LEVERAGING CLINICAL IT FOR DENGUE: OPPORTUNITIES

FOR TOMORROW

Nawanan Theera-Ampornpunt, M.D., Ph.D.

SlideShare.Net/Nawanan

Outline

BackgroundClinical Management of DengueRoles of Health IT in DengueSummary

Dengue: Epidemiology

Most rapidly spreading mosquito-borne viral disease in the world

30-fold increase in incidence in the last 50 years

Epidemic dengue spread to new areasSubstantial burden on health sector &

economy

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Dengue: Prevention & Control

Dengue surveillanceCase managementOutbreak response Integrated vector managementSocial mobilization & communicationResearch

Resolution SEA/RC61/R5 of WHO Regional Committee for South-East Asia (2008)WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Dengue: Clinical Management

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009), adapted from Yip (1980)

Dengue: Clinical Decisions

Diagnosis & differential diagnosis InvestigationsPhase & severityDisposition: To send back home or to admitMonitoring of patient status Fluid management & transfusion decisionsManagement of complications

Dengue: Differential diagnosis

Febrile Phase Flu-like syndromes Illnesses with a rash Diarrheal diseases Illnesses with neurological manifestationsCritical Phase Infectious Malignancies Others (e.g. acute abdomen, metabolic conditions,

hematologic disorders)

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Dengue: Admission Criteria

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Dengue: Management Guidelines

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Fluid Management in Compensated Shock

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Fluid Management in Hypotensive Shock

WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)

Image Source: aafp.org

Imagine This Scenario

Not enough sleep

“To Err Is Human”

Lack of attention Easily distracted Limited memory Difficulty putting relevant information together

(information overload?) Inappropriate decisions (lapses, cognitive errors) Poor decisions under pressure (emergencies) Difficulty in monitoring & triage of patients

Roles of Health IT

Assists in documentation & assessments Reminds or alerts Servers as external memory Better visualizations / information

presentations Suggests management optionsGuidelines at the point of care Patient monitoring

Example of “Alerts & Reminders”

Clinical Decision Support Systems

External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN

Roles of Health IT in Dengue Clinical Management

Online templates for complete patient assessment & documentation

Alerts & RemindersDecision support tools to offer

recommendations in case management Electronic disease reporting Information integration for early detection

of an outbreak

Clinical Decision Support Systems

External Memory

Knowledge Data

Long Term Memory

Knowledge Data

Inference

DECISION

PATIENT

Perception

Attention

WorkingMemory

CLINICIAN Alerts & Reminders, Templates

Guidelines & References

Improved information

presentations (graphs, tracking

tools, etc.)

- Differential Dx- Treatment Recommendations

Google Flu Trends

Source: Google.org/FluTrends

Disease Surveillance

Google Flu Trends uses search engine keywords (non-clinical data)Accurate for practical purposes of detection

of possible outbreaks (not confirmation)

Imagine how it would be if we use clinical data (e.g. chief complaints, diagnoses in ER/clinics). Would it help us respond faster?

Opportunities for Tomorrow

Dengue management relatively straightforward, easy to implement as logic

Improved IT infrastructure within hospitals & clinicsHospital information systems & electronic

health records common (high adoption)Can be leveraged for better dengue

management within those settings

Infrastructure: EHR Adoption in Thai Hospitals

Theera-Ampornpunt (2011)

22

Adoption Estimates: THAIS 2011

Estimate (Partial or Complete Adoption) NationwideBasic EHR, combined inpatient & outpatient settings

49.8%

Comprehensive EHR, combined 5.3%order entry of medications, combined 90.2%order entry of all orders, combined 79.4%

Theera-Ampornpunt (2011)

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Current State of IT Use in Dengue

Focus more on IT use in surveillance & outbreak detection

Some uses in patient education, teleconsultations, predictive modeling, & basic research

Few studies on use of health IT to manage dengue in clinical settings

Summary (1)

Dengue is an important epidemicManagement involves various steps

& criteria, maybe complicated for non-experts

Errors inevitable for inexperienced providers

Summary (2)

Health IT can be used to provide better care, e.g. through decision support

Opportunities exist for use of IT in dengue

Call for more focus on development & evaluation of IT uses in clinical management of dengue