Advancing Clinical Decision SupportDefining CDS Meaningful Use Objectives for

Clinical SpecialtiesEric C. Schneider, MD, MSc

Senior Scientist and Director, RAND BostonAssociate Professor, BWH and Harvard University

Sponsor: Office of the National CoordinatorHHSP23320095649WC--HHSP23337009T

May 13, 2011

                              

         

Presentation Outline

• Challenge • Goal of ACDS Task 6• Representation of CDS opportunities • Expert panel protocol• High-level results• Future opportunities

The Challenge: Relative Paucity of Specialty-specific

Clinical Decision Support (CDS) for Meaningful Use

• EHRs not yet widely in use• Use of CDS in practice is rare• Relatively few CDS tools currently available for

specialty care• Specialty workflow is highly variable so optimal uses

of CDS still uncertain

Goals of ACDS Task 6

• To develop a protocol for engaging specialists in the development and prioritization of future meaningful use objectives and measures related to Clinical Decision Support (CDS)

• To identify candidate CDS priorities for four specialties

What is a CDS Opportunity?

Specialist Panel Protocol

High Level Summary of Results

CDS Opportunity Sets* CDS Opportunities

Four PanelsConsidered

Rated high priority

ConsideredRated high

priority

Oncology(breast/CRC) 15 14 44 31

Orthopedics(hip/knee surgery)

6 3 16 4

Cardiovascular(PCI) 11 4 34 11

Pediatrics (general) 11 3 35 10

* A set is a collection of CDS opportunities that address a specific clinical performance gap.

Clinical Gap Importance Ratings: Oncology Example

Gap ImportancePotential Impact

(CDS Tools)Compatibility (CDS Tools)

Clinical performance gaps Median SD Median SD Median SD

Cancer patients receiving chemotherapy are at risk of experiencing adverse events due to errors in chemotherapy ordering

9.0 0.8

Cancer-specific documentation template that supports accurate staging for the type of cancer. 9.0 0.4 9.0 0.4

Info button to check latest staging criteria at the time that cancer diagnoses are being entered. 8.5 0.8 8.0 0.5

Cancer patients often have poorly documented information on staging

9.0 0.8

Cancer-specific documentation template that supports accurate staging for the type of cancer. 8.5 0.8 9.0 0.7

Info button to check latest staging criteria at the time that cancer diagnoses are being entered. 8.0 1.5 9.0 0.8

Patients undergoing chemotherapy often fail to have a current care plan documented.

9.0 0.5

Pathway based on standard multi-cycle regimens with order sets and appropriate refinements for each step 8.0 0.6 8.5 0.7

Smart form for chemotherapy that prompts documentation of current care plan and reasons for deviation from previous plan.

8.0 0.8 8.0 0.6

Timeline display of prior adverse reactions and therapy adjustments that should inform current care plan. 7.5 1.7 8.0 1.5

Clinical Gap Importance Ratings: Oncology Example

Gap ImportancePotential Impact

(CDS Tools)Compatibility (CDS Tools)

Clinical performance gaps Median SD Median SD Median SD

Cancer patients receiving chemotherapy are at risk of experiencing adverse events due to errors in chemotherapy ordering

9.0 0.8

Cancer-specific documentation template that supports accurate staging for the type of cancer. 9.0 0.4 9.0 0.4

Info button to check latest staging criteria at the time that cancer diagnoses are being entered. 8.5 0.8 8.0 0.5

Cancer patients often have poorly documented information on staging

9.0 0.8

Cancer-specific documentation template that supports accurate staging for the type of cancer. 8.5 0.8 9.0 0.7

Info button to check latest staging criteria at the time that cancer diagnoses are being entered. 8.0 1.5 9.0 0.8

Patients undergoing chemotherapy often fail to have a current care plan documented.

9.0 0.5

Pathway based on standard multi-cycle regimens with order sets and appropriate refinements for each step 8.0 0.6 8.5 0.7

Smart form for chemotherapy that prompts documentation of current care plan and reasons for deviation from previous plan.

8.0 0.8 8.0 0.6

Timeline display of prior adverse reactions and therapy adjustments that should inform current care plan. 7.5 1.7 8.0 1.5

Top CDS Opportunity Ratings for PCI

10

Clinical performance gaps

CDS OpportunityCDS

Category

Nearly half of patients with STEMI receive no reperfusion therapy or receive delayed reperfusion (>12 hours after onset).

Display ECG data, TIMI/GRACE scores, and likely time of symptom onset.

Relevant data presentation

Alert to inform ED physician and staff of possible ACS diagnosis triggered by abnormal biomarkers

Alerts/reminders

Many patients undergoing PCI are not prescribed statins at discharge despite having no contraindications.

Order set that includes statins along with other medications commonly prescribed at discharge from the cath lab

Order set or ordering tool

Reminder followed by alert to prescribe statin prior to discharge if not yet ordered

Alerts/reminders

Top CDS Opportunity Ratings for Orthopedics

11

Clinical performance gaps

CDS Opportunity CDS Category

Patients are not always assessed pre-operatively for their bleeding and VTE risks resulting in prophylaxis that does not match the patient’s risk.

Smart form that captures bleeding and VTE risk factors and recommends a prophylaxis strategy in accordance with guidelines.

Documentation forms/templates

Patients undergoing total hip or total knee replacement surgery may not receive VTE prophylaxis when it is indicated.

Order set for VTE prophylaxis that recommends treatment customized to patient’s bleeding risk and that conforms to guidelines.

Order set or ordering tool

Top CDS Opportunity Ratings for Pediatrics

12

Clinical performance gaps

CDS Opportunity CDS Category

Children and adolescents fail to receive all recommended immunizations.

Display immunization history and highlight missing immunizations.

Relevant data presentation

Order set that includes all recommended immunizations.

Order set or ordering tool

Alert for missing immunizations, with link to order set.

Alerts/reminders

Children with asthma are not routinely monitored for control of their condition.

Pathway to guide dose escalation or medication substitution.

Protocol or pathway support

Considerations for Future Panel Protocol

• Background materials– Availability of CDS tools and evidence– Development of clinician-friendly formats for conveying CDS

opportunities

• Panel-specific considerations– Content focus (disease, treatment, procedure)– Relevant settings (ambulatory, surgicenter, hospital, etc.)– Selection of panelists– Assisting panelists to focus on workflow insertion points

RAND HEALTH

15

CDS Evidence Table

15

Tool Description Impact on Performance

Impact on Workflow

Citation

Order Set/Ordering ToolHandheld computer with recommendations for management of acute asthma exacerbation

Handheld computer with AsthMonitor software. The clinician documents the encounter on the computer and the system generates recommendations for acute asthma exacerbation management based on the AAP guidelines including dosage calculations. The clinician can also print encounter summaries and prescriptions.

• Significantly increased adherence to guidelines for oxygen saturation measurement (56% vs. 29%, p<.01) and for systemic corticosteroid prescriptions (p=.055).

• There was no significant impact on adherence to guidelines for PEFR measurements, metered dose inhaler treatments, or oxygen treatments.

• The average duration of clinic visits was significantly longer when the AsthMonitor was used (p<.001).

(Shiffman, Freudigman et al. 2000)

16

Performance Gap/CDS Opportunity MatrixGap #4: Children often have poor documentation of their BMI and the corresponding percentile of the population distribution.

Actions that can be taken to reduce gap:For children aged 2 to 17 years:

•Determine overweight/obesity status

Information needed by

CDS system

Potential work flow insertion

points (relevant

personnel)

Potential CDS Opportunities

Documentation forms/templates

Relevant data

presentation

Order set or

ordering tool

Protocol or pathway support

Reference information

Alerts/reminders

•Patient’s BMI•Age- and gender-specific BMI percentiles

•History/ exam (physician, nurse)

Smart form that calculates BMI and determines obesity status.

Display patient’s weight/BMI data (current and historical) relative to national norms.

Alert if EHR does not have recent documentation of patient’s height and weight.

Rating Criterion #1: Importance of Clinical Performance Gap

• A gap is considered more important if it…– Affects a relatively large number of patients

(prevalence)

– On average, there are significant consequences to the patient in terms of increased morbidity, mortality or risk

– Poor performance leads to inefficient use of resources/waste in health care spending

– Scientific evidence or professional consensus exists on one or more actions to address the performance gap.

– The gap may be addressed by patient engagement and delivery of more patient-centered care

18

Rating Criterion #2: Compatibility of CDS tools with clinical

practice

• One or more of the CDS tools within the opportunity set can be readily introduced into a specialist’s workflow and/or the workflow of others on the care team

• The specialist or other members of the care team are likely to use the CDS tools in daily practice

19

Rating Criterion #3: Potential Impact of the CDS opportunity on

the clinical performance gap

• The CDS tool can provide the majority of the information needed to address the clinical gap.

• Information deficiencies or low-reliability systems are the main contributor to the performance gap rather than clinical uncertainty, insufficient scientific evidence, or other factors.

Top CDS Opportunity Ratings for Oncology

20

Clinical performance gaps

CDS Opportunity CDS Category

Many patients receiving chemotherapy are at risk of experiencing adverse events due to errors in chemotherapy ordering

Smart ordering forms that help reduce errors.Order set or ordering tool

Alert at time of ordering or infusion if chemotherapy orders differ from accepted standards.

Alerts/reminders

Cancer patients often have poorly documented information on staging.

Cancer-specific documentation template that supports accurate staging for the type of cancer.

Documentation forms/templates

Info button to check latest staging criteria at the time that cancer diagnoses are being entered.

Smart links to reference information