Decision Support at the Point of Care

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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 Womens Hospital
• Boston, MA, USA

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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

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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
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Demand for change

• Crossing the Quality Chasm A New Health System
  for the 21st Century
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

Richardson, William C. Crossing the Quality
Chasm, Institute of Medicine, 2001
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Consumer empowerment

• More involved in care process
• More knowledgeable
• More activist
• More technically savvy

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Disclosure
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Demand for CPOE
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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.
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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
• 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
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Drug-drug interaction alert
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Lab alerts
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Order sets
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Other functionality

• 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

• 55 decrease in serious medication errors
• Bates, JAMA 1998
• Decreased redundant labs
• Bates, Am J Med, 1997
• More appropriate renal dosing
• No reduction in inappropriate x-rays
• Harpole, JAMIA, 1997

• Minimal effect of charge display
• Bates, Archives of Internal Medicine, 1995
• More appropriate dosing, substitutions accepted
• Teich, Archives of Internal Medicine, 2000
• Decreased vancomycin use
• Sojania, JAMIA, 1998

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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

• 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 whats broken?

• Limited availability
• Most successes are one-of-a-kind, often academic
• Slow diffusion

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Converting research to care
17 years to apply 14 of research knowledge to
patient care!
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So whats 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
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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
• Standard representations for KBs
• Shared content repositories
• Tools
• 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 1990s
• adopted by ASTM and then HL7 in mid-late 90s

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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
Asympto- matic
Get age and occupation
Health-care worker or Agegt65?
Yes
No
Give Flu shot
Do Nothing
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Decision step, in GLIF

• name High risk determination
• condition Boolean_criterion 1
• type Boolean
• spec HCW OR agegt65
• destination (Action_Step 3)
• otherwise (Conditional_Step 2)

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Guideline authoring
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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

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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