GLIDES PROJECTGuideLines Into DEcision Support

sponsored bythe Agency for HealthCare Research and

QuickTime™ and a decompressor

are needed to see this picture.

Overview

• Intro– Project goals

• Project organization• Knowledge transformation• Implementation - Yale sites• Implementation - Nemours sites• Evaluation

GLIDES Steering Group

• Rick Shiffman• Mark Dixon• Paula Burns• Leora Horwitz• Ian Nathanson• Gabriela Ramirez• David Milov

Project DirectorProject ManagerYNHH IS&TEvaluation (Yale)Nemours LeadEvaluation (Nemours)Nemours Information Systems

AHRQProject Officer - White

Contracting Officer - ZuhlkeDecision Support CouncilProject Director - Shiffman

Project Mgr - DixonNemours Lead - Nathanson

YNHH IS&T - BurnsNemours CMIO - Milov

Evaluation Leaders:HorwitzRamirez

Guideline Transformation Group

Group Leader - ShiffmanProject Manager - Dixon

XML Programmer - MichelInformatics Fellow - Lomotan

IS&T Chief - BurnsClinical Experts:

Bazzy-AsaadTolomeoFenickCaprio

BanasialWerk

FenickBilskis

Cunningham

YNHH Implementation Group

Group LeaderProject Manager - DixonTechnical Sub-Group

IS&T Chief - BurnsCentricity Team Leader - SimonetteProgrammers: Bonilla, Atamanuk

Clinical Sub-GroupBazzy-Asaad

TolomeoFenick

BanasiakBilskis

CunninghamResidents

CMIO - Hsiao

Nemours Implementation Group

Group Leader - NathansonProject Manager - DixonTechnical Sub-Group

Chief, Medical Informatics - MilovEpic Team Leader

ProgrammerClinical Sub-Group

NathansonWerk

HassinkUser(s)/Tester(s)

Evaluation GroupGroup Leader - HorwitzProject Manager - Dixon

Yale Evaluation Lead - HorwitzNemours Evaluation Lead- RamirezNemours Evaluation Coordinator(s)

Yale Research Asst -Evaluation Consultant - Justice

Project Director - Shiffman

FinanceEileen Soto

John BeecherNemours FinanceYale G&C Finance

Project Plan Overview

Project Planning

Knowledge Transformation

Phase 1 Implementation

Asthma Yale Specialty

Phase 2Implementation

Yale PCObesity

Nemours Delaware PC

Nemours OrlandoNemours JacksonvilleAsthma

Nemours PensacolaPhase 3

ImplementationAsthma Yale Primary Care

Nemours Delaware

Jan-April 2008

Mar-June 2008

June-October2008

October 2008 – June 2009 June-November2009

Asthma ObesityDissemination

Evaluation

Goals 1 and 2

• Implement evidence-based guideline recommendations that address both preventive practices (pediatric overweight and obesity)1 and complex management of chronic disease (asthma)2.

• Apply the Guideline Elements Model and its associated tools (GEMCutter, EXTRACTOR, COGS, GLIA) to systematically and replicablytransform the knowledge contained in these guidelines into a computable format.

1CDC, AMA, HRSA/MCHB. Pediatrics 2007; 120: Suppl 4.2NHLBI NAEPP. Expert Panel Report 3; 2007.

• Knowledge model for guideline documents• Adopted as a standard by ASTM in 2002, 2006• Models heterogeneous information contained in guidelines

– Multi-level hierarchy (>100 elements)

QuickTime™ and aTIFF (LZW) decompressor

are needed to see this picture.

GEM

Knowledge Transformation1. Select guidelines and recommendations 2. Mark up selected guidelines using GEM Cutter II3. Perform guideline quality appraisal with GEM-COGS4. Apply EXTRACTOR to GEM files

=>recommendations, rules, decision variables, actions5. Restate recommendations in human-readable statement logic6. Categorize action-types7. Map concepts in recommendations to SNOMED codes8. Add critical terms to recommendation glossary9. Classify recommendations by clinical objective10. Identify obstacles to implementation with GLIA

Goal 3

Deliver the guideline knowledge via electronic decision support interventions at ambulatory sites that employ CCHIT- certified, widely-used EHR systems:– Centricity EMR

•Yale New Haven Hospital’s Primary Care Center •Yale Specialty Clinics

– EpicCare• Nemours primary care practices (Delaware Valley)• Nemours specialty clinics (Orlando, Jacksonville, Pensacola)

Yale New Haven Hospital

Local Implementation

1. Select recommendations to implement2. Define local workflow3. Define intervention triggers4. Map guideline concepts to local vocabularies5. Choose appropriate decision support interventions6. Design and programming7. Testing8. Rollout9. Monitor and support

• Healthcare system dedicated to children• >400 MDs and 4100 staff • AIDHC; planned NOCH • Multi-specialty practice sites inWilmington, DE, PA, NJOrlando, Jacksonville, Pensacola

~1 million encounters/yr

Goal 4

Evaluate the fulfillment of knowledge transformation goals and the effectiveness of the decision support tools in improving the quality of health care.

Logic Model

Evaluation Plan1. Perform literature review: asthma, obesity, and DSS2. Define pre- and post-intervention variables3. Design evaluations of process and outcomes

– Yale PCC– Yale specialty– Nemours specialty (Florida)– Nemours primary care (Delaware Valley)

4. Prepare IRB, PRA materials5. Create and install Use and Usability logs6. Collect data on processes and outcomes affected by DSS7. Analyze data8. Clinician survey9. Prepare reports

Domain Indicators Source

Structure Clinician training in CDS useClinician knowledge and attitudes about CDSOrganizational structures (Size of organization, staffing patterns, physical space and layout, equipment availability and usabilityGuideline quality

Clinician survey

Site visit, observation

COGS, GLIA

Process Clinician satisfaction with CDS systemVendor feedback processClinician use of CDS Adherence to recommendations

Data feedback (e.g. frequency, type of data, perceived validity) for clinicians

Identified participant interviewsVendor feedback logRapid cycle, data-based process checks / Retrieval of clinical data

Rapid cycle, data-based process checks

Outcomes Quality of lifeClinical outcomes (utilization, clinical variables)

Electronic patient survey (Nemours)Retrieval of Clinical Data

Goal 5

Disseminate the findings of the demonstrations in a variety of formats, including direct recommendations to guideline developers and IT vendors.

Scheduled and planned dissemination activitiesWebsite http://nutmeg.med.yale.edu/glides (private and external)AAP Partners for Policy Implementation (2/08)Meeting of national professional societies-AHRQ (3/08)New York City Dept. of Health (5/08)Interim Report to CCHIT (9/08)Guidelines International Network (9/08)AMIA panel (11/08)Final Report to CCHIT (6/09)

http://gem.med.yale.edu/glides

richard.shiffman@yale.edu

THANK YOU