# Presentation: 528822

## Antimicrobial Computerized Decision Support System (CDSS) in CPRS

**Eric Geurkink PharmD**
**Kristian Johnson RN, CAC**

- VeHU 2007 #211

## Also Known As...

## Educational objectives

- Session participants will:
- Understand the development process involved in creating the antimicrobial CDSS menus
- Learn how CPRS menu order dialogs can be adapted to provide decision support at the point of entry in CPRS
- Understand the flexibility and limitations of antimicrobial decision support within CPRS
- Appreciate how the implementation and incorporation of the antimicrobial CDSS varied among VISN 23 sites

## What is the CDSS?

_**C**_**omputer **_**D**_**ecision **_**S**_**upport **_**S**_**ystem**
**A tool within CPRS that offers empirical antimicrobial prescribing advice to clinicians at the point of order entry **

**Notes:**
The advice contained in the program was developed by reviewing texts and references like Sanford, Mandells, Johns Hopkins Website, IDSA guidelines, and other pertinent clinical literature.

These guidelines were then reviewed by committees from the pertinent specialties.  For example, pneumonia guidelines were reviewed by staff from Infectious Diseases, Pulmonary, Pharmacy, Urgent Care, and ICU.  Endocarditis guidelines were reviewed by staff from Cardiology, Cardiothoracic surgery, Pharmacy, Infectious Diseases.

## Why is this important?

- Guideline-concordant pneumonia mortality 65-75% of  controls (Tennessee Medicare data) 1** **
**Antimicrobial therapy is suboptimal about half of the time**
- In 2004, 55% of  MVAMC Medicine Service inpatients received suboptimal antimicrobial therapy2
**Antimicrobial Resistance is increasing and is expensive**
- Annual cost of nosocomial infections with resistant organisms ~$4.0 billion3
- Total cost of antibiotic resistance $30 to $100 billion per year3

**Guideline-concordant therapy improves outcomes**

- 1Gleason, Arch Int Med 1999; 159: 2562
- 2Johnson JR, et al.  Unpublished data
- 3cited in Protecting the Crown Jewels of Medicine: A strategic plan to preserve the effectiveness of antibiotics.  1998.  Center for Science in the Public Interest

**Notes:**
COST
The cost of antibiotic resistance in the United States is substantial, but it is difficult to estimate with precision. 
One investigator estimated that the cost is between $100 million and $30 billion annually (the wide range arises primarily from different values assigned to the value of a human life). 
The National Foundation for Infectious Diseases recently estimated the cost to be $4 billion annually. 
Costs will rise as resistance becomes more prevalent.   
OP Rx
In doctors’ offices, antibiotics are often seen as a quick-fix solution for patients. Doctors currently prescribe antibiotics for outpatients approximately 150 million times a year. However, according to the CDC, more than 50 million of those prescriptions (one-third) are prescribed inappropriately -- when the illness is not caused by bacteria or the disease-causing bacteria are not susceptible to the antibiotic prescribed. 
IP Rx
Overuse of antibiotics for inpatients also contributes to antibiotic resistance. Increasingly, today’s hospitalized patients are seriously ill. At any given time, 25 to 40 percent of hospital patients are receiving intravenous antibiotic treatment. However, many of those prescriptions are inappropriate. In a recent large-scale study of hospital records by the Health Care Financing Administration (HCFA), 63 percent of orders for vancomycin, the last line of defense against severe hospital-acquired infections, were inconsistent with CDC guidelines. 
Another trend that is contributing to the problem of antibiotic resistance is the shift in the types of antibiotics that are prescribed. Increasingly, stronger, newer, and more broad-spectrum antibiotics are being prescribed in place of narrower-spectrum antibiotics -- which is like using a cannon instead of a rifle. That shift is worrisome because the more broad-spectrum antibiotics are used, the more likely a wider spectrum of bacteria will develop resistance to them. Broad-spectrum antibiotics are appropriate for treating patients at high risk of succumbing to infection quickly. 

## Potential Benefits

- Patients
- Better infectious disease outcomes
- Fewer ADE
- Shorter stays
- Less resistant flora
- Hospitals
- Better outcomes
- Lower costs
- Antimicrobial stewardship
- Less resistant flora
- Happier staff

## Strategies to Influence Prescribing Behavior

- Education
- Personalized Feedback
- Rules and Limitations
- Academic Detailing
- Incentives
- Guidelines
- System Change
- Reminders
- Computer Decision Support

## Education
Personalized Feedback
Rules and Limitations
Academic Detailing
Incentives
Guidelines
System Change
Reminders
Computer Decision Support

- Personalized Feedback
- Rules and Limitations
- Academic Detailing
**Incentives**
**Guidelines**
**System Change**
- Reminders
**Computer Decision Support**

*CDSS highlights these strategies*

**Strategies to Influence ****Prescribing Behavior**

- Incorporate guidelines into clinical practice
- Incorporate computerized decision support into clinical practice
- Provide incentives for providers
**Antimicrobial CDSS uses all of these methods**

- * From:Infectious Diseases Society of America:Clin Infect Dis 2007;44: 159

- Methods for Improving Antimicrobial Prescribing*

## Goals of the CDSS project

-  Improve patient outcomes
-  Optimize costs
-  Prevent adverse drug effects
-  Reduce antimicrobial resistance
-  Improve life for prescribers

## Project Personnel

- Project Director

- Clinical Applications Coordinator

- Evaluation Specialist

- - All other VISN sites encouraged to form a similar team
-  Every prescriber and pharmacist is encouraged to contact the team with questions or suggestions

- Pharmacist

## Decision Support Content Process

- CDSS team physician and pharmacist review literature and develop recommendations
- These recommendations are reviewed with local experts in the pertinent fields
- e.g. Intra-abdominal abscess: General Surgery, GI, ER, ICU, Infectious Disease, Pharmacy
- Content revised and finalized after consensus is reached

## Updating Process

- Each site has own customized CDSS
- Significantly different prices and suggested content changes from CDSS team are disseminated ANNUALLY
- Each site can accept or reject the changes
- Emergent changes are dealt with ASAP
- (e.g. gatifloxacin removed from market)

## Schematic Diagram

## Example: 

- Cholecystitis

## Example: 

- Uncomplicated Cystitis

**Notes:**
Now, as we all know, guidelines do not apply universally.

If in your clinical judgement, the recommended antimicrobials do not apply, you can select and alternative from a list of drugs.  These are also automatically ID approved.

To assist in your decision making, we have placed “Important Drug Property” letters by each drug.  You can access this page with a few clicks, and brief drug info is listed.

## Example: 

- Prosthetic Valve Endocarditis

## Example: 

- Diverticulitis

## Example: 
Specific pathogen – 
Klebsiella pneumoniae

- Specific pathogen –
- Klebsiella pneumoniae

- Pathway to specific pathogen – Klebsiella

## Links to internal and external information sources

## Slide 76

## Antimicrobial CDSS 

- Technical Requirements

## The Raw Numbers

- (Really Dirty Harry)

## Antimicrobial CDSS - Technical Requirements

- ~200 Outpatient Medication Quick Orders
- ~200+ Inpatient Medication Quick Orders
- ~1600 Order Menus
- ~20 URL Links in Generic Orders

**Antimicrobial CDSS - Technical Requirements**

## Some amount of local programming was done to enhance the capabilities of the CDSS project.

- NOTE:  Those enhancements are NOT required for the CDSS to be successful!

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

- Captures:
- Patient name and SS#
- Ordering provider
- Time
- Drug
- Location
- Primary vs. alternative drug

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

- ZZ QUICK ORDER AUDIT and ZZ QUICK ORDER AUDIT(ALT)
- We placed the data object into the comments section of the medication quick orders.  This is the text that is entered:
- |ZZ QUICK ORDER AUDIT|
- |ZZ QUICK ORDER AUDIT (ALT)|

- The object methods for the data objects:
- S X=$$AUD^ANAZQUIC(DFN,"P")
- S X=$$AUD^ANAZQUIC(DFN,"A")

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

**Antimicrobial CDSS - Technical Requirements**

## A local VistA routine was created for pharmacy.  Pharmacists can go into a menu option and type in the confirmation number returned by the quick order.  This tells them whether or not the order was placed using the CDSS.

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

**Antimicrobial CDSS - Technical Requirements**

## Moving the CDSS System into other VistA Databases

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

- When the order dialogs are copied into another system, the higher number prevents the new order dialogs from overwriting existing dialogs.

**Antimicrobial CDSS - Technical Requirements**

## Antimicrobial CDSS - Technical Requirements

- Menus are copied into the new system intact, but quick orders must all be remapped to the local “orderable item”  (medication or consult service).

**Considerations for Copying Dialogs into Another VistA System**

**Antimicrobial CDSS - Technical Requirements**

## Additional Benefits
And Features

- And Features

## Help and Links throughout CDSS

- Site-specific antibiograms
- Allergy information and desensitization protocols
- Consults
- Information on how to contact the CDSS team (phone, email, pager)

## Alternative antimicrobial needed?

- Our system provides alternatives for MOST clinical scenarios
- If you want to select an alternative, we ask that you provide a reason, in order to help us improve our recommendations

## Important Drug Properties

- Concise, pertinent drug information
- Links to more complete resources
- Micromedex, Up-to-date
- Pharmacist contact information

## Usage data

## Minneapolis

## Central Iowa

## CDSS outcomes data in UTIKothari NJ, et al, unpublished data

- 274 cases of acute urinary tract infection for which antibiotics were prescribed. CDSS was used in 75 of these cases (27.3%)
- Antibiotics prescribed **with CDSS were less likely to have been prescribed for asymptomatic bacteriuria (15%) than those prescribed without CDSS use (27%) (p=0.037).**
- Prescribers using **CDSS are more likely to prescribe first line agents**: fluoroquinolones and TMP-sulfa, than those who do not use CDSS (64% vs. 40%, p=0.001).

## Summary

- CPRS offers great possibilities for incorporating decision support into routine care.

- Implementation of decision support systems requires buy-in, work, and feedback from providers, CAC’s, and pharmacy.

- Promotion and educational efforts are key to achieving sustained usage.

## Questions

- ??

## Thank You!