BPM Roundtable

Eindhoven University of Technology

5/11/2012

Opportunities for Evidence-based Clinical Decision Support Systems:

An Application for Oncology

Dr. Yaron Denekamp

CMIO, Hospital Division, Clalit Health Services, Tel Aviv

Faculty of Medicine, Technion, Haifa

European BPM Roundtable

Eindhoven University of Technology

5/11/2012

oSpecialist in Internal Medicine

oMedical Informatics - fellowship and studies at Harvard MIT division of Health Sciences and Technology in Boston

oChief Medical Informatics Officer Hospital Division, Corporate Headquarters, Clalit Health Services, Tel Aviv

oFaculty of Medicine, Technion, Haifa

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

Clalit Health Services Group Israel’s Leading Health Care Organization

Hospitals across Israel

• Community outreach • National centers of excellence

• Children’s Hospital • Cancer center • Organ transplant center

• Rehabilitation centers

5

I. Why do we need to support clinical

decisions and processes?

II. Types and examples of clinical decision support systems (CDSS)

III. Opportunities and challenges of implementing CDSS

oPreventable <> side effects

oMedication – allergy, dosages, drug-drug interactions etc.

oMisdiagnosis

oTreatment – medical and surgical

Covell study of LA Internists, Ann Intern Med 1985

2 unanswered clinical questions for every 3 pts

o Holds across PCPs and specialty care

o Holds across urban and rural

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 in disarray or out-of-date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

o17,000 new books per year

oSize doubles every 10-15 years

o2 Million facts needed to practice

‘‘Men are men; the best sometimes forget’’

Othello, 1605; Act II, Scene iii

Medical School

Conferences, CME, Lectures

Clinical Reports

Medical

Record

Books, Journals

Guidelines

Administrative Issues

Decisions, Decisions, Decisions

Curbside Consultation

o A constellation of psychological studies converging to a description of human decision making under uncertainty

o It was awarded the Nobel Prize of Economics (2002)

o Main points: o People use a few simple heuristics when

making judgments under uncertainty

o These heuristics sometimes are useful and other times lead to severe and systematic errors

“Information Technology must play a central role in the redesign of the health care system…”

oCurrent Approach

- Professional autonomy drives variability - Decision making is based on training and experience

oNew Rules - Knowledge is shared and information flows freely - Decision making is evidence-based

Richardson, William C. IOM 2001 Crossing the Quality Chasm, pg. 71

Active knowledge systems which use two or more

items of patient data to generate case-specific advice

Support <> Replace

link health observations with health knowledge to influence health decisions by clinicians for improved health care processes

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

Evidenced Based Medicine

Clinical Actions

CDSS

oMedications – prescribing, ordering

oTreatments – most useful cost effective alternatives

oDiagnostic – 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

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More challenging -

o Computer-interpretable guidelines

o Expert systems

Drug-Drug

Interaction

Screening

Dosages Renal and Hepatic

function

Duplicate Therapy

Checking

Drug Food

Interactions

Drug Allergy

Checking

Drug Indications Drug Side Effects

Drug Disease

Contraindication

Checking

Paediatric

Precautions Patient Education

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

o Pattern Matching

o Rule-based (Heuristic)

o Fuzzy sets

o Neural nets

o Bayesian

Knowledge

Base

Inference Engine

oStill are not a success

oProblem 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

oImproved patient safety - reduced medication errors and adverse events

- improved medication and test ordering

oImproved quality of care - increased application of clinical guidelines, facilitating the use

of up-to-date clinical evidence

oImproved efficiency in health care delivery - reductions in test duplication - decreased adverse events - changed patterns of drug prescribing favoring cheaper but equally effective generic brands