Transcript teich_1b
Clinical Decision Support for Quality: How to Reap the Benefits Jonathan Teich, MD, PhD Elsevier Health Sciences Harvard University August 20, 2008 CDS is Effective (often) • Increases guideline adherence • Decreases medication errors and adverse events • Increases surveillance and monitoring • Improves preventive care • Improves appropriate resource utilization • Saves money – BWH: $5-10M/yr estimate – $ 44 billion waste recoverable from ambulatory CPOE - CITL – $ 3.5 billion from inpatient ADEs – IOM Sources: Chaudhry et al., 2006; many others2 Impact – medication errors (dosing) 2.5 % of orders 2 1.5 1 0.5 0 Pre-OE Post-OE Year 1 3 Year 2 Year 3 News seems to fluctuate Causes errors! Not accepted! Prevents errors! Saves lives and $$! 4 So, the questions are: • What new trends in CDS and technology will help make it more widely valuable and effective? • What is being done at the national level by government and industry to improve the situation? • What can you do locally to make CDS a force for improved quality/safety/cost/benefit? 5 What’s New in CDS? It’s Not Just about Alerts 7 Workflow Support - Order Sets 8 Workflow support – Heads-Up Displays 9 Interactive reference prevents errors 10 Workflow Support - Procedures 11 Classes Reference Appointments Forums Personal record Home monitoring Medications 12 Tomorrow’s key sources – same, without the search • CDS = “Providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care.” • Traditional book and journal information needs to be reformatted and repurposed for effective CDS interventions 13 Infobuttons 14 15 Triggered reference Visit Type End of Visit QuickPicks Office visit, acute illness Lab Tests Dx Studies Meds Dx Codes CPT Codes Patient Next Visit Pt EducLeaf lets Leaflet s related t o the t opics addressed during t his visit : Lab Tests Dx Codes: CBC w/diff Blood cx Sinusitis Electrolytes End of Visit ESR Hematocrit Monospot PTH Nose Injuries LFT panel Sinus X-ray for TFT sinusitis Sinusitis Theo lvl Throat cx Urine spec grav Healt h UrineSearch cx Urinalysis Urine cx + sens Go Dx Studies Lab Tests: Abd CT scan CBC Abd w /U/S diff CXR PA+LAT Articles: Reason For Dx Study Head CT R/O infiltrate Sinus CT Complete Count KUB + upright Blood Sinus series EKG Echocardiogram Search Tests/Procedures Articles: Dx St udies: Go Dx Codes SinusGastroenteritis, CT Scan Head acute, 491.9 viral,CT NEC, 008.8 of t heBronchitis, Fever, 780.6 Sinusitis, 473.9 Influenza, 487.1 Pneumonia, bact, 482.9 Asthma, 493.90 Pharyngitis, strep, 034.0 Rank Order Dx Codes 1. 401.1 Hypertension, primary 2. 482.9 Pneumonia, bacterial 3. CPT Codes Visit type Office Procedures Print Selections Send Selections as Message to Patient Office visit, estab, moderate, 99214 Inhalation treatment, 94640 Urinalysis, 81000 I+D, abscess, 10040 Hematocrit, 85013 16 Connected CDS Meds handling CARDIAC CATH Post-procedure Skills Care Plan Procedure Guidance Order Set Discharge planning Angina Dx and Tx info Ambulatory Care Protocols Triage Protocols DISCHARGE NEW PATIENT ADMITTED WITH ANGINA 17 Better delivery Integrated delivery 18 CDS and Quality: National Efforts “End-to-End” CDS Quality Organizations Reporting Agencies Guideline Developers Providers/ Patients CDS Producers EHR Vendors 20 CDS for Quality • • • • • • • • • Quality goals are numerous, complex Guidelines not designed for easy clinical or EHR use No simple data set on which vendors can concentrate CDS not easily sharable from site to site CDS implementation confusion No quick, reliable scenario-based CDS Provider resistance and misuse Complex administrative reporting framework No consistent reimbursement tie to quality 21 National CDS Roadmap (AMIA/ONC) •Widespread, commercially-available information systems being produced, purchased, and implemented, and helping to improve quality and efficiency in many venues CDS Roadmap: Strategic Objectives 1. Develop practical standard formats for representing CDS knowledge and interventions 2. Establish standard approaches to organizing and distributing CDS 3. Compile and disseminate best practices for usability and implementation 4. Develop standards to collect, learn from, and share national CDS experience 23 Key activities and outputs EHR & CDS Industry Consortia (IHE, EHRVA) Core data set (NCQA) Pilot Demonstrations (CMS, AHRQ) National Standards and Structures (AHIC, AQA) 24 Impl. guides, education, Resources (HIMSS, DOQ-IT) Practical Implementation: Getting CDS to Work for You A technological and psychological affair CDS Success Factors • • • • • • • Define what your victory will be Find the right CDS for the job Communicate frequently Get everyone to own it Utilize clinician champions Top-level organizational support Communicate more frequently than that 26 The Right CDS at the Right Time 27 Technology success factors • • • • Clinically-oriented display & entry Support typical practice patterns Short learning curve to something useful Enhance workflow – Next-needed information is always at hand – Complete support for a process Add high-value safety features after the system has been accepted! 28 Clinician roles • Vetting original concepts • Giving input to design process – MD,RN,ancillary,management... • Taking clinical leadership – in exchange, system reflects your ideas • Cheerleaders, champions, communicators 29 Take-Home Lessons • CDS can facilitate improved safety, quality, and performance on quality metrics • Not just alerts – smart forms, task guidance, informational CDS • Currently CDS is not supplied or used to full effectiveness in all settings – Can usually attribute to design and communication issues • Full effectiveness comes from – usability design – best-practice implementation skills – facilitation of common elements – group help for small practices 30 [email protected] [email protected]