from thoughtless alerts to effective decision-support using the ehr in a learning health system
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From Thoughtless Alertsto
Effective Decision-Support
Using the EHR in a
Learning Health System
AgendaAgenda
Current Challenges to Outpatient Current Challenges to Outpatient MedicineMedicine
What is the Evidence for CDSWhat is the Evidence for CDS Threats and Challenges to CDSThreats and Challenges to CDS One system’s experience with CDSOne system’s experience with CDS
– GovernanceGovernance– ToolsTools– ReportingReporting
The way forwardThe way forward22
Aging of the Aging of the PopulationPopulation
33
No DataLess than 4% 4% to 6% Above 6%
Diabetes PrevalenceAmong U.S. Adults
NOTE: Data are age-adjusted to the 2000 standard population. SOURCE: Behavioral Risk Factor Surveillance System (BRFSS), CDC.
44
Burden of Chronic Burden of Chronic Disease -- 2008Disease -- 2008 6.5% -- Coronary Heart Disease6.5% -- Coronary Heart Disease 25.5% -- HTN25.5% -- HTN 2.7% -- Stroke2.7% -- Stroke 8.0% -- Asthma8.0% -- Asthma 6.6% -- COPD6.6% -- COPD 8.5% -- Cancer8.5% -- Cancer 9.2% -- Diabetes9.2% -- Diabetes
Source: National Health Interview Survey 2008
55
Meaningful Use
PQRS HEDISValue Based Purchasing
Burden of Quality Burden of Quality MeasuresMeasures
Breast Ca Screening Colon Ca
Screening
Lipids in CAD Osteoporosis Management Lipids
in Diabetes
Kidney Checks in Diabetes
Eye Exams in DM
Rheumatoid Arthritis
Management
Hi Risk Medications
in the Elderly
ACE/ARB in Diabetes
Cervical Ca Screening
Chlamydia ScreeningImmunizations
Controller Meds in Asthma
COPD:Spirometry
66
“ “To fully satisfy the USPSTF To fully satisfy the USPSTF recommendations, … 7.4 hours per recommendations, … 7.4 hours per
working day, is needed for the working day, is needed for the provision of preventive services.”provision of preventive services.”
Am J Public Health. 2003 April; 93(4): 635–641.
• Identify that someone is potentially eligible for a service
• Determine whether or not that service has already been provided
• Counsel the patient• Order the service
77
Quality of Health Care Quality of Health Care Delivered in USADelivered in USA Random sample of adults living in Random sample of adults living in
12 metropolitan areas12 metropolitan areas Evaluated performance on 439 Evaluated performance on 439
indicators – 30 conditions and indicators – 30 conditions and preventionprevention
44.7% - at least one chronic 44.7% - at least one chronic conditioncondition
NEJM 348;26: 2635-2645. 88
Percentage of Percentage of Recommended CareRecommended Care
Type of CareType of Care % of % of Recommended Recommended Care ReceivedCare Received
PreventativePreventative 54.9 54.9
AcuteAcute 53.553.5
ChronicChronic 56.156.1
99
““The lag between the discovery of The lag between the discovery of more efficacious forms of more efficacious forms of treatment and their incorporation treatment and their incorporation into routine patient care is into routine patient care is unnecessarily long, in the range of unnecessarily long, in the range of about 15 to 20 years.”about 15 to 20 years.” 1010
Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review
JAMA. 2005;293(10):1223-1238. doi:10.1001/jama.293.10.1223
1111
Characteristics ofCharacteristics ofSuccessful CDSSuccessful CDS
JAMA. 2005;293(10):1223-1238. doi:10.1001/jama.293.10.1223
1212
Challenges to CDSChallenges to CDS
Divergent prioritiesDivergent priorities– Primary care vs SpecialistPrimary care vs Specialist– Clinical Care vs “Business Needs”Clinical Care vs “Business Needs”– Unclear or contradictory standardsUnclear or contradictory standards
Disparate WorkflowsDisparate Workflows Alert FatigueAlert Fatigue
1313
Types of Decision Types of Decision SupportSupport Intrusive Reminders (“Pop-Ups”)Intrusive Reminders (“Pop-Ups”) ““Passive” RemindersPassive” Reminders Order SetsOrder Sets Information DisplaysInformation Displays Links to Relevant GuidelinesLinks to Relevant Guidelines
1414
Dealing with Divergent Dealing with Divergent PrioritiesPriorities Find a cartoonFind a cartoon
1515
Who’s In Charge?Who’s In Charge?
Decision-Support Working Group
(approx 10 physicians)
PhysicianIT
Leadership
• Meets monthly• Decides on
clinical content and standards
• Validates build
• Meets technical team weekly
• Sets DSWG agenda
• Suggests new rules
• Designs tools (with technical team)
• Executes build
• Tests build• Advises
leadership and DSWG
• Educates on new features
Technical Team
President, Physician Services DivisionPresident, Community Medicine, Inc
Chief Medical Information Officer
1616
Governing PrinciplesGoverning Principles Widely accepted guidelinesWidely accepted guidelines
– USPSTF, ACIP/CDCUSPSTF, ACIP/CDC– Support HEDIS and other quality measuresSupport HEDIS and other quality measures
Do not interrupt workflowDo not interrupt workflow– (may interrupt work that should be interrupted)(may interrupt work that should be interrupted)
Provide method to override Provide method to override alerts/customizealerts/customize
Leadership of receiving specialty must Leadership of receiving specialty must consentconsent
1717
Technical PrinciplesTechnical Principles
More important services have More important services have more intrusive alertsmore intrusive alerts
Use workflow tools for Use workflow tools for interventions that need to be done interventions that need to be done on every visiton every visit
Alerts for periodic services are tied Alerts for periodic services are tied to Health Maintenanceto Health Maintenance
Color code and prioritizeColor code and prioritize1818
Scenarios for CDSScenarios for CDS
Safety Alerts Prevention
Chronic Disease Management
Medications
Clinical Pathways
Meaningful Use/Billing
1919
Best Practice Best Practice Advisories - PrimerAdvisories - Primer
Problem List
Best Practice Alert
Med List PMH,PSH
ResultsOrders
FlowSheet Values
HM Modifiers and Topics
2020
Where to BPAs Fit In?Where to BPAs Fit In?
StrengthsStrengths– Powerful logicPowerful logic– Can evaluate in ‘real time’Can evaluate in ‘real time’– Department and role specificDepartment and role specific– Fit into workflow (Visit Navigator) OR Fit into workflow (Visit Navigator) OR
PopUp when neededPopUp when needed– Facilitate ActionFacilitate Action
WeaknessesWeaknesses– Hard to customizeHard to customize
2121
BPA StrategyBPA Strategy
Color Coded by TypeColor Coded by Type SafetySafety Meaningful UseMeaningful Use Disease managementDisease management PreventionPrevention ResearchResearch
2222
Pop-Ups --- Patient Pop-Ups --- Patient SafetySafety Order contrast for allergic patientOrder contrast for allergic patient Order MRI when pacer is presentOrder MRI when pacer is present
2323
2424
• Health Maintenance Health Maintenance is Epic's preventive is Epic's preventive health reminder tool. health reminder tool.
• Patients and Patients and providers can be providers can be reminded about reminded about mammograms, flu mammograms, flu shots, immunizations shots, immunizations and any other and any other preventive diagnostic preventive diagnostic and/or therapeutic and/or therapeutic procedures.procedures.
HealthHealth MaintenanceMaintenance
2525
Health Maintenance works in two Health Maintenance works in two ways:ways:o Automatic reminders Automatic reminders
o Gender, ageGender, ageo ProblemsProblemso MedicationsMedications
o Manual remindersManual reminderso Modifier is addedModifier is addedo BPA may suggest thisBPA may suggest this
How does Health How does Health Maintenance work?Maintenance work?
2626
Health Maintenance Health Maintenance 101 --- Topics101 --- Topics Topics are the Building BlocksTopics are the Building Blocks
– ServiceService on a on a scheduleschedule– Satisfied by completed proceduresSatisfied by completed procedures– Can be manually satisfiedCan be manually satisfied
A1c every 6 months LDL
yearlyPap
Every 3 yrs
Mammogram every year
2727
Health Maintenance Health Maintenance PlansPlans Plans correspond to diseases or Plans correspond to diseases or
conditionsconditions Apply these plans by ‘modifiers’Apply these plans by ‘modifiers’ Plans can:Plans can:
– Add topics to HMAdd topics to HM– Delete topics to HMDelete topics to HM– Change time intervals on existingChange time intervals on existing– topicstopics
A1c
every 6 months
LDL yearly
Eye Exam yearly
Urine Albumin yearly
Eye Exam yearly
Creatinine yearly
Diabetes Plan
2828
Diabetes HM TopicsDiabetes HM Topics YearlyYearly
– LDLLDL– Eye examEye exam– Foot examFoot exam– Urine microalbuminUrine microalbumin– Serum creatinineSerum creatinine– Flu shotFlu shot
Every 6 monthsEvery 6 months– A1cA1c
PneumovaxPneumovax 2929
Other HM PlansOther HM Plans
CADCAD– LDL yearlyLDL yearly
Lipid-Lowering DrugsLipid-Lowering Drugs– LDL and ALT yearlyLDL and ALT yearly
DiureticsDiuretics– K and creatinine yearlyK and creatinine yearly
ThyroidThyroid– TSH yearlyTSH yearly
3030
Shared TopicsShared Topics
Yearly LDLYearly LDL– DMDM– CADCAD– Lipid-lowering drugsLipid-lowering drugs
Serum creatinineSerum creatinine– DMDM– DiureticsDiuretics– ACE/ARBACE/ARB
3131
Customization with HMCustomization with HMOverridesOverrides ““Approved”Approved”
– DoneDone– Not ApplicableNot Applicable
ModifiersModifiers
Exclusion ModifiersExclusion Modifiers Modifiers to Change Modifiers to Change
IntervalInterval
Postpone TopicsPostpone Topics
3232
HM is Engine Driving HM is Engine Driving AlertsAlerts
Best Practice Alert
LDLUrine albuminCreatininePotassiumTSHEye Exam
HM Topics
Custom
izable
Act
ionable
Order Sets
3333
3434
Combined Chronic Dz Combined Chronic Dz BPABPA
3535
Combined Smart SetCombined Smart Set
3636
Prevention TopicsPrevention Topics
PapPap MammogramMammogram Colon Cancer ScreeningColon Cancer Screening DEXA ScanDEXA Scan
3737
3838
Combined Prevention Combined Prevention AlertAlert
3939
BPA Smart SetBPA Smart Set
4040
Finessing ControversyFinessing Controversy
Age 40-50 – Mammogram Age 40-50 – Mammogram DiscussionDiscussion
Age 50-75 – Annual MammogramAge 50-75 – Annual Mammogram– Every other year modifier availableEvery other year modifier available
Age 75 – Mammogram DiscussionAge 75 – Mammogram Discussion
4141
Medication BPAMedication BPA
4242
Medication Smart SetMedication Smart Set
4343
CKD – A Cautionary CKD – A Cautionary TaleTale CKD is underrecognizedCKD is underrecognized Progression to ESRDProgression to ESRD Poor ‘fistula first’ ratePoor ‘fistula first’ rate Comorbid events (CAD)Comorbid events (CAD)
4444
Hoped-For OutcomesHoped-For Outcomes
Recognize CKDRecognize CKD– Put on Problem ListPut on Problem List– Drive decision-supportDrive decision-support
Early referral to nephrologistEarly referral to nephrologist– How early?How early?
Screen for and treat cardiac risk Screen for and treat cardiac risk factorsfactors
4545
Recognize CKDRecognize CKD
• Too big• Too
complex• Suggestion
often wrong• Does not
reflect clinician’s views
4646
CKD-IV HM TopicsCKD-IV HM Topics
4747
CDS to Increase Nephrology CDS to Increase Nephrology ReferralReferral
Abdel-Kader, Fischer, et al. American Journal of Kidney Diseases. 58(6):894-902, 2011 Dec
4848
Smart Sets – Smart Sets – Osteoporosis PathwayOsteoporosis Pathway
4949
COPD MedicationsCOPD Medications
5050
How Many Alerts?How Many Alerts?
Type of Alert Number (Total 317)
Chronic Disease 99
Billing 28
Meaningful Use 8
Order Suggestions 14
Prevention 63
Patient Safety 29
Quality Reporting 24
Research 27
Miscl 18
5151
Quality ReportsQuality Reports
•Diabetes•CAD•CHF•Afib•Hypertension•Prevention
“Facts are stubborn, but statistics are more pliable.”
--Mark Twain
Diabetes Patient Detail Diabetes Patient Detail (PDF)(PDF)
5353
Diabetes Report CardDiabetes Report Card
5454
Clinic Summary by ProviderClinic Summary by Provider
5555
5656
Clinical Decision Support to Clinical Decision Support to Promote Safe Prescribing to Women Promote Safe Prescribing to Women of Reproductive Age: A Cluster-of Reproductive Age: A Cluster-Randomized TrialRandomized Trial
Randomized MDs to receive “simple” (n=17) Randomized MDs to receive “simple” (n=17) vs “complex” alert (n=24)vs “complex” alert (n=24)
No difference in ordering teratogenic meds or No difference in ordering teratogenic meds or counselling after 6 monthscounselling after 6 months
For last 6 months, “complex” alert turned offFor last 6 months, “complex” alert turned off No difference in ordering teratogenic meds No difference in ordering teratogenic meds
with or without alertwith or without alert
Schwarz EB; Parisi SM; Handler SM; Koren G; Shevchik G; Fischer GS. Journal of Women's Health. 22(10):817-24, 2013 Oct.
5757
5858
Chronic Disease Chronic Disease Process MeasuresProcess Measures
5959
Prevention MeasuresPrevention Measures
6060
Critical Success Critical Success FactorsFactors
Governance and LeadershipGovernance and Leadership Focus on Well-Established Guidelines and Focus on Well-Established Guidelines and
EvidenceEvidence Collaboration with Intended UsersCollaboration with Intended Users Understanding of workflowsUnderstanding of workflows CustomizabilityCustomizability Processes to improve efficiencyProcesses to improve efficiency Using tools appropriate to the problemUsing tools appropriate to the problem Reporting and FeedbackReporting and Feedback
6161
Make it easy for clinicians to Make it easy for clinicians to do what they know they do what they know they
should doshould do
6262
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