quality education for a healthier scotland decision support for diabetes: embedding knowledge in...
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Quality Education for a Healthier Scotland
Decision Support for Diabetes: Embedding Knowledge in Care Processes
Dr Ann Wales, Programme Director for Knowledge Management.
NHS Education for Scotland
Ann.wales@nes.scot.nhs.uk
Quality Education for a Healthier Scotland
Who is involved?
Dr Ann Wales and Mr Faiyaz Shaik, NHS Education for Scotland
Dr Rebecca Locke and SCI-Diabetes Team, NHS Tayside.
Dr James Walker, NHS Lothian
Dr Nicholas Conway, University of Dundee
Digital Health Institute for Scotland.
No conflict of interest
Quality Education for a Healthier Scotland
Overview
1. Aim
2. Drivers
3. Methods• Research question• Technical approach• Analysis and evaluation
4. Initial results
5. Implications for future national decision support.
Quality Education for a Healthier Scotland
Aim
Improve safety and reliability in applying evidence-based guidelines for diabetes…..in a way that reflects the reality of clinical practice….
• in a context-sensitive manner
• that responds to individual patient needs
• including complex care needs such as co-morbidities.
Quality Education for a Healthier Scotland
Drivers
Quality Education for a Healthier Scotland
Challenge of Long Term and Multiple Conditions
In the United Kingdom:• Long term conditions affect 1 in 5 people• 80% of general practice consultations• Costs £23.7bn per annum - 10% of NHS annual
spend.
In Scotland:• 77% of people with diabetes in Scotland have co-
morbidities.• 38% are taking more than 5 medications.
Quality Education for a Healthier Scotland
Limitations of Research Evidence
Classic research evidence, guidelines and pathways focus on single conditions and standardised study populations.
Context: Overestimation of impact in research studies compared with real-life contexts.
Ioannidis, 2011.
Personalisation: Limitations in applying research results and guidelines to individual patients with complex needs. Kent, 2007; Lutgenberg, 2009.
Quality Education for a Healthier Scotland
New Paradigm for Evidence-Based Practice
We need to find innovative ways of integrating knowledge from research and practice into clinical workflow to:
• Improve reliability of care
While
• Contextualising and personalising care• Responding to complex care needs especially co-
morbidity and polypharmacy.
Quality Education for a Healthier Scotland
NHSScotlandKnowledge into Action Strategy
• help practitioners to apply knowledge in the realities of day to day frontline practice.
• embed use of knowledge in healthcare improvement..
Quality Education for a Healthier Scotland
Methods
Quality Education for a Healthier Scotland
Research Questions
1. How does decision support derived from condition-specific, research-based guidelines need to be tailored and adapted for local contexts and individual patients with complex needs such as multiple conditions?
2. What factors influence implementation and spread of such tailored decision support across healthcare organisations?
Inform recommendations for decision support in NHSScotland.
Quality Education for a Healthier Scotland
Choice of Decision Support Platform
Requirements:
• Capability to interact with multiple clinical systems.
• Editing of decision support scripts and links.
• Shared pool of decision support scripts.
• Localisation of scripts.
• Selection – EBMEDS from Duodecim
Quality Education for a Healthier Scotland
Technical approach
• Integration in SCI-Diabetes – national electronic health record system for diabetes in NHSScotland.
• Community of practice converted SIGN guideline recommendations into 17 decision support scripts, e.g:• TSH monitoring• UKPDS Risk Engine• Weight gain• Recall of patients for retinal screening
• Mapping codes in patient record system to elements in scripts.
• Prompts, reminders, alerts• Links to national evidence, local handbooks and pathways
Quality Education for a Healthier Scotland
Example: Glitazone Prescribing Script
Patient record data Short message
Review drug list for insulin use Reminder Glitazone contraindicated due to insulin treatment?
Last B-Hb measurement less than 120 g/L (OR 12g/dl)
ReminderInformation given about the risk of anaemia?
Review drug list for drugs coded as BNF 6.1.2 Antidiabetic drugs.
MessagePossible interactions noted?
Weight monitoring arranged?
Links:
• Full message• Calculators, Formulary, Patient information.
Quality Education for a Healthier Scotland
Quality Education for a Healthier Scotland
Care Alerts/Re
Care Alerts/Reminders
Quality Education for a Healthier Scotland
Quality Improvement Cycles
Site 1
Sites 1-3
Sites 1-4
Case controls
1 5 10 15
Month
<COP>
<COP>
<COP>
Cycle 1
Cycle 2
Cycle 3
Improvement
Improvement
Sp
read
Quality Education for a Healthier Scotland
Evaluating Impact – Outcomes Chain
Inputs
Activities/ Outputs
Reach &
Reaction
Capacity &
Capability
Practice change
Long-term OutcomesINDIRECT
INFLUENCE
DIRECT INFLUENCE
DIRECT CONTROL
Numbers of clinicians accessing prompts.Number of prompts accessed.
Before-after comparison of system navigation data.
Technology Acceptance QuestionnaireFocus group and community feedback.
Case-control comparison of clinical processes.
Case-control comparison of HBA1c, blood pressure, cholesterol, UACRPatient Reported Experience Measures
Quality Education for a Healthier Scotland
Pre-intervention attitudes
I would like it if my CPD is automatically recorded when I read literature and/or guidelines.
I feel comfortable overriding a guideline if I feel it is not in the patient's best interests.
When I have a clinical query, I usually ask a colleague for advice
Pre-intervention access to literature and guidelines
positive neutral negative
If a CDSS was implemented, I would like the option to turn it off.
I would feel comfortable choosing to ignore the advice from the CDSS if I felt it was justified.
I would want to know the evidence behind the advice given by the CDSS.
I think that using a CDSS will lead to a better quality of care.
0% 50% 100%
Pre-intervention attitudes to CDSS
positive neutral negative
Quality Education for a Healthier Scotland
Emerging Results – First Cycle
Unified Theory of User Acceptance of Technology (Ventaktesh, 2003;
Heselmans et al 2012)
Perce
ived
influ
ence
Perfo
rman
ce e
xpec
tanc
y
Facilit
atin
g co
nditio
ns
Gener
al sa
tisfa
ction
Socia
l influ
ence
Attitud
e to
rem
inde
rs
Perce
ived
ease
of u
se
Perce
ived
use
0.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
HCP experience - Questionnaire constructs
Quality Education for a Healthier Scotland
Community of Practice Feedback
• Has influenced some decisions – investigations, prescribing.
• Script changes.
• Overriding of prompts when in patients’ interests – e.g.co-morbidities; personal circumstances.
• Facility to turn off individual scripts important.
• Different prompts relevant to primary and secondary care.
• No time to read underlying guidelines/evidence.
• Full message needed in pop-up.
• Interest in recording use for CPD.
Quality Education for a Healthier Scotland
Emerging Implications for National CDSS
• Responsive and flexible system, continually adaptable to user needs.
• Segmentation of clinician needs – generalist and specialist.
• Facility to override, turn off prompts
• Links across patient care pathways for multiple conditions.
• Combined decision support for guidelines and medicines.
• Link with CPD recording
Quality Education for a Healthier Scotland
Summary: “Adaptive” Evidence-Based Practice
1. Using quality improvement, programme evaluation and research methods to contextualise and personalise evidence-based practice for complex care needs.
2. Decision support as vehicle to combine knowledge from research, practice, patient and professional experience to improve quality of care.
Quality Education for a Healthier Scotland
Decision Support for Diabetes: Embedding Knowledge in Care Processes
Dr Ann Wales, Programme Director for Knowledge Management.
NHS Education for Scotland
Ann.wales@nes.scot.nhs.uk
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