augmented clinical intelligence€¦ · understand that usability is essentialand nuances matterto...

PEDIATRIC CRITICAL CARE MEDICINE

Past, Present, and Future of Clinical Decision Support SystemsThomas Fogarty, III MDAssistant Professor, Pediatric Critical Care MedicineBaylor College of Medicine / Texas Children’s Hospital

AUGMENTED CLINICAL INTELLIGENCE


• I have no financial relationships with commercial interests to disclose.

DISCLOSURES


• To Review Clinical Decision Support (CDS) Strategies in Medicine over the past 60 years

• To Describe the Benefits of CDS in Pediatric Critical Care

• To Provide a Framework for Intensivists to Use, Apply, and Develop CDS Tools locally

OBJECTIVES

QR Codes have been integrated for many of the slides to link to referenced studies. Use your phones camera or QR application to access the links!


HISTORY OF CLINICAL DECISION SUPPORT


Celi LA, Csete M, Stone D. Optimal data systems: the future of clinical predictions and decision support.


Miller, R. Computer-assisted diagnostic decision support: history, challenges, and possible paths forward.


Teich et al. The Brigham integrated computing system (BICS): advanced clinical systems in an academic hospital environment. 1999.


Humans are the most important component in

healthcare.

Its not just the data.

It’s the data, the people, and the system.


DOES DECISION SUPPORT WORK?


Evidence Favoring CDS System• Decreasing Morbidity (RR 0.88)• Recommending Preventative Care (OR 1.42)• Recommending Clinical Studies (OR 1.72)• Recommending Appropriate Treatment (OR 1.57)

No Significant Evidence against CDS Systems, plenty of unanswered questions


Risk of Medication Errors = RR 0.15 [0.03-0.80]

Risk of ICU Mortality = RR 0.88 [0.78-0.99]

Risk of Hospital Mortality = RR 1.17 [0.53-2.54]

Length of Stay = Mean Difference -0.1 days [-0.81 – 0.60]


Brigham & Women’s Hospital• $11.8 million invested in computerized order entry• $28.5 million saved over ten years


Brigham & Women’s Hospital• Renal Dosing – $2.24 million / year• Adverse Drug Events Prevention - $1.05 million / year• Adverse Drug Events Monitoring - $0.76 million / year• Expensive / Disease Specific Drug Guidance - $0.88 million / year• Nurse Time Utilization - $0.96 million / year• Physician Time Utilization - $0.10 million / year


IMPLEMENTING A CLINICAL DECISION SUPPORT TOOL


• The Right Information

• To the Right Person

• In the Right Intervention Format

• Through the Right Channel

• At the Right Time in Workflow

FIVE RIGHTS OF CDS


“TEN COMMANDMENTS OF CLINICAL DECISION SUPPORT”

• The CDS system must be fast.

• Keep the CDS system simple.

• Require the user to enter data only when it is essential.

• Routinely maintain and evaluate the CDS system.

• Identify latent needs and inform the end user.


• Build the CDS system to fit the existing workflow and seek input from end users early.

• Understand that usability is essential and nuances matter to end users.

• Changing behavior is easier than stopping a behavior. • Physicians will resist 'stopping.' • Measure and share success.

“TEN COMMANDMENTS OF CLINICAL DECISION SUPPORT”


PRE-ACTIVATION MONITORING


ONGOING MONITORING


WHERE DO WE GO FROM HERE?


SMART ON FHIR (FAST HEALTHCARE INTEROPERABILITY RESOURCES)

Borrow & Share Tools!


• Get Involved• Ask Questions of Current Decision Support Tools• Aim for Easy Targets• Remember: Workflow is Everything• Measure and Track the Intervention• Maximize Return on Investment• “Return the Returns” to the Patient and System!

INTENSIVE CARE FOCUSED DECISION SUPPORT


COMMENTS/QUESTIONS?

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