Clinical Decision Support (CDS) Options in a CPOE System. Lolita G. White, PharmD Clinical Applications Analyst

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1 Clinical Decision Support (CDS) Options in a CPOE System Lolita G. White, PharmD Clinical Applications Analyst

2 Clinical Decision Support Clinical decision support (CDS) systems provide clinicians, staff, patients, and other individuals with knowledge and personspecific information, intelligently filtered and presented at appropriate times, to enhance health and health care.

3 Goal of CDS in Computerized Provider Order Entry (CPOE) system Improve patient safety and outcomes Transform clinical process Maximize the use of technology Prevent initial inappropriate dosing

4 How did we get here? The Way of the Future. Robert A. Rosati, MD; Andrew G. Wallace, MD; Eugene A. Stead, Jr., MD. Arch Intern Med. 1973;131(2):

5 In search of the perfect CPOE/CDS combination Since 2004, when the Federal Government promoted the importance of electronic medical records (EMRs), there has been a slow but increasing adoption of health IT.

6 Challenges with CPOE and CDS Automation causes a false sense of security Healthcare Informatics Systems and CDS applications are not plug and play Must continue test, refine, update and customize to meet your needs some sites more than others

7 Areas Identified for CDS implementation DDI Allergies Diagnostic and Therapeutic advice Routine Tasks Communication Meds with narrow therapeutic range/serious toxicities High use meds High risk meds

8 Considerations with CPOE and CDS Alert Fatigue Hard Stops Soft Stops Non interruptive CDS Should alerts print on label If an alert fires, at what point and what does it say? Does the alert take you to a new window

9

10 Types of Clinical Decision Support

11 CDS: Feedback Use of a drug information database Standard content vs custom Duplicate Severity level Interactions Drug-food, drug-drug, drug-allergy

12 Drug-Drug Interactions (DDI) significant cause for: prolonged hospitalization morbidity mortality increased healthcare costs predictable and therefore preventable, and ideal candidates for CDS

13

14 Allergies Documentation of drug/drug, drug/food, drug/environmental allergies and notification to the enduser Documentation will alert the enduser of any interactions of current therapy and severity of interaction

15

16 CDS: Communication In times where there are special situations and its significant enough that you want to pass info on to the enduser, the alerts would be appropriate. For example a pt who is on a ketogenic diet.

17

18 Pharmacy specific CDS

19 Nursing specific CDS

20 CDS: Data Organization Decrease alert fatigue Facilitate compliance to institution & practice standards Improve order entry efficiency Improve clinical decision making

21 Order Sentences & Order Sets Order sentences suggested dosing regimen for specific medication Fill in as much as possible Make details available for special situations if possible

22 Order Sentences

23 Eliminate Irrelevant Choices

24 Eliminate Irrelevant Choices

25 CDS: Diagnostic/Therapeutic Advice and Proactive Information Order Sets with Reference Text Order groupings provide guidance in CPOE system Based on disease state Age Reference materials included Alerts optional

26

27

28 Reference Text

29

30

31 CDS Type: Expert Advice Dose range checking alerts Dose ranges are specific to one of three types of dose ranges: Single Dose Checking Daily Dose Checking Therapy Length Checking Options to take Cancel Modify Ignore override reason can be documented

32

33

34 Review Current Practices Important to continue quality improvements Multidisciplinary team Meet on a regular basis What alerts are firing What is being overridden and why Where is the patient located Are the alerts diagnosis dependent Does the alert require additional action

35 Alerts Review Taskforce Physicians/LIPs Nurses Pharmacists Ancillaries (lab, radiology, etc) Report writer

36 Change Control Routine requests Priority 2, 3 & 4 issues Identify need for change Update Change Control form for PROD approval Complete Change Control form for Non-Prod approval Submit to PM or Architect By 2pm Tuesday Submit to PM or Architect Review at Change Control on Wednesday No OK? OK? yes Setup in Non-Prod and Test it yes Setup in PROD and Validate it Emergency requests Priority 1 and urgent off-cycle issues Identify need for EMERGENCY change Complete Change Control form for Non-Prod approval Submit to PM or Architect No OK? yes Setup in Non-Prod and Test it Update Change Control form for PROD approval Submit to PM or Architect For emergency approval Forward to emergency approvers OK? yes Setup in PROD and Validate it

37

38 Are we doing OK? Assessment tools Leapfrog Group for hospital quality and patient safety Meaningful Use Center for Medicaid and Medicare Services (CMS) EHR incentive program Evaluation the number of errors reported and severity on an ongoing basis. Make changes as necessary remembering there are some that may require changes outside of the CPOE system

39 Questions?

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