The Clinical Decision Support Life-Cycle

04/14/2015

Charles Lagor, MD, PhD, CPHIMS Partners eCare, Boston, MA

DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

Conflict of Interest

Charles Lagor, MD, PhD, CPHIMS Has no real or apparent conflicts of interest to report.

© HIMSS 2015 2

Learning Objectives

Analyze the Clinical Decision Support life-cycle with a particular focus on the request and prioritization phases

Identify the roles, skills, and tools necessary to manage Clinical Decision Support requests

Recognize the ramifications of not having a systematic and collaborative process for Clinical Decision Support requests

3

An Introduction to the Benefits Realized for the Value of Health IT

http://www.himss.org/ValueSuite

Satisfied clinical customers

High quality Clinical Decision Support (CDS)

Reduced costs in producing CDS

S

T

S

SATISFACTION

TREATMENT/ CLINICAL

SAVINGS

4

Partners HealthCare System

3.3 Million Active Patients 70,000+ Clinicians and Staff $10 Billion Revenue

5

Transition to a Single Electronic Health Record (EHR)

CPOE = Computerized Physician Order Entry; eMAR = Electronic Medication Administration Record; ED = Emergency Department; EHR = Electronic Health Record

One EHR

EHR Viewing and Repository ED CPOE

Ambulatory Nursing Notes

Inpatient Nursing Assessment

Inpatient eMAR

Inpa

tient

CPO

E N

orth

Sho

re U

nion

North Shore Salem

Massachusetts General

McLean

Spau

ldin

g

Newton Wellesley

Brigham and Women's

Faul

kner

Mul

tiple

Ven

dors

Multiple Home-Grown

6

Partners eCare

Clinical Informatics

Partners HealthCare System

The Clinical Informatics Group

• Clinical Decision Support

• Knowledge Management

• Terminology Management

• Interoperability Standards

• Informatics Research

7

Clinical Informatician

• “System mindset”

• Clinical & technical training • Defines processes and tools • Understands clinical systems • Proficient in HIT standards • Detailed understanding of CDS

Knowledge Engineer

• “Collaborative mindset”

• Clinical training & HIT exposure • Applies processes and tools • Understands clinical systems • Proficient in HIT standards • Practical understanding of CDS

Two Major Roles

HIT = Healthcare Information Technology

8

Scope of Clinical Decision Support (CDS)

CDS that is in scope for Clinical Informatics team

• Alerts • Reminders • Medication warnings • Duplicate order warnings

CDS functionality implemented by other teams

• Order sets • Preference lists • Protocols • Flow sheets

• Forms • Care plans • Questionnaires • Patient instructions, and others

9

Simple Anatomy of a CDS Intervention

CDS Logic

Patient Inclusion/Exclusion

Criteria

Triggering Action

Follow-up Action

CDS Components

SNOMED = Systematized Nomenclature of Medicine; HbA1c = Hemoglobin A1c

IF patient is diabetic AND no HbA1c ordered THEN…

…order HbA1c

Code Name SNOMED Code Diabetes - beta cell function defect 609568004 Diabetes - insulin action defect 609569007 Diabetes in remission 703136005 Diabetes mellitus type 1 46635009 Diabetes mellitus type 2 44054006 Diabetes without complication 111552007

10

Challenge: Managing Code Dependencies

Diabetes HbA1C rule

Code Name SNOMED Code Diabetes - beta cell function defect 609568004 Diabetes - insulin action defect 609569007 Diabetes in remission 703136005 Diabetes mellitus type 1 46635009 Diabetes mellitus type 2 44054006 Diabetes without complication 111552007 Gestational diabetes 11687002

Code Name SNOMED Code Diabetes - beta cell function defect 609568004 Diabetes - insulin action defect 609569007 Diabetes in remission 703136005 Diabetes mellitus type 1 46635009 Diabetes mellitus type 2 44054006 Diabetes without complication 111552007

Diabetes HbA1C rule

Diabetes code set drives HbA1c rule

Diabetes code set is changed without checking dependencies

HbA1c rule stays dormant for pregnant patient

HbA1c rule fires inappropriately for pregnant patient

SNOMED = Systematized Nomenclature of Medicine; HbA1c = Hemoglobin A1c

11

Challenge: Managing Rule Dependencies

Diabetes LDL rule

CAD LDL rule

Scenario: A patient has diabetes and coronary artery disease

If rule dependencies were not checked during design…

…then two separate rules with similar follow-up action might fire

CAD LDL rule fires as intended

Diabetes LDL rule fires as intended

LDL= Low-density lipoprotein; CAD = Coronary Artery Disease

12

MU NQF 56

Lipid Panel every 3 months LIPID

PANEL ALT Level every 3 months

Why Do We Need the CDS Life-Cycle?

• Identify unintended consequences of CDS interventions • Manage CDS interventions and their components • Track development of CDS intervention • Improve efficiency of CDS development • Iteratively improve quality of CDS interventions

13

What are the Financial Benefits of the CDS-Life-Cycle?

Adapted from Garrison RH, Noreen EW, Brewer PC. (2014) Managerial Accounting 15th edition. Boston : McGraw-Hill/Irwin

Costs with a process

Costs without a process

Percent of CDS interventions without defect

Cos

ts

0 100

Prevention and inspection costs

Internal and external failure costs Total quality

costs

14

Clinical Decision Support (CDS) Life-Cycle

Request

Prioritize

Design

Build Test

Report

Analyze

15

Request Phase

Clinician fills out request form

Clinical Informaticians and Knowledge Engineers triage requests

Non-CDS items are routed to appropriate build team

CDS items are prepared for prioritization

Request Prioritize

Design

Build Test

Report

Analyze

16

Abridged CDS Request Form

Questions to be filled out by requestor

What do you want the CDS to do? Who are the intended recipients of the CDS? Explain the rationale for making the request. How is this handled in your institution today?

Do you know how this could be solved in the new system? Attach supporting documentation, if any Does the CDS help PHS meet a regulatory requirement? Does it improve patient safety? Is it required for Meaningful Use? Does it have financial implications? Does it assist clinician workflow?

Request Prioritize

Design

Build Test

Report

Analyze

17

Exception to the Process: Existing CDS Inventories

Brigham and Women’s Hospital (BWH) 2,500 CDS interventions from one system

Massachusetts General Hospital (MGH) 550 CDS interventions from two systems

Clinical Informaticians and Knowledge Engineers triage items in the inventories

Partners HealthCare 650 Enterprise CDS interventions from one system

Request Prioritize

Design

Build Test

Report

Analyze

18

Duplicative 8%

Not CDS 30%

CDS that falls outside of CDS life-cycle 38%

Current CDS covered by vendor

CDS 8%

Regulatory CDS 5%

Prioritized 8%

Not prioritized 3%

Candidates for CDS life-cycle (21%)

Brigham and Women’s Hospital CDS Inventory

Request Prioritize

Design

Build Test

Report

Analyze

19

Prioritization Phase

Clinical Informatician or Knowledge Engineer uploads requests to collaboration platform with voting capabilities

Members of the Clinical Decision Support Committee vote on requests

Request Prioritize

Design

Build Test

Report

Analyze

20

Request Prioritize

Design

Build Test

Report

Analyze

CDS and CDS Planning Committee

CDS Committee

Decide which CDS interventions are implemented

52 clinical members, of which 38 are

voting members

Bi-weekly meetings

CDS Planning Committee

Supports CDS

Committee

Subset of non-voting

CDS Committee members

Weekly meetings

21

Request Prioritize

Design

Build Test

Report

Analyze

Guiding Principles for Prioritizing CDS

Patient Safety

Research and Teaching

End User Acceptance

Evidence-based

Organization’s Goals Resources

Informatics Best Practices

22

Request Prioritize

Design

Build Test

Report

Analyze

Online Voting Platform

Description of CDS

CDS that prompts physician to order Hemoglobin A1C (HbA1C) for diabetic patient if there are no or abnormal vital signs documented

Rationale Supports healthcare initiative to improve the rate of ordering HbA1c labs for diabetic patients

Current State

Current workflow relies on clinicians to check the chart

Supporting Documentation

Voting Yes (Dr. K, 4 April, 1:18 PM) Yes (Dr. E, 7 April, 7:47 PM) Not sure (Dr. M, 8 April, 11:03 PM) Isn’t this the same as MU NQF 59?

MU NQF 59 (Dr. P, 10 April, 10:30 AM) Measure 59 is about reporting those diabetic patients whose A1C is >9%. This rule prompts physician to order HbA1C if missing.

Request Diabetes Initiative

23

Design Phase

Knowledge Engineer drafts design specifications for approved CDS interventions

Subject matter experts or requestor provide clinical advice and insights

Approved requests are uploaded to a collaboration platform that accommodates the development of specifications

Request Prioritize

Design

Build Test

Report

Analyze

24

Build Phase

Application Coordinator creates a copy of the design specification (“build specification”)

Application Coordinator creates the CDS intervention based on build specifications in the system

● ●

Deviations from design are captured in build specification

Knowledge Engineers provide clarification as needed

Request Prioritize

Design

Build Test

Report

Analyze

25

Request Prioritize

Design

Build Test

Report

Analyze

Online Specification Management

Details Type: CDS Build Status: Open Priority: Major Resolution: Unresolved

Description of CDS CDS that prompts physician to order Hemoglobin A1C (HbA1C) for diabetic patient if there are no or abnormal vital signs documented

Rationale CRITERION 1: Patient is diabetic (Diabetes Code Set 7825) CRITERION 2: No HbA1C within last 6 months

Logic 1 AND 2 Display Messgae Patient has diabetes and has not had an HbA1C order in the last six months. Please order an

HbA1C.

… … Comments Application Coordinator (14 Oct 7:11 PM)

Should the end user be required to provide an acknowledgment reason? Knowledge Engineer (15 Oct 3:13 PM) No, a recommendation is sufficient.

26

Test Phase

Request Prioritize

Design

Build Test

Report

Analyze

Test Script Author creates test script based on design specifications in testing application

Application Coordinator fixes failed CDS interventions and then notifies Tester to re-test the item

● ●

Tester runs test script by executing specified test script steps in the system

● ●

● ●

CDS passed and ready for transfer into production

CDS failed

27

Report Phase

Request Prioritize

Design

Build Test

Report

Analyze

Clinical Informatician and Knowledge Engineer monitor newly created CDS interventions

Reports for monitoring clinical performance on a routine basis

● ●

Reports for monitoring technical performance on a routine basis

● ●

Some CDS may need to be fixed by Application Coordinator

● ●

Some CDS need to be re-evaluated by CDS Committee

28

Analysis Phase

Request Prioritize

Design

Build Test

Report

Analyze

Clinical Informatician and Researcher interpret and analyze data from reports to…

…improve steps in CDS life-cycle

100 011

Reports for monitoring clinical performance

Reports for monitoring technical performance

…investigate impact of CDS

29

Advantages of Tools

Collaborate

Manage

Monitor

• Communicate asynchronously • Document decisions

• Find CDS and components • Identify dependencies

• Phase of development • Development efficiency

30

Future: One Knowledge Management Platform to Manage the CDS Life-Cycle

Request

Prioritize

Design

Build Test

Report

Analyze

• Artifacts • Dependencies • Dialogues • Audit trails

31

Summary

http://www.himss.org/ValueSuite

Request

Prioritize

Design

Build Test

Report

Analyze

Satisfied clinical customers

High quality Clinical Decision Support (CDS)

Reduced costs in producing CDS

S

T

S

SATISFACTION

TREATMENT/ CLINICAL

SAVINGS

32

Charles Lagor, MD PhD CPHIMS Senior Medical Informatician Partners eCare clagor@partners.org http://www.partners.org/

The CDS life-cycle would not be possible without the valuable contributions and indispensable support of our •Requestors,

•Partners Subject Matter Experts,

•Information Systems Engineers,

•Application Coordinators,

•Knowledge Engineers,

•Terminology Engineers, and

•Clinical Informaticians

Acknowledgements Questions?

33