VIReC CyberSeminar Series 2006 Clinical Informatics

1. VIReC CyberSeminar Series 2006Clinical Informatics Attributes of An Ideal Informatics System with Highlights from a State of the Art Conference Denise M. Hynes, Ph.D., R.N. Director, VIReCResearch Health Scientist, MCHSPR COE

2. HSR&D Resource Centers CiDER = Center for Information Dissemination & Education Resources HERC = Health Economics Resource Center metric = Measurement Excellence & Training Resources Information Center VIReC = VA Information Resource Center

3. Series/Course Objectives • To learnabout applications in clinical informatics in research and quality improvement efforts • VA and non-VA efforts • To understand approaches for evaluating clinical informatics and IT interventions

4. Selected Course Topics • Attributes of an Ideal Information System: Highlights from a State of the Art Conference • Approaches for Evaluating Health Informatics Technology and CDSS • Implementation of CDSS in Hypertension Management • Implementation of a CDSS in Mental Health • Using CDSS in Pain Management • Informatics Applications for Promoting Collaborative Care

5. Session Objectives • Understand the key aspects to consider in a clinical information system • Understand the desired attributes of a clinical information system • Become aware of the barriers and facilitators to use of IT in healthcare and research

6. IOM Quality Chasm Report, 2001 • Predominance of chronic care • Need for evidence-based practice • Critical value of information technology

7. IOM Committee on Quality of Health Care in America • Point-of-care access to health literature and evidence-based guidelines • Computer-assisted decision support systems; • Computerized patient clinical data • Automation of decisions to reduce errors • Electronic communication between providers • Electronic communication between providers and patients

8. Informatics Support for Clinical Practice Guideline Implementation • Pathman, et al. Medical Care 1996; 34:873-889

9. Diffusion of Innovation Theory: Key Dimensions • Nature of the innovation itself • How communication channels can be impacted • Time • Social system and organizational context

10. Challenge of Using Information Technology (IT) for QI • Integrating new forms of decision support into legacy data systems and electronic record interfaces • Sociotechnical aspects Goldstein, et al., JAMIA 11: 368-76, 2004.

11. Berg’s Sociotechnical Success • Technical success • generates correct recommendations offline • extracts and uses patient data correctly • integrates with CPRS to display for the right • Patient, • Provider • Clinical location • Time window • tracks the data needed for research evaluation • Sociological success • clinicians find it usable and useful Berg, M., Int J Med Inf, 1999. 55(2): p. 87-101.

12. Social Challenges of IT in Health • Clinicians’ time constraints • Strike balance between ease of access to system and ease of ignoring it • Balance with interpersonal needs of patients • Variability in comfort with computers • And virtually no training time available • Lack of consensus/agreement about the guidelines

13. State of the Art Conference SummaryAttributes of an Ideal Integrated Informatics System that Supports Implementation of Evidence

14. The ideal information management system supports managers, providers and patients to achieve practice and outcomes consistent with evidence

15. Attributes of the Ideal Information System • Supports knowledge-based decisions • Evaluation/Reporting Capability • Evolves with health care system • Accurate/Correct Content • Standardized/Compatible

16. Defined Accountability: organization vs. provider • Equitable:“No service/facility left behind” • Sustainable • Secure

17. Usable • Integrated • All electronic • flexible • transparent to users • non intrusive • easily up-datable

18. Priority 1: Supports knowledge-based decisions • Current Information Systems do not fully utilized knowledge-based decision support • Clinical reminders, order check system, notification and alerts • Data capture limited to local system • Difficult to prioritize • Handling of adverse events

19. Barrier: too much info/provider overload Strategies: • Research on how to prioritize • Require research to include data on added value in terms of mortality and morbidity

20. Barrier: lack of integration Strategies: • National patient data record • Patient ownership of patient data, guidelines and reminders • Common patient identifier • Common provider identifier • Integration across systems • Research on what information users need

21. Barrier: Operationalizing evidence Strategies: • Basic research in managing information complexity • Alignment of research priorities with clinical management • Performance measures focused on how much evidence informs practice • Regular presentation of significant translation research findings to senior leadership

22. Barrier: Threats to provider autonomy Strategies: • Flexibility in decision support with required feedback about reasons for non-compliance and barriers to compliance • Local review of compliance with local solutions (tailored training) • Add autonomy in other areas: e.g., guideline input, self-review, link to reference materials

23. Priority 2: Reporting/Evaluation Functions • rapid monitoring and feedback for evidence-based practice • recommend appropriate treatment (reminders), track actual treatment and results, provide ongoing analysis of effectiveness • Support analysis and review at different levels and contexts

24. Barrier: Data issues Strategies: • More automation of data (e.g., link diagnosis to test) • Review and monitoring of data quality • Linkages to other information in EHR so provider doesn’t have to reenter (e.g., test results)

25. Barrier: Reporting complexity Reporting complexity requires specialized knowledge Strategies: • Use OLAP cubes to simplify user generation of reports

26. Barrier: System resources Reporting function on existing patient care system eats system resources, slows response time Strategies: • Move reports off system – put analytical tools on a system separate from pt care system

27. Priority 3: Information system needs to evolve with health care system • Aspects of the information system are based on prior care models • Current methods of data collection may not match business process or support evidence-based practice

28. Barrier: Emphasis on provider-level activities and provider-entered data Strategies: • Develop patient-centered data collection methods, core data elements, and system capacity for patient-based health data sets • Encourage basic research on capturing home care data for all stakeholders

29. Barrier: Emphasis on workload rather than care received by patient • Focus on outcomes (maintaining/improving functional status of the patient), not workload • encourage “just in time” rather than “just in case” visits, collect interim data remotely

30. Some Summary Remarks • Technology must be tailored to providers’ needs • Fit into workflow in real time • Minimize request for additional information • Meet need for speed • Elicit feedback and respond • Tracking mechanisms needed to support research