BlackfordMiddleton,MD,MPH,MSc,FACP,FACMI,FHIMSSChairman,CenterforInformationTechnologyLeadership

CorporateDirector,ClinicalInformaticsResearch&DevelopmentPartnersHealthcareSystemHarvardMedicalSchool

HarvardSchoolofPublicHealth

 WhatisClinicalDecisionSupport? TheEvidenceForandAgainstCDS CurrentexamplesandR&DProjectsfromPartners TheClinicalDecisionSupportConsortium

 “Whatinformationconsumesisratherobvious:itconsumestheattentionofitsrecipients. Henceawealthofinformationcreatesapovertyofattention,andaneedtoallocatethatattentionefficientlyamongtheoverabundanceofinformationsourcesthatmightconsumeit.”

 Changingclinicianroles:  FromOmniscientOracle…toKnowledgeBroker.

compiled

analyzed

acted upon

After B Blum, 1984

 Medicalliteraturedoublingevery19years Doublesevery22monthsforAIDScare

 2Millionfactsneededtopractice CovellstudyofLAInternists:

 2unansweredclinicalquestionsforevery3pts•  40%weredescribedasquestionsoffact,•  44%werequestionsofmedicalopinion,•  16%werequestionsofnon‐medicalinformation.

Covell DG, Uman GC, Manning PR. Ann Intern Med. 1985 Oct;103(4):596-9

 Generally,withdirectobservation,orinterviewimmediatelyafterclinicalencounters,physicianshaveapproximatelyonequestionforevery1‐2patients Independentestimates:0.6,and0.62Q/pt HoldsacrossPCPandspecialtycare Holdsacrossurbanandrural

Gorman, 1995 Gorman and Helfand 1995

An objective measure of the amount of literature generated by medical scientists annually

Publication

Bibliographicdatabases

Submission

Reviews,guidelines,textbook

Negativeresults

variable

0.3year

6.0­13.0years50%

46%

18%

35%

0.6year

0.5year

9.3years

Dickersin,1987

Koren,1989

Balas,1995

Poynard,1985

Kumar,1992

Kumar,1992

Poyer,1982

Antman,1992

Negativeresults

Lackofnumbers

Inconsistentindexing

17:14

Originalresearch

Acceptance

PatientCare

17 years to apply 14% of research knowledge

to patient care!

BalasYearbookMedicalInformatics2000gtre4,courtesyMOverhage

AbrahamFlexner,MedicalEducationintheUnitedStatesandCanada.

Boston:MerrymountPress,1910

"...The curse of medical education is the excessive number of schools. The situation can improve only as weaker and superfluous schools are extinguished." “Society reaps at this moment but a small fraction of the advantage which current knowledge has the power to confer.”

 “Insteadofteachingdoctorstobeintelligentmapreaders,wehavetriedtoteacheveryonetobeacartographer.”

 “Wepracticehealthcareasifweneverwroteanythingdown.Itisaspectacleoffragmentedintention.”

 LarryWeed,M.D. (fatherof“S.O.A.P.”note)

 Pronetoerror Lotsofinformationbutnodata Limiteddecisionsupport,orqualitymeasurement DoesnotintegratewitheHealthcare Willnottransformhealthcare

 Medicalerror,patientsafety,andqualityissues 98,000deathsrelatedtomedicalerror 40%ofoutpatientprescriptionsunnecessary Patientsreceiveonly54.9%ofrecommendedcare

 Fracturedhealthcaredeliverysystem Medicarebeneficiariessee1.3–13.8uniqueprovidersannually,onaverage6.4differentproviders/yr

 Patient’smultiplerecordsdonotinteroperate An‘unwired’system

 90%ofthe30BhealthcaretransactionsintheUSeveryyearareconductedviamail,fax,orphone

http://tr.im/sVLA

“…driven primarily by local norms that tend towards heavier use of discretionary services – such as diagnostic testing and surgical versus less invasive interventions – for which there are no clear clinical guidelines.” Peter Orszag, OMB Blog http://www.whitehouse.gov/omb/blog/

El Paso

McAllen

TEXAS

790 mi., 1271 km

 “Aknowledge‐basedsystemisanAIprogramwhoseperformancedependsmoreontheexplicitpresenceofalargebodyofknowledgethanonthepresenceofingeniouscomputationalprocedures…”

Duda RO, Shortliffe EH. Expert systems research. Science. 1983 Apr 15;220(4594):261-8.

 Algorithmic Statistical PatternMatching Rule‐based(Heuristic) Meta‐heuristic Fuzzysets Neuralnets Bayesian

Knowledge Base

Inference Engine

A B

BloisMS.Clinicaljudgmentandcomputers.

NEnglJMed.1980Jul24;303(4):192‐7.

 Formatting Resultsreview,“pocketrounds”reports

 Interpreting EKG,PFTs,Pap,ABG

 Consulting QMR,DxPlain,Iliad,Meditel,AbdPain,MIrisk

 Monitoring Alerts:Criticallabs,ABx/Surgery,ADEs

 Critiquing Ventmgmt,anesthesiamgmt,HTNRx,Radiologytestselection,Bloodproductsordering

Kuperman GJ et al. J Hlth Info Mgmt (13)2, pg 81-96

  CDSyieldsincreasedadherencetoguideline‐basedcare,enhancedsurveillanceandmonitoring,anddecreasedmedicationerrors  (Chaudhryetal.,2006)

  CDS,atthetimeoforderentryinacomputerizedproviderorderentrysystemcanhelpeliminateoveruse,underuse,andmisuse.  (Batesetal.,2003;Austinetal.,1994;Linder,BatesandLee,2005;Tierneyetal.,2003)

  Forexpensiveradiologictestsandproceduresthisguidanceatthepointoforderingcanguidephysicianstowardorderingthemostappropriateandcosteffective,radiologictests.  (Batesetal.,2003;Khorasanietal.,2003)

  Showingthecumulativechargedisplayforalltestsordered,remindingaboutredundanttestsordered,providingcounter‐detailingduringorderentry,andremindingaboutconsequentorcorollaryordersmayalsoimpactresourceutilization  (BatesandGawande,2003;Bates,2004;McDonaldetal.,2004).

 Savingspotential:$44billion reducedmedication,radiology,laboratory,andADE‐relatedexpenses

 AdvancedCDSsystems SavingspotentialonlywithadvancedCDS costfivetimesasmuchasbasicCDS generate12timesgreaterfinancialreturn

 Apotentialreductionofmorethan2millionadversedrugevents(ADEs)annually

Johnston et al., 2003 http://www.citl.org

 HanYY(Pediatrics116:6,Dec2005) Analyzeddata13prior,and5monthspost,implementationofCPOEincriticalcare

 PreCPOEmortalityrate2.8%,Post6.57% 3.28Oddsratioaftermultivariateanalysisadjustingforcovariates

 Conclusion Orderdelayduetolackofpre‐register Upfronttimecosttoenterorders Nursesawayfrombedside,atcomputer AlteredinteractionsbetweenICUteammembers Delayedpharmacyadministration Problemswithordertiming(subsequentdoses)

 InformationErrors  Assumeddose Medd/cfailure  Procedure‐linkedmederror  Givenow,andprnd/cerror  Antibioticrenewal Diluentoptionerror  Allergydisplay  Conflictorduplicatemed

 HCI/WorkflowErrors  Patientselection Medselection Unclearlogon/off Medsaftersurgery  Postsurgerysuspendedmeds  Time/datalosswhenCPOEdown

 Meddeliveryerror  Timingerrors Delayednursingdocumentation

  Rigidsystemdesign

Koppel R et al. JAMA 293:10, Mar 2005

During the Clinical Encounter

History and Physical End of Visit

After the Encounter

Results Arrive

Proactive Reminders Warnings/

Feedback Templates/Order Sets

Alerts Guidelines

Relevant Info Display

Consequent Actions

Communication Time-Based Checks

Adapted from Osherorff JA, Pifer EA, Sittig DF, Jenders RA, and Teich JM. Clinical Decision Support Implementers' Workbook. 2004.

Before the Encounter Patient Prepares

for the Visit

Scheduling Record Review & Update

Patient Reminders

Health Information

Bates et. al. JAMA 1998.

Secure Messaging

Task Management Population Management

Clinical Alerts

Schedule

Patient Lists

Knowledge Links

Information Access Knowledge Linking

KnowledgeLink in the Workflow

Patient Disease Management

SmartView:DataDisplay

SmartAssessment,Orders,andPlan

Assessmentandrecommendationsgeneratedfromrulesengine

SmartDocumentation

•  Lipids•  Anti‐platelettherapy•  Bloodpressure•  Glucosecontrol•  Microalbuminuria•  Immunizations•  Smoking•  Weight•  Eyeandfootexaminations

MedicationOrders

LabOrders

Referrals

Handouts/Education

0% 10% 20% 30% 40% 50% 60% 70% 80%

Up­to­dateBPresult

ChangeinBPtherapyifabovegoal

Up­to­dateheightandweight

ChangeintherapyifA1Cabovegoal

Up­to­datefootexamdocumented

Up­to­dateeyeexamdocumented

#ofdeficienciesaddressed

SmartFormUsed Control

<0.001

<0.001

<0.001

<0.001

<0.001

0.05

0.004

0.006

Targetsare90thpercentileforHEDISorforPartnersproviders

Zerodefectcare:• Aspirin• Beta‐blockers• Bloodpressure• Lipids

Red,yellow,andgreenindicatorsshowadherencewithtargets

Discrepancy

Details

Grant RW et al. Practice-linked Online Personal Health Records for Type 2 Diabetes: A Randomized Controlled Trial. Arch Intern Med. 2008 Sep 8;168(16):1776-82. .

More medication changes in visits after diabetes journal submission:

 NewappreciationforpotentialunintendedconsequencesofCDS

 Knowledge“hardwired”intoapplications Knowledge‐engineeringtoolsassumeauthorsknowwhattoputintothem

 Proprietaryknowledgerepresentationstandards:notre‐usable,noteasilyshared

 Lackofhealthcareleadershiporresourceinvestmentinprocessesforknowledgeacquisitionandmanagement

ARoadmapforNationalActiononClinicalDecisionSupport

“toensurethatoptimal,usableandeffectiveclinicaldecisionsupportiswidelyavailabletoproviders,

patients,andindividualswhereandwhentheyneedittomakehealthcaredecisions.” !

Osheroff JA, Teich JM, Middleton B, Steen EB, Wright A, Detmer DE. J. Am. Med. Inform. Assoc. 2007;14(2):141-145.

Toassess,define,demonstrate,andevaluatebestpracticesforknowledgemanagementandclinicaldecisionsupportinhealthcareinformationtechnologyatscale–acrossmultipleambulatorycaresettingsandEHRtechnologyplatforms.

www.partners.org/cird/cdsc

  HowdoweimprovethetranslationofknowledgeinclinicalpracticeguidelinesintoactionableCDSinhealthcareinformationtechnology?

  HowdoweoptimallyrepresentknowledgeanddatarequiredtomakeactionableCDScontentinbothhumanandmachinereadableform?

  Howdowecollate,aggregate,andcurateknowledgecontentforCDSinaknowledgeportalusedbymembersoftheCDSConsortium?Howmayweusesuchatooltosupportknowledgemanagementandcollaborativeknowledgeengineeringforclinicaldecisionsupportatscale,acrossmultiplehealthcaredeliveryorganizations,andmultipledomainsofmedicine?

  Howdowedemonstratebroadadoptionofevidence‐basedCDSatscaleinawidearrayofHITproductsusedindisparateambulatorycaredeliverysettings?

  Further,howdowedeployclinicaldecisionsupportservicesinhealthcareinformationtechnologyinamannerthatimprovesCDSimpact?

  Howdowetakethelearningsgarneredthroughthecourseoftheseinvestigationsandbroadlydisseminatethembroadlytokeystakeholders?

1980 1990 2000

ONCOCIN EON(T-Helper) GLIF2

Arden

MBTA

GEODE-CM

EON2

GLIF3

Asbru

Oxford System of Medicine DILEMMA PROforma

PRESTIGE

PRODIGY

Decision Tables GEM

PRODIGY3

P. L. Elkin, M. Peleg, R. Lacson, E. Bernstam, S. Tu, A. Boxwala, R. Greenes, & E. H. Shortliffe. Toward Standardization of Electronic Guidelines. MD Computing 17(6):39-44, 2000

Shahar Y, et al. JBI 2004

1. Knowledge Management Life Cycle

2. Knowledge Specification

3. Knowledge Portal and Repository

4. CDS Public Services and Dashboard

5. Evaluation Process for each CDS Assessment and Research Area

6. Dissemination Process for each Assessment and Research Area

  Knowledgemanagementlifecycle  Knowledgespecification  KnowledgePortalandRepository  CDSKnowledgeContentandPublicWebServices  Evaluation  Dissemination

NarrativeRecommendationlayer

Narrativetextoftherecommendationfromthepublishedguideline.Semi‐StructuredRecommendationlayer

Breaksdownthetextintovariousslotssuchasthoseforapplicableclinicalscenario,therecommendedintervention,andevidencebasisfortherecommendation

Standardvocabularycodesfordataandmoreprecisecriteria(pseudocode)

AbstractRepresentationlayer

StructurestherecommendationforuseinparticularkindsofCDStools

•  Reminderandalertrules

•  Ordersets

Arecommendationcouldhaveseveraldifferentartifactscreatedinthislayer,oneforeachkindofCDStool

MachineExecutablelayer

KnowledgeencodedinaformatthatcanberapidlyintegratedintoaCDStoolonaspecificHITplatform

E.g.,rulecouldbeencodedinArdenSyntax

Arecommendationcouldhaveseveraldifferentartifactscreatedinthislayer,oneforeachofthedifferentHITplatforms

NarrativeGuideline

SemistructuredRecommendationAbstractRepresentation

MachineExecution

 ForeachknowledgerepresentationlayerinCDSstack: Datastandard(controlledmedicalterminology,conceptdefinitions,allowablevalues)

 Logicspecification(statementofrulelogic) Functionalrequirement(specificationofITfeaturerequirementsforexpressionofrule,etc.)

 Reportspecification(descriptionofmethodforCDSimpactmeasurementandassessment)

Collaboration eRoom for Adult Primary Care

51

1 Oct 08 9:55pm • How does everyone feel about this?

• Should we turn the reminder off for a shorter period of time if “Done Elsewhere” is chosen?

PersonalHealth

InformationNetwork

Community(”Crowd”)MedicalProfessional

ScienceRulebuilder

Knowledge

respository

Ruleengine

Clin.Inf.System

PetterK.RisøeHSPH HPM512 2009

Patient

“I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.”

Clem McDonald, MD NEJM 1976

Thank you! Blackford Middleton, MD bmiddleton1@partners.org www.partners.org/cird www.citl.org