Transcript Drowning in information, but starving for knowledge” John

Using computerized decision
support in hospitals
Kirsty Buising FRACP
Infectious Diseases Physician and Clinical Research Fellow
Victorian Infectious Diseases Service and NHMRC Centre for
Clinical Research Excellence in Infectious Diseases
Computerised decision support
what and why
Definitions
– Using technology to aid decision making
Drivers for decision support
– “Knowledge performance gap”
– Growth of medical knowledge
– Pressures to use knowledge
• Evidenced based medicine, clinical governance, cost
Implementation is the key
“Guidelines are useless if no-one uses them”
Implementation:
We have well established criteria to create a guideline,
but don’t know how to encourage guideline uptake
“Implementation is the Achilles heel for guidelines”
We need to:
Make the information usable
Present it in a form that fits workflow and suits the context
Types of Computerised
Decision Support
PASSIVE
Simply
presenting
guidelines
e.g paper
based docs
stored on
intranet
ALERTS
&
ACTIVE
Patient specific
TRIGGERS
Interactive
e.g Allergy
alerts
Dynamic
Out of range
test flagging
Can be very
advanced eg:
neural networks
Does CDS work in healthcare?
• Yes,
– Reduced medication errors: improved drug dosing, fewer
allergy mismatches (Level I)
– Increased concordance with guidelines (Level I)
– Reduced drug costs, test ordering, length of stay
(Systematic reviews: Walton BMJ 1999; Hunt JAMA 1998; Johnston 1994)
• Examples:
–
–
–
–
Warfarin, aminoglycoside, heparin dosing
Preventive vaccination prompts
Screening
Vancomycin use
• Limitations
– Publication bias - a few major centres heavily
computerised, well integrated
– US paradigm not applicable to Australia
– There are reports of failed systems
• must understand context, fit workflow, suit users
• Rousseau BMJ 1998, Thursky 2006
The 10 commandments of effective decision support
Primary determinant of user satisfaction is speed
Should anticipate needs and deliver in real-time
Integrated with clinical practice and user workflow
Usability is very important
Physicians will often override reminders/suggestions if they
have strong beliefs about the medication or clinical situation.
6. Simple interventions work the best
7. Additional information should not be requested from the user
unless necessary.
8. The impact should be monitored
9. The systems should provide incentives for use
10. Maintain the knowledge-based systems
1.
2.
3.
4.
5.
(Bates et al, JAMIA 2003; Shiffman, JAMIA 1999)
Antibiotic stewardship
Large volumes of antibiotics are prescribed, up to
50% of usage may be inappropriate
– wrong dose, wrong drug, wrong diagnosis, therapy too
prolonged etc. House Lords review 1995, EU Copenhagen recommendations 2002
• Impact upon rates of multiresistant pathogens
– affect patient outcomes, more costly drugs, longer
lengths stay etc
Need for strategies to improve prescribing practices
Local CDS projects
• Focus on antibiotic stewardship
– Driven by VIDS and pharmacy, 2000-present
• Pilot - cAAS
• Pilot - ADVISE
• GUIDANCE DS
– Evaluations of iApprove and CAP guideline
‘ADVISE’
Antibiotic Decision Support for Victorian Infectious Diseases Service
• Project 2000-2002 funded by DHS
• ICU chosen as pilot site
• Make information available at point of care
–
–
–
–
Microbiology browser
Access to core knowledge
Known and predicted sensitivities
Adjusted recommendations based on site, allergies
ADVISE Pre and post implementation study
Thursky et al IQHC 2006
986 ICU patients, 6 months pre and post ADVISE
• Change in pattern of antibiotic use
- 3rd gen cephalosporins OR 0.58 [0.52; 0.79, p 0.001]
- carbapenems OR 0.62 [0.39; 0.97, p 0.037]
- vancomycin OR 0.69 [0.45; 0.99, p 0.047]
• Increased de-escalation (4.6% to 10.1%, p=0.013)
• Cost savings $20,000/year
• Popular- accessed ~6000 times in 6 months
– 3 times per patient per day
‘GUIDANCE DS’
• Commonwealth Biotechnology Innovation
fund grant
• Internet based, .NET framework, eDSML
• Integration with existing hospital databases extracts and presents relevant information
• Launched Jan 2005 at RMH
3 modules of ‘GUIDANCE’
• iApprove - a Restricted Drug Approval
system
• iGuide - diagnostic/ management guidelines
• iMicro - recommendations in response to
microbiologic isolates (like ADVISE)
Evaluation of iApprove
• Uptake – number of uses and coverage
• Drug usage – patterns of consumption of
broad spectrum agents
• Resistance patterns of local bacteria
• Patient outcomes
eg: gram negative bacteraemia, mortality and
length of stay
• Usability- user’s opinions
iApprove
Uptake:
• Currently 250-300 approvals/ month
• 70-100% coverage in gen med/ surg wards
Usability:
• Independent Evaluation: Monash Uni
• 115 participants
– 80% believe iApprove easy to use
Zaidi 2007
Impact of iApprove
reduced use of broad spectrum antibiotics
iGuide:
Why would CDS improve guideline uptake?
– The user gets something back
•
•
•
•
Fast
Simple/ makes sense of complex documents
Educational
Accessible 24 hours
– Transparent - layers of background info
– Locally endorsed
– Always up to date
Make it easy to do the right thing
Presenting guidelines as
computerized decision support
• Need to modify the guideline to exploit the
benefits of CDS
–
–
–
–
–
–
Make it patient specific - algorithmic design
Extract and present data from other sites
Layered presentation - allow user to explore
Local information
Web enabled - external guidelines
References provided
Evaluation of iGuide
• Impact of different implementation strategies for
community acquired pneumonia (CAP) guideline
740 patients with over 4 years
– Passive dissemination: 62% concordance (at 1 year)
– Academic detailing : 68% concordance (at 2-3 years)
– CDS: 89% concordance
Concordance with guideline
Capacity building
• Guidance DS already at
– RMH
– PMCI
– Barwon Health
• and soon to be at
– Eastern Health
– Alfred Hospital
– Tasmania (statewide)
• Ability to share guidelines between hospitals and
modify content (taking ownership)
Summary
• CDS offers a new implementation strategy
for evidence based medicine
• Staff are adopting it
• Must fit workflow and understand the
context
• MH are leaders in this field
Acknowledgments
VIDS/ CCREID
– Karin Thursky
– Jim Black
– Alan Street
– Michael Richards
– Graham Brown
– Lachlan Macgregor
• Renu Shansugamundaram
Department of Pharmacy
– Marion Robertson
Intensive Care Unit
– Jeffrey Presneill
– Jack Cade
Emergency department
- Marcus Kennedy
•
Medseed Computing
– Ryan Warrener
– Russell Beattie
– Bron Gondwana
– Hugo Stephenson
– Michael Mahemoff
All Clinicians and Pharmacists of
RMH
• Declaration: VIDS staff are
employees of Melbourne Health
and have no financial ties to
Medseed