HIT Asthma: A Tale of Woe and Enlightenment


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

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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