Oppo Op portu rtunit nities ies for r Ev Evid idence nce-base based d Cli linic nical al De Decis isio ion n Sup uppo port rt Syst stems: ems: An An Ap Appl plic ication ation for r On Oncolo logy gy BPM Roundtable undtable Eind ndhov oven en Univ iver ersit ity of Technol hnology ogy 5/11/2012
Dr. Yaron on Denek nekam amp CMIO, Hospital Division, n, Clalit Health th Service ces, Tel Aviv Facul ulty ty of M Medicine ne, Techni hnion, Haifa Europ ropean an BPM Round undtabl table Eind ndhov oven en Univ iver ersit ity of Technol hnology ogy 5/11/2012
o Specialist in Internal Medicine o Medical Informatics - fellowship and studies at Harvard MIT division of Health Sciences and Technology in Boston o Chief Medical Informatics Officer Hospital Division, Corporate Headquarters, Clalit Health Services, Tel Aviv o Faculty of Medicine, Technion, Haifa
Clalit Health Services Group Israel’s Leading Health Care Organization o Largest health care provider in Israel o 4 Million Insured Members – over half of the population o Second largest organization of its type in the world o 14 hospitals, 1400 clinics o 36,000 employees, 10,000 physicians o Clinical IT systems - Community- one EMR system - Hospitals – mainly 2 EMR systems - Several BI systems
Hospitals across Israel • Community outreach • National centers of excellence • Children’s Hospital • Cancer center • Organ transplant center • Rehabilitation centers 5
Why do we need to support clinical I. decisions and processes? Types and examples of clinical decision II. support systems (CDSS) Opportunities and challenges of III. implementing CDSS
o Preventable <> side effects o Medication – allergy, dosages, drug-drug interactions etc. o Misdiagnosis o Treatment – medical and surgical
2 unanswered clinical questions for every 3 pts o Holds across PCPs and specialty care o Holds across urban and rural Covell study of LA Internists, Ann Intern Med 1985 Gorman, Medical Decision Making 1995, Gorman, Medinfo 2001
o 30% of questions were pursued o 70% of information needs were not-pursued! o Too busy, no immediate access to resources, or office materials (books, journals, etc.) in disarray or out-of-date Some outcomes - Overuse o 30% of children receive excessive antibiotics for ear infection o 20-40% of surgical procedures unnecessary o 50% of back pain x-rays unnecessary Underuse o 50 % of elderly patients don’t get the necessary immunizations in winter
o > 20,000 journals published o 17,000 new books per year o Size doubles every 10-15 years o 2 Million facts needed to practice
‘‘Men are men; the best sometimes forget’’ Othello, 1605; Act II, Scene iii
Conferences, CME, Lectures Medical School Books, Journals Guidelines Curbside Consultation Decisions, Decisions, Decisions Medical Record Administrative Issues Clinical Reports
A constellation of psychological studies converging to a o description of human decision making under uncertainty It was awarded the Nobel Prize of Economics (2002) o Main points: o People use a few simple heuristics when o making judgments under uncertainty These heuristics sometimes are useful and o other times lead to severe and systematic errors
“Information Technology must play a central role in the redesign of the health care system…”
o Current Approach - Professional autonomy drives variability - Decision making is based on training and experience o New Rules - Knowledge is shared and information flows freely - Decision making is evidence-based Richardson, William C. IOM 2001 Crossing the Quality Chasm, pg. 71
link health observations with health knowledge to influence health decisions by clinicians for improved health care processes Active knowledge systems which use two or more items of patient data to generate case-specific advice Support <> Replace
Evidenced Based Medicine o High quality level studies – ranking for quality of research, level of evidence Clinical practice guidelines o Developed by professional organizations, HMO’s, Ministry of health Problems – - Physicians are not aware to that knowledge - Time constraints to read and follow - Compliance
CDSS Evidenced Based Clinical Actions Medicine
o Medications – prescribing, ordering o Treatments – most useful cost effective alternatives o Diagnostic – complex multi step process o Institutional administrative processes – duplicated testing, consultations, transferring labs specimens to the labs etc.
o Alerting - when a clinical data is abnormal or a clinical guideline is not followed o Critiquing – when ordering a medication or a test o Reminders – reminding the clinician to follow desired practice guidelines and policies --------------------------------------- More challenging - o Computer-interpretable guidelines o Expert systems
Drug-Drug Renal and Hepatic Interaction Dosages function Screening Duplicate Therapy Drug Food Drug Allergy Checking Interactions Checking Drug Disease Drug Side Effects Contraindication Drug Indications Checking Paediatric Patient Education Precautions
Supporting cost effectiveness Redundant test example
Suporting the diagnostic process Alternate exam
Lower cost Guideline for expensive medication
Reminders Physicians reminded to give flu shots do so twice often
Inference methods o Algorithmic o Statistical Inference Engine o Pattern Matching Knowledge o Rule-based Base (Heuristic) o Fuzzy sets o Neural nets o Bayesian
o Still are not a success o Problem in having the probability data like for symptoms, signs etc.
o Awareness to the need, also from the perspective of claims and risk management o Platforms – EMR systems are increasingly used including CPOE cannot be a standalone system o Standards of clinical data and information More standards are used for diagnoses, medications, clinical information model o Less reluctance of healthcare workers o More evidence that it works o Documentation of the processes in EMR systems enables process mining to discover improved workflows
o Workflow integration on top of the EMR system - naturally fit into the process of care o Representing and maintaining medical knowledge and process models o Complexity of modeling time oriented data o Need for flexibility – supporting process, not replacing the professionals o Dealing with ambiguity o Mechanisms to avoid the alert fatigue phenomena o UI – simple interface directed by the user
o Improved patient safety - reduced medication errors and adverse events - improved medication and test ordering o Improved quality of care - increased application of clinical guidelines, facilitating the use of up-to-date clinical evidence o Improved efficiency in health care delivery - reductions in test duplication - decreased adverse events - changed patterns of drug prescribing favoring cheaper but equally effective generic brands
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