Education and Education and Clinical Decision Support:Clinical Decision Support:

Reuniting Twins Separated at BirthReuniting Twins Separated at Birth

Jerry Osheroff, M.D.Jerry Osheroff, M.D.

Thomson HealthcareThomson Healthcare

University of PennsylvaniaUniversity of Pennsylvania

ObjectivesObjectives

Outline the need for a joint model for Outline the need for a joint model for education and clinical decision education and clinical decision supportsupport

Describes how the two can be used Describes how the two can be used together to achieve outstanding care together to achieve outstanding care delivery and outcomes.delivery and outcomes.

Healthcare is BrokenHealthcare is BrokenSafetySafety 1 medication error/inpatient/day 1 medication error/inpatient/day – IOM– IOM >500K preventable ADE deaths/injuries (outpt) >500K preventable ADE deaths/injuries (outpt) – IOM– IOM

QualityQuality 55% chance of appropriate care 55% chance of appropriate care – McGlynn/NEJM– McGlynn/NEJM 17 years: effective treatment ->routine 17 years: effective treatment ->routine – Balas/IMIA– Balas/IMIA

Affordability Affordability $ 44 billion waste recoverable w/CPOE (outpt) $ 44 billion waste recoverable w/CPOE (outpt) - CITL- CITL $ 3.5 billion from inpatient ADEs $ 3.5 billion from inpatient ADEs – IOM– IOM

Education

“What should I know and do?”

Clinical Decision Support

“What should I do now?”

Part of the SolutionPart of the Solution

Orthopedic Surgery VTE prophylaxis schema for Orthopedic Surgery VTE prophylaxis schema for hip and knee arthroplasty and hip fracture surgeryhip and knee arthroplasty and hip fracture surgery

Any CONTRAINDICATIONS to pharmacologic prophylaxis?

High risk of bleeding Active bleeding

Systemic anticoagulation INR ≥ 1.5 or aPTT ratio ≥ 1.3

Platelet count < 50,000

Yes

Use TEDs/SCDs until contraindication no longer present. Consider serial duplex surveillance

or vena caval filter in high-risk orthopedic patients (Hip or knee arthroplasty-particularly with VTE risk

factors, Hip fracture surgery, major trauma, spine surgery with risk factors)

No Creatinine clearance < 30 ml/min

No

Hip surgery with VTE risk factors? Previous DVT/PE

CancerThrombophiliaMajor trauma

Fondaparinux 2.5 mg sc qday X 14 days(Start ≥ 6 hours post-op)

Enoxaparin 30 mg sc q12h X 14 days(Start 12-24 hours post-op; PREFERRED enoxaparin regimen)

Enoxaparin 40 mg sc qday X 14 days(Start 12 hours pre-op, next dose at least 12 hours post-op)

Warfarin 5 mg po qday (adjust to INR2-3)(Begin day of surgery)

(Use 2.5 mg for age>75, CHF or liver disease, interacting meds)

Consider extended prophylaxis for 28 days post-op with

Fondaparinux 2.5 mg sc qDay or Enoxaparin 40 mg sc qDay or

Warfarin (INR 2-3)(with at least weekly INR)

Yes

Complete 14 days of prophylaxis

No

Yes

Yes

Enoxaparin 30 mg sc q24h X 14 days(Start 12-24 hours post-op)

Warfarin 5 mg po qday (adjust to INR2-3)

(Begin day of surgery)(Use 2.5 mg for age>75, CHF or liver disease, interacting meds)

May addSCDs Foot pumps

Hip surgery with VTE risk factors? Previous DVT/PE

CancerThrombophiliaMajor trauma

Complete 14 days of prophylaxis

Consider extended prophylaxis for 28 days post-op with

Warfarin (INR 2-3)(with at least weekly INR)

Yes

No

Not in order set

Goal of EducationGoal of Education

Existing knowledge Exis

ting k

now

ledge

New knowledge

Provide cognitive framework, skills, and beliefs necessary for practice.

Tools of EducationTools of Education

DIDACTIC EXPERIENTIAL

Information Case PracticeBased Based Based

-Informational -Fictional -Apprenticeship

text & graphics or real -Quality -Books cases Improvement -Lectures -Virtual -Point of care

patients

Goals of CDSGoals of CDS

““Providing clinicians or patients with Providing clinicians or patients with clinical knowledgeclinical knowledge and patient-related and patient-related information, intelligently filtered or presented information, intelligently filtered or presented at appropriate times, at appropriate times, to enhance patient to enhance patient carecare.” .”

Includes and builds on what’s already being done Includes and builds on what’s already being done on a daily basis in healthcare organizations…on a daily basis in healthcare organizations…

NOTNOT just rules and alerts… just rules and alerts…

Tools of CDSTools of CDS

Documentation templates: Documentation templates: pt hx, visit notept hx, visit note

Relevant data presentation: Relevant data presentation: flowsheets, auditsflowsheets, audits

Order creation facilitators: Order creation facilitators: order setsorder sets

Protocol support: Protocol support: pathwayspathways    

Reference information: Reference information: infobuttonsinfobuttons

Unsolicited alerts: Unsolicited alerts: proactive warningsproactive warnings

Must do items clearly identified

Help with order selection, core measures identified

Links to drug info from every medication orderC

Acute MI Order Set

Drug information at a glance

Knowledge NeedsKnowledge Needs

What I know that I What I know that I don’t knowdon’t know

(Recognized need)(Recognized need)

What I know that I What I know that I knowknow

What I don’t know What I don’t know that I don’t knowthat I don’t know

(Unrecognized need)(Unrecognized need)

What I don’t know What I don’t know that I knowthat I know

COMPETENCE

CO

NS

CIO

US

NES

S

Links to synoptic disease information

Reunion DriversReunion Drivers CME Accreditation changesCME Accreditation changes

• Improve physician competence, performance, patient outcomes* Improve physician competence, performance, patient outcomes* • Continuous improvement: knowledge, strategies, and Continuous improvement: knowledge, strategies, and

performance-in-practice**performance-in-practice**

Point of care learningPoint of care learning• Leverages decision support tools and adds reflective componentLeverages decision support tools and adds reflective component• Responds to learning needs from patients’ clinical problems ***Responds to learning needs from patients’ clinical problems ***

Quality improvementQuality improvement• Broader examination of quality gapsBroader examination of quality gaps• Integrated into Maintenance of CertificationIntegrated into Maintenance of Certification

* * ACCME, Updated Accreditation Citeria, 2006ACCME, Updated Accreditation Citeria, 2006

** Regnier et al., JCEHP 2005** Regnier et al., JCEHP 2005

*** Davis and Willis, JCEHP 2004*** Davis and Willis, JCEHP 2004

5 ‘Rights’: Joint Model for Education and CDS5 ‘Rights’: Joint Model for Education and CDS

CDS and Education should provide:CDS and Education should provide:

• the right the right informationinformation (ebm),(ebm),

• to the right to the right personperson (clinicians (clinicians andand patients…), patients…),

• in the right intervention in the right intervention format or activityformat or activity (alert, (alert, answer, virtual patient, assessment, reflection),answer, virtual patient, assessment, reflection),

• at the right point in at the right point in timetime (relative to workflow and other (relative to workflow and other interventions)interventions)

• through the right through the right systemssystems and and peoplepeople (cds and (cds and education professionals, multimodal solutions)education professionals, multimodal solutions)

to improve health care delivery and outcomesto improve health care delivery and outcomes. .

Keys to Joint ModelKeys to Joint Model

Comprehensive user needs assessmentComprehensive user needs assessment

Diverse development team (clinical Diverse development team (clinical experts, informaticians, educators)experts, informaticians, educators)

Multiple interventions and modalitiesMultiple interventions and modalities

IntegratedIntegrated perspective/action perspective/action

A Question

in Practice

Physician Performance

In Practice

PhysicianCompetence

Strategy

Wisdom

Judgment

Information

Analysis

Data

Syn

thesis

Kno

wle

dge

Regnier et al, JCEHP, Fall 2005

Assessment

Education

Decision Support

= Added

Continuing Professional Development

Implementing the Joint ModelImplementing the Joint Model

Work with colleagues in CDS Work with colleagues in CDS or Educationor Education

Understand the tools Understand the tools availableavailable

Look at clinical systems for Look at clinical systems for needs assessment dataneeds assessment data

Analyze root causes of poor Analyze root causes of poor performanceperformance

Create interventions fully Create interventions fully appropriate for needsappropriate for needs

Education + CDS =

Best Healthcare Outcomes

DiscussionDiscussion

Thank you!Thank you!

Comments? Questions?Comments? Questions?

Contact info:Contact info:• jerry.osheroff@thomson.comjerry.osheroff@thomson.com• www.thomsonhealthcare.comwww.thomsonhealthcare.com