Clinical Decision Support s Impact on Quality of Care. Greg Adams, Vice President of Strategic Business Development, UpToDate

Clinical Decision Support s Impact on Quality of Care Greg Adams, Vice President of Strategic Business Development, UpToDate

Agenda What is Clinical Decision Support (CDS)? How does CDS help clinicians provide better care? Evidence linking impact of CDS on the quality of patient care

What is Clinical Decision Support (CDS)?

AMIA Taxonomy of CDS Tools Medication dosing support Medication dose adjustment Formulary checking Singe dose range checking Maximum daily dose checking Maximum lifetime dose checking Default doses/pick lists Indication based dosing Order facilitators Medication order sentences Subsequent or corollary orders Indication based ordering Service specific order sets Condition specific order sets Procedure specific order sets Condition specific treatment protocol Transfer order set Non medication order sentences Point of care alerts/reminders Drug condition interaction checking Drug drug interaction checking Drug allergy checking Plan of care alerts Clinical laboratory value checking Duplicate order checking Care reminders Look alike/sound alike medication warnings Ticklers Problem list management Radiology ordering support Intravenous (IV)/per os (PO) conversion High risk state monitoring Polypharmacy alerts Workflow support Order Routing Registry functions Medication reconciliation Automatic order termination Order approvals Free text order parsing Documentation aids Expert Systems Antibiotic ordering support Ventilator support Diagnostic support Risk assessment tools Prognostic tools Transfusion support Nutrition ordering Laboratory test interpretation Treatment planning Triage tools Syndromic surveillance Relevant Information display Context sensitive information retrieval Patient specific relevant data display Medication/test cost display Tall man lettering Context sensitive user interface

How Does CDS Help Clinicians Provide Better Care?

By addressing an important problem Unanswered clinical questions impact patient management decisions Approximately 2 out of 3 clinical encounters generate a question Physicians have approximately 11 clinical questions a day 40 % of questions get answered Covell, DG. Ann Intern Med 1985; 103:596; Green, ML. AM J Med 2002; 109:218; Osheroff, JA. Ann Intern Med 1991:575; Ely, JW. J Am Med Inform Assoc 2005; 12:217; Gorman, PN. Med Decis Making 1995; 15:113.

Answering those questions changes decision making Answering all clinical questions could change 5 to 8 patient management decisions each day Covell, DG. Ann Intern Med 1985; 103:596; Green, ML. AM J Med 2002; 109:218; Osheroff, JA. Ann Intern Med 1991:575; Ely, JW. J Am Med Inform Assoc 2005; 12:217; Gorman, PN. Med Decis Making 1995; 15:113.

Keeping up with Medical Knowledge In 1965 there were just 39 published randomized trials in medicine. In 2011 there were over 21 000, posing a major challenge for doctors who want to keep up with relevant information. The volume of literature is just too large for the average clinician to master.

Evidence Linking CDS with Improved Quality of Care

Global Acceptance of UpToDate By far the dominant clinical knowledge resource worldwide Used by 700 000 doctors in 25 000 hospitals in 158 countries 90% of academic medical centers in the United States 100% in the Netherlands, and Luxemburg 90% in Belgium 95% in Germany 90% in Japan 88% in Sweden All of Norway All Public Hospitals in Spain Working on National Licenses for many countries around the world Used by most leading militaries around the world

Ample Evidence for Impact of CDS Widespread, global usage of UpToDate has led to it being most researched and studied CDS Over 30 studies

Use of UpToDate Associated with Improved Outcomes Impact Solucient (1) studied the impact of UpToDate on length of stay, patient complications and patient safety (2) Significantly shorter lengths of stay Significantly lower complication rates Significantly lower adverse events (1) Solucient maintains the nation's largest healthcare database, comprised of more than 26 million discharges per year from 2,900 hospitals. (2) Bonis PA. Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the US. Int J Med Inform 2008; 77:745.

The more UpToDate was used the better the Outcomes UpToDate Usage Levels and Impact on Patient Complications, Patient Safety, and length of stay Improvement in Risk Percent UpToDate Topic Reviews Per Week Int J Med Inform 2008;77:745

Researchers at Harvard University Find UpToDate Associated with Improved Outcomes Use of UpToDate Associated with: Improved Quality Every condition on Hospital Quality Alliance Metrics Shorter Lengths of Stay 372 000 days over 1 year Lower Mortality Rates 11 500 lives over 3 years Isaac T, Zheng J, Jha A. Use of UpToDate and outcomes in US hospitals. J Hosp Med 2012; 7:85.

Research Extends Beyond the United States For Singapore s National University Hospital: Use of UpToDate led to changes in investigations, diagnosis or management 37% of the time.

Over 4 Million Physician Responses on UpToDate Usage Accredited Provider of AMA PRA Category 1 credits to physicians Accreditation Council requires documentation of 3 steps: The clinical question or search Review of clinical content Reflection on how the information is used in physician practice 4 million reflections on impact of UpToDate on physician practice Data date range: June 1, 2011 June 1, 2012

I Searched for Information About: Percent of Total Responses Total Responses Clinical Manifestations 15.4% 634,274 Diagnosis 25.4% 1,050,355 Prevention 2.1% 87,374 Prognosis 3.5% 144,889 Treatment 48.3% 2,010,770 Other 5.3% 221,570 Total Responses 4,149,232

Results by Question Types (n= 4.1 Million CME Responses )

Clinicians Save Time with UpToDate Percentage of users who report that UpToDate saves them time in answering clinical questions

EMR/EHR on the Rise: 2010 2013 Growth Source: Accenture. Overview of International EMR/EHR markets. August 2010. http://www.ac centure.com/ SiteCollectio ndocuments/ PDF/Accentu re_emr_mar kets_whitep aper_vfinal.p df#zoom=50

UpToDate was rated as the most influential IT initiative in benefitting quality/safety of care 2012 Individual Subscriber Survey

Increased Clinician Satisfaction with the EHR Users said that having UpToDate embedded in their EHR Is important to patient care Enhances satisfaction with their EHR Encourages utilization of their EHR Source: June 2011 Clinicians Survey N=1228

UpToDate Partner Integration Options Basic Single Sign on HL7 Infobutton Instructions to easily insert UpToDate search into any clinical system Removes need for additional sign on to UpToDate, allows CME Placement Automate search with context sensitive links relevant to patient, user, or encounter Portal or EMR Portal or EMR EMR

Summary Use of evidence based CDS resources at the pointof care helps clinicians answer important clinical questions Answering these questions changes decision making Improving decision making leads to better health outcomes and reduced variability in care

Clinical Decision Support: Getting it Right