Clinical Decision Support

Transcription

1 Clinical Decision Support Dennis Morrison, PhD CEO Centerstone Research Institute I always wanted to be somebody, but I should have been more specific. Jane Wagner

2 Transitions "The internet is a great way to get on the net" Republican presidential candidate Bob Dole

3 Ahhnuld I think that gay marriage is something that should be between a man and a woman. Arnold Schwarzenegger How hard can it be?

4 Why Change? The reason organizations fail is the assumptions on which the organization has been run no longer fit reality. Peter Drucker The End of Delegation? Information Technology and the CEO. HBR Perspectives Sept-Oct 1995 Reprint Number This may seem daunting even impossible

5 Clinical Decision Support (CDS) Dennis Morrison Similar to Medicine

6 Evidence-Based Practices in Medicine Medical knowledge has not been science based i.e. no randomized clinical trials or quasiexperiments 85 percent of everyday medical treatments have never been scientifically validated Millenson, M. L. (1997). Demanding medical excellence. Chicago: The University of Chicago Press. Information Overload Is there anyone here who has not experienced information overload over the past 5 or so years?

7 Why do we need CDS? It is now humanly impossible for unaided healthcare professionals to possess all the knowledge needed to deliver medical care with the efficacy and safety made possible by current scientific knowledge. (Note: Good resource for basic info on Medical Informatics) Life s tough it s tougher if you re stupid. John Wayne Sands of Iwo Jima

8 Information Change in Behavioral Healthcare Half-life for Psychology literature is 6 years. 50% of the information we have today about psychology will be obsolete in 6 years 17 yr Science to Service Gap (NIMH) Relying on clinical researchers to keep us appraised of Best Practices is too slow. Example: Assertive Community Treatment EHRs allow in vivo studies and CQI loops to be done in real time 42.7% of all statistics are made up on the spot. Stephen Wright

9 EHR is different than a paper record Paper Questionable Legibility Static Unidirectional EHR Legible Dynamic Interactive Key Point An EHR is NOT an electronic recapitulation of a paper record The EHR can and should do things for you that the paper record can t.

10 Definition Clinical Decision Support Systems Clinical Decision Support Systems are active knowledge systems which use two or more items of patient data to generate case-specific advice" Wyatt J, Spiegelhalter D, 1991 Types of CDS Systems Alerts and reminders. Diagnostic assistance. Therapy critiquing and planning. Prescribing decision support systems. Information retrieval. Image recognition and interpretation. Guide to Health Informatics 2nd Edition, Enrico Coiera

11 No EHR Reasons for Failure of CDSS After Implementation Poor human interface design Poor fit with clinical workflow Reluctance or computer illiteracy of clinicians Adapted from Guide to Health Informatics 2nd Edition, Enrico Coiera My mechanic told me, "I couldn't repair your brakes, so I made your horn louder." Stephen Wright

12 Managing by Data Behavioral Health Care is not good at this Cause: Tradition Inertia (It s an art, not a science) State and Federal Regulations First Question to be answered: Is what we do measurable? What to measure? Types of Measures Diagnosis Symptoms Depression Scores Anxiety Scores Functionality Quality of Life GAF (If done well) From Different Perspectives Client/Family Self Report Therapist Ratings

13 Clinical Decision Support Case Study: Center for Behavioral Health CBH Treatment Plans With Integrated Clinical Decision Support

14 What you ll see CDSS as implemented at CBH pre merger Current system is different Goal: standardize across 3 orgs/2 states Case conceptualizations are updated and appended to a running history. Updates are time stamped with the clinician name.

15 Diagnoses by psychiatrists are imported from Infoscriber, the prescription management system, the clinician may add to these. Diagnostic system validates, encourages full five-axis diagnosis.

16 DLA is objective assessment of needs and strengths.

17 Imported from DLA Needs from DLA import automatically to Problem List

18 Associate Problem with a Diagnosis Associate diagnosis and define problem for targeted impairments. Pre-selected list of likely outcomes. Clinician can override Most likely outcomes chosen based on Functional Impairment

19 Outcomes Groups function similar to order sets in medicine Outcomes can be grouped for similar clinical presentations Note as evidenced by provides outcomes in behavioral terms Close-up view.

20 Pre-selected list Problem of likely is Depression Interventions. so don t see treatments Includes for EBTs anxiety, kids, or lower Clinician cannot override functioning Interventions are pre-selected based on unique combination of diagnostic related group, overall GAF score and Age. Completed Treatment Plan Clear chain established: Problem-Impairment-Diagnosis-Intervention- Outcome All driven by CDS

21 A word about productivity Expect a drop CBH experience 10-15% for 3-6 months Budget accordingly Productivity

22 Mobile Workers Productivity CBH Progress Notes With Integrated Clinical Decision Support

23 Creating a new case note Notes not yet completed easily accessible New case note Number of hours of authorized service shown Billing Information defaults to last used for this client and preselects only allowable combinations of services

24 Choosing problems Problems to be dealt with during this session preselected on basis of service rendered (Case Management) Problems for a med. monitoring/somatic treatment Problems to be dealt with during this session preselected on basis of service rendered (Medication Management)

25 Choosing outcomes Any problem assessed as Much Worse prompts a lethality assessment Outcomes achieved & progress towards Goals during this session preselected on basis of service rendered Back to the case note Context-sensitive keywords are presented to assist with charting System will automatically check for Clinician can view recent errors that would prevent case notes and current note from being signed treatment plan or saved

26 Signing all notes at once System allows signing of notes after they have passed audit (especially useful for Palm users) New Challenges Due to Merger Need to get on a common EHR platform Three EHRs using three different platforms across two states Need to radically change the way IT did business and was perceived Learn to say no Increase customer responsiveness

27 Update since the merger PsychREMIX front end peeled off PsychConsult and attached to Centerstone s product, CenterNet Modifications to the software made per user specifications Indiana now on a common EHR (Jan 1) Tennessee coming up May 15 Clinical Trajectory & Handheld Applications END

28 OCR Data Capture: BASIS 32 Handheld Applications

29 Handheld Application Case managers capture information in the field. Heavy use of drop down menus Not connected wirelessly Handheld Application Medicaid significantly increased documentation requirements for transportation Handhelds used to capture trip specifics

30 Handheld Application Handhelds used to capture client signature Not in handouts Enhanced Palm Functionality CDSS functionality integrated into Palm

31 Handhelds But will the dogs eat it? People didn t use it Decision Support in Prescription Writing

32 Electronic Prescription Service Bottom Line: It s all about workflow.

33 Impossible to Achieve? Think back We can lick gravity, but sometimes the paperwork is overwhelming. ---Wernher von Braun

34 END Predictions of Lord Kelvin, president of the Royal Society, "Radio has no future" "Heavier than air flying machines are impossible" "X rays will prove to be a hoax

35 No flying machine will ever fly from New York to Paris... [because] no known motor can run at the requisite speed for four days without stopping Orville Wright Computers in the future may perhaps only weigh 1.5 tons. Popular Mechanics Magazine 1949

36 There is no reason for any individual to have a computer in their home. Kenneth Olsen, founder Digital Equipment Corp Change I cannot say whether things will get better if we change; what I can say is they must change if we are to get better. G.C. Lichtenberg

37 Too often we hold fast to the clichés of our forbearers. We subject all facts to a prefabricated set of interpretations. We enjoy the comfort of opinion without the discomfort of thought. -John F. Kennedy Impossible? I have learned to use the word impossible with the greatest of caution. Werner Von Braun

38 Questions