Opportunities for Evidence-based Clinical Decision Support Systems: An Application for Oncology. BPM Roundtable Eindhoven University of Technology

Transcription

1 Opportunities for Evidence-based Clinical Decision Support Systems: An Application for Oncology BPM Roundtable Eindhoven University of Technology 5/11/2012

2 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

3 o Specialist in Internal Medicine o Medical Informatics - fellowship and studies at Harvard MIT division of Health Sciences and Technology in Boston o Chief Medical Informatics Officer Hospital Division, Corporate Headquarters, Clalit Health Services, Tel Aviv o Faculty of Medicine, Technion, Haifa

4 Clalit Health Services Group Israel s Leading Health Care Organization 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

5 Hospitals across Israel Community outreach National centers of excellence Children s Hospital Cancer center Organ transplant center Rehabilitation centers 5

6 I. Why do we need to support clinical decisions and processes? II. III. Types and examples of clinical decision support systems (CDSS) Opportunities and challenges of implementing CDSS

7

8 opreventable <> side effects omedication allergy, dosages, drug-drug interactions etc. omisdiagnosis otreatment medical and surgical

9 2 unanswered clinical questions for every 3 pts o Holds across PCPs and specialty care o Holds across urban and rural Covell study of LA Internists, Ann Intern Med 1985 Gorman, Medical Decision Making 1995, Gorman, Medinfo 2001

10 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 in disarray or out-of-date Some outcomes - Overuse o 30% of children receive excessive antibiotics for ear infection o 20-40% of surgical procedures unnecessary o 50% of back pain x-rays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

11

12 o> 20,000 journals published o17,000 new books per year osize doubles every years o2 Million facts needed to practice

13 Men are men; the best sometimes forget Othello, 1605; Act II, Scene iii

14 Conferences, CME, Lectures Books, Journals Medical School Guidelines Curbside Consultation Decisions, Decisions, Decisions Administrative Issues Medical Record Clinical Reports

15 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 o Main points: 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

16 Information Technology must play a central role in the redesign of the health care system

17 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

18 link health observations with health knowledge to influence health decisions by clinicians for improved health care processes Active knowledge systems which use two or more items of patient data to generate case-specific advice Support <> Replace

19 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

20 CDSS Evidenced Based Medicine Clinical Actions

21

22 omedications prescribing, ordering otreatments most useful cost effective alternatives odiagnostic complex multi step process oinstitutional administrative processes duplicated testing, consultations, transferring labs specimens to the labs etc.

23 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 More challenging - o Computer-interpretable guidelines o Expert systems

24 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

25

26

27 Supporting cost effectiveness Redundant test example

28 Suporting the diagnostic process Alternate exam

29 Lower cost Guideline for expensive medication

30 Reminders Physicians reminded to give flu shots do so twice often

31 Inference methods o Algorithmic o Statistical o Pattern Matching o Rule-based (Heuristic) o Fuzzy sets o Neural nets o Bayesian Inference Engine Knowledge Base

32 ostill are not a success oproblem in having the probability data like for symptoms, signs etc.

33

34 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

35

36 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

37 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

38