Computer-Assisted Decision Making in the Twenty-First Century

1. Computer-Assisted Decision Making in the Twenty-First Century James J. Cimino, M.D. Departments of Medical Informatics and Medicine Columbia University

3. Overview • Analyzing medical errors • Evidence-based practice (EBP) • Using computers to support EBP • Challenges and impediments to achieving EBP

4. Analyzing Medical Errors Leape, LL. Error in Medicine. JAMA 1995; 272(23):1851-7. Errors Slips: errors of action Mistakes: errors of conscious thought Solution: Monitoring Solution: Information

5. Analyzing Medical Errors • Reduced reliance on memory • Increased vigilance • Improved information access • Error proofing (“forcing functions”) • Training emphasis error prevention • Patient education • Standardization of practice patterns

6. Evidence-Based Practice (EBP) • Decisions based on clinical evidence • Spectrum of evidence quality • Skills needed to: • Access literature • Summarize findings • Apply conclusions Sackett DL, et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312(7023):71-2

7. Application of EBP • Etiology • Prevention • Diagnosis • Therapy

8. Computer Support of EBP • EBP and: • access to literature • guidelines • diagnostic aids • order checking • Identify: • applications • problems • solutions

9. Literature • Applications • Medline • Textbooks • Problems • Search expertise • Time constraints • Solutions • Infobuttons • Palm-based access

16. Guidelines • Applications • Computer-based text guidelines • Problems • Finding applicable guidelines • Navigation • Applying to specific cases • Solutions • Indexing text guidelines • Customizing guidelines • Automating guidelines

21. Diagnostic Decision Support • Applications • Interpretation of tests • Expert systems • Problems • Need human intervention • Terminology translation • Solutions • Identify where aids are needed • Translate data to clinical terms • Automate data transfer

24. Order Checking • Applications • Drug-interaction programs • Alerting systems • Problems • Don’t know whole patient • May be inappropriate • Solutions • Integration with clinical record • Open-loop

28. Alerts Problems: Terminology • One day, an apparent epidemic of positive results… …but lab showed “No Growth to Date” • Alert checked Result not equal “No Growth” • “No Growth to Date”  “No Growth”

29. Alert Problems: No Human Review • Alert checks for trends in creatinine level • MD receives alert for patient’s Creat=1.7 • MD calls patient to come to ER • Patient risks storm of decade to come to ER • Creatinines are 1.1, 1.3, 1.8, 1.6, 1.3, 1.7

32. Challenges • Identifying context-specific information needs • Modeling patients and the care process • Integration of systems • Terminology translation • User education

33. Conclusions • Potential areas for errors: • Diagnostic testing • Interpretation of results • Therapeutic interventions • Monitoring • Computers and EBP can be brought bear: • Literature at the point of care • Facilitating use of guidelines • Expert systems • Alerting • Patient decision support • Enhance, not replace, human decision-making