peak flow
T h e c h a lle n g e p o s e d b y v o c a b u la r y : www.CenterForUrbanHealth.org• Anticipating who the user/consumer is• Testing vocabulary with users to make sure it works• Resolving conflicts between need for specificity among one group of users vs. need for simplicity among another
S o m e p r e lim in a r y c o n c lu s io n s
P o lic y Q s t h e p r o c e s s r e v e a ls : www.CenterForUrbanHealth.org• At what point in guideline development should “codification” be considered? By the expert panel while deliberating? After the text of the guidelines released?• Who is responsible for resolving textual inconsistencies and ambiguities? Expert panel? Software developers? Front-line clinicians?
A d d l p o lic y Q s t h e p r o c e s s r e v e a ls : www.CenterForUrbanHealth.org• What should the “update” process be? Reconvene expert panel every xxx years? Regular software maintenance?• Should users be enabled to maintain their own lists of therapeutic choices? Pros: Can be customized to site (e.g. locally supported formularies) Cons: Induces site-to-site variability in dissemination of latest evidence
S u s t a in a b ilit y q u e s t io n s www.CenterForUrbanHealth.org• Who bears the costs of development? Original guidelines Original software for guideline-based decision support• Who bears the costs of maintenance? Guidelines Software, especially when software and clinical expertise are seldom the same
O u r w o r k c o n t in u e s : www.CenterForUrbanHealth.org• Conveying user requirements to software developers, where requirements include: Adherence to interpreted guidelines “Smooth” & supportive clinical workflow• Documenting issues we encounter in attempting to achieve that goal• Preparing our sites for implementation, albeit a year late
And: www.CenterForUrbanHealth.org• Sharing process & results with all of you!
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 Sheri 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) Yiscah Bracha, MS (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); Robert Grundmeier, MD (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)
…a nd now , B ob www.CenterForUrbanHealth.orgM a ye s o u r Ta s k O r d e r O f f ic e r