decision support at the point of care robert a. greenes, m.d., ph.d. harvard medical school brigham...
TRANSCRIPT
Decision Support at the Point of Care
Robert A. Greenes, M.D., Ph.D. Harvard Medical School
Brigham & Women’s Hospital
Boston, MA, USA
Representing & Managing Knowledge & Integrating it into the Care Process
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We are at a turning point in clinical information systems
Old focus: EMR, retrieval, reporting, communication
New focus: Knowledge access & decision support
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Seeds of change
New technologies for Dx & Rx Medical literature doubling every 19 yr
– Doubles every 22 months for AIDS care– 2 million facts needed to practice
Gene expression analyses doubling every 8 months
volume
months
Medline reports
gene analyses
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Safety and quality concerns
To Err is Human (IOM 1999)– Adverse events in up to 3.7% of
hospitalizations in US• Up to 13.6% lead to death
– Half preventable• 22,000 – 49,000 people
– Medical errors kill more people than MVAs (43,458), or breast cancer (42,297)
– Costs to society of $17-29B • 50% is health care
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The treatment gap
Approximately 25% of U.S. population has an abnormal LDL requiring intervention– 10% qualify for drug intervention – Of those, only ¼ are presently being treated– Treatment gap for hyperlipidemia presently =
7.5% of US population)
Disparities: Variability in CABG
where HRR = Hospital Referral Region
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Demand for change
Crossing the Quality Chasm: A New Health System for the 21st Century
– Safe– Effective – Patient-centered – Timely – Efficient – Equitable
Richardson, William C.Crossing the Quality Chasm,Institute of Medicine, 2001
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More involved in care process More knowledgeable More activist More technically savvy
Consumer empowerment
Disclosure
Demand for CPOE
Amendment to California SB 1875 Introduced
On February 15, 2002, California state Sen. Jackie Speier (D-San Francisco/San Mateo) introduced Senate Bill (SB) 801, which amends Section 1339.63 of the California Health and Safety Code, bolstering the requirements specified by SB 1875, “Facility Plan to Eliminate or Substantially Reduce Medication Errors.”
SB 1875 required as a condition of licensure that all general acute care hospitals, surgical clinics, and special hospitals adopt a formal plan to eliminate or substantially reduce medication-related errors. Plans must be implemented on or before January 1, 2005.
Amendment to California SB 1875 Introduced
On February 15, 2002, California state Sen. Jackie Speier (D-San Francisco/San Mateo) introduced Senate Bill (SB) 801, which amends Section 1339.63 of the California Health and Safety Code, bolstering the requirements specified by SB 1875, “Facility Plan to Eliminate or Substantially Reduce Medication Errors.”
SB 1875 required as a condition of licensure that all general acute care hospitals, surgical clinics, and special hospitals adopt a formal plan to eliminate or substantially reduce medication-related errors. Plans must be implemented on or before January 1, 2005.
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Error reduction, safety, quality Safety
– Appropriate drug dose & form– Adjustments
• allergies, renal status, age, contraindications• interactions
Quality– Best Rx for indication – Appropriate referrals
Cost-effectiveness, efficiency– Reduced redundant or inappropriate tests– Generic or lower-cost medications– Order sets & care pathways– Optimal workflow
Correct dispensation, administration Monitoring for adverse events Providing feedback, education
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Experience exists
Demonstrated success of CPOE– Error checks, ADE reduction– Decreased cost
Alerts & reminders Appropriateness criteria Guidelines
BWH Order entry
Drug-drug interaction alert
Lab alerts
Order sets
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Other functionality
Check for redundant tests Interpretive reporting Identify non-indicated imaging procedures Adverse event monitoring rules Charge display Signout Reference/handbook
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Cost-effective
55% decrease in serious medication errors– Bates, JAMA 1998
Decreased redundant labs– Bates, Am J Med, 1997
More appropriate renal dosing
No reduction in inappropriate x-rays– Harpole, JAMIA, 1997
Minimal effect of charge display– Bates, Archives of Internal
Medicine, 1995 More appropriate dosing,
substitutions accepted – Teich, Archives of Internal
Medicine, 2000 Decreased vancomycin
use– Sojania, JAMIA, 1998
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Guidelines
Much development of guidelines since 1970s
Recent efforts aimed at computer-based interpretation– Goal of delivering patient-specific
recommendations at point of care– Guidelines as core technology for many
decision support applications
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Guidelines as a core technology
Protocol-based care Chronic disease management Consultations Critical pathways, UR/monitoring Referral management Workflow/process optimization “Infobuttons” Education/training …
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All told, there is much to cheer about …
Public interest, demand Growing number of activities Successes
– in error reduction– in cost-effectiveness
Momentum is building!
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So what’s broken?
Limited availability– Most successes are one-of-a-kind, often
academic– Slow diffusion
Converting research to care
Publication
Bibliographic databases
Submission
Reviews, guidelines, textbook
Negative results
variable
0.3 year
6. 0 - 13.0 years50%
46%
18%
35%
0.6 year
0.5 year
9.3 years
Dickersin, 1987
Koren, 1989
Balas, 1995
Poynard, 1985
Kumar, 1992
Kumar, 1992
Poyer, 1982
Antman, 1992
Negative results
Lack of numbers
ExpertExpertopinionopinion
Inconsistentindexing
17:14
Original research
Acceptance
Patient Care
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
17 years to apply 14% of research knowledge
to patient care!
17 years to apply 14% of research knowledge
to patient care!
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So what’s broken? Limited availability
– Most successes are one-of-a-kind, often academic
– Slow diffusion Incompatibility among approaches Little sharing of experience or capabilities Little ability to share
– Knowledge embedded in systems– Difficulty to extract, generalize, and replicate– Vendor incompatibilities, lack of standards
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Non-technical factors Isolated implementations
– Getting the message out– Failures as well as successes
Regulatory issues– e.g., HIPAA
Financial constraints or disincentives Cultural issues
– “Culture eats strategy for lunch”– Leadership and commitment level
Human factors– Ease of use– Time requirements
Cedars-Sinai Experience
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Technical factors
Infrastructure limitations– Vendor capabilities, platform– Foundational systems: EMR, KBs– Design approach
Lack of local expertise Inability to capitalize on
external expertise
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Standards & sharing Major area of activity in past two years Gaining momentum
– National Health Information Infrastructure (NHII)
– National Electronic Disease Surveillance System (NEDSS)
– Legislative initiatives• For quality and safety, support of NHII
– Advocacy• Connecting for Health (Markle Foundation)• Leapfrog Group
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Decision support has special requirements
Knowledge bases– Evidence-based, authoritative
• e.g., drugs, interactions, contraindications, alternative forms Decision rules
– Calculations, constraints• e.g., limits, ranges, dose adjustments
– Alerts and reminders– Guidelines
Regularly updated Expressed in executable form
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Executable KBs are expensive to develop & update
This argues for:1. Standard representations for KBs
2. Shared content repositories
3. Tools • For authoring and updating
• For adaptation, integration into host systems
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Arden syntax was first approach to knowledge standardization
For Medical Logic Modules (MLMs)• single step rules/reminders
– data section defining all variables– logic section defining conditions– action if the condition is true
Intended as a standard– First proposed early 1990’s– adopted by ASTM and then HL7 in mid-late
’90’s
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Guideline standardization: the GLIF* experience
Goal of creating a common representation for sharing executable clinical guidelines
InterMed project of Harvard, Columbia, Stanford
Supported by NLM, AHRQ, Army
* GuideLine Interchange Format
Get age and occupation
Health-care workeror Age>65?
Yes
NoGive Flu shot
Do Nothing
Flu vaccine guideline
Asympto-matic
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Decision step, in GLIF
{ name = “High risk determination”;
condition = Boolean_criterion 1
{ type = Boolean;
spec = “HCW OR age>65”;};
destination = (Action_Step 3);
otherwise = (Conditional_Step 2);}
Guideline authoring
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Standardization effort Clinical Guidelines Special Interest Group
formed in HL7– Part of Clinical Decision Support Technical
Committee– Arden Syntax SIG also under this TC– First meeting in Jan ’01
CDS TCCDS TC
CG SIGCG SIG Arden Syntax SIGArden Syntax SIG
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Standards approach
Work in HL7 CDS TC focusing on common infrastructure components:– vMR: an object-oriented virtual medical record subset
for decision support – GELLO: object-oriented query & expression
language – for all decision rules– Vocabulary management tools– Taxonomy of services invoked by rules
Work in HL7 CG SIG– Process/workflow model
• Specific to guidelines
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Knowledge content resources Meds, interactions Indications, allergies, contraindication,
interactions Templates for orders Order sets Rules
– for order entry safety, quality, efficacy checking– for dose modification for age, renal disease, …– for monitoring for ADEs
Clinical guidelines & care pathways Clinical trial protocols
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Content dissemination
Government repositories– GenBank, Nat. Guideline Clearninghouse:
guidelines.gov, ClinicalTrials.gov Consortia, open source libraries
– IMKI, OpenClinical, … Professional specialty organizations
– ADA, ACP, CAP, Medbiquitous, … Commercial
– First DataBank, Micromedex, …
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Tools & infrastructure
For authoring, validation, dissemination, adaptation, execution
Most difficult problem Must be done in conjunction with
standards & content development Should follow a lifecycle process
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Conclusions - 1
Health care safety & quality now a priority
Examples of successful approaches demonstrate potential benefits
Yet impediments to widespread experimentation, dissemination, and adoption
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Conclusions – 2
Concerted effort needed for integrating knowledge– Standards-based approaches– Sharing of knowledge, tools, and experiences– A joint activity of academic, vendor, health
provider, payer, and public sectors