Leveraging Clinical Decision Support for Optimal Medication Management Anne M Bobb, BS Pharm., Director Quality Informatics Children s Memorial Hospital, Chicago IL, February 20, 2012 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure Anne M Bobb, BS Pharm. Director Quality Informatics Children s Memorial Hospital, Chicago IL Has no real or apparent conflicts of interest to report. 2012 HIMSS
Learning Objectives Describe how CDS can improve medication use, with a focus at the ordering phase Give an example of how vendors and providers can work together to overcome the challenges of CDS Discuss how CDS can be used to address targeted outcomes, such as the Meaningful Use quality measures
Agenda Definitions Evidence supporting medication CDS Clinician experience Overcoming the challenges CDS for targeted outcomes Keys to success
CDS Definition CDS is a process for enhancing healthrelated decisions with pertinent, organized clinical knowledge and patient information to improve healthcare delivery. 1 Variety of information recipients Wide range of guidance Intelligently filtered 1. Improving outcomes with clinical decision support: an implementer s guide. Second Edition. HIMSS. 2011 (in press).
CDS Intervention Types 2 Documentation forms/templates: structured guidance, required fields, checklists Relevant data presentation: optimize decision making by ensuring all pertinent data are considered Order/prescription creation facilitators: picklists, pre-completed order sentences, order sets Protocol/Pathway support: multistep care plans, link to evidence or protocol, pertinent reference information Alerts and reminders Patient data reports: dashboards, surveillance 2. Improving outcomes with clinical decision support: an implementer s guide. First Edition. HIMSS. 2004.
Medication Use Process and where potential ADEs initiate History, Reconcile Order Transcribe Dispense Administer Monitor Educate, Discharge 3% + of patients 56% of identified ADEs 6% of identified ADEs 4% of identified ADEs 34% of identified ADEs? 8% of patients Patient Harm Estimates of Harm from Peer Reviewed Literature
Evidence Supporting Effectiveness of CDS
AHRQ MMIT Whitepaper 3 Thorough review of literature on medication management information technology Seven key questions Within and across phases of medication management, what evidence exists that technology is effective? RCTs of CDS 3. McKibbon KA, et al. Enabling Medication Management Through Health Information Technology. Evidence Report/Technology Assessment No. 201. 2011.
Technology Studied by Phase 3 CDS CPOE Health IT Prescribing Order Communication/ Dispense e-prescribing Administration Monitoring 177 12 5 63 90 17 9 11 31 13 4 2 Barcode Med Administration 1 2 20 0 emar 2 4 14 0
Effectiveness-Healthcare Process 379 studies total 225 (60%) studied process changes Considered a positive outcome if at least 50% of outcomes studied were positively impacted by MMIT Phase Process Outcome Setting Percent Positive Prescribing Patient Safety Related Hospital 87% Ambulatory 68% Guideline Adherence Hospital 83% Ambulatory 64% Monitoring 70%
Clinical Outcomes 76 studies measured clinical outcomes or ADEs 34% reported significant benefits Highly targeted interventions appear to be more effective than more diffusely focused systems such as CPOE and CDS.
Randomized Controlled Trials 87 RCTs primarily CDS Prescribing 71% Monitoring 29% Poor - mediocre study quality 68% (26/38) had positive process outcomes 15% (5/34) had positive clinical outcomes
The Clinician Experience
Basic Medication Decision Support Defaults, sentences, order sets Drug - drug Interaction Drug formulary Drug Allergy Therapeutic Duplication Advanced Medication Decision Support Drug associated lab reminder Dose guidance based on indication Renal function dose guidance Age dose guidance Pregnancy guidance 1 3 3 1 3 3 3 Drug disease contraindication Weight based dosing/pediatrics Drug utilization restriction Drug age contraindication Breastfeeding guidance 1 3 3 3 3 Kuperman G et al. J Am Med Inform Assoc 2007;14(1):29-40
Duplication CDS Metropolitan Hospital Center with CPOE and CDS for allergies, drug-drug interactions, drug duplication, dose range checking (Igboechi 2003) Overall medication errors were reduced by more than 40% Increase in therapeutic duplication problems Duplicate medication ordering errors increased after CPOE/CDS implementation (Wetterneck 2011) 48 errors (2.6% total) pre to 167 errors (8.1% total) post p<0.0001 Most post-implementation duplicate orders were for the same medication Identical Order 15 to 69 (p<0.0001) Same Medication 13 to 75 Same therapeutic class 20 to 23
Allergy and Drug Interaction CDS Drug Allergy and Drug-drug interactions (Weingart 2003) Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts In record review of 189 charts, no ADEs in cases where physicians observed the alert versus 3 ADEs among alert overrides (NS) 36.5% of alerts were judged inappropriate by physician reviewers Drug allergy alerts (Hsieh 2004) 80% of 7,761 total alerts overridden in 1,150 patients 19 patient (6%) experienced ADEs attributed to the overridden drug (none considered preventable)
Estimated value of DDI alerts Expert panel estimates of potential harm averted due to accepted DDI alerts Annual savings of $402,619 ADEs prevented per year # (%) Interquartile Range 25-75 th Percentile # of Alerts to prevent 1 ADE Serious 49 (12.2) 10-130 2715 Significant 125 (31.1) 34-307 1064 Minor 228 (56.7) 85-409 584 All 402 (100) 133-846 331 Weingart SN et al. Arch Intern Med. 2009;169(16):1465-1473.
MD assessment of erx Alerts Perceived Benefits Improve quality of care 78% Prevent medical errors 83% Enhance patient satisfaction 71% Enhance clinician efficiency 75% Action in response to alert in past 30 days Modified a potentially dangerous prescription 35% Action other than discontinue or modify prescription 63% Alert problems leading to poor satisfaction Alerts triggered on discontinued medications 58% Alerts failed to account for appropriate drug combinations 46% Excessive volume of alerts 37% Weingart SN et al. Arch Intern med. 2009;169(17).
Basic CDS (Alert) Assessment Override rate cannot be the only measure of effectiveness DDI, allergy alerts improve safety Signal to noise ratio needs work CPOE changes workflow leading to increased drug duplication errors Lack of evidence that alerts for duplication are effective Consider targeted alerts
Overcoming the Challenges
DDI Alerts Vendor Control User interface Ability to customize locally Most topical medications should not trigger a DDI alert DDI alerts should not trigger on refills/renewals Ability to review ALL DDI warnings when a clinician chooses Workflow timing - Rounds report
DDI Alerts Local Options Tier alerts or suppress categories/low risk alerts Show selected alerts to MDs, more alerts to Pharmacists Perform in-house review of DI database to revise existing alerts Outsource review of DI database to revise existing alerts National efforts
DDI Resource Comparison Resource Risk Rating Severity Onset Reliability Rating LexiComp Hansten and Horn Interaction Analysis and Management Multum X Avoid Combination D Consider Therapy Modifications C Monitor Therapy B No Action Needed A No Known Interaction Significance 1 Avoid Combination 2 Usually Avoid Combination 3 Minimize Risk 4 No Action Needed 5 No Interaction Major Moderate Minor Severity 1 Mild 2 Moderate Immediate Rapid Delayed Interaction Headers 1. Contraindicated 2. Generally Avoid Excellent Good Fair Poor 3 Severe 3. Monitor Closely 4. Adjust Dosing Interval 5. Adjust Dose 6. Additional Contraception Recommended 7. Monitor
Allergy Alerts Goal: Clinician receiving alert has information necessary to make an appropriate decision Allergy vs Contraindication Intolerance Side effect Adverse reaction Example: Vancomycin Red man syndrome
Allergy Alerts Importance of information integrity Who can/should document Patient ability to report Clinician ability to assess type of reaction No free-text Should a clinician be able to enter a medication order without allergies documented?
Allergy Interface
Allergy Interface
Our Plan Require allergy documentation before medication order entry Allow an out for emergencies Require a codified reaction Unknown option Map severity where appropriate Require override reasons Future plans may include filtering Some risk involved
Order Entry
CDS for Targeted Outcomes Implement one clinical decision support rule relevant to specialty or high clinical priority along with the ability to track compliance to that rule.
VTE Prophylaxis Multidisciplinary Approach: Set of CDS Interventions Provider Embedded standardized VTE prophylaxis order set in all admission and post op order sets Daily Alert Nursing Included in interdisciplinary plan of care to prompt discussion with physician during rounds Pharmacy Surveillance list of patients NOT receiving chemoprophylaxis
Daily Alert Reminder
Quick access to source of truth
Pharmacoprophylaxis missing list Pharmacist Surveillance
Keys to Success
CDS Five Rights Right information: evidence-based, suitable to guide action, relevant to circumstance Right person: physician, nurse, pharmacist, patient, etc. Right CDS information format: order set, alert, reference information Right channel: EHR, PHR, pager, mobile device Right time in workflow 2. Improving outcomes with clinical decision support: an implementer s guide. First Edition. HIMSS. 2004.
The Ten Commandments Speed is everything Anticipate needs and deliver in real time Fit into the user s workflow Little things can make a big difference Recognize that physicians will strongly resist stopping Changing directions is easier than stopping Simple interventions work best Ask for additional information only when you really need it Monitor impact, get feedback, and respond Manage and maintain your knowledge-based systems Bates DW et al. JAMIA. 2003;10:523-30.
Physician s Perspective Make me faster! Make me smarter! Show me the data! Used with permission: David Liebovitz MD
CDS intervention plan Involve affected stakeholders in design Do CDS with stakeholders, not to them Assess the change environment Culture User buy-in to the clinical intervention User buy-in to the intervention delivery mode Implement with anticipated benefits in mind Measurable outcomes Test prior to go-live Use cases and testing scenarios Importance of end-user testing Improving medication use outcomes with clinical decision support. HIMSS. 2009.
CDS intervention plan Pilot if possible Alert in the background or in silent mode Communicate launch details Train if necessary Provide feedback mechanisms Execute the launch plan Intervention owner should be available Evaluate Improve Improving medication use outcomes with clinical decision support. HIMSS. 2009.
Dose Checking Implementation Lessons Learned
End user testing DRC activated in PC and then removed due to rule problem 1000 900 800 700 600 500 400 300 200 100 0 946 131 149 128 123 95 65 8/13 8/14 8/15 8/16 8/17 8/18 8/19 # of Alerts
Non-actionable Alerts
Dose checking challenge Missing weight Missing creatinine (Cockcroft-Gault) Greater than 20% of alerts are due to missing weight or creatinine Weight typically entered within the hour after the alert Most orders entered on admission when these variables may be missing Would prefer an alert when the weight or creatinine posts and the ordered dose is out of range
Conclusions
Conclusions Evidence supporting improved process outcomes with medication CDS is strong Evidence supporting clinical outcomes is there, but less strong Alert fatigue should be addressed by a multi-prong approach Vendor Local National standards
Conclusions Keys to success identified by the pioneers in this field hold true Basic medication CDS alerts may have high override rates Not equivalent to rejected advice Need to work together to solve alert fatigue Unintended consequences will happen plan for them