s06/s29:configuring cds rules to improve care and achieve mu

8/9/2019 S06/S29:Configuring CDS Rules to Improve Care and Achieve MU

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Configuring CDS Rules To ImproveCare And Achieve Meaningful Use

AMIA NOW!,

FacultJerome A. Osheroff, MD

Robert A. Greenes, MD, PhD

ra nwar, ,



Workshop Objectives

• escr e genera s ra eg es or success uCDS deployments; e.g. ‘CDS 5 Rights.’

• n ers an ro e or ma er a s or com ngfrom AHRQ to support CDS ruleim lementation.

• Demonstrate skill in configuring CDS rulesto address meanin ful use and related

performance improvement targets.

• implementation considerations.



Jerome A. Osheroff, MDChief Clinical Informatics Officer, Thomson ReutersAdjunct Assistant Professor of Medicine, University of Pennsylvania

Robert A. Greenes, MD, PhDIra A Fulton Chair and Professor, Department of Biomedical Informatics

Arizona State University

Siraj Anwar, MS, MBBSCDS Clinical InformaticistMemorial Hermann Healthcare System

-



Sector?• ea care e very vs. o er consu an , ven or

• Large/small practice vs. hospital/health system

Role?• Informatics (CMIO/director) vs. IT vs. other

CDS stage?

• ave you ever mp emen e a ru e



Of Meaningful Use…

…prov e persons nvo ve n care

processes with general and person-

,

and organized, at appropriate times, to

enhance health and health care” – from

MU NPRM

Includes/builds on current processes…

6

…



HIMSS/AMIA Textbook •2005 HIT book of the

year

•All-time HIMSS

•Published by Elsevier,2007

•Widely used reference

•Widely used by

CMIOs/others

•Focus on fundamentals,technologies, and

strategies

•Co-published 4/09 byleading societies; ~100

•2009 HIT book of theyear

-

•10 commandments for CDS:Bates et al. JAMIA 2003

AHRQ, 3 CIS vendors

•“This is not a book”



Rules to query. .

registries) toidentify patients

needingintervention

Population-based Encounter-based



Goals of Structured Care Recommendations for

pro ec

• 12-month project funded by AHRQ (Oct 09-Sept 10)

• Thomson Reuters as prime, subcontractors at Arizona State, UCSD, and Intermountain Health

• Goal is to develop methods to facilitate wide dissemination and uptake of CDS

• Focus on US Preventive Services Task Force (USPSTF) prevention and screening

• Limit to A & B recommendations (45 in all)

• Turn these into implementable rules (alerts, reminders, etc.)

• Also include selected additional recommendations tied to Meaningful Use QualityMeasures

• Emphasis on

• Consensus on level of specificity to satisfy vendor/implementer desires for further adaptation bythemselves

• Adaptable to multiple platforms

• Approach

• Rapid turnaround

• Broad availability of results

• Iterative refinement in future efforts



Life Cycle of Rule Refinement

Start with EBM statement (such as USPSTF recommendation)

age

1. Identify key elements and logic – who, when, where, what to be done

• Structured headers, unstructured content

• e ca y spec c

2. Formalize definitions and logic conditions

• Structured headers, structured content (terms, code sets, etc.)

•

3. Specify adaptations for execution

• Taxonomy of possible workflow scenarios and operational considerations

• - -

considerations as start of this stage

4. Convert to target representation, platform, for particular implementation

• Host language (Drools, Java, Arden Syntax, …)

• Host architecture: rules en ine SOA other

• Ready for execution



1. Header Information

eRecommendation Name USPSTF SCREENING FOR BREAST CANCER

(B Recommendation on mammography only)

Recommendation Set USPSTF A and B

Recommendations

eRecommendation ID USPSTF-MAMMO-B-REC Set ID USPSTF-A-B-RECSeRecommendation Version Date/Number Recommendation Version Date/Number 2 (revision of 2002 guidelines)

Template Version Date/Number

Related eMeasure(s) PQRI112:Preventive Care and Screening: Screening Mammography [PQRI age range40 69]

Author

Verified by

Maintained by Agency for Healthcare Research and Quality (AHRQ) and Preventive Services Task Force (USPSTF)

Description/Purpose U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for breast cancer in the general population.

Recommendation Text from Source Summary Statement The USPSTF recommends biennial screening mammography for women between

the ages of 50 and 74 years.

Additional Inclusion/Exclusion Criteria . . . . . . . . . This recommendation statement applies to women 40 years or older who

are not at increased risk for breast cancer by virtue of a known underlying genetic

mutation or a history of chest radiation. . . . . . .

Setting (if specified by Source) Not specified. See implementation considerations.

Recommendation classification Screening: primary prevention

Rationale Importance

Breast cancer is the second-leading cause of cancer death among women in the . Widespread use of screening, along with treatment

advances in recent years, has been credited with significant reductions in breast cancer mortality.

Mammography, as well as physical examination of the breasts (CBE and BSE), can detect pre-symptomatic breast cancer. Because of its demonstrated effectiveness in randomized, controlled trials of screening, film mammography is the standard for detecting breast

cancer; in 2002, the USPSTF found convincing evidence of its adequate sensitivity and specificity.

Benefits of Detection and Early Intervention:

There is convincing evidence that screening with film mammography reduces breast cancer mortality, with a greater absolute reduction

for women aged 50 to 74 years than for women aged 40 to 49 years. The strongest evidence for the greatest benefit is among women

aged 60 to 69 years.

15

Reference Clinical Guidelines: Screening for Breast Cancer: Preventive Services Task Force Recommendation Statement. U.S. Preventive

Services Task Force. Ann Intern Med 151:716-726

Reference URL http://www.ahrq.gov/clinic/uspstf/uspsbrca.htm



on .

2.b Logic StatementCategory Logic Elements Relevant Note

<Eligibility/inclusion

criteria>

Patient gender = Target gender

AND:<Patient age >= Target age low l imit>

AND

<Patient age <= Target age high limit>

AND: -

<Evidence of condition/risk> statement is a template placeholder for other

rule types: not pertinent to this breast cancer screening sample

<Exclusion criteria> <Patients for whom a different intervention protocol may be warranted>•<Value set: History of chest radiation > = non-null

•OR: <Value set: Known genetic mutation > = non-null

<Patients that have already received intervention within recommendedinterval><Value set: mammogram results documented within 2 years > = non-null

See section 3, subsection on Optimizing Rule Specificity for further details on

operational exclusion criteria, e.g., related to pertinent pending interventions,

etc.

<Operational exclusioncriteria>

[Will depend on implementation considerations/choices: See Section 3,Implementation Considerations for examples ]

<Action> <Recommended action: perform Intervention:procedure/test/medication/counseling/etc.>•<Bilateral mammogram>

o Quality data type: Diagnostic Study Order>

o <Code set: (CPT,LOINC, SNOMED)

o Code list: {list of relevant codes for screening mammography tests}

17



eRec Tem late Sam le Cont.

3. Implementation ConsiderationsOPTIMIZING RULE SPECIFICITY :

Operational datao Notification fired : Provider, date; …

Operational exclusion criteria datao Tests for diagnosis or problem in process or done within specified screening interval: Mammogram completed within past 2 years: Record of the patient having

received a mammogram in the previous 2 years (by history or by stored data); By history: Mammogram externally as per patient history or need for suchre uest to be asked in CDS …

o Pre-existing condition diagnosis or problem: Patient has condition being screened (thus being managed, not in primary prevention mode); … ;Indirect evidenceof diagnosis or problem already made: Recurrent tests or procedures implying diagnosis; <Value set: Pathology diagnoses, cytology, etc.; …

o Rule having fired within specified alerting interval; …

Operational exclusion criteria logic- AND NOT: Tests for diagnosis or problem in process; AND NOT: Pre-existing condition diagnosis or problem;

- ELSE AND NOT: Rule having fired within specified alerting interval; OR NOT: Reason noted for not following rule recorded within specified alerting interval

DETERMIN ING RULE TRIGGERING:• Is operation interactive/real time? Batch mode, e.g., through clinic/practice administration? Can information be obtained from patient at time of rule firing?

DEFINING NOTIFICATION APPROACH :• User notification: Is it desirable to set an indicator that a notification has been delivered, e.g., to avoid redundant firing? Notification Acknowledgment: Is it

, . .,

OBTAINING KEY DATA :• What minimum data are needed to fire a useful rule for this recommendation in your organization?…

ACCOMODATING LOCAL CLINI CAL POLICIES :• Target age high limit; …

18



Governance: Role of CDSOversight Committee

• Co-Chaired by CMIO and System Exec,

• (Primarily led by CDS Clinical Informaticist!!)

-

• Physicians, nursing, pharmacy, quality, case

mana ement risk mana ement informatics ISD

• Reports to (1) System Quality and (2) Clinical

Systems Workgroup



Com rehensive A roach toImplementation

• CDS used to be departmental focused

…

• Now requires more attention on workflow

, ,

notifications

•

systems to optimizing systems to achieve

ualit and safet



Thank You!ra nwar:

[email protected]

Bob Greenes:.

Jerry Osheroff: [email protected]



Workshop Exercise

• Simulates tasks done by CDS experts to

recommendations



Exercise Goal

• Take proposed AHRQ eRecommendation for

implementation considerations for sample

• Worksheet 1: Obtaining Key Data

• Worksheet 2: Determining Rule Triggers and

Defining Notification Approach



Logistics

• Tables:• Small group practice (1-5 practices)

• Medium-sized multispecialty clinic (5-100 providers)

• Large academic medical center (>100 providers)• Assign table spokesperson

• Use templates to structure your analysis

• Time is artificially condensed here…try to focusquickly on most valuable approaches (Worksheet 2)



Read out of pearls from hands-on



Workshop Takeaways

• CDS 5 Rights as a success strategy

• Potential role for eRecs/related shared tools

• Pearls for implementing rules for MU, etc.

• Draft rule on breast cancer

s06/s29:configuring cds rules to improve care and achieve mu

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