From Thoughtless Alertsto

Effective Decision-Support 

Using the EHR in a

Learning Health System

AgendaAgenda

Current Challenges to Outpatient Current Challenges to Outpatient MedicineMedicine

What is the Evidence for CDSWhat is the Evidence for CDS Threats and Challenges to CDSThreats and Challenges to CDS One system’s experience with CDSOne system’s experience with CDS

– GovernanceGovernance– ToolsTools– ReportingReporting

The way forwardThe way forward22

Aging of the Aging of the PopulationPopulation

33

No DataLess than 4% 4% to 6% Above 6%

Diabetes PrevalenceAmong U.S. Adults

NOTE: Data are age-adjusted to the 2000 standard population. SOURCE: Behavioral Risk Factor Surveillance System (BRFSS), CDC.

44

Burden of Chronic Burden of Chronic Disease -- 2008Disease -- 2008 6.5% -- Coronary Heart Disease6.5% -- Coronary Heart Disease 25.5% -- HTN25.5% -- HTN 2.7% -- Stroke2.7% -- Stroke 8.0% -- Asthma8.0% -- Asthma 6.6% -- COPD6.6% -- COPD 8.5% -- Cancer8.5% -- Cancer 9.2% -- Diabetes9.2% -- Diabetes

Source: National Health Interview Survey 2008

55

Meaningful Use

PQRS HEDISValue Based Purchasing

Burden of Quality Burden of Quality MeasuresMeasures

Breast Ca Screening Colon Ca

Screening

Lipids in CAD Osteoporosis Management Lipids

in Diabetes

Kidney Checks in Diabetes

Eye Exams in DM

Rheumatoid Arthritis

Management

Hi Risk Medications

in the Elderly

ACE/ARB in Diabetes

Cervical Ca Screening

Chlamydia ScreeningImmunizations

Controller Meds in Asthma

COPD:Spirometry

66

“ “To fully satisfy the USPSTF To fully satisfy the USPSTF recommendations, … 7.4 hours per recommendations, … 7.4 hours per

working day, is needed for the working day, is needed for the provision of preventive services.”provision of preventive services.”

Am J Public Health. 2003 April; 93(4): 635–641.

• Identify that someone is potentially eligible for a service

• Determine whether or not that service has already been provided

• Counsel the patient• Order the service

77

Quality of Health Care Quality of Health Care Delivered in USADelivered in USA Random sample of adults living in Random sample of adults living in

12 metropolitan areas12 metropolitan areas Evaluated performance on 439 Evaluated performance on 439

indicators – 30 conditions and indicators – 30 conditions and preventionprevention

44.7% - at least one chronic 44.7% - at least one chronic conditioncondition

NEJM 348;26: 2635-2645. 88

Percentage of Percentage of Recommended CareRecommended Care

Type of CareType of Care % of % of Recommended Recommended Care ReceivedCare Received

PreventativePreventative 54.9 54.9

AcuteAcute 53.553.5

ChronicChronic 56.156.1

99

““The lag between the discovery of The lag between the discovery of more efficacious forms of more efficacious forms of treatment and their incorporation treatment and their incorporation into routine patient care is into routine patient care is unnecessarily long, in the range of unnecessarily long, in the range of about 15 to 20 years.”about 15 to 20 years.” 1010

Effects of Computerized Clinical Decision Support Systems on Practitioner Performance and Patient Outcomes: A Systematic Review

JAMA. 2005;293(10):1223-1238. doi:10.1001/jama.293.10.1223

1111

Characteristics ofCharacteristics ofSuccessful CDSSuccessful CDS

JAMA. 2005;293(10):1223-1238. doi:10.1001/jama.293.10.1223

1212

Challenges to CDSChallenges to CDS

Divergent prioritiesDivergent priorities– Primary care vs SpecialistPrimary care vs Specialist– Clinical Care vs “Business Needs”Clinical Care vs “Business Needs”– Unclear or contradictory standardsUnclear or contradictory standards

Disparate WorkflowsDisparate Workflows Alert FatigueAlert Fatigue

1313

Types of Decision Types of Decision SupportSupport Intrusive Reminders (“Pop-Ups”)Intrusive Reminders (“Pop-Ups”) ““Passive” RemindersPassive” Reminders Order SetsOrder Sets Information DisplaysInformation Displays Links to Relevant GuidelinesLinks to Relevant Guidelines

1414

Dealing with Divergent Dealing with Divergent PrioritiesPriorities Find a cartoonFind a cartoon

1515

Who’s In Charge?Who’s In Charge?

Decision-Support Working Group

(approx 10 physicians)

PhysicianIT

Leadership

• Meets monthly• Decides on

clinical content and standards

• Validates build

• Meets technical team weekly

• Sets DSWG agenda

• Suggests new rules

• Designs tools (with technical team)

• Executes build

• Tests build• Advises

leadership and DSWG

• Educates on new features

Technical Team

President, Physician Services DivisionPresident, Community Medicine, Inc

Chief Medical Information Officer

1616

Governing PrinciplesGoverning Principles Widely accepted guidelinesWidely accepted guidelines

– USPSTF, ACIP/CDCUSPSTF, ACIP/CDC– Support HEDIS and other quality measuresSupport HEDIS and other quality measures

Do not interrupt workflowDo not interrupt workflow– (may interrupt work that should be interrupted)(may interrupt work that should be interrupted)

Provide method to override Provide method to override alerts/customizealerts/customize

Leadership of receiving specialty must Leadership of receiving specialty must consentconsent

1717

Technical PrinciplesTechnical Principles

More important services have More important services have more intrusive alertsmore intrusive alerts

Use workflow tools for Use workflow tools for interventions that need to be done interventions that need to be done on every visiton every visit

Alerts for periodic services are tied Alerts for periodic services are tied to Health Maintenanceto Health Maintenance

Color code and prioritizeColor code and prioritize1818

Scenarios for CDSScenarios for CDS

Safety Alerts Prevention

Chronic Disease Management

Medications

Clinical Pathways

Meaningful Use/Billing

1919

Best Practice Best Practice Advisories - PrimerAdvisories - Primer

Problem List

Best Practice Alert

Med List PMH,PSH

ResultsOrders

FlowSheet Values

HM Modifiers and Topics

2020

Where to BPAs Fit In?Where to BPAs Fit In?

StrengthsStrengths– Powerful logicPowerful logic– Can evaluate in ‘real time’Can evaluate in ‘real time’– Department and role specificDepartment and role specific– Fit into workflow (Visit Navigator) OR Fit into workflow (Visit Navigator) OR

PopUp when neededPopUp when needed– Facilitate ActionFacilitate Action

WeaknessesWeaknesses– Hard to customizeHard to customize

2121

BPA StrategyBPA Strategy

Color Coded by TypeColor Coded by Type SafetySafety Meaningful UseMeaningful Use Disease managementDisease management PreventionPrevention ResearchResearch

2222

Pop-Ups --- Patient Pop-Ups --- Patient SafetySafety Order contrast for allergic patientOrder contrast for allergic patient Order MRI when pacer is presentOrder MRI when pacer is present

2323

2424

• Health Maintenance Health Maintenance is Epic's preventive is Epic's preventive health reminder tool. health reminder tool.

• Patients and Patients and providers can be providers can be reminded about reminded about mammograms, flu mammograms, flu shots, immunizations shots, immunizations and any other and any other preventive diagnostic preventive diagnostic and/or therapeutic and/or therapeutic procedures.procedures.

HealthHealth MaintenanceMaintenance

2525

Health Maintenance works in two Health Maintenance works in two ways:ways:o Automatic reminders Automatic reminders

o Gender, ageGender, ageo ProblemsProblemso MedicationsMedications

o Manual remindersManual reminderso Modifier is addedModifier is addedo BPA may suggest thisBPA may suggest this

How does Health How does Health Maintenance work?Maintenance work?

2626

Health Maintenance Health Maintenance 101 --- Topics101 --- Topics Topics are the Building BlocksTopics are the Building Blocks

– ServiceService on a on a scheduleschedule– Satisfied by completed proceduresSatisfied by completed procedures– Can be manually satisfiedCan be manually satisfied

A1c every 6 months LDL

yearlyPap

Every 3 yrs

Mammogram every year

2727

Health Maintenance Health Maintenance PlansPlans Plans correspond to diseases or Plans correspond to diseases or

conditionsconditions Apply these plans by ‘modifiers’Apply these plans by ‘modifiers’ Plans can:Plans can:

– Add topics to HMAdd topics to HM– Delete topics to HMDelete topics to HM– Change time intervals on existingChange time intervals on existing– topicstopics

A1c

every 6 months

LDL yearly

Eye Exam yearly

Urine Albumin yearly

Eye Exam yearly

Creatinine yearly

Diabetes Plan

2828

Diabetes HM TopicsDiabetes HM Topics YearlyYearly

– LDLLDL– Eye examEye exam– Foot examFoot exam– Urine microalbuminUrine microalbumin– Serum creatinineSerum creatinine– Flu shotFlu shot

Every 6 monthsEvery 6 months– A1cA1c

PneumovaxPneumovax 2929

Other HM PlansOther HM Plans

CADCAD– LDL yearlyLDL yearly

Lipid-Lowering DrugsLipid-Lowering Drugs– LDL and ALT yearlyLDL and ALT yearly

DiureticsDiuretics– K and creatinine yearlyK and creatinine yearly

ThyroidThyroid– TSH yearlyTSH yearly

3030

Shared TopicsShared Topics

Yearly LDLYearly LDL– DMDM– CADCAD– Lipid-lowering drugsLipid-lowering drugs

Serum creatinineSerum creatinine– DMDM– DiureticsDiuretics– ACE/ARBACE/ARB

3131

Customization with HMCustomization with HMOverridesOverrides ““Approved”Approved”

– DoneDone– Not ApplicableNot Applicable

ModifiersModifiers

Exclusion ModifiersExclusion Modifiers Modifiers to Change Modifiers to Change

IntervalInterval

Postpone TopicsPostpone Topics

3232

HM is Engine Driving HM is Engine Driving AlertsAlerts

Best Practice Alert

LDLUrine albuminCreatininePotassiumTSHEye Exam

HM Topics

Custom

izable

Act

ionable

Order Sets

3333

3434

Combined Chronic Dz Combined Chronic Dz BPABPA

3535

Combined Smart SetCombined Smart Set

3636

Prevention TopicsPrevention Topics

PapPap MammogramMammogram Colon Cancer ScreeningColon Cancer Screening DEXA ScanDEXA Scan

3737

3838

Combined Prevention Combined Prevention AlertAlert

3939

BPA Smart SetBPA Smart Set

4040

Finessing ControversyFinessing Controversy

Age 40-50 – Mammogram Age 40-50 – Mammogram DiscussionDiscussion

Age 50-75 – Annual MammogramAge 50-75 – Annual Mammogram– Every other year modifier availableEvery other year modifier available

Age 75 – Mammogram DiscussionAge 75 – Mammogram Discussion

4141

Medication BPAMedication BPA

4242

Medication Smart SetMedication Smart Set

4343

CKD – A Cautionary CKD – A Cautionary TaleTale CKD is underrecognizedCKD is underrecognized Progression to ESRDProgression to ESRD Poor ‘fistula first’ ratePoor ‘fistula first’ rate Comorbid events (CAD)Comorbid events (CAD)

4444

Hoped-For OutcomesHoped-For Outcomes

Recognize CKDRecognize CKD– Put on Problem ListPut on Problem List– Drive decision-supportDrive decision-support

Early referral to nephrologistEarly referral to nephrologist– How early?How early?

Screen for and treat cardiac risk Screen for and treat cardiac risk factorsfactors

4545

Recognize CKDRecognize CKD

• Too big• Too

complex• Suggestion

often wrong• Does not

reflect clinician’s views

4646

CKD-IV HM TopicsCKD-IV HM Topics

4747

CDS to Increase Nephrology CDS to Increase Nephrology ReferralReferral

Abdel-Kader, Fischer, et al. American Journal of Kidney Diseases. 58(6):894-902, 2011 Dec

4848

Smart Sets – Smart Sets – Osteoporosis PathwayOsteoporosis Pathway

4949

COPD MedicationsCOPD Medications

5050

How Many Alerts?How Many Alerts?

Type of Alert Number (Total 317)

Chronic Disease 99

Billing 28

Meaningful Use 8

Order Suggestions 14

Prevention 63

Patient Safety 29

Quality Reporting 24

Research 27

Miscl 18

5151

Quality ReportsQuality Reports

•Diabetes•CAD•CHF•Afib•Hypertension•Prevention

“Facts are stubborn, but statistics are more pliable.”

--Mark Twain

Diabetes Patient Detail Diabetes Patient Detail (PDF)(PDF)

5353

Diabetes Report CardDiabetes Report Card

5454

Clinic Summary by ProviderClinic Summary by Provider

5555

5656

Clinical Decision Support to Clinical Decision Support to Promote Safe Prescribing to Women Promote Safe Prescribing to Women of Reproductive Age: A Cluster-of Reproductive Age: A Cluster-Randomized TrialRandomized Trial

Randomized MDs to receive “simple” (n=17) Randomized MDs to receive “simple” (n=17) vs “complex” alert (n=24)vs “complex” alert (n=24)

No difference in ordering teratogenic meds or No difference in ordering teratogenic meds or counselling after 6 monthscounselling after 6 months

For last 6 months, “complex” alert turned offFor last 6 months, “complex” alert turned off No difference in ordering teratogenic meds No difference in ordering teratogenic meds

with or without alertwith or without alert

Schwarz EB; Parisi SM; Handler SM; Koren G; Shevchik G; Fischer GS. Journal of Women's Health. 22(10):817-24, 2013 Oct.

5757

5858

Chronic Disease Chronic Disease Process MeasuresProcess Measures

5959

Prevention MeasuresPrevention Measures

6060

Critical Success Critical Success FactorsFactors

Governance and LeadershipGovernance and Leadership Focus on Well-Established Guidelines and Focus on Well-Established Guidelines and

EvidenceEvidence Collaboration with Intended UsersCollaboration with Intended Users Understanding of workflowsUnderstanding of workflows CustomizabilityCustomizability Processes to improve efficiencyProcesses to improve efficiency Using tools appropriate to the problemUsing tools appropriate to the problem Reporting and FeedbackReporting and Feedback

6161

Make it easy for clinicians to Make it easy for clinicians to do what they know they do what they know they

should doshould do

6262