A Measurable Difference: Clinical Decision Support Improves Care and Safety

Scott Weingarten, MD President and CEO, Zynx Health Clinical Professor of Medicine UCLA School of Medicine

Convergence of Ideas

 Executives, physicians and Board members will require an ROI for Clinical Information Systems.

 Patient-specific evidence-based information, provided to clinicians at the time of care (CDS), can improve care.

 CDS maintenance, updates require clinical knowledge management.

 Implementation is key to success.

CIS - ROI

 HIMSS Analytics 46% (1,904 / 4,115) hospitals have bought CPOE  Expensive Requires CFO, CEO, Board approval Someone promised improvements in quality, safety, and efficiency Someone will remember

CIS Potential – Side Effects

 Studies Introduction of errors Pediatrics 2005;116:1506-1512

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CIS Potential – Side Effects

Interviews from 176 hospitals  CPOE Median 5 years (6 months to 25 years) % Concern More work System demands New errors Users with emotional reactions J Am Med Inform Assoc 2007;14:415-23 95% 92% 91% 90%

CIS Potential – Placebo Effect

      Ambulatory EHRs 2003, 2004 17 ambulatory quality indicators 1.8 billion EHR ambulatory visits “As implemented, EHRs were not associated with better quality ambulatory care.” “In selecting an EHR, physician practices should carefully consider the inclusion of clinical decision support to facilitate quality care…”

Physician Decisions 17 Year Lag

Practice guidelines Print Sources Clinical pathways Physician order Patient Algorithms / maps Textbooks Other referential content sources

CIS Potential Referential CDS

Source Time to Conduct Search Up-to-Date Medline Clinical Evidence Cancer Net 15 20 3 7 Median time (minutes) Information very or somewhat helpful 91% 59% 23% 4%

Total

42 minutes per patient JGIM 2004;19:402-9

CIS Potential Referential CDS

 23 physicians, 46 questions  6.5 minutes searching per question  1.8 resources per question  39.1% answers correct before searching  42.1% answers correct after searching McKibbon KA, et al. J Am Med Inform 2006;13:653-9

“Six Sigma”

3 2 1 5 4 Sigma Level 6 Error rate per million opportunities 3.4

Health Care 5.4 Deaths from anesthesia 230 6,210 210,000 580,000 790,000 Antibiotics for colds Depression – adequately treated Beta blocker treatment after acute myocardial infarction Mark Chassin Milbank Quarterly Outside of Health Care Publishing misspelled words Airline fatalities Airline baggage handling Restaurant billing

CIS Potential

 Improves legibility  Microsoft Word also improves legibility

CIS Potential

Cost Reduction (per year) Deaths Avoided (per year)

Errors of Commission Eliminate Hospital ADEs Eliminate Ambulatory ADEs

$1 billion $3.5 billion

Errors of Omission 5 Preventive Care Services

$1.74 billion -$3.65 billion

DM for Diseases Prevention and Management of Chronic Conditions

$28 billion $139 billion 39,900 to 83,800 400,000 Hillestad R, et al. Health Affairs 2005;24:1103-17

CIS Potential – Personal Order Sets

 1,100 physicians 560 physicians with POS 2,247 POS 10,123 unique orders Each physician had an average of 4 POS  Include SL nifedipine, droperidol AMIA 2003 Symposium Proceedings – page 1031

CIS Potential Personal Order Sets

 “At QMC, there are more than 10,000 unique orders in POS. This is an unwieldy number to administer centrally. Additionally, these POS contain orders that are no longer considered best medical practice and in some cases may be dangerous. Such disadvantages need to be considered when implementing POS.” AMIA 2003 Symposium Proceedings - page 1031  If orders are reviewed once a year 40 unique orders need to be reviewed daily

CIS Potential – Personal Order Sets

 “When order sets are…inadequately maintained, they become templates for efficiently practicing outdated medicine on a widespread basis” A. Bobb et,al. JAMIA v14 Jan/Feb’07 pp 41-47

CIS - ROI

Advisory Board Observations  “Project goals abandoned in light of overwhelming workload; sole focus becomes completion.”  “Far fewer CIOs focusing on meeting intended business value of the technology.” IT Pursuit of Clinical Transformation. Blueprints for Foundational IT. 2006  “The potential for significant expense without a measurable return on investment could result in costly mistakes, ultimately hindering profitability and balance sheet growth.” Fitch Ratings

HCIT Consultants

Selection of CPOE system Implementation of CPOE Try to find benefits

The World’s Literature

Meta-analysis 68% effective, (n= 6,000 clinicians), (n=130,000 patients) Predictors of Success N=70 studies

Automatic provision of decision support as part of workflow

Adjusted odds ratio

112 • Provision of decision support at the time and location of 15

“75% of interventions succeeded when

7 assessments

clinicians automatically, whereas none succeeded when clinicians were required to seek out the advice…”

6

Kawamoto K, et al. BMJ 2005;330:1065

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CIS ROI

“Meanwhile in the trenches, we are struggling to extract the anticipated value from the hefty bets we are making on clinical systems. Taken alone, clinical information technologies like bar-coding, smart pumps, nursing documentation, pharmacy and physician order entry systems don’t sufficiently improve clinical practice to justify these investments. The systems must be supplemented by embedding intelligence into the clinical workflow. Decision support is the key to driving high quality and fail safe care.” True North “Hardwiring The Evidence” The Advisory Board Company, Washington, DC

Strategies for Deploying Patient-Specific Clinical Information

Electronic Order sets Plans of care Alerts Default settings Structured documentation Default settings

Future Physician Decisions

Practice guidelines Clinical pathways Physician order Patient Algorithm / map Referential content sources

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Evidence-based Order sets

Pediatric Inpatient Asthma  790 patients Measure Pulse oximetry Systemic corticosteroid use Use of MDIs Order Set 94% Before 75% 56% 48% 91% 79% p-Value <0.001

<0.02

<0.001

Pediatr Allergy Immunol 2006;17:199-206

Evidence-based Order Sets

 “The integration of evidence-based treatment recommendations as computerized order sets within an inpatient CPOE system can improve compliance with evidence-based treatment recommendations. Our study provides further evidence to support the argument that expansion of the use of CPOE with integrated order sets can lead to general improvements in quality of care, consistency of care, and hopefully, outcomes.” Pediatr Allergy Immunol 2006:17;199-206

Evidence-based Order Sets

 259 hospitals  OPTIMIZE – HF  48,612 patients  Tools Practice algorithms Customizable admission order sets Customizable discharge order sets Arch Intern Med 2007;167:1493-1502

Evidence-based Order Sets

     Pre-printed Order Sets and Discharge Checklists 259 hospitals 48,612 patients “largest national hospital-based program dedicated to quality-of-care improvement for patients hospitalized with HF in the United States” Process of care improvement tools included customizable admission and discharge order sets, evidence-based algorithms Arch Intern Med 2007;167:1493-1502

Evidence-based Order Sets

No PrCl p<0.001

100 90 80 70 60 50 40 30 20 10 0 p<0.001

Discharge Instructions Assess LVEF PrCl p<0.002

ACE-I

Arch Intern Med 2007;167:1493-1502

p<0.001

Smoking Cessation

Evidence based Order Sets…

Acute MI care (n=2,857 patients) Standardized orders, pocket guideline, discharge tool Increase in standard orders from 19.8% to 45.5% (p<0.001)

Hospital mortality 30-day Evidence-based order sets 10.4% Usual order sets 13.6% 16.7% 21.6% 38.3% 1-year 33.2%

21% to 26% reduction in mortality J Am Coll Cardiol 2005;46:1242-8

Evidence-based Order Sets

 52% of denials for order tests for conditions that are not allowable  Insurance denial reduction MRI/MRA 37% Colonoscopy 29% AMIA Symposium Proceedings 2005, page 1151

CDS Benefits

 C-section, vaginal deliveries  290 malpractice claims  Compliance with evidence-based clinical pathways associated with an almost 6 fold decrease in malpractice claims  Risk of not following evidence-based clinical pathway (6.1 claims for 1000 non compliant deliveries) – Ransom S, et al. Ob Gyn 2003;101:751-5

Patient-specific evidence-based information

Professionalism With Decision Support

 Pilots require extensive knowledge, training and experience  Utilize decision support

Clinical Knowledge Management

 20,000 biomedical journals  500,000 indexed in PubMed annually*  >150,000 articles per month  6,000 articles a day  >3,000 molecular diagnostic tests Medical References Services Quarterly 2007;26:1-19

Clinical Knowledge Management

200 MB capacity*

GAP

•6,000 articles/day** •150,000 articles/month** •300,000 RCTs •20,000 biomedical journals * Dr. Frank Davis **Ann Intern Med 2001;135:309-12

Clinical Knowledge Management

Finish medical school and residency knowing everything Read and retain 2 articles every single night At the end of 1 year 1,225 years behind W Stead. JAMIA 2005;12:113-20 Alper BS, Hand JA, Elliott SG, et al. J Med Libr Assoc 2004;92:429-37.

Clinical Knowledge Management

Total Unique Active Performance Measures Active Regulatory Measures Active P4P Measures 2268 887 154 1302 312 98

Before

For every 20 patients treated with albumin, 1 excess death 2

Clinical Knowledge Management

Clinical Decision Support Before

“Do not prescribe albumin” alert

New Evidence

Study with 5-times sample size 3

New Evidence Results

Albumin does not increase mortality No significant benefit of adding dipyridamole to aspirin 4 Dipyridamole not on order set Larger study published 5

Clinical Decision Support After

Remove alert Composite reduction in cardiovascular outcomes with ASA and dipyridamole 1% per year Add dipyridamole to order set 1.

2.

3.

4.

5.

Ann Intern Med 2007;147:224-233 Cochrane Database 2002;CD0011208 N Engl J Med 2004;350:2247-56 BMJ 2002;324:71-86 Lancet 2006;367:1665-73

Clinical Knowledge Management

CPOE readiness components Organizational Structure & Function Information Technology Composition Information Technology Infrastructure Organizational Leadership External Environment Access to Information Order Management Process Organizational Culture Care Standardization JCJQS 2003;29:336-44 Readiness score (mean range) 70 (35-94) 64 (24-94) 63 (47-73) 59 (21-95) 57 (45-82) 56 (30-90) 53 (25-78) 51 (27-93) 44 (25-100)

Clinical Knowledge Management

 Updates, maintenance  Most hospitals will want 250 to 1000 order sets Update at least once per year  1 to 4 order sets updated per business day

Clinical Knowledge Management

 Internally developed “Notify physician when blood sugar is >40” “Administer O 2 at ___ liters per min via ___ (if PAO 2 >60mm Hg or spot check pulse-ox sat.>90%)” “Raise HOB>30’ ”

Clinical Knowledge Management

  Iterative process “of the 48 order sets that are actively used in POE, nearly all have been changed multiple times since initial release for clinical use. One particular order set has been revised 44 times…”  J Biomed Inform 2007

Disease Specific - CAP

What Works?

  Clinician Awareness Familiarity Agreement Time to perform Computer Couple reminder with order on same screen Distinctive color screen to highlight Making override more difficult Default set to “order” Repetition BMC Med Inform Decis Mak 2006;Feb 1, 6

What Works?

Computer Default Settings

What Works?

 Hospital -

Default Values

Pneumococcal immunization Influenza immunization Removal of all urinary catheters within 72 hours unless otherwise indicated  Intensive care units Elevated head of bed  Physician office HbA1C for diabetic patients Retinal examinations for diabetic patients  N Engl J Med 2007;357:1340-4

80:20 Rule

 Today 80% development 0% maintenance 20% marketing, selling order sets to physicians • Result --- under-utilization  Tomorrow <5% development 50% maintenance, updates 50% marketing, selling to physicians • Result --- better utilization

CDS Framework

Discipline Venue Critical Care Hospital Care Ambulatory Care Emergency Care Home care

Future Hypothetical



Clinical Case

“Mr. Jones is a 69-year-old white man with a history of diabetes who was hospitalized with a temperature 101.2

0 F, non-productive cough, and a left-lower-lobe infiltrate. His room air O 2 sat was 85%. I was planning on performing blood cultures, administering oxygen, and prescribing doxycycline”

Future Hypothetical Clinical Case

 “ Clinical decision support has been run against the patient’s demographic, genomic, hemodynamic, physiological, history, physical, radiographic, and laboratory findings. The patient’s probability of mortality can be reduced by 12% and length of stay reduced by 8% by prescribing an antipneumococcal fluoroquinolone. The patient’s mortality may be reduced by an additional 3% by using the hyperglycemia order set. Also, a fall reduction program will reduce the patient’s risk of a fall leading to prolonged stay by 11%.”

Conclusions

     CIS have great potential for delivering clinical and ROI benefits Executives, physicians and Board members will ask for the ROI.

Patient-specific evidence-based information, provided to clinicians at the time of care, can provide the benefits.

Clinical knowledge management required for CDS.

Implementation is key to success Marketing and selling CDS to clinicians

Questions???