# Presentation: 666295

## American Health Information CommunityEvidence Development for Clinical Decision Support:Process & Outcomes Improvement

- Keith Larsen, RPh
- Intermountain Healthcare
- September 17, 2007

## Presentation Outline

- Background
- Questions
- What problem is being solved with Clinical Decision Support?
- Is a lack of evidence a barrier to care?
- How is evidence generated and adopted? What are the factors affecting adoption?
- What software tools are required to support Clinical Decision Support?

- Confidential and Proprietary to IHC Health Services, Inc.

## What is Clinical Decision Support?

- Any tool or artifact that assists the clinician in making correct clinical decisions.
- Rules and alerts
- Consolidated reports, graphs, and other visualizations of patient data
- Protocols, order sets

- Confidential and Proprietary to IHC Health Services, Inc.

## Founded in 1975 
Based in Salt Lake City
21 hospitals: from 520 bed tertiary care to 20 bed rural facilities
More than 130 clinics in Utah and Southeastern Idaho
Employs about 27,000, including 780 physicians;  affiliated with another 2,500 physicians. 
Provides health insurance to more than 500,000 through its insurance branch, SelectHealth.
Charge for treatment at Intermountain facilities is 27%, on average, below the national average

- Based in Salt Lake City
- 21 hospitals: from 520 bed tertiary care to 20 bed rural facilities
- More than 130 clinics in Utah and Southeastern Idaho
- Employs about 27,000, including 780 physicians;  affiliated with another 2,500 physicians.
- Provides health insurance to more than 500,000 through its insurance branch, SelectHealth.
- Charge for treatment at Intermountain facilities is 27%, on average, below the national average

- Confidential and Proprietary to IHC Health Services, Inc.

## Electronic Medical Records
HELP system – started 1972
Premise: 
Computerized decision support can provide a safety net or insure a base level of care
Approach: 
What information needs to be automated to facilitate clinical decision support?
Current concerns
How can we promote best practices?
Do no harm
Do the right thing

- HELP system – started 1972
- Premise:
- Computerized decision support can provide a safety net or insure a base level of care
- Approach:
- What information needs to be automated to facilitate clinical decision support?
- Current concerns
- How can we promote best practices?
***Do no harm***
***Do the right thing***

- Confidential and Proprietary to IHC Health Services, Inc.

## What is the problem that we are trying to solve with Clinical Decision Support?

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## Slide 7

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## IOM ReportTo Err is Human: Building a Safer Health System (November, 1999)

- 	“One of the report’s main conclusions is that the majority of medical errors do not result from individual recklessness or the actions of a particular group--this is not a “bad apple” problem. More commonly, *errors are caused by faulty systems, processes, and conditions* that lead people to make mistakes or fail to prevent them.”

- Confidential and Proprietary to IHC Health Services, Inc.

## IOM ReportCrossing the Quality Chasm: A New Health System for the 21st Century 

- Barrier to Quality: Knowledge explosion
- Unprecedented rate of advancement of Medical science and technology
- Increasing complexity of health care
- Health care delivery system has fallen far short in its ability to translate knowledge into practice

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## The Clinical Knowledge-Processing Burden

- Many years ago

- Today

- This gap
- injures patients

- Knowledge processing capacity

- Knowledge processing requirement

- “Current medical practice relies heavily on the unaided mind to recall a great amount of detailed knowledge – a process which, to the detriment of all stakeholders, has repeatedly been shown unreliable”
- Crane and Raymond
- The Permanente Journal
- Winter 2003 Volume 7 No.1
- Kaiser Permanente Institute for Health Policy

- Confidential and Proprietary to IHC Health Services, Inc.

## How good is American health care?

**How good is American health care?**

- Confidential and Proprietary to IHC Health Services, Inc.

## Core assumptions

- ‘The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.’   ~ David M. Eddy, MD, Ph.D.
- ‘... man is not perfectible.  There are limits to man’s capabilities as an  information  processor that assure the occurrence of random errors in his activities.’  ~ Clement J. McDonald, MD
- Problem to solve:
- 	***Assimilation of medical knowledge into repeatable processes.***

- Confidential and Proprietary to IHC Health Services, Inc.

## Process Intervention:Cardiology Discharge Meds

- Evidence:
- Discharging patients with appropriate medication after a cardiac event had a more significant impact on survival than the type of cardiac intervention.

- Confidential and Proprietary to IHC Health Services, Inc.

## Process Intervention:Cardiology Discharge Meds

*~71%*

- Education and Blood Oaths

**Process Intervention:****Cardiology Discharge Meds**

- Confidential and Proprietary to IHC Health Services, Inc.

## Process Intervention:Cardiology Discharge Meds

*~71%*

- Education and Blood Oaths

- Process Change

- ~ 95%

**Process Intervention:****Cardiology Discharge Meds**

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## Cardiac discharge medicines

- CHF = Chronic heart failure;  IHD = Ischaemic heart disease

- Confidential and Proprietary to IHC Health Services, Inc.

## Knowledge Assimilation Process

- Confidential and Proprietary to IHC Health Services, Inc.

## Knowledge Assimilation Process

- Confidential and Proprietary to IHC Health Services, Inc.

## Increased Risk of Newborn Ventilation

**Increased Risk of Newborn Ventilation**

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## Percent Inductions < 39 Weeks

**Percent Inductions < 39 Weeks**

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## Intermountain Knowledge Strategy

- Intermountain’s strategy is to provide high value care by managing ***clinical processes****** ***so that we improve ***medical outcomes*** and ***member satisfaction***** **at the ***lowest necessary cost**** *
***Clinical Programs*** are the ***vehicles*** we have developed to implement the strategy

- Confidential and Proprietary to IHC Health Services, Inc.

## Key Clinical Work Processes

- Health Care is a complex business consisting of thousands of work processes
- A limited number of these work processes make up the vast majority of the services we provide to patients
- In order to optimize our probability of success, we must:
- Identify our ***key clinical work processes***, organize around Clinical Program/Clinical Support Services groupings of shared work processes and stay focused on them
- Develop the appropriate ***knowledge assets*** (e.g., care process models, provider/patient education materials) for each key clinical work process
- Focus ***measurement system, research ***and*** analytic*** efforts on these key work processes

- Confidential and Proprietary to IHC Health Services, Inc.

## Campus Care Clinical Work Processes

**$0M**

**CV**

**W&N**

**NMS**

**Surgery**

**Intensive Medicine**

**Intensive Behavioral**

**$60M**

**$30M**

**Labor & Delivery**

**Abnormal Newborn 3a**

**Benign Gyn**

**Normal Newborn**

**Liver & Billiary Procs**

**Bowel Disorders**

**ENT Procs**

**Eye Disorders**

**Urology Procs**

**Stomach/ Esoph/  Duodenum Procs**

**Appendectomy**

**Major Joint Disp. Hip/Knee**

**Spine Disorders**

**Knee Procs**

**Fx/Upper Extremity**

**Intracranial Procs**

**Fx/Pelvis/Hip/Thigh**

**Adult ICU (Trach/ARDS)**

**Pulmonary**

**Nervous System**

**Infectious Disease**

**Trauma**

**Psychoses**

**Dx & Tx Cardiology**

**CABG and other major non-valve**

**Valves**

**Arrhythmias & Pacemakers**

**Vascular**

**Acute Chest Pain**

**Congestive Heart Failure**

**Other Major Chest Surg**

**Campus Care Clinical Work Processes**

- Confidential and Proprietary to IHC Health Services, Inc.

**Notes:**
Example of analysis

## Implementing Evidence Based Medicine

***Team leader***
***	******- respected physician leader, in active practice***
***	******- functionally a knowledge expert***
***Core work group***
***	******- knowledge experts***
***	******- build initial Care Process Model***
***	******- provide academic detailing, run referral clinic***
***	******- geographically based***
***Front line clinicians***
***	******- physicians, nurses, clerks, techs, etc.***
***	******- first level review; keep knowledge experts grounded***
***	******- 2-way street: fundamental knowledge up, ownership down***
***	******- geographic representation***
***Staff support*** ***- flow charter, statistician, data manager, clinical ops ***

- Confidential and Proprietary to IHC Health Services, Inc.

## Knowledge Assimilation Process

- Confidential and Proprietary to IHC Health Services, Inc.

## Predictors of Improved Clinical Practice

- Automatic provision of decision support as part of clinician workflow (P < 0.00001)
- Provision of recommendations rather than just assessments (P = 0.0187)
- Provision of decision support at the time and location of decision making (P = 0.0263)
- (Kawamoto, K et al:  BMJ, doi:10.1136/bmj.38398. 500764.8F)

- Confidential and Proprietary to IHC Health Services, Inc.

## Bilirubin Monitoring in Newborns

- Problem statement
- Unrecognized hyperbilirubinemia
- Re-admissions because of hyperbilirubinemia
- Process change
- Increase bilirubin measurements
- Interpretation of results
- Actionable suggestions

- Confidential and Proprietary to IHC Health Services, Inc.

**Notes:**
Example of process integration

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## Slide 29

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## Slide 30

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## Hyperbilirubinemia readmissions

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## Knowledge Assimilation Process

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## Quality: Management Support

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## Diabetic Care: measurement example

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## Poor HbA1c control

**Poor HbA1c control**

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## What are the software tools required to support Clinical Decision Support?

- Confidential and Proprietary to IHC Health Services, Inc.

## Components of a Complete Clinical Information System

**Automation**

**Data Mining**

**Connectivity**

**Advanced**
**Decision**
**Support**

**Enhanced**
**Care**

- Confidential and Proprietary to IHC Health Services, Inc.

## Components of a Complete Clinical Information System

- Automation & Connectivity
- Standard processes automation
- Set by expectation, regulation, & certification methods
- Examples
- Provider Order Entry
- Medication management process
- Data Mining & Advance Decision Support

- Confidential and Proprietary to IHC Health Services, Inc.

## Components of a Complete Clinical Information System

- Automation & Connectivity
- Data Mining & Advance Decision Support
- Localized issues & processes
- Tools-based support
- Analytical tools
- Rules, forms, reports, & workflow authoring tools

- Confidential and Proprietary to IHC Health Services, Inc.

## Components of a Complete Clinical Information System

**Automation**

**Data Mining**

**Connectivity**

**Advanced**
**Decision**
**Support**

**Enhanced**
**Care**

**State of the Art Vendor**

- Confidential and Proprietary to IHC Health Services, Inc.

## Conclusions: Coral Reef Metaphor

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