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Improving Quality of Care for Vulnerable Populations Through Health IT

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, Jane M. Brokel, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (1.4 MB).

Slide 1

Use of Clinical Decision Support Expert Rules within Clinician Workflows: Improving Quality of Care for Vulnerable Populations Through Health IT—AHRQ 2008 Conference

Jane M. Brokel, PhD, RN
Assistant Professor, University of Iowa
Informatics Consultant—Trinity Health

Slide 2

Outline—Background

The slide shows a large map of the U.S. and a smaller, drawn one of Iowa.

Inpatient Setting:
Rural Iowa Redesign of Care Delivery with EHR [electronic health records] Functions and Collaborative EHR—Implementation to Bridge the Continuum of Care in Rural Iowa.
- Provide challenges and success of implementing evidence-based practices with clinical decision support tools.
- Share examples.
- Provide a model to approach Clinical Decision Support aligned with an implementers guide.

Slide 3

Clinical Decision Support Definition

"Providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care."—Osteroff et al, 2006.

Many interventions that are already being done on a daily basis in healthcare organizations.
Rules are one of the interventions.

Slide 4

Methods: Formative Evaluation of Implementation

Descriptive Findings:
- Rules to Prevent Error 4
- Rules to Promote Safety 6
- Rules to Use Evidence-based Practices—17 Clinics and 17 Hospital
- Rules to Promote Interdisciplinary Communication—25
- Rules for other reasons—3
Findings: Clinical Decision Support Rules for Use
- Use/Location: Hospital
  - System Use: 22
  - Highly Recommend: 16
  - Optional Use: 12
  - Pilot Use: 4
- Use/Location: Clinics
  - System Use: 17
  - Highly Recommend: 0
  - Optional Use: 0
  - Pilot Use: 0

Slide 5

Clinical Decision Support in Workflow Process

The document image shows a completed worksheet relating "Clinical Workflow", and specific numbers for "Number of Rules", "Number to Prevent Error", "Number to Promote Safety", "Number to Use Evidence-Based Practice", and "Number to Promote Communication."

Slide 6

Fall Risk—Clinical Decision Support Rule

Fall/Safety Assessment Form (Morse Fall Scale)

Evidence
- Data Input/Triggering event.
Evaluation of conditional limits.
- Inclusions.
- Exclusions.
Triggered action response.

Slide 7

Fall Risk—Clinical Decision Support Rule

Clinician Performed Response.
- Fall Prevention Intervention & Teaching Patients/Family.
- Web page shows a Careset of nursing interventions for the patient.
Patient Outcome: Safe mobility; no injuries.
- Colored photograph shows people walking.

Slide 8

Archetype to Design

The diagram shows the Conceptual Model for Design of Clinical Decision Support (CDS) Expert Rules.

Slide 9

Fall Risk Data Model

Patient Data
- Admission into MO Facility.
Trigger —Documented Data Elements Used: Assessment limits (eforms).
- Medication Review: Patient considered High Risk for Falls (Yes) (Boolean field DTA).
- Finds Meds- antihypertensive agents, ACE inhibitors, diuretics, trycyclic antidepresants, antianxiety agents, opiates, hypnotics or tranquilizers.
  OR
- Morse Fall Risk (eform: calculated field) x > 44 (DTA) or Morse Fall Risk 0 < x < 44 (DTA) OR.
- Date & time of Fall eform SNOMED-CT—Fall event 1912002.
  - Admission Profile—Social section —alcohol use; Lives alone; Lower Limb Prothesis; Currently uses an assistive. device; Gender —Female (elder) or Male (toddlers).
Conditional Limits —Inclusions.
- IC:Age > 17 for adults (or Age < 2—children).
- IC:Encounter type —Inpatient types.
  - HOSPICEINPATIENTP2; INPATIENT; IPMAJORSURGERY; LABORDELIVERYP2; LONGTERMCAREP2; OBSERVATIONP2; PSYCHIATRICINPATIENTP2; REHABINPATIENTP2; RESIDENTIALINPATIENTP2; SKILLEDNURSINGFACILP2.
Conditional Limits —Exclusions.
- Problem List: Nursing diagnosis—At Risk for Falls r/t history of falls (SNOMED CT code 129839007).
- Date & time of Fall form SNOMED-CT—Fall event 1912002.
- Medication Review: Patient considered High Risk for Falls (Yes).
Action Response.
- CDS message At Risk for Falls and actions taken.
- CDS actions:
  1. Order Activate Fall Prevention (TH) Orderset.
  2. Add Problem "At Risk for Falls" if not pre-existing Problem List.
Primary Responding Clinician.
- Role RN, (other disciplines charting falls—PT, OT).
- Relationship ( Encounter).
- Secondary Responding Clinician.
  - Specialties (NA).
Performed Response.
- Order the Fall Prevention Order set (required, pre-selected or optional orders)—Existing orders found.
- Documented Nursing Interventions (where are NIC data entered) Fall Prevention (form), Dementia management (form), Surveillance: Safety (form).
- Patient Education (from) completed.
Patient Outcome.
- No Falls (2.3 to 7 falls per 1000 patient days ).
- Fall Prevention Behaviors demonstrated such as use assistive devices.
Future Options.

Slide 10

Risk for Impaired Skin Integrity—Rule

Automation—Patient's Problem List —Risk for Impaired Skin Integrity.
- Web page showing a patient's problems list.
Clinician Performed Response—order set.
- Web page showing a Careset—Pressure Ulcer prevention list.

Slide 11

Skin Integrity Data Model

Patient Data.
- Admission into MO Facility.
Trigger—Documented Data Elements Used: Assessment limits (eforms).
- Braden Scale Review:
  - Finds Meds:
  - Date & time.
Conditional Limits —Inclusions.
- IC:Age >
- IC:Encounter type —Inpatient types
  - HOSPICEINPATIENTP2; INPATIENT; IPMAJORSURGERY; LABORDELIVERYP2; LONGTERMCAREP2; OBSERVATIONP2; PSYCHIATRICINPATIENTP2; REHABINPATIENTP2; RESIDENTIALINPATIENTP2; SKILLEDNURSINGFACILP2.
Conditional Limits —Exclusions.
- Problem List: Risk for Pressure Ulcer.
  - Date & time.
  - Medication Review.
Action Response.
- CDS message.
- CDS actions:
  1. Order Activate...(TH) Orderset.
  2. Add Problem "...if not pre-existing Problem List.
Primary Responding Clinician.
- Role RN, (other disciplines charting falls—PT, OT).
- Relationship ( Encounter).
- Secondary Responding Clinician.
  - Specialties (NA).
Performed Response.
- Order the.... Order set (required, pre-selected or optional orders)—Existing orders found.
- Documented.
- Patient Education (from) completed.
Patient Outcome.
- No Pressure Ulcer.
Future Options.

Slide 12

Challenges—Clinical Decision Support (CDS)

Priorities: Specific CDS goals & objectives
- High alerts? Congestive heart failure (CHF)? Diabetes? Medication exchange?
Design: Capabilities to address goals
- CDS Types of Interventions? Clinical solutions?
Share & Select: Specifications for CDS rules or interventions to achieve goals within workflow
Test & Launch in Rural areas
Monitor & Maintain
Evaluate interventions impact = outcome effect

Slide 13

National Pressures

Medicare/Medicaid.
- Tobacco Dependence.
- Major Depression.
- Obesity.
- Pain Control.
- Nosocomial Infections.
- Stroke.
- Childbirth.
- Heart Disease.
Institute of Medicine.
- Asthma.
- Cancer.
- Immunization.
- Diabetes.
- Frail Elders.
- Hypertension.
- End of Life.
Joint Commission.
- Patient Safety.
  - Sentinel Events.
- Surgical sites.
  - Pediatric dosing.
Institute Safe Medication Practices (photograph of medication).
- Wrong dose, rate or frequency.
- Therapeutic duplication—supp/oral.
- Effects of drug on Pregnancy.
- Allergies, Drug Interactions.
- Failure to monitor response pre-, during, and post—therapy.
Health Information Technology Standards Panel.
- Medication Mgmt Use Case IS07.
  - Interoperability specification that defines specific standards to facilitate access to medication and allergy information.

Slide 14

Acknowledgements

The research team acknowledges the support of the Agency for Healthcare Research and Quality for Health Information Technology grant #HS015196, Trinity Information Systems and Trinity Health of Novi, Michigan, Mercy Medical Center—North Iowa, The University of Iowa and the University of Missouri Center for Health Care Quality.
- Tammy J. Schwichtenberg, MSN, RN
  Clinical Informatics Manager, Mercy Medical Center—North Iowa, Mason City, IA.
- Mike G. Shaw, BSN, RN
  Clinical Analyst, Trinity Information Systems, Farmington Hills, MI.
- Douglas Wakefield, PhD
  Center for Health Care Quality University of Missouri—Columbia, MO.
- Marcia M. Ward, PhD
  Dept Health Management and Policy, University of Iowa, Iowa City, IA.
- Donald K. Crandall, MD
  Clinical Informatics Consultant, Trinity Health—Novi, MI.

Slide 15

Contact Information

Brokel, Jane, M.S. PhD, RN

Role: Assistant Professor—College of Nursing
University of Iowa, Iowa City, IA
Email: jane-brokel@uiowa.edu
Phone: 319-335-7133
Role: Informatics—Consultant
Trinity Health—Novi, MI
Email: brokelj@trinity-health.org

Slide 16

Thank You
Clinical Decision Support Capabilities and Effects in Rural Areas

Current as of January 2009

Internet Citation:

Improving Quality of Care for Vulnerable Populations Through Health IT—AHRQ 2008 Conference. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/090808slides/Brokel.htm