EMR optimisation with clinical decision support August 2019 Ian Z. Chuang, MD, MS, CCFP
Ian Z. Chuang, MD, MS, CCFP Chief Medical Officer, Elsevier Health, International Clinical Experience: • Licensed Family Physician • Previously, teaching practices in Canada & USA Healthcare Informatics: • 20 year in Informatics • Private/Public sector projects in the USA & globally • Clinical leadership role with: McKesson, Cerner, Cigna
Setting the scene eMR adoption in Australia • Large variation across the states eMR vendors in Australia • Epic, Cerner, Allscripts, Intersystems, Emerging Actual stage of eMR • Low maturity 3
Some known challenges with EHRs • Variation in care / Inappropriate ordering • Impacts on clinician productivity • Lack of Clinical Decision Support (Order Sets/Care Plans) • If CDS exists − Significant resource needed to build and maintain in house − Lack of governance − Low compliance / clinician dissatisfaction − Lack of template consistency leading to inefficiencies − Non-evidence based or lack of supporting evidence • Clinician usability 4
Goals for Digitalisation of Health Care Cost Access Efficiency Quality Safety Effectiveness/ Value
Complementary Value of EMRs and CDS • Usability requires seamless intersection between clinical workflow and clinical decision flow • EMR Value − Productivity through data flow and automation − Transaction reliability − Care delivery efficiency • CDS Value − Clinical decision consistency and optimization (evidence, guideline, patient) − Clinical decision reliability − Physician workflow efficiency 6
What is Clinical Decision Support? Clinical Decision Support is a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery. Information recipients can include patients, clinicians and others involved in patient care delivery information delivered can include general clinical knowledge and guidance , intelligently processed patient data, or a mixture of both; and information delivery formats can be drawn from a rich palette of options that includes data and order entry facilitators, filtered data displays, reference information , alerts, and others. Improving outcomes with clinical decision support: an implementer’s guide. Second Edition. HIMSS 2012. “ Order sets … have the potential to be among the most impactful forms of clinical decision support (CDS). Ideally, they are deeply embedded in the EMR and have the opportunity to influence point-of- care decisions….” KLAS, Clinical Decision Support 2012. www.klasresearch.com
EHR Modernization • Streamline Vist A Cerner • Standardize • Add More Solutions “This implementation of the EHRM is forcing us Stone Dr. Richard to address programmed variation in care and Charge, Executive in define the VA standard of care, and we will lead Veterans Health Administration in the USA. - EHRM Workshop 6, July 8, 2019 8
Challenge - Variation & inappropriate ordering Some commonly over-ordered or inappropriately ordered tests include: • CT Angiogram (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711245/) • BNP (https://link.springer.com/article/10.1186/1472-6947-13-43) • Thyroid Function (https://www.ncbi.nlm.nih.gov/pubmed/29105255) – see slide 7 • Antibody Testing (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016776/) • Head CT (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5722638/) • Chest x-ray daily for ICU patients ( https://pulmccm.org/critical-care-review/daily-chest-x-rays-the-norm-in- ventilated-patients-despite-guidelines/) • Antibiotic ordering ( safetyandquality.gov.au/AURA2019) • Medication ordering errors • Roughead L, Semple S, et al. Medication Safety in Australia. Australian Commission on Safety & Quality in Health Care 2013 • Drugs and Medical Errors Killing One of Every Five Australians. Best Health (online) 2009; http://besthealth.com.au/drugs-and- medical-errors-killing-one-of-every-five-australians 9
Inappropriate ordering • AURA 2019 Third Australian report on Antimicrobial Use and Resistance in human health • In 2017, the proportion of prescriptions for surgical prophylaxis that extended beyond the recommended 24 hours dropped from 41.1% in 2013 to 30.5% safetyandquality.gov.au/AURA2019 10
Thyroid function “Current guidelines recommend thyroid stimulating hormone (TSH) alone as the best test to detect and monitor thyroid dysfunction, yet free thyroxine (FT4) and free triiodothyronine (FT3) are commonly ordered when not clinically indicated. Excessive testing can lead to added economic burden in an era of rising healthcare costs, while rarely contributing to the evaluation or management of thyroid disease.” Kluesner, JK, Beckman, DJ, Tate, JM, et al. Analysis of current thyroid function test ordering practices. J Eval Clin Pract . 2018; 24: 347 – 352. https://doi.org/10.1111/jep.12846 11
The clinician’s story – first year resident in ED Imagine being a first year resident on your first day in the emergency department of a busy city hospital – and you are on your own due to an influx of patients. A patient arrives via ambulance with suspected pneumonia. The nurses have done their observations, put an IV line in and begun O2 via a face mask. They are waiting for you to order the necessary medications, labs, radiology and interventions. You enter a provisional diagnosis of pneumonia within the patient record and then begin to order medications and labs BUT you haven’t had to do this before and all of the senior doctors are busy. You start to order blood cultures, but the clinical decision support advisory notes the blood cultures should be avoided in patients who are not systemically septic, have a clear source of infection and in whom a direct specimen for culture (e.g. urine, wound swab, sputum, cerebrospinal fluid or joint aspirate) is possible. 1
Solution – Embedded evidence can guide appropriate ordering
Solution – Embedded evidence can guide appropriate ordering
Solution – Embedded evidence can guide appropriate ordering
Usability at Point-of-Action
Guidance and Knowledge at the Point-of-Action
User Feedback on Quality (300 responders)
User Feedback on Evidence (300 responders)
User Satisfaction (300 responders)
Return on investment – financial gains Reduction in unnecessary and inappropriate tests leads to organisational financial gains WITHOUT compromising patient care Education of clinicians on the cost of tests leads to a decrease of inappropriate orders, unnecessary orders and repeat ordering for no clinical reason A study completed at GCUH found that these tests are frequently ordered with little consideration of purpose or intent: • Full blood count $13.71 • Electrolyte urea and creatinine $12.61 • Liver function test $12.61 • C-reactive protein $12.61 Education of clinicians and the use of Order Sets realised a marked decrease in over and unnecessary ordering of these tests • http://www.amsj.org/archives/6357 • https://www.health.gov.au/internet/main/publishing.nsf/Content/2D6AC97D6665CF42CA257EF30015DB17/$File/Qual%2 0Path%20Ording%20NCOPP.pdf
Challenge – Clinician Productivity One potential cause – inefficient ordering • Lack of structure/standardisation of order set template leading to time lost searching for orderable items • Too many orderable items included to satisfy every possible option • Too many order sets based on clinician preference • No suitable order set leading to ordering individual items https://www.healthcareittoday.com/2015/07/08/survey-physician- ehr-satisfaction-and-ehr-productivity/ 23
Usability Metrics: Human Computer Interaction
CDS Metrics
Challenge – Order Set Development Process
Order Set Development Workflow with Elsevier tool
Solution - Intuitive project management tools • Create, modify and reuse standard workflows • Automatic and configurable notifications when a stage is nearly due, complete or overdue • Flexible role-based tools let you set reviews for specific groups, such as pharmacy and pathology
Content is tracked with version control and audit logs • You can revert to previous versions at any time • Change log and version history retained indefinitely • Flag order sets due for review
Solution - Collaborate with easy-to-use commenting • Intuitive, forum-like commenting and discussion on any order, section or topic • Each thread must be positively closed – no more ignored comments • Comment threads are available later when order set is due for periodic review, so previous discussions are remembered
Collaboration Process Carotid Stenosis Carotid Carotid Endarterec- Stent tomy CT NIR Vascular Neuro Cardiologist Surgeon
Highly scalable across multiple hospitals or health services Health Service 1 Health Service 2 Health Service 3 • Any client can choose to share content with any other subscriber, with separate tabs for each organisation’s content • For example, a tab for each hospital within a health system, or even tabs for other organisations in ANZ or worldwide that have agreed to share content with you
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