Guidelines Into Decision Support (Text Version)

On September 14, 2009, Richard Shiffman made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (15.5 MB) (Plugin Software Help).

Slide 1

AHRQ Annual Meeting September 14th, 2009

Slide 2

AHRQ's Goals for Advancing Clinical Decision Support (CDS)

To facilitate the development, adoption, implementation and evaluation of best practices using clinical decision support
To further enhance the nation's efforts to make evidence-based clinical knowledge more readily available to health care providers
Consonant with ARRA
- "meaningful use"

Slide 3

Goals of the GLIDES Project

Implement evidence-based guideline recommendations that address prevention of pediatric obesity and chronic management of asthma

Slide 4

 [ Image of Panel Report]

Slide 5

This revised guideline differentiates asthma severity from asthma control and provides several age-based
matrices relating these summary parameters to specific clinical findings and to recommendations for treatment.

Slide 6

We replicated the guideline matrix in our design of computer-based data entry template. These EHR templates prompt
users to assess and document relevant findings--providing important supports for clinical decision making.

Slide 7

The guideline also differentiates impairment (frequency and intensity of symptoms and functional limitations)
From risk (the likelihood of exacerbations, decline in lung function, or medication related adverse effects)

Slide 8

Display of previously collected data also supports decision making.

On this assessment template, the patient's asthma severity classification and date are displayed as is the most recent classification of level of control.

In the top left corner, the computer assists wioth INTERPRETATION of the recorded findings.
The provider is prompted to record her assessment of severity and control and to explain the reasons for any variation from the computer-generated appraisal.

Slide 9

The NHLBI guideline describes 6 levels or STEPS of increasing intensity of management.

The computer suggests appropriate management based on age, severity, impairment and risk--in this case calling for Step 3, which includes low dose inghaled corticosteroids + either a long acting beta agonist, a leukotriene antagonist or a combination.
The clinician can agree or select any other step and is encouraged to record reasons for variation.

Slide 10

Goals of the GLIDES Project

1) Implement evidence-based guideline recommendations that address prevention of pediatric obesity and chronic management of asthma
2) Apply GEM (Guideline Elements Model) and its associated tools to systematically and replicably transform the knowledge contained in these guidelines into a computable format

Slide 11

Challenge of Representing
Guideline Knowledge Electronically

A black box stands between the published guideline document and the computer-based decision support tool.
Very often, following poorly defined, largely non-generalizable processes, a published guideline is input into the black box and emerges in some computable format.
Our group has been particularly interested in opening and understanding what goes on in the box.

Slide 12

In an effort to be systematic and replicable about the translation process, we have exploded the black box into a rainbow of 4 levels of activity.

Slide 13

Narrative Guideline
Semi-structured
Semi-formal
Formal
Statement logic
Coded decision variables & actions
Local workflow & barrier analysis;
Local codes; Origins/insertions
Decision support modalities
Local EHR scripting language
XML file
GEM Cutter Markup
EXTRACTOR Transforms

 

Slide 14

Goals of the GLIDES Project

1) Implement evidence-based guideline recommendations that address prevention of pediatric obesity and chronic management of asthma
2) Apply GEM and its associated tools to systematically and replicably transform the knowledge contained in these guidelines into a computable format
3) Deliver the guideline knowledge via electronic decision support at ambulatory sites that employ Centricity EMR at Yale and EpicCare at Nemours

Slide 15

Project Timeline

Project Planning
Knowledge Transformation According to our originally proposed timeline, we are on schedule and within budget for the first 18 months of the contract. We have completed the knowledge transformation from the guidelines and implemented decision support for asthma in Yale specialty clinics, and have implemented decision support for obesity in Yale and Nemours primary care clinics. We have also operationalized asthma decision support at Nemours specialty centers on 3 sites. Implementation is underway for asthma decision support in primary care at Yale and Nemours.

Slide 16

Goals of the GLIDES Project

1) Implement evidence-based guideline recommendations that address prevention of pediatric obesity and chronic management of asthma
2) Apply GEM and its associated tools to systematically and replicably transform the knowledge contained in these guidelines into a computable format
3) Deliver the knowledge via electronic decision support at ambulatory sites that employ Centricity EMR at Yale and EpicCare at Nemours
4) Evaluate the fulfillment of these goals and the effectiveness of the decision support tools in improving the quality of health care

Slide 17

Key Findings: Implement evidence-based guideline recommendations...
Workflow is king
- Simply inserting powerful CDS applications into a sub-optimal EHR workflow will not work well
- CDS designers must be prepared to tackle wider EHR workflow challenges, for example
  - Streamline capture of data required to trigger CDS
  - Identify "golden moments" when CDS can be invoked and delivered

Slide 18

 Key Findings: Apply GEM to systematically and replicably transform knowledge into computable format
GEM worked
- Knowledge transformation was relatively straightforward (moving from the Narrative Guideline to the Semiformal level)
- Moving from Semi-formal to Formal level is challenging and needs further investigation
- Expect to encounter problems with narrative guidelines
  - Missing details, vague and underspecified text, a lack of guidance re anticipated level of adherence
 

Slide 19

Key Findings: Deliver the knowledge via electronic decision support at ambulatory sites
"All Implementation Challenges Are Local"
- Customization of centrally-produced "knowledge specifications" was required at each site
- CDS implementers should be prepared to customize for local needs, rather than assume that a centrally-prescribed solution can be imposed

Slide 20

Key Findings: Evaluate fulfillment of goals and effectiveness of CDS in improving the quality of health care

Qualitatively obtained information (why) to complement quantitative (what) is invaluable in understanding what's going on

Slide 21

Next Steps

- Complete implementation activities
- Continue evaluation
- Introduce incentives to increase use
- Disseminate lessons learned
  - CCHIT
  - Vendors
  - TEP
  - Guideline developers
  - ...

Slide 22

Thank You!

YCMI.med.yale.edu/GLIDES

richard.shiffman@yale.edu

Slide 23

Behind the Scenes

• Save each symptom and its frequency for consultant's letter
• Interpret Impairment: None, Mild, Moderate, Severe
• Interpret Risk: Low, Moderate, High
• Interpret Control: Well-controlled, Not well-controlled, Very poorly controlled
  

Slide 24

Define Clinical Objectives

• Stakeholder meetings and teleconference
  • Goals distilled
  • E.g.,Measure asthma control in a formal manner
• Each goal scored
  • Addressed by the selected guidelines?
  • Can IT facilitate attainment?
  • Evaluable?

Slide 25

Key Findings: Implement evidence-based guideline recommendations...

Stakeholder meetings and teleconference
- Goals distilled
- E.g.,Measure asthma control in a formal manner
Each goal scored
- Addressed by the selected guidelines?
- Can IT facilitate attainment?
- Evaluable?

Slide 26

Invest effort in good project governance
- Clinician commitment is important, but elusive
  - Commitment to implementing the guideline must extend from the design/prototyping phase all through implementation
  - Hearing the words "well, it's only a guideline", shortly after CDS implementation, is not a good omen
- Define clear and measurable clinical goals with users

Slide 27

And finally, the computer offers a skeleton asthma action plan based on red, yellow and green zones, and offers providers the opportunity to create medication authorization forms for school, camp or daycare.,