The Next Generation of Clinical

Decision Support (CDS)

Pilar Hermida, Director

UpToDate

pilar.hermida@wolterskluwer.com

15th January 2015

PART I: What is CDS?

• Clinical Decision Support (CDS): Definitions

• Clinical Decision Support (CDS): Impact

PART II: Future of CDS

• Business Trends

• Workflow Integration & Access Options

PART III:

• CDS: Considerations for Estonia’s e-Health Plan.

Q&A

Objectives

First, a Story:

The Night mHealth Saved a Life

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The Night mHealth Saved a Life

• Obstretician-Gynegologist was called in at 3 am.

• Patient in massive shock post-partum

• Common maneuvers were not working

• Rarely performed emergency measures needed

• Doctor was not familiar with them

• What happens next?

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UpToDate.!

The Night mHealth Saved a Life

• Conducted a search on UpToDate: Surgical techniques were

“perfectly and efficiently described.”

• “I read them aloud to the surgical team.”

• “Within 5 minutes I was performing the exact maneuver

described in the text.”

• “It worked perfectly. The patient's life was saved by that

maneuver.”

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“…a life I was able to save thanks to immediate access to UpToDate on my cell phone.”

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Doctors Have Clinical Questions

Covell, DG. Ann Intern Med 1985; 103:596; Green, ML. AM J Med 2002; 109:218;

Osheroff, JA. Ann Intern Med 1991:575; Ely, JW. J Am Med Inform Assoc 2005; 12:217;

Gorman, PN. Med Decis Making 1995; 15:113.

Unanswered clinical questions

impact patient management decisions

Approximately 2 out of 3 clinical

encounters generate a question

Physicians have approximately

11 clinical questions a day

60% of questions

go unanswered

Answering all clinical

questions could change

5 to 8 patient management

decisions each day

Clinical Decision Support (CDS)

Definitions

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UpToDate is the number one online evidence-based

clinical decision support system in the world that helps

doctors answer their clinical questions at the point of

care.

Our 5 700 physician-editors from 51 countries (the top

experts in their fields) synthesize the most recent

medical information in evidence-based practical

recommendations to:

Find quick answers to point-of-care questions

Save doctors’ time

Improve medical education

IMPROVE OUTCOMES AND QUALITY OF CARE

What is UpToDate?

10 000+ Clinical topics

1500+ Patient topics

28 000+ Graphics

140+ Medical calculators

380 000+ Evidence links

What’s New/

Practice Changing

Updates

22 Specialties

CME/CPD

5 100+ Drug entries

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A New Way to Practice Medicine

5 700+ Physician authors

CHANGE IN MEDICAL PRACTICE

Option 1: UpToDate Search Box

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Best

Practice!

UpToDate search page accessed via a link

User clicks on “UpToDate” button/icon, menu option, etc.

From toolbar at top of page or from menu

UpToDate Search Box is preferred method (Option 1 - previous slide)

Option 2: UpToDate Link

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Menu/List:

Toolbar:

Option 3: UpToDate Targeted Search

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Obtain clinical information for medical term displayed on EHR page

Single-click access is recommended for quick decision support

Versus right-click or drop-down, or Icons within a table/list

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A Trusted Resource

21+ years For 21+ years, the most trusted evidence

based, peer reviewed editorial content,

proven to improve patient care quality

5 700+ authors Expert evidence-based recommendations made by

over 5 700+ physician authors from 51 countries

850 000 clinicians Over 850 000 clinicians and 29 000 hospitals

worldwide in 164 countries rely on UpToDate,

including: 95% of medical teaching institutions in Benelux and Germany

90% of medical teaching institutions in Japan

90% of medical teaching institutions in the United States

250 000 000+ searches Clinicians view more than 250 million topics

annually in UpToDate, changing 80 million clinical

decisions

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Find Answers Faster

Patent translation technology

with:

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Search in

languages Auto complete

Customized

default language

Navigation

Translation

feedback

Clinical Decision Support (CDS)

Impact

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Research Demonstrates UpToDate Impacts Outcomes

We invite you to review the study data yourself: http://www.uptodate.com/home/research

Over 60 research studies

UpToDate is the most widely

studied point of care clinical

decision support tool. To

date there have been over

60 studies that have studied

UpToDate as a tool to:

Allow more questions to

be answered faster

Change decisions

Improve outcomes

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Clinical Decision Support Changes Clinical Decisions

Phua J, See KC, Khalizah HJ, et al. Utility of the electronic information resource UpToDate for clinical decision-making at bedside rounds.

Singapore Med J 2012; 53:116.

37%

Researchers at Singapore’s National University

Hospital report that bedside use of UpToDate led to

changes in patient care decisions 37% of the time

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Researchers at Harvard University Find: UpToDate Associated with Improved Outcomes

Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US hospitals.

J Hosp Med 2012; 7:85.

Use of UpToDate Associated with...

Improved Quality Every condition on Hospital Quality Alliance Metrics

Shorter Lengths of Stay 372 000 days over 1 year

Lower Mortality Rates 11 500 lives over 3 years

Impact: Changing Millions of Clinical Decisions

-

5,000,000

10,000,000

15,000,000

20,000,000

25,000,000

30,000,000

Topic Hits

A Quarter Billion (254 877 259) Topic Views in 2013

over 80 million changed Decisions

Using UpToDate Increases Medical Knowledge

20 Minutes a day

McDonald, F, Zeger, SC, Kolars, JC. Factors Associated with Medical Knowledge

Acquisition During Internal Medicine Residency J Gen Intern Med 2007. 19

Equals an Entire

Year of Residency

Future of CDS

Business Trends

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Unsustainable costs

Demographic trends/shortages of clinicians

Quality of care Emphasis shift from quantity to quality

Improved outcomes

Patient satisfaction

Reduced waiting times

Patient safety

Length of stay

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Global Healthcare Challenges

See “Future Challenges to the Provision of Healthcare in the 21st Century,” Dr Raymond Lang

Medical education Knowledge of the latest medical information

Providing effective patient information as

patients become more engaged

Policies: Patient Safety in the EU 2014: What is the

Issue?

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What is the EU Response?

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Areas to Improve

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Areas to improve (Cont.)

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STRUCTURAL & INVESTMENT FUNDS (EIFS):

ERDF= European Regional Development Funds

ESF=European Social Funds

Cohesion Funds

CENTRAL FUNDS:

THIRD HEALTH FRAMEWORK PROGRAMME (€450M)

Objective 4: Access to better and safer healthcare through better a access to medical expertise and

information

HORIZON 2020 (€80B)

Predictive medicine Open Call : €104M

AGEING WELL WITH ICT INITIATIVE (€700M)***

Good News: FOCUS = €

**Previous framework

Architectural view: One Roadmap for the Future

The European EMR Adoption Model in 7 Stages to Highest

Quality in Patient Care

“Paperless” patient record environment for highest quality of

care, data continuity & full HIE

Electronic diagnostic and pharmacy department

information

A patient-centered electronic data repository

Clinical ordering and documentation – especially nursing care

Electronic order entry with decision support and result

reporting

Completely electronic diagnostic image management

Full electronic clinical decision support, and highest

medication safety

• Knowledge Base

• Current, comprehensive, evidence-based

• Summary & detailed presentations

• Expert recommendations

• Rich & dynamic content: graphics, video, calculators

• Advanced Search

• Intuitive, auto-complete

• Filters for content type (e.g., adult vs pediatric)

• Multi-lingual search and navigation*

• Context > Bidge Patient-Doctor Gap

• Personalised Medicine: Integrates EHR data re: patient

• Location: Available at the point of care.

Architecting Tomorrow’s Clinical Decision Support

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The Right Guidance

The Right Decision

At the Right Time

Context & Format Clinicians

Find Useful

*Search in Korean is currently in beta testing

Simplified &

Traditional Chinese;

Korean*, Japanese,

English, Portuguese,

Spanish, French,

German, Italian

The Point of Care is … Anytime, Anywhere

30 UpToDate 2014 Survey of 930 practitioners in 68 countries.

Mobile Health Adoption is

here to stay:

77% Doctors use a smartphone

during practice

70% Doctors use mobile devices for

clinical decision support

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National Strategies: CDS is Key to Standardizing

Public Healthcare

UpToDate has national contracts

with the governments of Norway,

Spain , Saudi Arabia and Oman to

standardize public healthcare on

UpToDate

In countries such as the

Netherlands, Belgium,

Switzerland and Luxembourg,

UpToDate is used country-wide

STANDARDIZATION OF CARE = HEALTHCARE DEMOCRACY

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Scalable Solutions to Increase the Impact on Care:

From silos to integrated approaches

National Access

Hospital System/ Group /Region

Hospital

Care Team

Individual Doctor

I

M

P

A

C

T

Future of CDS

Integration and Access: A new way to practice

medicine

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The Most Valuable HIT Initiative for Patient Care

Source: UpToDate individual subscriber survey 2012

Which IT initiative produces the greatest benefit

to the quality and safety of patient care?

26.53

31.35

32.68

33.41

36.28

37.39

54.31

20 30 40 50 60

Order sets

CPOE

Patient ed

Alerts/reminders

eRx

EHR system

UpToDate CDS

Proportion ranking each initiative a 9 or 10 on a 10 point scale (n = 17,127)

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Increased Clinician Satisfaction with the EHR

Is important

to patient care

Enhances

satisfaction with their EHR

Encourages

utilization of their EHR

Source: June 2011 Clinicians Survey N=1228

Users said that having UpToDate embedded in their EHR

Realize Benefits of Embedding UpToDate in the EHR:

CDS in the Workflow

Increase utilization of EHR and

UpToDate

Personalized searched based on the patient’s profile

Easy access in the clinical

Workflow

(“one-shop”)

Increase clinician satisfaction

Benefits

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Standard search

UpToDate accessed via search box, button/icon or link

Very limited contextual support (e.g., adult/pediatric/patient)

HL7 Infobutton or HL7-assisted free text search

More contextual information is sent for an HL7 targeted search

than for a standard targeted search

UpToDate accessed via a button/icon or search box

Access Options:

Standard Search versus HL7 Infobutton

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Leveraging HL7 Infobuttons

Context Aware Knowledge Retrieval Applications

“Lower barriers to the access of knowledge

resources at the point of need” (HL7)

Tailored searches of CDS content contextual to your

specific patient

Search CDS targeted to your patient:

• Disease

• Condition

• Medication

• Lab results

• Age

• Gender

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Are You Future-Ready?

CDS considerations for your eHealth Strategy

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An Achievable Vision: CDS everywhere

Imagine:

• CDS resources accessible in

the workflow of all your

country’s major clinical

systems within 3 years.

• Improved access to CDS

ensuring improved quality of

care

• Estonia at the vanguard of

medicine

• Treat mobile as “the” next platform

• Not a “nice-to-have”, but a “must-have”

• Develop next-gen experience with mobile in mind:

• Globally scaled: Multi-language search and navigation

• Mobile-Responsive display/formatting

• Adaptable for smartphones vs tablets

• App support for iOs, Android, Windows 8

• Ease of use tools for mobile: Bookmarks, history, etc.

• Access support for both individuals and enterprises.

Evolving Clinical Decision Support for Mobile

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CDS: Impact for Estonia

Healthcare Standardization => Health democracy (Geo/Function)

Egalitarian InfOstructure = > Unlimited usage 24/7 > Anywhere,

Anytime, as much as needed and on-demand.

Easy to integrate into your eHealth strategy/EHR => Quick Win.

Demonstrated ROI => Scalable and Sustainable Healthcare System.

Advancement of medical education => Capacity Building /e-Learning)

Key Building Block of eHealth Strategy (possible from Phase I) and one of

the best solutions at the point of care.

IMPROVED HOSPITAL PERFORMANCE AND PATIENT CARE

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Evaluate CDS in a partnership between HIT and clinical leaders

Ensure that CDS is an integral part of your EHR plan from the

outset

mHealth is here to stay – include CDS in your eHealth strategy

Getting it Right: Anticipate Tomorrow’s CDS Today

Aitäh!

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