quality education for a healthier scotland decision support for diabetes: embedding knowledge in...

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

[email protected]


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


Overview

1. Aim

2. Drivers

3. Methods• Research question• Technical approach• Analysis and evaluation

4. Initial results

5. Implications for future national decision support.


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.


Drivers


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.


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.


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.


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..


Methods


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.


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


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


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.


Care Alerts/Re

Care Alerts/Reminders


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


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


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


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


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.


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


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.


Decision Support for Diabetes: Embedding Knowledge in Care Processes

Dr Ann Wales, Programme Director for Knowledge Management.

NHS Education for Scotland

[email protected]

quality education for a healthier scotland decision support for diabetes: embedding knowledge in...

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