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From Thoughtless Alerts to Effective Decision-Support Using the EHR in a Learning Health System Agenda Current Challenges to Outpatient Medicine What is the Evidence for CDS Threats and Challenges to CDS One system’s experience with CDS – Governance – Tools – Reporting The way forward 2 Aging of the Population 3 Diabetes Prevalence Among U.S. Adults Less than 4% 4% to 6% Above 6% No Data NOTE: Data are age-adjusted to the 2000 standard population. SOURCE: Behavioral Risk Factor Surveillance System (BRFSS), CDC. 4 Burden of Chronic Disease -- 2008 6.5% -- Coronary Heart Disease 25.5% -- HTN 2.7% -- Stroke 8.0% -- Asthma 6.6% -- COPD 8.5% -- Cancer 9.2% -- Diabetes Source: National Health Interview Survey 2008 5 Burden of Quality Measures PQRS Breast Ca Screening Lipids in CAD HEDIS Rheumatoid Colon Ca Screening Arthritis Management ACE/ARB in Diabetes Osteoporosis Management Value Kidney Hi Risk Based Checks in Medications in Meaningful Diabetes Purchasing the Elderly Cervical Ca Eye Screening Use Exams in DM Chlamydia Screening Immunizations Lipids in Diabetes COPD: Spirometry Controller Meds in Asthma 6 “To fully satisfy the USPSTF recommendations, … 7.4 hours per working day, is needed for the provision of preventive services.” Am J Public Health. 2003 April; 93(4): 635–641. • Identify that someone is potentially eligible for a service • Determine whether or not that service has already been provided • Counsel the patient • Order the service 7 Quality of Health Care Delivered in USA Random sample of adults living in 12 metropolitan areas Evaluated performance on 439 indicators – 30 conditions and prevention 44.7% - at least one chronic condition NEJM 348;26: 2635-2645. 8 Percentage of Recommended Care Type of Care Preventative % of Recommended Care Received 54.9 Acute 53.5 Chronic 56.1 9 “The lag between the discovery of more efficacious forms of treatment and their incorporation into routine patient care is unnecessarily long, in the range of about 15 to 20 years.” 10 Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review 11 JAMA. 2005;293(10):1223-1238. doi:10.1001/jama.293.10.1223 Characteristics of Successful CDS 12 JAMA. 2005;293(10):1223-1238. doi:10.1001/jama.293.10.1223 Challenges to CDS Divergent priorities – Primary care vs Specialist – Clinical Care vs “Business Needs” – Unclear or contradictory standards Disparate Workflows Alert Fatigue 13 Types of Decision Support Intrusive Reminders (“Pop-Ups”) “Passive” Reminders Order Sets Information Displays Links to Relevant Guidelines 14 Dealing with Divergent Priorities Find a cartoon 15 Who’s In Charge? President, Physician Services Division President, Community Medicine, Inc Chief Medical Information Officer Decision-Support Working Group (approx 10 physicians) • Meets monthly • Decides on clinical content and standards • Validates build Physician IT Leadership Technical Team • Meets technical team weekly • Sets DSWG agenda • Suggests new rules • Designs tools (with technical team) • Executes build • Tests build • Advises leadership and DSWG • Educates on 16 new features Governing Principles Widely accepted guidelines – USPSTF, ACIP/CDC – Support HEDIS and other quality measures Do not interrupt workflow – (may interrupt work that should be interrupted) Provide method to override alerts/customize Leadership of receiving specialty must consent 17 Technical Principles More important services have more intrusive alerts Use workflow tools for interventions that need to be done on every visit Alerts for periodic services are tied to Health Maintenance Color code and prioritize 18 Scenarios for CDS Safety Alerts Prevention Clinical Pathways Medications Chronic Disease Management Meaningful Use/Billing 19 Best Practice Advisories Primer Results Orders FlowSheet Values Problem List HM Modifiers and Topics Med List PMH,PSH 20 Best Practice Alert Where to BPAs Fit In? Strengths – Powerful logic – Can evaluate in ‘real time’ – Department and role specific – Fit into workflow (Visit Navigator) OR PopUp when needed – Facilitate Action Weaknesses – Hard to customize 21 BPA Strategy Color Coded by Type Safety Meaningful Use Disease management Prevention Research 22 Pop-Ups --- Patient Safety Order contrast for allergic patient Order MRI when pacer is present 23 24 Health Maintenance • • Health Maintenance is Epic's preventive health reminder tool. Patients and providers can be reminded about mammograms, flu shots, immunizations and any other preventive diagnostic and/or therapeutic procedures. 25 How does Health Maintenance work? Health Maintenance works in two ways: o Automatic reminders o o o Gender, age Problems Medications o Manual reminders o Modifier is added o BPA may suggest this 26 Health Maintenance 101 -- Topics Topics are the Building Blocks – Service on a schedule – Satisfied by completed procedures – Can be manually satisfied Mammogram A1c Pap Every 3 yrs every 6 months every year LDL yearly 27 Health Maintenance Plans Plans correspond to diseases or conditions Apply these plans by ‘modifiers’ Plans can: – Add topics to HM – Delete topics to HM – Change time intervals on existing – topics Urine Albumin Diabetes Plan Creatinine yearly A1c yearly every 6 months Eye Exam LDL yearly yearly yearly 28 Diabetes HM Topics Yearly – – – – – – LDL Eye exam Foot exam Urine microalbumin Serum creatinine Flu shot Every 6 months – A1c Pneumovax 29 Other HM Plans CAD – LDL yearly Lipid-Lowering Drugs – LDL and ALT yearly Diuretics – K and creatinine yearly Thyroid – TSH yearly 30 Shared Topics Yearly LDL – DM – CAD – Lipid-lowering drugs Serum creatinine – DM – Diuretics – ACE/ARB 31 Customization with HM Overrides “Approved” – Done – Not Applicable Modifiers Exclusion Modifiers Modifiers to Change Interval Postpone Topics 32 HM is Engine Driving Alerts HM Topics LDL Urine albumin Creatinine Potassium TSH Eye Exam Best Practice Alert Order Sets 33 34 Combined Chronic Dz BPA 35 Combined Smart Set 36 Prevention Topics Pap Mammogram Colon Cancer Screening DEXA Scan 37 38 Combined Prevention Alert 39 BPA Smart Set 40 Finessing Controversy Age 40-50 – Mammogram Discussion Age 50-75 – Annual Mammogram – Every other year modifier available Age 75 – Mammogram Discussion 41 Medication BPA 42 Medication Smart Set 43 CKD – A Cautionary Tale CKD is underrecognized Progression to ESRD Poor ‘fistula first’ rate Comorbid events (CAD) 44 Hoped-For Outcomes Recognize CKD – Put on Problem List – Drive decision-support Early referral to nephrologist – How early? Screen for and treat cardiac risk factors 45 Recognize CKD • Too big • Too complex • Suggestion often wrong • Does not reflect clinician’s views 46 CKD-IV HM Topics 47 CDS to Increase Nephrology Referral Abdel-Kader, Fischer, et al. American Journal of Kidney Diseases. 58(6):894-902, 2011 Dec 48 Smart Sets – Osteoporosis Pathway 49 COPD Medications 50 How Many Alerts? Type of Alert Number (Total 317) Chronic Disease 99 Billing 28 Meaningful Use 8 Order Suggestions 14 Prevention 63 Patient Safety 29 Quality Reporting 24 Research 27 Miscl 18 51 Quality Reports •Diabetes •CAD •CHF •Afib •Hypertension •Prevention “Facts are stubborn, but statistics are more pliable.” --Mark Twain Diabetes Patient Detail (PDF) 53 Diabetes Report Card 54 Clinic Summary by Provider 55 56 Clinical Decision Support to Promote Safe Prescribing to Women of Reproductive Age: A ClusterRandomized Trial Randomized MDs to receive “simple” (n=17) vs “complex” alert (n=24) No difference in ordering teratogenic meds or counselling after 6 months For last 6 months, “complex” alert turned off No difference in ordering teratogenic meds with or without alert Schwarz EB; Parisi SM; Handler SM; Koren G; Shevchik 57 G; Fischer GS. Journal of Women's Health. 22(10):81724, 2013 Oct. 58 Chronic Disease Process Measures 59 Prevention Measures 60 Critical Success Factors Governance and Leadership Focus on Well-Established Guidelines and Evidence Collaboration with Intended Users Understanding of workflows Customizability Processes to improve efficiency Using tools appropriate to the problem Reporting and Feedback 61 Make it easy for clinicians to do what they know they should do 62