Slide Presentation from the AHRQ 2008 Annual Conference
On September 8, 2008, Jonathan R. Nebeker, MS, MD,
made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.1 MB).
Slide 1
Information Integration to support Medication Management
Jonathan R. Nebeker, MS, MD
VA Salt Lake City GRECC
University of Utah
Slide 2
Acknowledgements
- Charlene R. Weir, PhD
- Frank Drews, PhD
- Molly Leecaster, PhD
- Rand Rupper, MPH MD
- Kenneth Boockvar, MD
- Kevin Meldrum
- Sandi Geary
- Mike Lincoln, MD
- Chris Nielson, MD PhD
- Brittany Mallin, MS MPH
- AHRQ R18 HS017186
- VA Salt Lake City GRECC
- VA Salt Lake City IDEAS Center
Slide 3
Overview
- The Electronic Health Record (EHR) context
- Current
- Future
- How theory gets us to future
- Theoretical Framework
- Demonstration
Slide 4
Current Computerized Patient Record System (CPRS) Veterans Health Information Systems & Technology Architecture (VistA)
- Access, presentation, and inputs:
- Tables, charts, lists, graphs, text fields
- Logical relationships:
- Storage of basic clinical information:
- Lab, pharmacy, vitals, reports/notes, demographics
- Emphasis on access
- Information siloed in tabs
- Physician centric
- Patient excluded
- No interface for control
Slide 5
Future CPRS VistA
- Access, presentation, and inputs:
- Integrated tables, charts, lists, graphs, controls, text fields
- Logical relationships:
- Diagnoses and supporting evidence; treatments, conditions, and goals;
prescriptive decision support
- Storage of basic clinical information:
- Ontologies of lab, pharmacy, vitals, reports/notes, demographics
- Emphasis on control
- Information integrated
- Supports all healthcare professionals and the patient
Slide 6
Progress
- The Electronic Health Record context
- Theoretical Framework:
- Joint Cognitive Systems or Cognitive Systems Engineering
- Contextual Control Model
- Demonstration
Slide 7
Cognitive System Engineering
- Contextual Control Model (CoCoM)
- Understanding/Sense making
- Goal reconciliation
- Feedback/Feed Forward Control
- Sharp-end efficiency, resiliency
- Assistive decision support
Slide 8
Decision Support v. Sense Making
- Computerized decision support is typically normative and targets the right
decision.
- The CPRS of the future will emphasize an information-rich environment that
targets sense making to support higher quality decisions in the highly variable
context of patient care.
Slide 9
Contextual Control Model (CoCoM)
- Performance in context
- Different types of behaviors predict better outcomes
- Functional not structural approach:
- Not about information processing models: Memory, programs, etc.
- Used in engineered systems:
- ABS at Saab
- Nuclear Power Plants
Slide 10
Control Cycle in Healthcare
The flowchart shows the healthcare of a patient.
- What is going on?
- Physician, Patient, Nurse, Pharmacist, Social Worker, etc., construct/shared
understanding of patient health:
- Determines
- Action/care plan
- Produces
- Events/Feedback:
- Disturbances can have inpact
- Modifies
Slide 11
Control Modes
- Scrambled:
- Lack of purposeful activity
- Opportunistic:
- Addressing salient characteristics
- Tactical:
- Following procedure, limited scope
- Strategic:
- Broader scope and higher-level goals
Slide 12
Preliminary Conclusions
- CoCoM translates well to chronic disease care.
- High-mode characteristics have face validity for predicting better outcomes.
- Implications for software design:
- Need to support efficient, rich reconstruction of mental model of patient
- Need to highlight interaction of goals and therapies
- Need to increase time horizon including feed forward
Slide 13
Demonstration
The slide shows an image of a rectangle with various icons.
- Click icon to add content.
- The icon includes:
- Insert table
- Insert chart
- Insert clipart
- Insert picture
- Insert diagram or organizational chart
- Insert media clip
Slide 14
Example of Integrated Control
The colored photograph shows Star Trek characters Capt. Kirk, Dr.
McCoy, and Spock watching over a sleeping Vulcan character in the medical wing.
Slide 15
Building up to Understanding
Interventions |
Conditions |
Goals |
Lisinopril 40 mg po qhs |
Congestive Heart Failure |
Lowering Wt. |
Spironolactone 50 mg po qd |
Hypertension |
Raising BP |
Aspirin 162.5 mg po qd |
Coronary Artery Disease |
Regulate Angina |
Carvedilol 25 mg bid |
Benign Protatic Hypertorphy |
Regulate HbA1c |
Terazosin 5 mg po qhs |
Depression |
Lower PHQ9 |
Glipizide 10 mg po qd |
Diabetes Mellitus II |
Raise K+ |
Simvastatin 40 mg po qhs |
|
Raise Creat |
Hydrochlorothiazide 25 mg po qd |
|
Regulate Nocturia |
Slide 16
Snapshot of condition
The table is repeated from the previous slide showing how particular interventions
are used to treat a condition and the goal(s) attained.
- Intervention use of Apironolactone 50 mg po qday-MPR 100%; Carvedilol 25
mg bid-MPR 80%; Hydrochlorothiazide 25 mg po qday-MPR 30%; Lisinopril 40
mg po qhs-75%; and Terazosin 5 mg po qhs-MPR 80%
- Treats the condition of Hypertension
- Goal is to raise systolic blood
pressure (SBP):
Slide 17
The table is repeated from the previous slide, along with two graphs, one
charting the daily status and range of Systolic blood pressure, Diastolic blood
pressure, and K+ (Goals), and the other, daily uses and prescribed amounts
of Lisinopril, Spironolactone, and Hydrochlorothiazide (Interventions).
Slide 18
The table and graphs from the previous page are repeated along with a screen
shot of a drop screen for Spironolactone.
- The screen includes Spironolactone's:
- Dose
- Route
- Frequence
- Medication possession ratio (MPR)
- Days supply/refills/arrival/cut pills? (for savings purpose)
- Special instructions
- Dispensed as
- Reasons for change
- Auto generated note
Slide 19
This slide is identical to the slide with the table and 2 charts (Slide 17),
but instead shows the lowering of Spironolactone to 25 mg po qday-100% and
raising Hydrochlorothiazide 25 mg po qday-to 100%. The 2 graphs chart
the new measurements of the daily status and range of Systolic blood pressure,
Diastolic blood pressure, and K+ (Goals), and daily uses and prescribed amounts
of Lisinopril, Spironolactone, and Hydrochlorothiazide (Interventions).
Slide 20
The 2 graphs from the previous slide are repeated with a box open showing
the doctor's name/date and Adverse Effect Management: Reduce spironolactone
from 50 mg po qd to 25 mg po qd, to reduce potassium from 5.5 mmol/dl.
Slide 21
The 2 graphs from the previous slides are repeated but now also show the projected
measurement status and range of Systolic blood pressure, Diastolic blood pressure,
and K+ with lowering the dose of Spironolactone.
Slide 22
Advantages of Contextual Control
- Simplification of current systems:
- Medication reconciliation
- Alerts
- Allows for shared mental model of care plan by all professions and the
patient:
- Provides natural coordination of care
- Reduces errors?
- Facilitate the relevance of nursing documentation
Slide 23
Summary
- Theory-driven design (human factors)
- Reintegrates patient and system
- Patient-centric outcomes
- Assistive decision support
- Facilitates geriatric-style care
Current as of January 2009
Internet Citation:
Information Integration to Support Medication Management.
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/Nebeker2.htm