Education and Clinical Decision Support: Reuniting Twins Separated at Birth

1. Education and Clinical Decision Support:Reuniting Twins Separated at Birth Jerry Osheroff, M.D. Thomson Healthcare University of Pennsylvania

2. Objectives • Outline the need for a joint model for education and clinical decision support • Describes how the two can be used together to achieve outstanding care delivery and outcomes.

3. Healthcare is Broken Safety • 1 medication error/inpatient/day – IOM • >500K preventable ADE deaths/injuries (outpt) – IOM Quality • 55% chance of appropriate care – McGlynn/NEJM • 17 years: effective treatment ->routine – Balas/IMIA Affordability • $ 44 billion waste recoverable w/CPOE (outpt) - CITL • $ 3.5 billion from inpatient ADEs – IOM

4. Part of the Solution Clinical Decision Support “What should I do now?” Education “What should I know and do?”

5. Orthopedic Surgery VTE prophylaxis schema for hip and knee arthroplasty and hip fracture surgery Creatinine clearance < 30 ml/min • Fondaparinux 2.5 mg sc qday X 14 days • (Start ≥ 6 hours post-op) • Enoxaparin 30 mg sc q12h X 14 days • (Start 12-24 hours post-op; PREFERRED enoxaparin regimen) • Enoxaparin 40 mg sc qday X 14 days • (Start 12 hours pre-op, next dose at least 12 hours post-op) • Warfarin 5 mg po qday (adjust to INR2-3) • (Begin day of surgery) • (Use 2.5 mg for age>75, CHF or liver disease, interacting meds) • Any CONTRAINDICATIONS to • pharmacologic prophylaxis? • High risk of bleeding • Active bleeding • Systemic anticoagulation • INR ≥ 1.5 or aPTT ratio ≥ 1.3 • Platelet count < 50,000 No No Yes Yes • Hip surgery with VTE risk factors? • Previous DVT/PE • Cancer • Thrombophilia • Major trauma • Consider extended prophylaxis • for 28 days post-op with • Fondaparinux 2.5 mg sc qDay or • Enoxaparin 40 mg sc qDay or • Warfarin (INR 2-3) • (with at least weekly INR) Use TEDs/SCDs until contraindication no longer present. Consider serial duplex surveillance or vena caval filter in high-risk orthopedic patients (Hip or knee arthroplasty-particularly with VTE risk factors, Hip fracture surgery, major trauma, spine surgery with risk factors) Yes No Complete 14 days of prophylaxis Not in order set • Enoxaparin 30 mg sc q24h X 14 days • (Start 12-24 hours post-op) • Warfarin 5 mg po qday (adjust to INR2-3) • (Begin day of surgery) • (Use 2.5 mg for age>75, CHF or liver disease, interacting meds) • May add • SCDs Foot pumps • Consider extended prophylaxis • for 28 days post-op with • Warfarin (INR 2-3) • (with at least weekly INR) • Hip surgery with VTE risk factors? • Previous DVT/PE • Cancer • Thrombophilia • Major trauma Yes Yes No Complete 14 days of prophylaxis

6. Goal of Education New knowledge Existing knowledge Existing knowledge Provide cognitive framework, skills, and beliefs necessary for practice.

7. Tools of Education DIDACTIC EXPERIENTIAL Information Case PracticeBasedBasedBased -Informational -Fictional -Apprenticeship text & graphics or real -Quality -Books cases Improvement -Lectures -Virtual -Point of care patients

8. Goals of CDS “Providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care.” • Includes and builds on what’s already being done on a daily basis in healthcare organizations… • NOT just rules and alerts…

9. Tools of CDS • Documentation templates: pt hx, visit note • Relevant data presentation: flowsheets, audits • Order creation facilitators: order sets • Protocol support: pathways • Reference information: infobuttons • Unsolicited alerts: proactive warnings

10. C Acute MI Order Set Help with order selection, core measures identified Must do items clearly identified Links to drug info from every medication order

11. Drug information at a glance

12. Knowledge Needs CONSCIOUSNESS COMPETENCE

13. Linksto synoptic disease information

14. Reunion Drivers • CME Accreditation changes • Improve physician competence, performance, patient outcomes* • Continuous improvement: knowledge, strategies, and performance-in-practice** • Point of care learning • Leverages decision support tools and adds reflective component • Responds to learning needs from patients’ clinical problems *** • Quality improvement • Broader examination of quality gaps • Integrated into Maintenance of Certification * ACCME, Updated Accreditation Citeria, 2006 ** Regnier et al., JCEHP 2005 *** Davis and Willis, JCEHP 2004

15. 5 ‘Rights’: Joint Model for Education and CDS CDS and Education should provide: • the right information(ebm), • to the right person(clinicians and patients…), • in the right intervention format or activity(alert, answer, virtual patient, assessment, reflection), • at the right point in time(relative to workflow and other interventions) • through the right systems and people(cds and education professionals, multimodal solutions) to improve health care delivery and outcomes.

16. Keys to Joint Model • Comprehensive user needs assessment • Diverse development team (clinical experts, informaticians, educators) • Multiple interventions and modalities • Integrated perspective/action

17. A Question in Practice Physician Performance Data Analysis Information Synthesis In Practice PhysicianCompetence Knowledge Judgment Wisdom Strategy Assessment Education Continuing Professional Development Decision Support = Added Regnier et al, JCEHP, Fall 2005

18. Implementing the Joint Model • Work with colleagues in CDS or Education • Understand the tools available • Look at clinical systems for needs assessment data • Analyze root causes of poor performance • Create interventions fully appropriate for needs Education + CDS = Best Healthcare Outcomes

19. Discussion • Thank you! • Comments? Questions? • Contact info: • jerry.osheroff@thomson.com • www.thomsonhealthcare.com