Transcript Moving Patient Safety and Best Practices Into the Mainstream

Decision Support
at the Point of Care
Representing & Managing
Knowledge & Integrating
it into the Care Process
Robert A. Greenes, M.D., Ph.D.
Harvard Medical School
Brigham & Women’s Hospital
Boston, MA, USA
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
Medline reports
gene analyses
volume
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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)
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Disparities: Variability in CABG
where HRR = Hospital Referral Region
Demand for change
Crossing the Quality
Chasm: A New Health
System for the 21st Century
– Safe
– Effective
– Patient-centered
– Timely
– Efficient
Richardson, William C.
Crossing the Quality Chasm,
Institute of Medicine, 2001
– Equitable
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Consumer empowerment
 More involved in care process
 More knowledgeable
 More activist
 More technically savvy
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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.
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
–
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–
–
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
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BWH Order entry
Drug-drug interaction alert
Lab alerts
Order sets
Other functionality
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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
 Minimal effect of charge
display
 55% decrease in serious
medication errors
– Bates, Archives of Internal
– Bates, JAMA 1998
 Decreased redundant labs
– Bates, Am J Med, 1997
 More appropriate renal
dosing
 No reduction in
inappropriate x-rays
Medicine, 1995
 More appropriate dosing,
substitutions accepted
– Teich, Archives of Internal
Medicine, 2000
 Decreased vancomycin
use
– Sojania, JAMIA, 1998
– Harpole, JAMIA, 1997
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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
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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
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Converting research to care
Original research
18%
Negative
results
variable
Dickersin, 1987
Submission
46%
0.5 year
Kumar, 1992
Koren, 1989
Negative
results
Acceptance
17 years
to apply 14% of
0.6 year
research
knowledge
Publication
17:14
to patient
care!
35%
0.3 year
Kumar, 1992
Poyer, 1982
Lack of
numbers
Balas, 1995
Bibliographic databases
50%
Poynard, 1985
Inconsistent
indexing
Expert
opinion
6. 0 - 13.0 years Antman, 1992
Reviews, guidelines, textbook
9.3 years
Patient Care
Balas EA, Boren SA. Managing clinical knowledge for health care improvement. Yrbk of Med Informatics 2000; 65-70
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
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Cedars-Sinai Experience
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
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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
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Flu vaccine guideline
Asymptomatic
Get age and occupation
Health-care worker
or Age>65?
Yes
No
Give Flu shot
Do Nothing
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);}
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Guideline authoring
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 TC
CG 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
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