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Informatics Solutions in the Current System. Petr Jarolim Director, Clinical Chemistry, Laboratory Control, And Ambulatory Care Center Clinical Laboratories Brigham and Women’s Hospital Assistant Professor of Pathology Harvard Medical School . TDM: What Does That M Stand for?.

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informatics solutions in the current system

Informatics Solutions in the Current System

Petr Jarolim

Director, Clinical Chemistry, Laboratory Control,

And Ambulatory Care Center Clinical Laboratories

Brigham and Women’s Hospital

Assistant Professor of Pathology

Harvard Medical School

tdm what does that m stand for
TDM: What Does That M Stand for?
  • Monitoring?
  • Management?
partners 2003 signature initiatives
Partners 2003 Signature Initiatives

(1) investing in quality and utilization infrastructure

(2) enhancing patient safety by reducing medication errors system-wide

(3) enhancing uniform high-quality by measuring performance to benchmark for selected inpatient and outpatient conditions

partners 2003 signature initiatives continued
Partners 2003 Signature Initiatives (Continued)

(4) expanding disease management programs by supporting activities for certain patients with chronic illnesses

(5) improving cost-effectiveness through managing utilization trends and analysis of variance

1 quality and utilization infrastructure
1. Quality and Utilization Infrastructure
  • Information system (IS) infrastructure
  • Computerized provider order entry (CPOE)
  • Electronic medical record (EMR, LMR)
2 enhancing patient safety by reducing medical errors
2. Enhancing Patient Safety by Reducing Medical Errors
  • CPOE
  • Decision support
  • EMR
  • Bar coding
  • Smart pumps
3 uniform quality
3. Uniform Quality
  • Evidence-based medicine
  • JCAHO – process and outcome measures
  • State initiatives and voluntary oversight groups
  • Measuring, feeding information back, sharing best practices, re-measuring, looking for improvements
evidence based medicine
“Evidence-based” Medicine
  • EBM is a set of skills which allow critical appraisal of the literature
    • JAMA, 1993;270:2093-2095
  • Evidence is often gray, decisions black/white
  • Emphasis on literature more than opinion
  • Can help physicians make decisions to provide optimal patient care
5 trend management
5. Trend Management
  • Pharmaceuticals
  • High-cost tests
    • Radiology
    • Laboratory tests
goals
Goals
  • Discuss how information systems can be used to improve use of clinical laboratory
    • Quality
    • Efficiency
  • Specific examples
    • Laboratory utilization
    • Therapeutic drug management
reengineering medicine the role of is
Reengineering Medicine:The Role of IS
  • Could be changed by providing external aids
    • Linking medical knowledge and patient-specific data
    • Identifying options, helping with decisions
  • Without such tools, experts
    • Overlook available knowledge
    • Don’t sufficiently account for uniqueness
why not rely on experts
Why Not Rely on Experts?

“The telephone is an amazing invention, but who would ever want to use one of them?”

  • President Rutherford B. Hayes, 1876

“The Japanese auto industry isn’t likely to carve out a big slice of the U.S. market.”

  • Business Week, 1968

“There is no reason for any individual to have a computer in their home.”

  • President, Digital Equipment Corp, 1977

From “The Experts Speak,” Cerf and Navasky, Pantheon Books, 1984

principles of changing physician behavior
Principles of Changing Physician Behavior
  • Changing behavior is hard
    • “It’s easier to predict rain than to get people to carry umbrellas” (Lee Goldman)
  • Education and feedback are most likely to succeed
  • Feedback is most likely to influence decision-making if it is delivered as closely as possible to the time of the decision
    • Ideal to deliver at the time the decision is being made
types of decision support
Types of Decision Support
  • Passive display of information
  • Alerts and reminders
  • Context-specific steering
  • Guidelines

Note:

  • All above can be patient-specific or not
guidelines and algorithms
Guidelines and Algorithms

Can improve care BUT

  • Hard to remember
  • Hard to find when needed
  • Sometimes providers forget/don’t know about availability
  • Must be used by many providers
  • Dissemination slow
  • Some central control necessary
problems with paper guidelines protocols
Problems With Paper Guidelines/Protocols
  • Paper not findable at decision time
  • Contain ambiguous words
  • No way to follow how/whether people are using or why they don’t use it
  • No easy way to get feedback to developers
  • Iterative refinement is hard
advantages of computerized guidelines
Advantages of Computerized Guidelines
  • Facilitate memory, always findable
  • Immediately generalizable to all patients, providers
  • Possible to point providers to them
  • Facilitate central control
  • Allow measurement of outcomes
  • Easy to get feedback to developers, allow iterative refinement
slide20

Architecture of the Event Monitor

Applications (new data)

Patient database

Applications (new data)

Applications (new data)

page, email, write to file (real time message)

Annun-ciators

Inference engine

(decisions)

Coverage List

Rule editor

Knowledge base

interventions to improve laboratory utilization
Interventions to Improve Laboratory Utilization
  • Charge display
  • Redundant test reminders
  • Structured ordering with counterdetailing
    • Guidelines
  • Critical laboratory results paging
redundant reminders frequency guidelines
Redundant Reminders - Frequency Guidelines
  • Urine and sputum cultures, UA, Chem-20
    • >1/day
  • Digoxin, aminophylline
    • >1/day, suppress if last result abnormal
  • Aminoglycosides, vancomycin
    • >2/day
  • Fibrin split products
    • >Q8h
redundant reminder study
Redundant Reminder Study
  • 5700 intervention admissions, 5886 control
    • 939 apparently redundant tests ordered
    • Tests cancelled 69% of time in intervention group
  • Redundant tests performed:

Intervention group 27%

Control group 51% p<0.001

evaluating the appropriateness of digoxin level monitoring
Evaluating the Appropriateness of Digoxin Level Monitoring

1998 – Digoxin levels accounted for 21% of all TDM

Aim of the study:

  • To develop appropriate criteria for measuring digoxin levels in both inpatients and outpatients
  • To use these criteria to evaluate the appropriateness of digoxin determinations
  • To determine how often levels with an inappropriate indication generated clinically important results
digoxin level monitoring results for inpatients
Digoxin Level Monitoring –Results for Inpatients

- 16% of orders were appropriate

- Only 14% had results > 1.7 ng/ml, none of these levels resulted in an important change in therapy and no patient had a toxic reaction

- Daily routine monitoring accounted for 78% of inappropriate levels

Canas et al, Arch Intern Med 1999;159:363-8

digoxin level monitoring results for outpatients
Digoxin Level Monitoring -Results for Outpatients

- 52% of orders were appropriate

- Only 6% had results > 1.7 ng/ml, one result led to a change in therapy, none of the patients were believed to experience a toxic reaction

- Among the inappropriate levels, 87% patients underwent early routine monitoring before a steady state was achieved

Canas et al, Arch Intern Med 1999;159:363-8

errors in outpatient amiodarone monitoring goals
Errors in Outpatient Amiodarone Monitoring - Goals
  • To develop a model of medication monitoring
  • To use the model to determine at what medication monitoring stages most errors occur
  • To assess the incidence and preventability of ADEs associated with monitoring errors

Stelfox T et al., BWH, 2002

amiodarone
Amiodarone
  • Numerous organ toxicities:
    • Liver
    • Lung
    • Thyroid
    • Heart
    • Skin
  • High incidence of ADEs: 34% - 93%
  • Toxicities dependent on dose and duration of therapy
initiation of therapy
Initiation of Therapy
  • Prescription for amiodarone
  • Baseline evaluation (< 2 months of first prescription):
    • Electrolytes and creatinine
    • Pulmonary function tests (PFTs) including CO diffusion capacity
surveillance
Surveillance
  • Liver enzymes every 6 mo.
  • Thyroid tests (TSH or free T4) every 6 mo.
  • Electrocardiogram (ECG) every 12 mo.
  • Chest x-ray or PFTs every 12 mo.
surveillance response within 2 months of an abnormal result
Surveillance Response (Within 2 Months of An Abnormal Result)
  • If liver enzymes >2 times normal then
    • Any hepatic test, provider visit or dose change
  • If TSH abnormal (<0.5 or >5.0) then
    • Any thyroid test, provider visit, dose change or thyroid therapy
  • If possible pulmonary toxicity then
    • Any pulmonary test, provider visit, dose change or oral corticosteroid prescription
  • If ECG with HR < 50, long QTc or PR>0.2 then
    • Any cardiac test, provider visit or dose change
follow up visit
Follow-up Visit
  • Provider visit every 3 months during the first year and subsequently every 6 months
errors in outpatient amiodarone monitoring conclusions
Errors in Outpatient Amiodarone Monitoring - Conclusions
  • 9% received recommended monitoring
  • Errors identified at all monitoring stages
  • Study highlights the challenges of outpatient monitoring
  • Some amiodarone-related ADEs are associated with monitoring errors

Stelfox T et al., BWH, 2002

appropriateness of antiepileptic drug level monitoring
Appropriateness of Antiepileptic Drug Level Monitoring

Drug % Appropriate

Phenytoin 29

Carbamazepine 26

Phenobarbital 28

Valproic acid 26

Schoenenberger RA et al.: JAMA 1995;274:1622-6

a computer based intervention for improving the appropriateness of antiepileptic drug monitoring
A Computer-Based Intervention for Improving the Appropriateness of Antiepileptic Drug Monitoring

Design and implementation of 2 automated computerized screens for use at the time of AED test order entry

Aim: Improve appropriateness by reminding physicians when a potentially redundant test was ordered and providing common indications for monitoring AED

Chen P et al., Am J Clin Pathol 2003;119:432-438

slide44

Algorithm for computerized interventions

Inpatient AED test orders placed via computerized order entry

Potentially redundant tests

Non-redundant tests

Orders not canceled

Automated reminder screen

Education and indications screen

Test indication selected by physician

Orders cancelled by physician

Orders cancelled by physician

Test orders completed

slide45

Algorithm for computerized interventions

Inpatient AED test orders placed via computerized order entry

Potentially redundant tests

Non-redundant tests

Orders not canceled

Automated reminder screen

Education and indications screen

Test indication selected by physician

Orders cancelled by physician

Orders cancelled by physician

Test orders completed

a potentially redundant test reminder
A Potentially Redundant Test Reminder

Potential Redundant Lab

Redundant Order: PHENOBARBITAL LEVEL: NEXT AVAILABLE;

1)PHENOBARBITAL LEVEL (05/24 1:15P)

RESULTS: PHENO:pend,

This reminder may be ignored if drug toxicity is suspected or if seizures have recurred

CONTACT .... IF YOU HAVE QUESTIONS

[X]C Cancel order(s) [ ]P Proceed with order(s)

slide47

Algorithm for computerized interventions

Inpatient AED test orders placed via computerized order entry

Potentially redundant tests

Non-redundant tests

Orders not canceled

Automated reminder screen

Education and indications screen

Test indication selected by physician

Orders cancelled by physician

Orders cancelled by physician

Test orders completed

drug specific information on aed orders
Drug-Specific Information on AED orders

INDICATIONS FOR PHENOBARBITAL DRUG LEVEL

Please enter the indication for ordering this level

[ ]A Recent seizure

[ ]B Suspected toxicity (sedation, depression)

[ ]C Baseline determination (>20 days after start of therapy)

[ ]D New determination (>20 days after change in therapy)

[ ]E Additional interacting drug added (>20 days ago)

[ ]F Recent change in liver/GI function

[ ]O Other

70% of phenobarbital levels done at BWH were found to be inappropriate in a recent study. A steady state is not reached until 20 days after initiation of change in therapy. Daily determination is almost never indicated. The test may not be indicated if it is not being done for one of the reasons listed above

indication for ordering inpatient serum aed levels
Indication for Ordering Inpatient Serum AED Levels

Indications for ordering Non-redundant Appearing Redundant

(n = 409) (n=305)

New or baseline serum level 159 (38.9%) 82 (26.9%)

Recent seizure 121 (29.6%) 72 (23.6%)

Suspected toxic effects 52 (12.7%) 32 (10.5%)

Addition of interacting drugs 12 (2.9%) 8 (2.6%)

Change in liver or GI function 15 (3.7%) 8 (2.6%)

Other 24 (5.9%) 26 (8.5%)

Orders canceled at prompt 26 (6.4%) 77 (25.2%)

lessons learned
Lessons Learned
  • Simple guidelines are easiest
    • “Use aspirin in patients after MI unless contraindicated”
  • Physicians are happy to change direction
  • Much less willing to stop after an action is started
  • Even if low-yield utilization is identified they may proceed
  • Some on-going monitoring is useful when stakes are high
lessons learned continued
Lessons Learned (Continued)
  • Physicians tolerate these interventions when delivered appropriately
  • High-level support essential to achieve major change
  • Many pitfalls with process not going as expected
    • Need to be creative to succeed
  • Success depends on integrating guideline with practice flow
  • Collaborative effort, multispecialty teams essential
future trends
Future Trends
  • Increasing emphasis on patient safety and therefore on therapeutic drug management
  • LMR with comprehensive decision support
  • Complex rules and reminders
  • Pharmacogenomics – manage before you start monitoring
conclusions
Conclusions
  • Electronic records are vital for providing integrated, inexpensive, high-quality care
  • Computerized decision support can decrease costs, improve quality, by:
    • Pointing out redundancies
    • Suggesting alternatives
    • Emphasizing important abnormalities
    • Making guidelines accessible
conclusions continued
Conclusions (Continued)
  • Better follow-up/monitoring crucial; computers can:
    • Help providers remember things
    • Organize and improve access to information
  • Quality measurement will be vital as we strive to provide better care at lower cost
  • Most future quality measurement will be done by computer as a part of routine care