Clinical Decision Support Systems: Implications for Advancing - - PowerPoint PPT Presentation

Clinical Decision Support Systems:

Implications for Advancing Optimal Medical Imaging Use in Canada

DISCLOSURE

• Relationship with Commercial Interest:
• Grant/Research Support:
• Speaker Bureau/Honoraria:
• Consulting fees:
• Memberships on advisory committees, boards:
• Other Affiliations:

Clinical Decision Support Systems:

Implications for Advancing Optimal Medical Imaging Use in Canada

A Perspective From A Frontline CDS User

Brian H. Rowe, MD, MSc Emergency Physician, University of Alberta Hospital Co-Chair, Choosing Wisely Working Group, Canadian Association of Emergency Physicians (CAEP) Professor, Department of Emergency Medicine University of Alberta

DISCLOSURE: B Rowe

• Relationship with Commercial Interest: None.
• Employment: University of Alberta/CIHR
• Grant/Research Support: CIHR, AHS, AIHS
• Speaker Bureau/Honoraria: None.
• Consulting fees: None.
• Memberships on advisory committees, boards: CIHR.
• Other Affiliations: will be passing the hat at the end
• f the session!

Emergency Department

• Clinicians working in

emergency departments face pressure to reduce delays;

• Practice variation is well

documented;

• Most EDs are paper-based

(although this is changing);

• CDS are well developed.

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CDS in Emergencies

• Pneumonia severity: CURB-65, PSI;
• Pulmonary embolism: PERC, Well’s,

more;

• DVT: Well’s criteria;
• C-spine: Canadian C-Spine rule;
• Concussion: Canadian CT Head Rule;
• Ankle/foot: Ottawa Ankle Rule;
• Evidence no longer the issue;
• So many rules, so little time!.

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Emergency Department Reality

• ED overcrowding and long waits

are common in Canada.

• Crowding related to:
• Input factors;
• Throughput factors;
• Output factors; and
• System factors.
• One more reason for

unnecessary testing, procedures and treatment.

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Example: CT Scans for mTBI

• Reasonably easy to

acquire at most large hospitals.

• Risks:
• Radiation

exposure;

• Time in ED;
• Costs.
• Does everyone need
• ne?

Canadian CT Head Rules

• Well-validated, sensitive

decision rule for use of CT head in mTBI.

• Canadian CT head rule

(CCTHR) for minor head injuries.

• CCTHR performance:
• Sn = 100%: if you have no

criteria, the risk of a serious head injury is ~0% (1: 10,000).

• Decreases need for CT and

time in ED;

• Still need to provide

concussion F/U.

Stiell I, et al. JAMA. 2005;294(12):1511-1518.

…but its hard to change practice

• 12 Canadian Centres
• Controls (n = 6): standard

practice;

• Intervention sites (n = 6):
• Strategies to implement

CCT to reduce CT

• rdering;
• Paper-based to

computer-based;

• Each strategy required

ED MDs to complete a CCT sheet regarding CT

• rdering

Patterns: I’ve always done it this way Patterns: Better to do something than nothing Demand: The patient “wants” it Innovation: New tests are good Peer Pressure: Referring doctor wants it Fear: I don’t want to get sued Income: Financial incentives

Physicians: Common reasons for tests, procedures and therapies.

CAEP Approach

• Initiated CWC WG and surveyed members.
• Developed CWC/CAEP lists:
• Top-5: 2015;
• Top-10: 2017.
• Dissemination: passive (websites + local).
• Evaluation: limited.
• Some regions: evaluation grants (PRIHS).
• Debate: continues.

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Solutions

• Valid and reliable utilization

data.

• Evidence-based solutions.
• CDS incorporated into

electronic medical record;

• Computerized physician order

entry;

• Audit and feedback strategies

(but not too much).

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National Approaches

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Thank you!

Questions/Comments?

15

Diagnostic Imaging Referral Guidelines

Martin H. Reed MD FRCPC FACR FCAR Chair, Referral Guidelines Working Group Canadian Association of Radiologists

DISCLOSURE

• Relationship with Commercial Interest: no
• Grant/Research Support: no
• Speaker Bureau/Honoraria: no
• Consulting fees: CADTH
• Memberships on advisory committees, boards: no
• Other Affiliations: Canadian Association of

Radiologists

Diagnostic Imaging Referral Guidelines

• iRefer - The Royal College of Radiologists (1989)
• Appropriateness Criteria – The American College of

Radiology (1993) Guide du bon usage des examens d’imagarie médicale - La Société Française de Radiologie

• Diagnostic Imaging Pathways
• Diagnostic Imaging Referral Guidelines – Canadian

Association of Radiologists

Diagnostic Imaging Referral Guidelines

CAR Diagnostic Imaging Referral Guidelines

Diagnostic Imaging Referral Guidelines

ACR Appropriateness Criteria

Diagnostic Imaging Referral Guidelines

Diagnostic Imaging Pathways

Computerized Decision Support

• Canadian Association of Radiologists
• J Am Coll Radiol. 2011;8:251-8.The effect of incorporating guidelines into a

computerized order entry system for diagnostic imaging. Bowen S1, Johnson K, Reed MH, et al.

• J Am Med Inform Assoc. 2011;18;267-70. Electronic decision support for diagnostic

imaging in a primary care setting. Curry L1, Reed MH.

• American College of Radiology
• ACR Select
• European Society of Radiology
• iGuide
• The Royal College of Radiologists

Thank You

23

Clinical Decision Support Systems:

Mark MacMillan Director, Clinical Decision Support, Diagnostic Imaging, AHS

DISCLOSURE

• Relationship with Commercial Interest: None
• Grant/Research Support: None
• Speaker Bureau/Honoraria: None
• Consulting fees: None
• Memberships on advisory committees, boards: None
• Other Affiliations: Alberta Health Service Employee

Utilization vs Appropriateness

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Alberta’s Opportunity

• AHS Diagnostic Imaging
• Connect Care Initiative
• Clinical Decision Support

Framework

• 2019 Alberta CDS

Integration

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• the right information,
• to the right person,
• in the right intervention

format,

• through the right channel,
• at the right time in workflow

Clinician Engagement

28

• De- implementation
• Physician Learning
• Audit and Feedback
• Learn from the past

Thank You

29

References

CT Utilization by Population CADTH Medical Imaging Inventory 5 rights of clinical decision support:

“Improving Outcomes with CDS: An Implementer’s Guide (second edition),” written by by Jerome Osheroff, MD, in 2012

CDS Cube

“CIS Frameworks–Clinical Decision Support,” Alberta Health Services, concept Dr. Allen Ausford,

• Dr. Rob Hayward, Dr. Doug Campbell

Clinical Decision Support Systems:

Lynne Zucker Executive Vice President, ACCESS Health Canada Health Infoway

DISCLOSURE

• Relationship with Commercial Interest:
• Grant/Research Support:
• Speaker Bureau/Honoraria:
• Consulting fees:
• Memberships on advisory committees, boards:
• Other Affiliations:

Canada Health Infoway

Clinical Decision Support in the pan Canadian Digital Health Landscape

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• Established in 2001 as an independent, not-for-profit corporation
• Equally accountable to 14 federal, provincial and territorial governments, through the Members (f/p/t

Deputy Ministers of Health) who appoint the independent Board of Directors

• Since inception, $2.45 billion in capitalization from the federal government through Health Canada:

Electronic health records (EHRs) 2001: $500M EHRs, Standards & Telehealth 2003: $600M Public Health Surveillance Systems 2004: $100M EHRs & Wait Time Systems 2007: $400M Electronic Medical Records (EMRs) 2010: $500M 2017-2022: $300M

Foundational Mandate - Completed Current Mandate

E-Prescribing & Telehomecare 2016-2018: $50M E-Prescribing, Virtual Care, Patient Access to Health Information, Linking EHR Systems

2017-2022: $300M

Evolution of Infoway’s Activities

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2017-2022: $300M

Opportunity for Clinical Decision Support

• Standardized guidelines available at time of referral or
• rdering have made little progress integrating with

primary care EMRs - while it is acknowledged as a best practice

• A pan-Canadian CDS framework and business case for

integration into community based clinical systems is

• required. This will require co-ordination between the

various “guideline owners” and possibly shared infrastructure

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“Used appropriately and based on quality EMR data, CDS tools have a great potential to improve the efficiency and quality of care provided within a family practice.”

Thank You

36

Clinical Decision Support Systems:

What is the evidence?

Harindra Wijeysundera

Vice President, Medical Devices & Clinical Interventions CADTH

DISCLOSURE

• Relationship with Commercial Interest: none
• Grant/Research Support: Edwards Lifesciences and

Medtronic Inc

• Speaker Bureau/Honoraria: none
• Consulting fees: none
• Memberships on advisory committees, boards:

CorHealth Cardiac Funding Reform

• Other Affiliations: CADTH exec

What is the evidence?

Rapid Response Report Clinical Decision Support Systems for Appropriate Medical Imaging: Clinical Evidence and Cost-Effectiveness January 2019

Findings

• Mixed results
• One systematic review
• Prospective (3) and retrospective before and after studies

(11)

• 2 RCT
• Signal of increase yield, and clinical benefit with no

evidence of harm.

40

Findings

Why is this so difficult to study?

• Wrong intervention
• Wrong design
• Temporal impact
• What is the right outcome
• Bias to the null

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