MUDr. Vojtech Huser PhD

1. Overview of approaches for translating clinical guidelines into routine careCurrent trends in USA and possible lessons for Czech republic and EU MUDr. Vojtech Huser PhD

2. Agenda • Introduction • Ultra-brief examples of • Non-executable representations • Executable representations • Status quo in USA • Related topics • Quality improvement, Pay for performance • Lessons applicable to Czech rep./EU • Future trends http://www.linkedin.com/in/vojtechhuser Vojtech Huser, MD, PhD

3. Background points • Increasing number of clinical guidelines, communications of updates to clinicians • Hard to follow -> computerized guidelines, executable • Varying quality of guidelines • Involvement of professional societies • E.g., European/Czech society for endocrinology • New technology adoption • Yong physicians more used to work with healthcare IT Vojtech Huser, MD, PhD

4. Methods • Several examples • Not comprehensive overview • Selected subset • Focusing on lessons learned rather then results of a particular project • http://www.ncbi.nlm.nih.gov/pubmed?term=Huser V [Author] • www.intermountainhealthcare.org • www.marshfieldclinic.org/BIRC Vojtech Huser, MD, PhD

5. GEM • Guidelines element model • Yale University • Set of tools (e.g., GEM cutter) • Improve quality of the textual guidelines • Semi-structured format • http://www.nice.org.uk(NHS Evidence) • http://neo.euromise.cz/kkdp Vojtech Huser, MD, PhD

6. GEM • Guidelines element model • Yale University • Set of tools (e.g., GEM cutter) • Improve quality of the textual guidelines • Semi-structured format • http://www.nice.org.uk(NHS Evidence) • http://neo.euromise.cz/kkdp Vojtech Huser, MD, PhD

7. Arden Syntax • Representation language for simple rules • Complex guidelines have to be handled by set of Arden MLMs (Medical Logic Modules) • Formally accredited standard (HL7) • Accepted by several EHR vendors • McKesson, Siemens Vojtech Huser, MD, PhD

8. Arden Syntax example Vojtech Huser, MD, PhD

9. Vojtech Huser, MD, PhD

10. GLIF • Guidelines Interchange format • Graphical editor (Protégé) • Limitedadoption • Researchimplementation http://healthcareworkflow.wordpress.com Vojtech Huser, MD, PhD

11. … and numerous other formats

12. Current state of the art (USA) (executable guidelines) • Legal status • Meaningful use of EHR • Use of decision support within an EHR system • Financial incentives • Government agencies (AHRQ) • Office of National Coordinator (ONC) • AMIA lobbying efforts in Congress • Vendors and societies • Professional societies adoption • Early adopters (e.g., ACP http://pier.acponline.org) • Vendor specific decision support platforms • Vendors compete on default knowledge content in EHR system • Additional knowledge bases for sale • Client forums, inter-client exchange of knowledge content • Research based decision support platforms • Knowledge vendors • Thomson Reuters Order sets • Zynx • TheraDoc Vojtech Huser, MD, PhD

13. Related: Quality Improvement • Research • Research on quality of care provided • Secondary Use of Data • Administrative billing data + clinical data • http://www.hmoresearchnetwork.org/members.htm • Medicare, Medicate data set available to university-based researchers • Link of guidelines to QI • Truely modern medicual guidline may have a: „Related/Suggested quality measures section“, „coded terms“, „relevant billing or SNOMED-CT codes“ • Legislation, business environment • health plans compete for patients based on quality of their contracted providers • Healthcare Effectiveness Data and Information Set (HEDIS) • accreditation (JCAHO) is condition of Medicare contract • Pay for performance contracts • Investment into redesign: healthcare provider network • Benefits: to payor (health plan (insurance company), savings • Problem: decreased revenue (inpatient), same system vs. competitor system • Integrated environment: outpatient and inpatient facilities + health plan • https://kvalita.nrc.cz/ukazatele • http://www.sakcr.cz Vojtech Huser, MD, PhD

14. Lessons applicable to Czech rep./EU • Not every aspect applies to EU/CZ • Few possible ones: • More reports available to consumers on guidelines adoption (QI measures) • Complement Clinical Data to Administrative Data • NRC level -> local level • Linking data from several sources in a research data warehouse • Direct financial incentives (chief quality officer, internal measures) • Limited reporting of quality measures to payors (similar to newly introduced CPT results codes) • healthcare consumer empowering • right to export electronic version of all clinical data (HITEC part of ARRA)) • increased education of professional societies about executable guielines approaches and standards • Market place changes (integrated decision support, third party decision support (legislative changes) • legistative changes defining healthcare data deidentification levels and secondary use of EHR data in research • Clear rules about waiver of consent • Primary care GP data set, Medicare data set (in non-UK context) Vojtech Huser, MD, PhD

15. Future trends • International cooperation and better structured guidelines • E.g., G-I-N approach • Exchange of executable guidelines/guideline elements • Decision support mandate from meaningful use (USA, from 2015) • Tight coordination of clinical guidelines with quality improvement measures and decision support • Secondary use of data • healthcare data privacy/public health/improved research Vojtech Huser, MD, PhD

16. Summary • Goals: • 1. executable guidelines • 2. trends in USA • 3. implications for CZ/EU and future trends • Questions? • vojtech.huser@gmail.com • http://www.linkedin.com/in/vojtechhuser Vojtech Huser, MD, PhD