Clinical Decision Support Systems

1. Clinical Decision Support Systems Syed Tirmizi, M.D. Medical Informatician Veterans Health Administration

2. Clinical Decision Support Systems • Definition (What) • Business case (Why) • Use Cases (How) • Usability testing & Evaluations

3. Decision Support Systems Decision support systems are a class of computer-based information systems including knowledge based systems that support decision making activities. -Wikipedia

4. Decision Support Systems • A passive DSS is a system that aids the process of decision making, but that cannot bring out explicit decision suggestions or solutions. • An active DSS can bring out such decision suggestions or solutions. • A cooperative DSS allows the decision maker (or its advisor) to modify, complete, or refine the decision suggestions provided by the system, before sending them back to the system for validation. Haettenschwiler

5. Clinical Decision Support Systems • computer software employing a knowledge base designed for use by a clinician involved in patient care, as a direct aid to clinical decision making • a set of knowledge-based tools that are fully integrated with both the clinician workflow components of a computerized patient record, and a repository of complete and accurate data • providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered and presented at appropriate times, to enhance patient care Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan Report of the Joint Clinical Decision Support Workgroup JONATHAN M. TEICH, MD, PHD, JEROME A. OSHEROFF, MD, ERIC A. PIFER, MD, DEAN F.SITTIG, PHD, ROBERT A. JENDERS, MD, MS, THE CDS EXPERT REVIEW PANEL J Am Med Inform Assoc. 2005;12:365–376.

6. “98,000 Hospital Patients Die Yearly Because of Adverse Events” (IOM, 1999) “Virtually Every Patient Experiences a Gap Between the Best Evidence and the Care They Receive” (IOM, 2001) Patient Safety & Quality Gaps Acknowledged

7. Outpatient Adverse Drug Events • Overall • 25% of outpatients incurred an ADE • 39% were preventable • Antidepressants and antihypertensives were largest contributors • Elderly (over 65) • Adverse Events in 5% of population per year • 28% preventable Gandhi et al, NEJM 2003;348(16):1556-1564 Gurwitz et al, JAMA 2003;289:1107-16

8. Chances of Receiving Appropriate Preventive Care is about 50% -NEJM

9. Employer/Payor business case for CDS - Diabetes • Estimated avg $21,000/year per diabetic employee in absenteeism, disability and medical costs (study of 6 employers with 375,000 employees • Glycemic control is associated with $1000-$2000 medical costs savings/year to payor • Currently, we are “reimbursed” to measure HgA1c annually (captured claim for test ordered) • Will soon be reimbursed for maintaining control through test result surveillance, goal is < 7 Tonya Hongsermeier, MD, MBA Partners Healthcare Systems

10. Knowledge Processing Required for Care Delivery • Medical literature doubling every 19 years • Doubles every 22 months for AIDS care • 2 Million facts needed to practice • Genomics, Personalized Medicine will increase the problem exponentially • Typical drug order today with decision support accounts for, at best, Age, Weight, Height, Labs, Other Active Meds, Allergies, Diagnoses • Today, there are 3000+ molecular diagnostic tests on the market, typical HIT systems cannot support complex, multi-hierarchical chaining clinical decision support Covell DG, Uman GC, Manning PR. Ann Intern Med. 1985 Oct;103(4):596-9

11. Cochrane Library EB Practice Guideline Clinical Evidence Clinical Inquiries Specialty-specific POEMs Best Evidence Reviews: Textbooks, Up-to-Date, 5-Minute Clinical Consult Usefulness Medline Drilling for the Best Information

12. Links Reminder With Actions With Documentation

22. Suggest Use of Thiazide • Set up the reminder dialog so that if the patient is a reasonable candidate for a thiazide and not currently on one, then suggest use of a thiazide. • Suppressed by Cr>2.0, Calcium>10.2, Na+<136 or allergy.

23. Standard HTN dialog copied from the national reminder

24. Insert section at the top if the patient is a candidate for use of a thiazide

26. “Clinical Reminders” Performance Measures • Clinical Reminders • Real time decision support • Targeted to specific patient cohort • Targeted to specific clinic/clinicians • Reminder Dialogs • Standard documentation • Capture of data (HF, encounter data, etc) • Reminder Reports • Performance improvement/scheduled feedback • Identification of best practices • Targeting low scorers for educational intervention • Patient recall if missed intervention

27. Clinical Reminder Reports • Multiple Uses for Reminder Reports • Patient care: • Future Appointments • Which patients need an intervention? • Past Visits • Which patients missed an intervention? • Action Lists • Inpatients • Which patients need an intervention prior to discharge?

28. Clinical Reminder Reports • Identify patients for case management • Diabetic patients with poor control • Identify patients with incomplete problem lists • Patients with (+) Hep C test but no PL entry • Identify high risk patients • on warfarin, amiodarone • Track annual PPD due (Employee Health)

29. Clinical Reminder Reports • Quality Improvement: • Provide feedback (team/provider) • Identify (& share) best practices • Identify under-performers (develop action plan) • Track performance • Implementation of new reminders or new processes • Identify process issues early (mismatch of workload growth versus staffing) • Provide data for external review (JCAHO)

30. Clinical Reminder Reports • Management Tool • Aggregate reports • Facility / Service • Team (primary care team) • Clinic / Ward • Provider-specific reports • Primary Care Provider • Encounter location • If one provider per clinic location

31. Reminder/Dialogs: Other Uses Examples: Reminder dialogs linked to note title • Present ordering dialogs • Medications Orders • Sildenafil/levitra (screening for risk factors) • Clopidogrel (Plavix) (updated criteria) • Discharge Order • Support medication reconciliation (when pharmacists are not available to review meds) • Gather information for display on Health Summary • Non VA surgery

32. Computerized Patient Record System CPRS • Improve healthcare outcomes • Translate Clinical Practice Guidelines into clinical activities • Real time decision support for clinicians at point of care – reminders, alerts • Prevent patient from falling through the cracks • Avoid reliance on memory, vigilance • Reduce errors (omissions, transcriptions, etc) • Facilitate documentation for performance measurement and improvement efforts

33. However This is NOT about technology… It is about RESULTS: • Improved Health Care Quality • Improved Health Outcomes

34. How Do We Compare to non-VA Providers?VHA Continues to exceed HEDIS in the vast majority of 17 common measures HEDIS = Health Plan Employer Data & Information Set From the National Committee on Quality Assurance (NCQA)

35. How Do We Compare to non-VA Providers?VHA Continues to exceed HEDIS in the vast majority of 17 common measures

36. Amputations per 1000 patients FY99-04 Changes in Total, Major and Minor Age-Adjusted Amputation Rates Among Patients With Diabetes

37. Pneumococcal Vaccination Rates in VHA --BRFSS 90th-- --BRFSS-- • Iowa: Petersen, Med Care 1999;37:502-9. >65/ch dz • HHS: National Health Interview Survey, >64

38. Performance has improved

40. Changed to include refusals as failures

41. Outcomes have improved • Increased rates of pneumococcal vaccination over past 5 years has averted over 4000 deaths nationally in VA patients with lung disease • Diabetic complications markedly decreased – amputations, peripheral neuropathy, visual impairment and loss

42. The Chronic Disease Care Model Community HealthSystem Resources and Policies Organization of Health Care Self-Management Support VistA DeliverySystem Design Decision Support Productive Interactions Informed, Empowered Patient and Family Prepared, Proactive Practice Team My HealtheVet Improved Outcomes

43. Highest Quality of Care For Patients with Diabetes in VA “Diabetes processes of care and 2 of 3 intermediate outcomes were better for patients in the VA system than for patients in commercial managed care.” Annals of Internal Medicine, August 17, 2004

44. Highest Quality of Care For Patients in VA Measured Broadly “Patients from the VHA received higher-quality care according to a broad measure. Differences were greatest in areas where the VHA has established performance measures and actively monitors performance.” Annals of Internal Medicine, December 21, 2004

45. Guideline-Based Decision Support for Hypertension with ATHENA DSS Implementation & Evaluation Mary K. Goldstein, MD

46. Developing a Model Program To Provide a Model Program that can be extended to other clinical areas They selected hypertension as a model for guideline implementation because… • Hypertension is highly prevalent in adult medical practice • There are excellent evidence-based guidelines for management • There is also evidence that the guidelines are not well-followed • a big ‘improvability gap’ in IOM terms • Steinman, M.A., M.A. Fischer, M.G. Shlipak, H.B. Bosworth, E.Z. Oddone, B.B. Hoffman and M.K. Goldstein, Are Clinicians Aware of Their Adherence to Hypertension Guidelines? Amer J. Medicine 117:747-54, 2004.

47. What the Clinician Sees…

48. ATHENA Hypertension Advisory:BP- Prescription Graphs Goldstein, M. K. and B. B. Hoffman (2003). Graphical Displays to Improve Guideline-Based Therapy of Hypertension. Hypertension Primer. J. L. Izzo, Jr and H. R. Black. Baltimore, Williams & Wilkins.

49. ATHENA HTN Advisory BP targets Primary recommendation Drug recommendation

50. ATHENA HTN Advisory: More Info