hitasthma: a tale of woe and enlightenment

www.CenterForUrbanHealth.org

AHRQ Annual Meeting09SEP08

HIT Asthmaa tale of woe and enlightenment

Yiscah Bracha, [email protected]


Project Objective:

• Demonstrate use of HIT to improve ambulatory asthma care

• Two existing technologies:1. Interactive Asthma Action Plan (IAAP)

(developed by MN Dept of Health)2. Commercially available electronic

health record (EHR) (EpicSystems Inc.)


What we knew:

• For asthma, IAAP beats Epic in user and patient friendliness

• Difficult for Epic user to get to IAAP• Untapped potential to use EHR data

to support QI


What we wanted to propose:

• Make IAAP available from within Epic-driven workflow Brings guidelines to the point of care

• Use IAAP database as asthma registry Evaluate effect of QI initiatives Identify at-risk patients Generate reports required by external

agencies


• Existing IAAP based on guidelines released in 2002

• 2007 guidelines soon to be released• Our project would link the EHR

system to a soon-to-be-obsolete tool

One small problem…


What we actually proposed:

• Update IAAP to be consistent with 2007 guidelines

• Make updated IAAP available from within Epic-driven workflow Brings new guidelines to the point of care

• Use IAAP database as asthma registry Evaluate effect of QI initiatives Identify at-risk patients Generate reports required by external agencies


Expected challenges

• Accessing IAAP from Epic Pushes boundaries both technically &

organizationally

• Creating & using asthma registry Technology well-understood;

organizational barriers to readiness

• Updating IAAP Trivial technically; no impact

organizationally


3 months after project inception:

• IAAP-EHR interface: Technical boundaries identified Organization is ready within those

boundaries

• Registry Organizational barriers quickly overcome Demanding to establish what fields to

pull, but a well-understood task.

• Update IAAP ….


• “It will be simple to update the existing IAAP to make it consistent with the new guidelines”

Famous last words:


Oops:

• Original IAAP contained: Out-of-date, unsupported version of Java Database not designed to support

analysis List of meds not designed to be updated

• “Update” of any kind not possible Radical shift in perspective from 2002 to

2007 FROM: Treating acute symptoms TO: Managing chronic disease


The struggle:

• Clinicians try to convert guidelines directly into screens: They get trapped in logical circles from

which they cannot escape

• Analytically-minded Project Director tries to display their thinking in flow diagrams Clinicians can’t follow the diagrams

• Many expressions of frustration exchanged!


Some concerns:

• Close scrutiny of guidelines reveals: Ambiguous and/or internally

inconsistent recommendations: Inadequate dosing instructions for young

children Recommendations for formulations not

available commercially

Recommendations for off-label uses of drugs Drugs for young children not approved by

FDA


More concerns:

• Even with close scrutiny, no answers to front-line clinical questions: What should the dosing instructions be

in the “red zone” of the asthma action plan?

How can we determine the current treatment step for a new patient who is already receiving asthma care?


And more struggles:

• Enormous effort required to communicate needs to software development company

• Even with that effort, still uncertainty that they really understand what’s required


The tale of woe…

• We are failing at our most trivial task AHRQ will give up on us We will disappoint the users whose

expectations we have raised

• We have over-extended ourselves and our budget trying to cope with this

• If we succeed, who will be responsible for harm that may arise because we delivered vague guidelines to the point of care?


The tale of enlightenment:

• Bob* (unexpectedly) says: This is very interesting! Let’s reduce your anxiety … there are lots

of ways to make lemonade here We have an agency interest in alternative

ways to disseminate guidelines Document these issues Analyze them Make recommendations to future expert

panels

* Bob Mayes, our AHRQ Task Order Officer


From: Expert Panel Guidelines

To:

Electronic Clinical Decision Support:


What are the Primary Challenges?

• Logical complexity• Volume of therapeutic choices• Different languages used by:

Academic experts Front-line clinicians with limited time Patients responsible for self-

management


The Primary Challenges


Academic experts Front-line clinicians with limited time Patients responsible for self-

management


The human mind:

• Do I know this patient?• Is the patient already being treated?

How aggressively? Is the patient being treated the right way?

• How is the patient doing? Is the therapy adequate? Is the patient using the therapy as prescribed?

• What might happen if I changed the dose?


The software mind…1. System displays all known values, as

shown on UI screen.

2. User accepts or changes value for weight

3a. User accepts value

for weight

4b. System changes value for date of last weight to current date.

5. User accepts or changes value for height.

7b. System changes value for date of last height to current date. System

changes value of predicted peak flow.

3b. User changes value

for weight

6a. User accepts value

for height

6b. User changes value

for height


More peaks into the software mind…

10.System transfers user to

‘Determine Control’ interface.

1.IAAP Screen_03_01. (User Interface_03_01)

User opts to establish asthma control or severity.User opts to infer level, or to enter known level.

To User Interface_03_01

8. System check: If neither current

treatment step nor pharmacy order for

asthma meds available, then

POPUP

6. USER CHOOSES:ASSESS CONTROL

3a. USER CHOOSES:Infer severity from

symptoms

3b. USER CHOOSES:Enter severity level

as known.

4a.System transfers user to process that classifies

severity from symptoms

4b.System calculates [step_recommend],

based on severity and patient age.

To Pop-Up_03_02To Process Flow_04S

To Process Flow_04CTo Function_04. Step recommend.

Clinicians: How do you want to

handle this choice and/or this screen

if there is an existing value for

severity in the system?


Human vs software “minds”:

Humans Software

Fast, unarticulated thought processes

Series of nested and explicit if-then statements

“Gestalt” Linear, step-by-step

Counterfactuals entertained

Counterfactuals not possible

Approximate meanings of words OK

Precise meaning of words required

Can tolerate ambiguity

No tolerance for ambiguity


The negotiation challenge:

• Clinicians must: Clearly explicate their thought processes Force themselves to use precise

vocabulary Think linearly

• Software developers must: Obtain necessary initial values without

burdening users Replicate clinical “flow”


Software Development Challenges

• Logical complexity• Volume of therapeutic choices• Bridging languages

Academic medical expertise Front-line clinicians with limited time Patients responsible for self-

management


From this….


… to this


Combinatorial volume

• > 23,000 possible combinations of Age Step Preferred vs. alternative Instructions for use Brands

• Some combinations are impossible, or unsupported by evidence, or contradict FDA

• Changing all the time New drugs New delivery mechanisms New evidence


Challenges posed by volume:

• Effort required to capture all possibilities

• Likelihood of errors & inconsistencies increase with volume

• Deciding when to stop, when every month something new comes out

• Responsibility for on-going maintenance


Software Development Challenges


Academic medical experts Front-line clinicians with limited time Patients responsible for self-

management


Different words for same ideas:

Academic: Clinical: Ordinary:

Long-acting beta agonist

Daily controller

Purple inhaler

FEV1 actual vs. predicted

What you can and should be able to blow

My top number on the meter

Exacerbation ED visitI thought my child would die


Because of differing vocabulary:

• Text in guidelines doesn’t work on screen Guidelines: “Step up one” Clinician question: “What is the current

step?” (Patient question: What is a step?)


Because of differing vocabulary:

• On-screen text for clinical users doesn’t work in asthma action plan. Drug example:

Clinician: Fluticasone MDI (44 mcg/puff) Patient: Fluticasone inhaler 44 mcg

Condition example: Clinician: Best peak flow, predicted peak

flow Patient: Peak flow


The challenge posed by vocabulary:

• Anticipating who the user/consumer is

• Testing vocabulary with users to make sure it works

• Resolving conflicts between need for specificity among one group of users vs. need for simplicity among another

Some preliminary conclusions


Policy Qs the process reveals:

• At what point in guideline development should “codification” be considered? By the expert panel while deliberating? After the text of the guidelines released?

• Who is responsible for resolving textual inconsistencies and ambiguities? Expert panel? Software developers? Front-line clinicians?


Addl policy Qs the process reveals:

• What should the “update” process be? Reconvene expert panel every xxx years? Regular software maintenance?

• Should users be enabled to maintain their own lists of therapeutic choices? Pros: Can be customized to site (e.g.

locally supported formularies) Cons: Induces site-to-site variability in

dissemination of latest evidence


Sustainability questions

• Who bears the costs of development? Original guidelines Original software for guideline-based

decision support

• Who bears the costs of maintenance? Guidelines Software, especially when software and

clinical expertise are seldom the same


Our work continues:

• Conveying user requirements to software developers, where requirements include: Adherence to interpreted guidelines “Smooth” & supportive clinical workflow

• Documenting issues we encounter in attempting to achieve that goal

• Preparing our sites for implementation, albeit a year late


And:

• Sharing process & results with all of you!


Improving Asthma Care in an Integrated Safety Net through a Commercially Available Electronic Medical

Record

Prime contractor: Denver Health and Hospital Association. Subcontractor: Minneapolis Medical Research Foundation. Project site: Hennepin County Medical Center, Mpls MN

AHRQ Contract No. HHSA290200600020, Task Order No. 5

Staff and contractors – Minneapolis Medical Research FoundationGail Brottman, MD (Chief, Pediatric Pulmonology, HCMC)Kevin Larsen, MD (Chief Medical Informatics Officer, HCMC)Yiscah Bracha, MS (Research Director, Center for Urban Health)Cherylee Sherry, MPH (Project Manager, Pediatric Research & Advocacy HCMC )Touch Thouk (Administrative Manager, Center for Urban Health)Angeline Carlson, PhD (Principle, Data Intelligence Inc.)

Staff – Denver Health and Hospital AssociationSheri Eisert, PhD (Director, Health Services Research)Michael (Josh) Durfee (Research Projects Coordinator, Health Services Research)

Contributors of Ideas, Information & Effort:Michael Barbouche (University of Wisconsin Medical Foundation); Robert Grundmeier, MD (Children’s Hospital of Philadelphia); Michael Kahn, MD, PhD (Denver Children’s Hospital)Donald Uden, PharmD (University of Minnesota), Faith Dohman, RN (Hennepin Faculty Associates); Susan Ross, RN (Minnesota Department of Health)

www.CenterForUrbanHealth.org… … and now, Bob and now, Bob Mayes our Task Order Mayes our Task Order

OfficerOfficer

hitasthma: a tale of woe and enlightenment

Technology

existing iaap

update iaap

iaap trivial

original iaap

vague guidelines

iaapehr interface

ambulatory asthma care

iaap untapped potential