Making trees out of paper. Computer supported implementation and evaluation of clinical practice guidelines

Transcription

1 Making trees out of paper Computer supported implementation and evaluation of clinical practice guidelines Jorne Meijer, Xander Verbeek

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3 Netherlands Comprehensive Cancer Organization (IKNL) IKNL is the knowledge and quality center for oncological and palliative care and cooperates with managers, care professionals and patients on continuous quality improvement. Netherlands Cancer Registry (NCR) population based registry since medical data of 2,3 million cancer patients (>200 million data items) /year. Clinical practice guidelines Development, maintenance, implementation and evaluation. 60 guidelines oncological care (

4 Care quality cycle NCR

5 International Context Registration - Registration at the source, but what is the source? Guidelines - More effective development, implementation, evaluation. Patient involvement - Shared decision making. - PROMS. Information standardization.

6 In the consultation room Dr. Smith, surgeon Mrs. Johnson has a consultation with Dr. Smith. Mrs. Johnson has a breast tumor. It has been a while since Dr. Smith has seen a case like this

7 Gap between research and practice Mrs. Johnson is interested in the best possible treatment. For herself. She is entitled to it. Dr. Smith wants to provide high quality of care to Mrs. Johnson. Even more, it is his duty. To keep up to date Dr. Smith has to read 27 scientific publications. Every day..for breast cancer only

8 10/day 27/day

9 Multidisciplinary oncological care Tumor Board

10 Field research decision making in practice

11 Reinterpretation of data during tumor boards Field research: reinterpretation, new insights. Scientific research*: different interpretation radiology 40%, pathology 20% different treatment 10%. Tumor board report as source Higher level aggregated source document with new insights as basis for: Delivered care to patient. Transparency towards patients. Starting point (shared) decision support. Accurate registration. * Newman, E.A., et al.,. Cancer, 2006., Lim, H.K. et al., ANZ J Surg, Whelles SA et al, Otolaryngol Head Neck Surg. 2010, Wiggans MG et al, HPB Surg. 2013, van Hagen P et al, Int J Clin Oncol 2013, Santoso JT et al, Int J Gyn Cancer 2004,

12 Ambition healthcare informatics innovation program Decision Support Tumor board, shared decision making Patient Pre Tumor board Post Guideline Information standard Registration at the source PROMS, Tumor board report NCR Closed loop New knowledge generation

13 From guideline via tumor board to registry Tumor board (EHR) Guideline (IKNL knowledge server) Guideline recommendation: Surgery Send to NCR NCR (database)

14 OncolinQ and Oncoguide OncolinQ OncolinQ Linking Information Sources for Quality Tumor board (EHR) Information standard Guideline (IKNL knowledge server) Oncoguide Oncoguide Decision trees and knowledge server NCR (database) Richtlijn werkgroep mammacarcinoom

15 Oncoguide

16 Oncoguide From guideline to decision trees and information standard - Decomposition of care pathway. Successfully applied to national Clinical Practice Guidelines: - Breast cancer: 229 pages (> words) 115 data items, 73 decision trees. - Colorectal, prostate cancer: concept.

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20 Sneak preview

21 Mrs. Johnson, 67 jaar breast cancer Clinical staging ct-diameter 2,3 cm ctnm ciii Diagnostiek bij neo-adjuvant _ Primary treatment Neo-adjuvante therapy Pathological staging Grade G3 Grade >G1 Vascular invasion G1 <2cm ct-diameter 2cm Vascular invasion ctnm L2 L3 >L3 <cii ciii Eerste keuze 4 x q3wk AC Tamoxifen Hormonale therapy 4 x q3wk AC à 12 x q1wk paclitaxel Hormonale therapy Chemotherapy OF OF OF FAC Vervolgbeleid na neo-adjuvant RT with Boost RT with Boost Tweede keuze FEC Vervolgbeleid na neo-adjuvant Primary treatment: Neo-adjuvant therapy by chemotherapy Vervolgbeleid na neo-adjuvant

22 Mrs. Johnson, 67 jaar breast cancer Clinical staging ct-diameter 2,3 cm ctnm ciii Diagnostiek bij neo-adjuvant _ Primary treatment Neo-adjuvante therapy Pathological staging Grade G3 Grade >G1 Vascular invasion G1 <2cm ct-diameter 2cm Vascular invasion ctnm L2 L3 >L3 <cii ciii Eerste keuze 4 x q3wk AC Tamoxifen Hormonale therapy 4 x q3wk AC à 12 x q1wk paclitaxel Hormonale therapy Chemotherapy OF OF OF FAC Vervolgbeleid na neo-adjuvant RT with Boost RT with Boost Tweede keuze FEC Vervolgbeleid na neo-adjuvant Primary treatment: Neo-adjuvant therapy by chemotherapy Vervolgbeleid na neo-adjuvant

23 Mrs. Johnson, 67 jaar breast cancer Clinical staging ct-diameter <2 cm ctnm ciii Diagnostiek bij neo-adjuvant _ Primary treatment Neo-adjuvante therapy Pathological staging Grade G3 Grade >G1 Vascular invasion G1 <2cm ct-diameter 2cm Vascular invasion ctnm L2 L3 >L3 <cii ciii Eerste keuze 4 x q3wk AC Tamoxifen Hormonale therapy 4 x q3wk AC à 12 x q1wk paclitaxel Hormonale therapy Chemotherapy OF OF OF FAC Vervolgbeleid na neo-adjuvant RT with Boost RT with Boost Tweede keuze FEC Vervolgbeleid na neo-adjuvant Vervolgbeleid na neo-adjuvant Primary treatment: recommendation not yet possible, enter Vascular invasion

24 Mrs. Johnson, 67 jaar breast cancer Clinical staging ct-diameter <2 cm ctnm ciii Diagnostiek bij neo-adjuvant _ Primary treatment Neo-adjuvante therapy Pathological staging Grade G3 Grade >G1 Vascular invasion >L3 G1 <2cm ct-diameter 2cm Vascular invasion ctnm L2 L3 >L3 <cii ciii Eerste keuze 4 x q3wk AC Tamoxifen Hormonale therapy 4 x q3wk AC à 12 x q1wk paclitaxel Hormonale therapy Chemotherapy OF OF OF FAC Vervolgbeleid na neo-adjuvant RT with Boost RT with Boost Tweede keuze FEC Vervolgbeleid na neo-adjuvant Vervolgbeleid na neo-adjuvant Primary treatment: Neo-adjuvant therapy by 4 x q3wk AC à 12 x q1wk paclitaxel OR RT with Boost

25 Phased approach App and website. EHR systems. Quality and regulatory. - Class 1 medical device. - MDD, CE-certification. - Maintenance and post market surveillance. - NEN 75xx Clinical evaluation.

26 OncolinQ

27 OncolinQ Information standard breast cancer Information analysis 200 tumor board reports 134 dataitems 115 dataitems Guideline analysis 81 dataitems NCR Dataset

28 OncolinQ Information standard breast cancer Only ~60% guideline required items currently in tumor board reports 134 dataitems dataitems ~50% NCR items in tumor board reports dataitems ~30% guideline items already monitored in NCR

29 OncolinQ phased approach towards information standard Pathology Radiology 3 Tumor board 2 1 Guide line Lab Information Standard 2 4 NCR

30 Guideline Better guidelines faster Tumor board Transparent decision making NCR More efficient registration Patient Transparent and better care

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33 twitter.com/iknl

34 Roadmap Informatiestandard/ Decision trees Mamma Prostaat Colorectaal Long Hematologie Melanoom Gyn IKNL Knowledge server Oncoguide App/Web MDO / EPD interface Nomogram/ Trial alert Pilots POC Source registration POC Decision support Research/ Clinical evaluation Methodology from guidelines to flowcharts / information standard SUS evaluation Impact QoC Retrospectief Impact QoC Prospectief Shared decision making PhD