Transcript Document

Royal College of Surgeons in Ireland
Coláiste Ríoga na Máinleá in Éirinn
Usability and Clinical Decision Support Systems
Oxford, 29th September 2010
Derek Corrigan, Borislav D. Dimitrov, Tom Fahey
PHS / Department of General Practice
Overview
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What is a Clinical Decision Support System?
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What are the technical barriers to be considered? – “usability” issues
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What role can Clinical Predication Rules (CPRs) play in a CDSS?
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What form might a state of the art CPR based system look like?
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What are the challenges to achieving this state of the art?
PHS / Department of General Practice
Clinical Decision Support Systems
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Clinical decision support system (CDSS)
– I.T. based systems that are designed to improve clinical decision
making by suggesting possible clinical actions/interventions based
on an underlying clinical evidence base
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CDSS Types
– Diagnostic systems – diagnose appendicitis
– Reminder systems – generate patient letters
– Disease management systems – diabetes management
– Drug dosing/prescribing – insulin, warfarin
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CDSS - Barriers to Implementation
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Human Issues
– As previously discussed - knowledge, attitudes, behavior
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Technical Issues
– Need to consider usability issues of CDSS and how we can
potentially use CPRs as part of them
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CDSS - Usability Issues
10 Commandments for Effective CDSS –
(Bates et al 2003)
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CDSS must fit into the clinical workflow – logical sequence and steps
– Primary care diagnosis tool on laptop or PC in practice as part of consultation
– Secondary care drug administration as part of round system may need something
more mobile and compact – palm held application
– No point developing tools that can only be accessed outside of the clinical
process workflow – they are then seen as an additional overhead
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Speed is everything – users will not tolerate slow systems!
– No matter how useful an application is, it will not be used if performance is
prohibitively slow – need to prototype and user test during development
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Deliver needs in real time – relevant information presented as needed - user
should not need to go searching for information
– In drug prescription systems, one action may imply another associated action that the
system can automatically prompt for e.g. drug interactions, corollary orders or order
sets
– Do not wait until end of the entire process to highlight issues to the user
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Physicians will resist stopping – offer alternatives and overrides
– Users will not accept blanket restrictions – result in lack of confidence and frustration
– Provide alternative suggestions justified by clinical evidence and always allow override
of recommended actions – ultimately the clinician must be trusted
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Changing direction in a system is easier than stopping
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Can modify clinician behavior with beneficial results
Change default medication dosages based on evidence
Change default frequency of dosage based on evidence
Bates et al detail a change resulting in cost savings of $250,000 per year
Monitor impact of CDSS and usage patterns and revise
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Understand how clinicians are using your system
Track underlying usage of rules, alerts and overrides
Large levels of overrides indicate potential problem
Amend evidence base where necessary and/or provide more detailed justification
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Simple interventions work best – CPRs rather than books of guidelines
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Simple rules may offer easiest gains e.g. Ottawa Ankle Rule
Working clinicians will not have time to review pages of guidelines – these
should be provided as supporting documentation where necessary
Usability testing – include the users!
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No point having state of the art evidence base with a bad user interface
Get user feedback through prototyping early in the design process
PHS / Department of General Practice
CDSS - Usability Issues (contd.)
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Manage your knowledge base – needs to be easily updated
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Ensure that formal evidence base review and update is done regularly based
on latest clinical evidence
Provide patient specific recommendations based on electronic patient
record (EPR)
– Ideally integrate CDSS as part of EPR
– Use individual patient data to generate individual recommendations
PHS / Department of General Practice
CDSS - Clinical Prediction Rules
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Evidence Base
– Potentially can use Clinical Prediction Rules (CPRs) as part of a
clinical guideline to drive evidence based care in a CDSS
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Issues to consider
– Level of CPR validation of potential CPRs
– Type of clinical setting where validation of CPR has been done
– Impact assessment of CPR – does it indicate a high quality CPR with
impact for patient, physician or process?
PHS / Department of General Practice
CDSS – Maintaining the Evidence Base
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Huge potential evidence base in EHRs in primary care e.g. General Practice
Research Database in UK (GPRD)
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Create clinical trials/ epidemiological studies from primary care data
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May be used to amend an existing CPR i.e. the inclusion of additional
symptoms/signs identified by data analysis as potential diagnostic cues
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May be used to create new CPR’s based on new diagnostic cue combinations
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Evidence base becomes “self-learning” and adds or improves the list of CPR’s
used as the evidence base
PHS / Department of General Practice
The TRANSFoRm Project
PHS / Department of General Practice
TRANSFoRm
Services
1 CPR Repository
Clinical Prediction
Rules Service
2 Distributed
GP EHRs
With CDSS
3 Research Study Designer
Study Criteria
Design
CP Rules
Manager
CP Classifier
5 CPR Data Mining
and Analysis
CPR Analysis &
Extraction Tool
Find Eligible Patient
4 Research Study Management
Recruit Eligible Patient
Study Data Management
PHS / Department of General Practice
CDSS - Challenges
The EPR
– Still a huge amount of work to be done just to create usable EPRs
System Interoperability – consistent representation of clinical data using
technologies
– Health Level 7 (HL7), OpenEHR – pool and share clinical data by allowing
systems to ‘talk together’
Semantic Interoperability – being able to interpret clinical concepts contained
within data in a consistent way
– Clinical Coding Terminologies such as SNOMED-CT, ICPC, ICD
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In Summary
• CPRs have huge potential as a form of evidence in CDSS
• Need to consider technical usability issues as well as human
issues
• Future directions - develop the Electronic Patient Record
and incorporate research tools to generate and update the
evidence base – “self-learning”
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Thank You
Discuss!
PHS / Department of General Practice