tools to support evidence-based clinical...

After the HoneymoonAfter the Honeymoon::Tools to Support EvidenceTools to Support Evidence--based based

Clinical DecisionClinical Decision--MakingMaking

Nancy Greengold, MD, MBANancy Greengold, MD, MBAFebruary 14, 2006February 14, 2006

Introduction and welcome

Presentation ObjectivePresentation Objective

Once we've tied the knot between Once we've tied the knot between knowledge and technology, how do we knowledge and technology, how do we ensure a happilyensure a happily--everever--after partnership?after partnership?

We will explore practical solutions for We will explore practical solutions for implementing actionable evidenceimplementing actionable evidence--based based clinical decision support.clinical decision support.

Many organizations have recognized the importance of having content available to practitioners from within their clinical information systems. But not all of these organizations have effectively integrated the content so that it can be maximally useful to clinicians at the point of decision-making. This presentation will address some of the key promises and pitfalls involved in bringing together content and technology.

Presentation OutlinePresentation OutlineEvidenceEvidence--based Medicinebased Medicine–– Study typesStudy types–– LimitationsLimitations–– Gaps between knowledge and practiceGaps between knowledge and practice

Technology Technology –– to the rescue?to the rescue?–– Clinical decision supportClinical decision support

Implementation successImplementation success–– CustomizationCustomization–– Clinical communitiesClinical communities–– ChampionsChampions–– Feedback/assessmentFeedback/assessment

This presentation will address the meaning of an evidence-based approach, including what it is not. I will explore three major types of clinical decision support and how technology can help narrow the gap between the latest published clinical information and practice. Finally, I will talk about some of the key factors involved in being successful with implementation of clinical information systems.

Dr. Osler PearlDr. Osler Pearl

Medicine is a science of uncertainty and Medicine is a science of uncertainty and an art of probability.an art of probability.

---- 18491849--19191919

Sir William Osler’s quote is perhaps a valuable reminder that medicine is often not as scientific as we might think or want it to be. Being aware of some of the limitations of an evidence-based approach is important to appreciating how we can blend this approach with an experiential one, taking into account the individuality of the patient (and values of the patient) in making clinical decisions.

Aphorism: Aphorism: On the EvacuationsOn the Evacuations

A copious sweatA copious sweat……indicates a superabundance of indicates a superabundance of humidity; we must evacuate then, in a strong humidity; we must evacuate then, in a strong person upward, and in a weak one, downward.person upward, and in a weak one, downward.

Hippocrates, 460 B.C.Hippocrates, 460 B.C.

This quote from the father of medicine suggests that not all practice guidelines have always been based on rigorous controlled trials, but rather based on observation, which is not a flawless approach.

1919thth/20/20thth Century Expert RemediesCentury Expert Remedies

Dr. Pierce's Pleasant PelletsDr. Pierce's Pleasant PelletsDr. WilliamsDr. Williams’’ Pink PillsPink Pills for Pale Peoplefor Pale PeopleProfessor Anderson'sProfessor Anderson's DermadorDermador

»» "good for man or beast" "good for man or beast" »» treated everything from diphtheria, rheumatism, sore treated everything from diphtheria, rheumatism, sore

throat, and bee stings to horse distemper, cracked throat, and bee stings to horse distemper, cracked heels, ring bone, pole evil, mange, and bad breath heels, ring bone, pole evil, mange, and bad breath

A few examples of 19th and 20th century remedies will perhaps reinforce the message that not all medical recommendations, even in our recent history, have been based on scientifically constructed studies.

EvidenceEvidence--Based ApproachBased Approach

Searching

Appraising

Synthesizing

To provide guidelines that

facilitate clinical

decision-making

A Systematic ProcessAvailableevidence

(published articles)

Grading strength

Synoptic information

This schematic illustrates some of the key steps involved in taking an evidence-based approach to developing practice recommendations, includingthe meticulous and systematic process of searching, reviewing, and rating the strength of the literature. For succinct and effective communication with clinicians, the resulting information should be synopsized into small bites of knowledge that can be masticated easily at the point of need. Many institutions are keen to use this information for creating practice guidelines and care pathways that help improve the safety, quality, and cost-effectiveness of care.

Common Types of EvidenceCommon Types of Evidence

Randomized, controlled trialsRandomized, controlled trialsProspective observational studiesProspective observational studiesRetrospective studiesRetrospective studiesExpert opinionExpert opinionConsensusConsensusMetaMeta--analysisanalysisReview articlesReview articlesEconomic AnalysesEconomic AnalysesCase reportsCase reports

This slide is designed to give the reader a sense for the breadth and depth of published knowledge. Many groups consider randomized controlled trials and meta-analyses to be at the top of the heap. However this is not always the case. Many other factors such as study sample size, research methodology, statistical analysis, and follow-up are important in assessing the rigor and validity of any given type of evidence.

Randomization: My Two CentsRandomization: My Two Cents

Random assignment to groupsRandom assignment to groups–– Coin flipCoin flip–– Random number generatorRandom number generator

Potential confounders if not randomly Potential confounders if not randomly selectedselectedWant to minimize biasWant to minimize biasFeasibility/generalizability issuesFeasibility/generalizability issues

Randomized controlled trial (RCTs) are ones in which individuals or groups of individuals are allocated at random to receive one of a variety of interventions. These trials are experimental, wherein the investigator (not the study subject) assigns the intervention to a random sample of the study subjects. Random allocation means that the assignment of groups is not controlled by the investigator or the study subject. RCTs are believed to minimize bias and the problem of confounding. At the beginning of the trial, covariates are supposedly evenly distributed across the groups. The best way to assign groups is to use a random number generator.However, there are reasons that RCTs are not always possible or desirable (e.g., ethical reasons, expense, diseases with rare outcomes that would require huge numbers of study subjects). Also, the results of RCTs may not always be generalizable to groups of individuals who may be eligible for a given intervention but who were not studied in the particular trial.

Observational Study DesignsObservational Study DesignsProspective & RetrospectiveProspective & Retrospective

Cohort designCohort design–– Patients with different levels of exposure are followed forward Patients with different levels of exposure are followed forward in time to in time to

determine the incidence of the outcome in question in each exposdetermine the incidence of the outcome in question in each exposure groupure group

CaseCase--control designcontrol design–– First identify those with the outcome of interest First identify those with the outcome of interest –– the casesthe cases–– Next, the investigator selects the controls from the source popuNext, the investigator selects the controls from the source populationlation–– Good design for studying rare outcomes, which would require a huGood design for studying rare outcomes, which would require a huge sample ge sample

sizesize

CrossCross--sectional designsectional design–– Also called prevalence studiesAlso called prevalence studies–– Exposure and outcome are measured simultaneouslyExposure and outcome are measured simultaneously–– Generally used to provide basis for a subsequent study Generally used to provide basis for a subsequent study

(cohort, case(cohort, case--control, or RCT)control, or RCT)

ExamplesExamples–– Smokers and nonSmokers and non--smokerssmokers–– Carnivores and vegetariansCarnivores and vegetarians

Ref: Jepsen P, et al. Interpretation of observational studies. Ref: Jepsen P, et al. Interpretation of observational studies. Heart 2004;90:956Heart 2004;90:956--960.960.

Observational study designs are believed to be weaker than randomized, controlled trials because there is more bias associated with the former. For example, when the preference of patients, physicians, or investigators determines whether a patient receives a given treatment or control, results can be biased since there are many factors that influence outcomes aside from the treatment itself. If one were to conduct a trial that looked at the development of coronary artery disease in people who eat meat versus those who don’t, one would have to consider the potential confounders – perhaps patients who are vegetarians might be more likely to jog or work out, might go to the doctor more often, and might not smoke. It would be much more powerful to assign patients to be vegetarians or carnivores, although this is a difficult study to do since many people are picky about their eating habits.

Retrospective StudiesRetrospective Studies

Sometimes, for a variety of reasons, the only types of studies one can do are retrospective ones (examples: interviewing patients, reviewing clinical charts). Retrospective studies are generally considered to be inferior to prospective trials because they have more inherent bias including problems of recall and response as well as confounding variables. Nonetheless, retrospective studies can serve a useful purpose.

Case ReportsCase Reports

Helpful for alerting us to issues we had not Helpful for alerting us to issues we had not previously consideredpreviously consideredCan lead to the instigation of randomized, Can lead to the instigation of randomized, controlled trialscontrolled trials

Case reports can be very helpful for calling attention to issues of interest. In fact, many case reports have led to Food and Drug Administrationinvestigations, some of which have resulted in withdrawal of products from the market.

Case ReportCase Report

““Dear DoctorDear Doctor……

‘‘ABC companyABC company’’ has submitted to the FDA a report of a has submitted to the FDA a report of a patient who passed an patient who passed an orangeorange rubbery mass in his stool the rubbery mass in his stool the day after ingesting day after ingesting ‘‘xx’’ Suspension immediately followed Suspension immediately followed by by ‘‘yy’’ Solution. Subsequent testing has shown that mixing Solution. Subsequent testing has shown that mixing ‘‘xx’’ Suspension and Suspension and ‘‘yy’’ Solution (both generic and brand Solution (both generic and brand name)name)……results in the precipitation of a rubbery results in the precipitation of a rubbery orangeorangemassmass……

Systematic testing is underway to determine the cause and Systematic testing is underway to determine the cause and nature of this interaction.nature of this interaction.””

This is an example of a case report.

Conflicts & ControversiesConflicts & Controversies

Hormone replacement therapyHormone replacement therapyCOXCOX--2 inhibitors2 inhibitorsAntiAnti--hypertensive treatmenthypertensive treatmentHysterectomyHysterectomyProstate cancerProstate cancerBreast cancer screeningBreast cancer screening

These topics exemplify the changing of opinion and conflicts over the years with respect to different areas of medicine. Although we may think we have the definitive answers today, the only thing we can count upon is that new studies will be published and more controversy will develop. Nonetheless, most people agree that it is valuable to know the latest evidence even though it likely will not be the last word.

Applying the EvidenceApplying the Evidence

Most agree that having current evidence is importantMost agree that having current evidence is importantYet there are Yet there are major gapsmajor gaps between between what is knownwhat is known and and what we dowhat we do in practice:in practice:–– ““The lag between the discovery of more efficacious forms of The lag between the discovery of more efficacious forms of

treatment and their incorporation into routine patient care istreatment and their incorporation into routine patient care is……in the in the range of about 15 to 20 years.range of about 15 to 20 years.””11

–– Discrepancies between evidence contained in randomized controlleDiscrepancies between evidence contained in randomized controlled d trials and timeliness of expert recommendationstrials and timeliness of expert recommendations22

1. IOM Report, Crossing the quality chasm: A new health s1. IOM Report, Crossing the quality chasm: A new health system for the 21ystem for the 21stst

century, March 2001.century, March 2001.2. Antman EM, et al. A comparison of results of meta2. Antman EM, et al. A comparison of results of meta--analyses of randomized analyses of randomized control trials and recommendations of clinical experts. Treatmencontrol trials and recommendations of clinical experts. Treatments for MI. ts for MI. JAMA 1992; 268:240JAMA 1992; 268:240--248.248.

The literature indicates that there are major gulfs between the knowledge “out there” and the current practice of medicine. One study has shown that the recommendations of experts (writing book chapters and clinical guidelines) often do not include assessments of the most recent evidence. One of the challenges is providing these experts with synthesized, organized summaries of all the evidence to date.

Technology: To the Rescue?Technology: To the Rescue?Clinical Decision Support (CDS)Clinical Decision Support (CDS)

“…“…clinical knowledge and patientclinical knowledge and patient--related related information, intelligently filtered and presented at information, intelligently filtered and presented at appropriate times, to enhance patient careappropriate times, to enhance patient care””11

“…“…delivered using information systems, ideally with delivered using information systems, ideally with the electronic medical record as the platform, will the electronic medical record as the platform, will finally provide decision makers with tools making it finally provide decision makers with tools making it possible to achieve large gains in performance, possible to achieve large gains in performance, narrow gaps between knowledge and practice, and narrow gaps between knowledge and practice, and improve safetyimprove safety…”…”22

1.1. Osheroff JA, et al. Improving outcomes with clinical decision suOsheroff JA, et al. Improving outcomes with clinical decision support: An implementerpport: An implementer’’s guide. HIMSS s guide. HIMSS 2005.2005.

2.2. Bates DW, et al. Ten commandments for effective clinical decisiBates DW, et al. Ten commandments for effective clinical decision support: Making the practice of on support: Making the practice of evidenceevidence--based medicine a reality. JAMIA 2003;10:523based medicine a reality. JAMIA 2003;10:523--530.530.

TT

Offering true support with clinical decision-making can be one of the best ways of closing the gap between knowledge that is known and the application of that knowledge in practice.

But What Sort of a Marriage is This?But What Sort of a Marriage is This?

Need to ask detailed questions about clinical content Need to ask detailed questions about clinical content when purchasing EHR and CPOE systemswhen purchasing EHR and CPOE systems

Need to make sure CDS tools will truly support, and not Need to make sure CDS tools will truly support, and not interfere with, decisioninterfere with, decision--makingmaking

Need to make sure true integration and customization Need to make sure true integration and customization offered offered

In order to make sure that we create a successful partnership between knowledge and technology, we need to ask the right questions of our EMR and content vendors, alike. We need to go beyond the provision of merely “referential” content and offer content that provides real decision support at the point of care.

CDS Success FactorsCDS Success FactorsSystematic review of RCTsSystematic review of RCTs

Computerized systems significantly more effective than Computerized systems significantly more effective than manual systemsmanual systems75% of interventions succeeded when clinical decision 75% of interventions succeeded when clinical decision support was provided support was provided automaticallyautomatically (push rather than pull)(push rather than pull)Information/advice provided at the Information/advice provided at the point of carepoint of care more more likely to lead to success than when not provided in this likely to lead to success than when not provided in this contextcontext

Kawamoto, K et al Improving clinical practice using clinical decKawamoto, K et al Improving clinical practice using clinical decision support systems: a ision support systems: a systematic review of trials to identify features critical to sucsystematic review of trials to identify features critical to success. BMJ 330(7494):765, cess. BMJ 330(7494):765, 2005 Apr 2.2005 Apr 2.

One systematic review has underscored the value of computerized decision support and the difference between automatic provision of information as opposed to requiring clinicians to retrieve it on their own.

CDS Success FactorsCDS Success FactorsMore likely to succeedMore likely to succeed

Systems offered as an Systems offered as an integrated facetintegrated facet of charting or order of charting or order entry (as compared with standentry (as compared with stand--alone systems)alone systems)Systems that give a recommendation as opposed to an Systems that give a recommendation as opposed to an assessmentassessmentSystems that prompt users to record a reason for not Systems that prompt users to record a reason for not following a recommendationfollowing a recommendation

Kawamoto, K et al Improving clinical practice using clinicKawamoto, K et al Improving clinical practice using clinical decision support systems: a al decision support systems: a systematic review of trials to identify features critical to sucsystematic review of trials to identify features critical to success. BMJ 330(7494):765, cess. BMJ 330(7494):765, 2005 Apr 2.2005 Apr 2.

Integrated solutions can be much more powerful than referential ones.

Effects of Computerized CDSEffects of Computerized CDS

Systematic review of RCTs and nonSystematic review of RCTs and non--RCTsRCTs

The majority reported improved practitioner performance The majority reported improved practitioner performance (diagnosis, preventive care, disease management, drug (diagnosis, preventive care, disease management, drug dosing, or drug prescribing)dosing, or drug prescribing)

The effects on patient outcomes understudied and The effects on patient outcomes understudied and inconsistent (inadequate statistical power in many studies). inconsistent (inadequate statistical power in many studies). Further research into these effects neededFurther research into these effects needed

Supporting evidence for improved efficiency and costSupporting evidence for improved efficiency and cost--reduction limitedreduction limited

Garg AX, et al. Effects of computerized clinical decisiGarg AX, et al. Effects of computerized clinical decision support systems on practitioner on support systems on practitioner performance and patient outcomes: A systematic review. JAMA 200performance and patient outcomes: A systematic review. JAMA 2005;293:12235;293:1223--1238.1238.

This systematic review of both randomized controlled trials and non-randomized controlled trials supports the benefits of clinical decision support in terms of practitioner performance, although it honestly points out that patient outcomes have not adequately been studied nor has proof of improved cost-effectiveness been well-demonstrated.

Partnership Success:Partnership Success:Key Issues to ExploreKey Issues to Explore

CDS in Computerized SystemsCDS in Computerized SystemsReferential vs. Integrated?Referential vs. Integrated?–– Is the knowledge base incorporated into the clinical Is the knowledge base incorporated into the clinical

application?application?

Evidence provided?Evidence provided?Ability to customize?Ability to customize?Ability to execute orders?Ability to execute orders?Ability to create and document care plans?Ability to create and document care plans?Templates provided or doTemplates provided or do--itit--yourself approach?yourself approach?

These are some of the key questions to ask when trying to achieve the greatest impact from clinical decision support in computerized systems. Having truly integrated knowledge is vital. Moreover, access to clinical evidence, the ability to customize content, and access to vendor-created decision-support templates all can aid in the adoption and successful implementation of computerized clinical systems.

Examples ofExamples ofClinical Decision SupportClinical Decision Support

Reminding/alerting clinicians about important Reminding/alerting clinicians about important concerns:concerns:–– DrugDrug–– DiseaseDisease–– LabLab–– PreventionPrevention

Answering clinical questions at the point of needAnswering clinical questions at the point of needHelping clinicians choose approaches with regard Helping clinicians choose approaches with regard to diagnosis and treatmentto diagnosis and treatment

Sequentially, I will address these 3 areas, beginning with the ups and downs of reminders/alerts.

Sensitivity (Allergy) Checking

Duplicate Therapy

Precautions

Drug Doubling

Contraindications

Drug Interactions

Warnings

Drug Decision Support Drug Decision Support

Dose Range Check

Starting Dose

Here are some of the various areas in which drug decision support is available today, ranging from drug-drug interactions to drug/disease contraindications, to dose range checking. Although these can be very useful, there is also the problem of “alert overload,” causing some clinicians to override important reminders, which can put patients in jeopardy.

Striking theStriking the Right BalanceRight Balance

Helpful, relevant remindersHelpful, relevant reminders–– Drug allergies, drugDrug allergies, drug--drug drug

interactions, doseinteractions, dose--checkingchecking–– Practice guidance (diagnosis and Practice guidance (diagnosis and

treatment)treatment)

Structured documentationStructured documentation–– DropDrop--down menusdown menus

Current recommendationsCurrent recommendations–– For clinicians and patients, alikeFor clinicians and patients, alike

Too many reminders, too oftenToo many reminders, too often–– Interrupting workflowInterrupting workflow–– Questionable relevanceQuestionable relevance

»» Pregnancy contraindication for Pregnancy contraindication for male patientmale patient

Too much time needed to Too much time needed to document and orderdocument and order

Questionable reference sourcesQuestionable reference sources–– AnectodalAnectodal report, outdated inforeport, outdated info

The left side of the slide demonstrates some of the helpful facets of reminders. The right side of the slide represents the counter viewpoint, the risk of pushing too many alerts into the faces of busy clinicians. We need to be careful not to interrupt clinical workflow and force clinicians to spend more time with machines than with people. Moreover, we need to be cognizant of the danger of having clinicians ignore important alerts when they stop reviewing them due to fatigue.

Current Technology/Knowledge Current Technology/Knowledge Issues to AddressIssues to Address

Limited patient contextLimited patient contextLack of standards for recording patient Lack of standards for recording patient information (inconsistent coding)information (inconsistent coding)Medical record fragmentationMedical record fragmentationKnowledge bases not granular enoughKnowledge bases not granular enoughSeverity levels (drugs) not helpful enoughSeverity levels (drugs) not helpful enough

Unfortunately, we are not living in a perfect world. There are limitations with regard to our ability to bring the latest, greatest information from the patient medical record to the fingertips of clinicians, not the least of which is a lack of coding standards for actually recording patient information, fragmentation of the medical record (ambulatory, inpatient), and the fact that knowledge bases are not sufficiently granular. Although many drug database vendors have attempted to help guide users to understand the relative importance of various drug alerts, available severity levels are sometimes not helpful enough.

On the HorizonOn the HorizonSeverity levels with key descriptors regarding Severity levels with key descriptors regarding originorigin–– Manufacturer insertManufacturer insert–– Society recommendationSociety recommendation–– Randomized, controlled trialRandomized, controlled trial

Ability to filter information based onAbility to filter information based on–– Evidence strengthEvidence strength–– Frequency information on adverse effect or interactionFrequency information on adverse effect or interaction–– Patient parameters (age, gender, renal/hepatic function)Patient parameters (age, gender, renal/hepatic function)–– Disease informationDisease information

More guidance to help users turn down the noiseMore guidance to help users turn down the noise

The good news is that help is on the way. Some drug database vendors are giving serious thought to ways in which they can make their severity levels more useful, including providing the strength of the evidence behind various reminders. If users could have more guidance regarding the origin of the alert and could have the ability to filter information based on certain patient-specific factors, this could help them appropriately dial down the noise and dial up the important reminders.




Would that all clinical questions were easy to address!…but they are not and so we sorely need sources to provide quick access to clinical information at the point of care.

Unanswered QuestionsUnanswered Questions““SixtySixty--four residents were interviewed after 401 (99%) of four residents were interviewed after 401 (99%) of 404 patient encounters. They identified 280 new 404 patient encounters. They identified 280 new questions, approximately 2 questions for every 3 patients.questions, approximately 2 questions for every 3 patients.””

““The residents were subsequently contacted about 277 The residents were subsequently contacted about 277 (99%) of their questions. Of these, only 80 (29%) were (99%) of their questions. Of these, only 80 (29%) were pursued, most commonly by consulting textbooks (31%), pursued, most commonly by consulting textbooks (31%), original articles (21%), or attending physicians (17%)original articles (21%), or attending physicians (17%)””

““Lack of timeLack of time (60%)(60%) and and forgetting the question (29%)forgetting the question (29%)were the most frequent reasons for failing to pursue a were the most frequent reasons for failing to pursue a question.question.””

---- Green ML, et al. ResidentsGreen ML, et al. Residents’’ medical information needs in clinic: are they medical information needs in clinic: are they being met? Am J Med. 109(3):218being met? Am J Med. 109(3):218--23, 2000 Aug 15.23, 2000 Aug 15.

An interesting study by Green and colleagues indicated that young physicians admit to having many questions for each patient they see, yet not the time or memory to investigate most of these. Similar research has been done with attending physicians and has demonstrated similar results.

Barriers to Using InformationBarriers to Using Information

Pilot study, RCT (10/95Pilot study, RCT (10/95--10/96)10/96)Emergency physicians at 2 Indianapolis hospitalsEmergency physicians at 2 Indianapolis hospitalsIntervention: patient data stored in a computerIntervention: patient data stored in a computer--based patient recordbased patient record

–– Via printed clinical abstract (limited info about problem lists,Via printed clinical abstract (limited info about problem lists, recent lab results, recent lab results, radiographic and cardiac study impressions, and dispensed meds)radiographic and cardiac study impressions, and dispensed meds)

–– Online (provided more data than printed abstract)Online (provided more data than printed abstract)ControlControl

–– No clinical information sharedNo clinical information sharedPrimary outcomePrimary outcome

–– ED chargesED chargesComplex studyComplex study

–– Charge captureCharge capture–– Physicians at one hospital always were aware of abstractPhysicians at one hospital always were aware of abstract–– Only 47% of physicians at other hospital saw abstractOnly 47% of physicians at other hospital saw abstract

Overhage JM, et al. A randomized, controlled trial of cliniOverhage JM, et al. A randomized, controlled trial of clinical information shared cal information shared from another institution. Ann of Emerg Med. 39;1:14from another institution. Ann of Emerg Med. 39;1:14--23. 2002.23. 2002.

A pilot study by Overage et al examined the value of having patient-related information stored in computerized form, with some of it available by abstract. The study itself had design challenges, some related to the fact that 2 discrete institutions were involved, which often leads to complexities and inconsistencies in design and data analysis.

Barriers to Using InformationBarriers to Using InformationPhysicians accessed online information in <0.5% of Physicians accessed online information in <0.5% of encountersencounters70% of surveyed physicians agreed or strongly agreed that 70% of surveyed physicians agreed or strongly agreed that they would they would ““like to receive a printed summary for all like to receive a printed summary for all patients.patients.””Of the categories of information provided in the printed Of the categories of information provided in the printed abstracts, respondents thought the following 2 were the abstracts, respondents thought the following 2 were the most usefulmost useful–– Problem lists (86%)Problem lists (86%)–– Medication lists (78%)Medication lists (78%)

44% of physicians cited the following as the most 44% of physicians cited the following as the most important barriers to looking up information onlineimportant barriers to looking up information online::–– Time required to search for informationTime required to search for information–– Forgetting their password!Forgetting their password!

Overhage JM, et al. A randomized, controlled trial of clinical iOverhage JM, et al. A randomized, controlled trial of clinical information shared nformation shared from another institution. Ann of Emerg Med. 39;1:14from another institution. Ann of Emerg Med. 39;1:14--23. 2002.23. 2002.

This study found that the most valuable portions of the abstracts (which were accessed by clinicians) were the problem lists and medication lists – items that are not always up to date in paper charts. Interestingly, the 2 factors cited as being barriers to the use of more in-depth clinical information related to time and something as simple (but problematic) as forgetting one’s password.

What Do Clinicians Need?What Do Clinicians Need?

Speed in obtaining informationSpeed in obtaining informationThe right informationThe right informationInformation that anticipates needsInformation that anticipates needs–– read my mindread my mind

If we don’t make information easy to retrieve and review, clinicians will not look up questions during their workday when they most need answers.

Tools to Answer QuestionsTools to Answer Questions

Various approachesVarious approaches–– ReferentialReferential

»» Part of library electronic resourcesPart of library electronic resources

–– QuasiQuasi--integratedintegrated»» Links from within a specific areaLinks from within a specific area

–– IntegratedIntegrated»» Information from disparate sources brought Information from disparate sources brought

together; logical thinking across electronic health together; logical thinking across electronic health recordsrecords

Today, clinical information is available in various formats, ranging from paper and electronic look-up sources to links embedded tightly within information systems. How the knowledge is deployed is critical to the usefulness of it.

Here is an example of content that can be accessed via search of multiple products, after the word “asthma” is typed into the Search box.

After clicking on the selected resource, the clinician sees information in traditional textbook form.




With the subsequent slide, I will address the third bullet point on this slide.

Help Me ChooseHelp Me Choose

Very few sources out there help with Very few sources out there help with tough decisionstough decisions–– Which initial antibiotic to select and whyWhich initial antibiotic to select and why–– What alternative drug to pick (allergy, What alternative drug to pick (allergy,

formulary)formulary)–– What test to order for the nonspecific What test to order for the nonspecific

abdominal painabdominal painNeed to go beyond Need to go beyond ““textbooktextbook”” approach to approach to delivering knowledgedelivering knowledge

It is rare to find a resource that really gets down to the nitty-gritty of helping a clinician decide between or among options. Many sources include lots of choice, without informing healthcare professionals about the reasons that a practitioner would select one road over another. For information to truly be useful, to improve practice, affect outcomes, and educate, more attention to helping with choice will be needed. Content vendors are looking into this area. As information increasingly becomes available in integrated format, it becomes much more relevant to structure content in this manner.

Standardized Order Sets:Standardized Order Sets:TimeTime--Saving ToolsSaving Tools

Templates that provide a starting pointTemplates that provide a starting pointIcons that alert to key quality initiatives Icons that alert to key quality initiatives and regulatory issuesand regulatory issuesEvidence embeddedEvidence embeddedWhatWhat’’s news new

Order sets have become very popular in healthcare institutions nationwide. But many administrators are leery of having physicians develop so-called “personal” order sets since each doctor can effectively have his or her own favorite, which can lead to uncontrollable costs and increased practice variation. Therefore standardized order sets, based on recommendations in the literature, with templates that serve as a starting point, are very desirable.

Here is an example of a standardized order set with the main categories showing. Clicking on the “Expand All” tab, the user can see all of the sub-categories, some of which are shown on the next slide.

The arrow indicates that one can scroll to see the entire order set template.

Including information from agencies focused on quality and safety improvement can be valuable to teams trying to ensure that their institutions adhere to the latest regulations and performance measures. The boxed information is seen only if the user “hovers” a computer mouse over the blue ribbon.

Clicking on the word “evidence” reveals structured information on the topic. However, it does not interfere with the workflow. If a physician wants to check off boxes and not review the literature, this is possible.

In this case, the “evidence” is presented with a “reminder” and a “rationale”statement. All of the cited articles are linked to PubMed, where abstracts and/or full text articles can be obtained.

Here are the references. The clinician can click on “PubMed.”

Access to full-text articles, embedded within the order set framework, is desirable. These articles can be used by committees customizing order sets and/or used for educational purposes. Time is saved, without the need for clinicians to run to the library to do literature searches and photocopy articles –should they remember their question at the end of a long, hard day!

Order Sets:Order Sets:Importance of Decision SupportImportance of Decision Support

Narrative information to help guideNarrative information to help guide»» Example: Consider cefazolin as firstExample: Consider cefazolin as first--line for line for

antibiotic prophylaxisantibiotic prophylaxis

Evidence Evidence –– colorcolor--coding or other insignia coding or other insignia to help indicate importanceto help indicate importanceRules/reminders with Rules/reminders with ““if/thenif/then”” logiclogic

Standardized order sets will become even more useful if they can provide more information to aid in clinical decision-making. This can be done in subtle narrative fashion, with color-coding of evidence to reflect strength, and with rules and reminders to highlight the key aspects of order sets.

CuttingCutting--Edge InformationEdge Information

Update cycle importantUpdate cycle important–– Notification of new evidenceNotification of new evidence–– Synthesis of diverse elementsSynthesis of diverse elements

Making sure that new literature Making sure that new literature recommendations are translated into recommendations are translated into practicepracticePractice is constantly changing and Practice is constantly changing and evolvingevolving

It is important for clinicians to know exactly when the latest literature updates were done (by seeing date stamps in content programs) and to be able to save time by focusing on flagged “new” evidence from these updates. Where there is already a body of information on a given subject, it is imperative for the new literature to be synthesized with the previous material.

Different Ordering ScenariosDifferent Ordering ScenariosContent can be accessed via standardized order Content can be accessed via standardized order sets for patients with anticipated sets for patients with anticipated ““predictablepredictable””coursescourses–– Examples:Examples:

»» communitycommunity--acquired pneumoniaacquired pneumonia»» elective hip replacementelective hip replacement

Content can be accessed for patients with Content can be accessed for patients with ““complicatedcomplicated”” courses or during course of courses or during course of admissionadmission–– Examples:Examples:

»» patients with multiple copatients with multiple co--morbiditiesmorbidities»» beyond the initial set of ordersbeyond the initial set of orders

For many situations, it is not enough to have standardized order sets. Patients and their courses of care are often not predictable and therefore physicians may need to order medications and other diagnostic/therapeutic items as needed. In this case, an order set may not be the best vehicle for writing the order. Physicians often have a desired drug or procedure in their heads; useful content systems need to be able to offer relevant guidance once the physician enters the name of a drug type (e.g., antibiotic), drug class (e.g., cephalosporin), or drug name (Keflex). See next slide.

And time is of the essenceAnd time is of the essence……

The order entry itself must be quickThe order entry itself must be quickFewest clicks as possibleFewest clicks as possible

If weIf we’’re going to have to order by computer, re going to have to order by computer, we need it to be intuitivewe need it to be intuitive

Constructed the way different clinicians thinkConstructed the way different clinicians thinkExample: drug information for physician ordering Example: drug information for physician ordering must not be pharmacistmust not be pharmacist--centriccentric

But the fewest clicks possible are desirable in this context. We must construct databases in a way that thinks like a clinician. Understanding clinical workflow and clinical issues is paramount. For example, making sure not to provide a prescriber with dispensing options (more relevant to a pharmacist) is important. Ideally, content will be structured and coded according to user type and profile.

Ordering Ordering MedicationsMedications

Routed Med

Dispensable Medication Dose/Frequency

Dose/Frequency

The “routed med” is not always the most efficient path. Employing variable-level, drug-specific navigation can reduce clicking and scrolling significantly. With effective use of pre-built pick lists, ordering a medication can be reduced to a few keystrokes or as few as one or two clicks. For some drugs, however, it is more efficient to expose additional attributes such as strength and dosage form right in the pick list to correlate with how a physician orders (e.g hydrocortisone 1% topical cream).

Med Name Med Name (Ingredients)(Ingredients)

Med Name + RouteMed Name + Route

Hydrocortisone

Commonly Required Drug Commonly Required Drug ConceptsConcepts

Hydrocortisone Hydrocortisone Topical Ointment

Hydrocortisone Topical Hydrocortisone Topical Ointment 1%

Med Name + Route + Med Name + Route + Dose FormDose Form

Med Name + Route + Med Name + Route + Dose Form + StrengthDose Form + Strength

These are four key levels commonly used to represent the drug world. In addition, the National Drug Code or NDC number is used extensively in pharmacy and reimbursement, particularly in the outpatient world.

Here is an example of how physician orders can be written quickly, with relevant information passed by the clinical information system, with a minimal number of “clicks.” The physician begins to type in the word “warfarin.”

All the physician has to do is select the route of administration (in this case oral) and the common medication doses given via this route are listed below. The physician can then click the desired order item and send it to the pharmacy.

Although the physician may order warfarin 7mg without having to consider how this is dispensed, the pharmacist needs information indicating the various ways to carry out this order. So, the physician sees information presented the way a physician orders, and the pharmacist sees information presented the way a pharmacist dispenses.

OpportunityOpportunity

More integration through ITMore integration through IT»» Need to use standards for codingNeed to use standards for coding»» Need more consistent coding in patient recordsNeed more consistent coding in patient records»» Need improved internal data structuresNeed improved internal data structures

Better coding should help improveBetter coding should help improve»» Retrieval of Retrieval of relevantrelevant knowledgeknowledge»» Speed in getting answersSpeed in getting answers

Need cooperation of EMR/CPOE vendors, Need cooperation of EMR/CPOE vendors, content suppliers, and healthcare providers content suppliers, and healthcare providers

Coding is not a trivial issue. We need to standardize our methods so that we can achieve the often-stated goal of interoperability. Increasingly, groups are recognizing the importance of using a common language.

Building on StandardsBuilding on Standards

Drug TerminologyDrug Terminology RxNorm RxNorm ---- USUSNHS dm+d NHS dm+d ---- UKUK

Medical ConditionsMedical Conditions SnomedSnomed--CTCT

Dose Syntax ModelDose Syntax Model HL7HL7

Standards help build a “shareable” record

Here is an example of how standards can help build a record that can be shared. None of these is bullet proof, but many make a good start at enhancing communication from one system to another.

IndicationIndication

Allergy History

Change Event

Condition History

Age and Sex

Enhanced ResultsMedication History

Asthma

Suggest Appropriate Dose

This slide and the subsequent two slides indicate the ways in which information passed from the clinical information system can be useful in helping clinicians choose the appropriate medication dose and timing for a given patient.

Laboratory ResultsLaboratory Results

Allergy History

Change Event

Condition History

Age and Sex


Creatinine clearance, Na+ ,K+

Suppress Interactions if effect is not negative

TimeTime

Allergy History

Change Event

Condition History

Age and Sex


Time

Contraindicated within 2 weeks of surgery

To Be Truly UsefulTo Be Truly Useful

More integration focusing on delivery of More integration focusing on delivery of contextcontext--sensitivesensitive informationinformation

»» Hepatic, renal functionHepatic, renal function»» Age, genderAge, gender»» CoCo--morbiditiesmorbidities

Parsed, chunked contentParsed, chunked contentKeep it simple Keep it simple –– clinicians need quick clinicians need quick answers during the workflowanswers during the workflow

»» abstract may be sufficientabstract may be sufficient

Many groups are working on delivering information that is more context-sensitive, so that clinicians are presented with only the most relevant and concise care recommendations. It appears that carefully targeted nuggets of content are desired by most busy clinicians.

Implementation SuccessImplementation Success

No outNo out--ofof--thethe--box solutionsbox solutionsItIt’’s about peoples about people–– CustomizationCustomization–– Clinical communitiesClinical communities–– ChampionsChampions–– Feedback/assessmentFeedback/assessment

Tactical approach importantTactical approach important–– Details, detailsDetails, details

This slide lists some of the factors key to the success of institutional quality improvement projects. Any group can develop order sets and guidelines, but making sure that these are used and that they are having a positive effect upon patient care requires dedicated people effort. Sharing experiences from one institution to another, and using well-respected clinical champions, are some of the ways of trying to ensure success with project implementation.

Customization ToolsCustomization Tools

Backbone: current evidence repositoryBackbone: current evidence repositoryAllow modifications made based onAllow modifications made based on

»» FormularyFormulary»» Local practice, policies, and proceduresLocal practice, policies, and procedures

Aid in gaining consensusAid in gaining consensus»» Argue the evidenceArgue the evidence

Customization is important. Institutions must be able to “localize” their guidelines and order sets, even if their material ends up looking strikingly similar to that of other groups. However, if clinicians are not offered the ability to make modifications, they may become resentful of institutional efforts to change and not follow those recommendations.

Items to VetItems to Vet

Clinical guidelinesClinical guidelinesClinical pathwaysClinical pathwaysClinical algorithmsClinical algorithmsOrder setsOrder setsDrug alertsDrug alertsNursing care/management plansNursing care/management plans

Here are some of the projects that often require “vetting” at the committee level to help with both development and successful implementation of quality-and safety-improvement projects.

The nurse can select the topic of interest, in this case Pain, Acute.

Here’s an example of important facets of a care pathway for nurses, which may need to be pruned down to be more effective and appropriate to the patient for whom it is being used.

Clinical CommunitiesClinical Communities

SuccessesSuccessesFailuresFailuresAvoid reinventing the wheelAvoid reinventing the wheel

Many believe that “clinical communities,” which may involve electronic exchange of order sets and care plans, are an entity of the future for sharing successes and failures alike, and helping organizations become more efficient without reinventing various and sundry wheels.

Implementation SuccessImplementation Success

Need focused clinical review teamNeed focused clinical review teamAvoid sending too much material to digest by Avoid sending too much material to digest by consensus groupconsensus group

»» large binders will probably remain unread*large binders will probably remain unread*Need championsNeed champions

»» do not need to involve all clinicians in do not need to involve all clinicians in development workdevelopment work

Need to assess/measure and share resultsNeed to assess/measure and share results

**Hardwiring The EvidenceHardwiring The Evidence, , ©© The Advisory Board The Advisory Board Company, Washington DC, September 2005Company, Washington DC, September 2005

Providing a clinical review team with synthesized, summarized evidence-based material can make this team much more efficient and effective. Having clinical champions who are well-respected by their peers can help jumpstart implementation efforts. It is critical to measure results and share this information widely throughout an organization.

Measure ResultsMeasure Results

Return on InvestmentReturn on InvestmentCost and efficiency measuresCost and efficiency measures–– Average cost/dayAverage cost/day–– Length of stayLength of stay

Process measuresProcess measures–– Treatment ratesTreatment rates–– Timeliness of care Timeliness of care –– Appropriate medicationsAppropriate medications

Clinical outcomesClinical outcomes–– Morbidity/complicationsMorbidity/complications–– MortalityMortality–– HospitalizationsHospitalizations–– Patient SatisfactionPatient Satisfaction

Measuring results is a sine qua non. We must make sure that we know if our best laid plans are really best after all. People with administrative roles may be interested in operational and financial ROI, whereas clinicians may be more focused on clinical (morbidity and mortality) ROI. Ultimately, administrators and clinicians alike should be interested in all aspects – since the goal is to improve patient care and yet remain a viable operation.

Contact InformationContact Information

Nancy Greengold, MD, MBANancy Greengold, MD, MBAVice President & Medical DirectorVice President & Medical DirectorHearst Business MediaHearst Business MediaFirst DataBank and Zynx Health, Inc.First DataBank and Zynx Health, Inc.(310) 954(310) 954--1948 1948 –– directdirectEmail: [email protected]: [email protected]

Thank you very much. Please do not hesitate to contact me with any questions or comments.

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