VIReC CyberSeminar Series 2006

Clinical InformaticsClinical Informatics

Attributes of An Ideal Informatics System with

Highlights from a State of the Art Conference

Denise M. Hynes, Ph.D., R.N.

Director, VIReCDirector, VIReCResearch Health Scientist, MCHSPR COEResearch Health Scientist, MCHSPR COE

HSR&D Resource Centers

CCiiDERDER = Center for Information Dissemination & Education Resources = Center for Information Dissemination & Education Resources

HERCHERC = Health Economics Resource Center = Health Economics Resource Center

metricmetric = Measurement Excellence & Training Resources Information Center = Measurement Excellence & Training Resources Information Center

VIReCVIReC = VA Information Resource Center = VA Information Resource Center

Series/Course Objectives

• To learn about applications in clinical informatics in research and quality improvement efforts– VA and non-VA efforts

• To understand approaches for evaluating clinical informatics and IT interventions

Selected Course Topics• Attributes of an Ideal Information System:

Highlights from a State of the Art Conference• Approaches for Evaluating Health Informatics

Technology and CDSS• Implementation of CDSS in Hypertension

Management• Implementation of a CDSS in Mental Health• Using CDSS in Pain Management• Informatics Applications for Promoting Collaborative

Care

Session Objectives

• Understand the key aspects to consider in a clinical information system

• Understand the desired attributes of a clinical information system

• Become aware of the barriers and facilitators to use of IT in healthcare and research

IOM Quality Chasm Report, 2001

• Predominance of chronic care

• Need for evidence-based practice

• Critical value of information technology

IOM Committee on Quality of Health Care in America

• Point-of-care access to health literature and evidence-based guidelines

• Computer-assisted decision support systems;• Computerized patient clinical data• Automation of decisions to reduce errors• Electronic communication between providers • Electronic communication between providers

and patients

Informatics Support for Clinical Practice Guideline Implementation

Step Facilitators Informatics Support

AwarenessPriming Activities such as

profiling of baseline performance

Profiling from prescription order and diagnosis database

Acceptance

Active education such as Academic Detailing;

Clinical Opinion Leaders

Present evidence relevant to patient; allow opinion leaders to browse knowledge base

AdoptionEnabling strategies such

as incorporation into clinic workflow

Integration with existing EMR/CPRS

AdherenceReinforcing Strategies such

as remindersPoint-of-care patient-specific

advisories & alerts

Pathman, et al. Medical Care 1996; 34:873-889

Diffusion of Innovation Theory: Key Dimensions

• Nature of the innovation itself

• How communication channels can be impacted

• Time

• Social system and organizational context

Challenge of Using Information Technology (IT) for QI

• Integrating new forms of decision support into legacy data systems and electronic record interfaces

• Sociotechnical aspects

Goldstein, et al., JAMIA 11: 368-76, 2004.

Berg’s Sociotechnical Success• Technical success

– generates correct recommendations offline– extracts and uses patient data correctly– integrates with CPRS to display for the right

• Patient,• Provider• Clinical location• Time window

– tracks the data needed for research evaluation

• Sociological success– clinicians find it usable and useful

Berg, M., Int J Med Inf, 1999. 55(2): p. 87-101.

Social Challenges of IT in Health

• Clinicians’ time constraints– Strike balance between ease of access to system and

ease of ignoring it– Balance with interpersonal needs of patients

• Variability in comfort with computers– And virtually no training time available

• Lack of consensus/agreement about the guidelines

State of the Art Conference Summary

Attributes of an Ideal Integrated Informatics System that Supports

Implementation of Evidence

The ideal information management system supports managers, providers and patients to achieve practice and outcomes consistent with evidence

• Supports knowledge-based decisions • Evaluation/Reporting Capability • Evolves with health care system• Accurate/Correct Content • Standardized/Compatible

Attributes of the Ideal Information System

• Defined Accountability: organization vs. provider

• Equitable: “No service/facility left behind”• Sustainable • Secure

• Usable – Integrated – All electronic– flexible– transparent to users– non intrusive – easily up-datable

• Current Information Systems do not fully utilized knowledge-based decision support

• Clinical reminders, order check system, notification and alerts

• Data capture limited to local system• Difficult to prioritize• Handling of adverse events

Priority 1: Supports knowledge-based decisions

Strategies:• Research on how to prioritize• Require research to include data on added

value in terms of mortality and morbidity

Barrier: too much info/provider overload

Strategies: • National patient data record• Patient ownership of patient data, guidelines and

reminders• Common patient identifier• Common provider identifier• Integration across systems• Research on what information users need

Barrier: lack of integration

Strategies: • Basic research in managing information

complexity• Alignment of research priorities with

clinical management • Performance measures focused on how

much evidence informs practice• Regular presentation of significant

translation research findings to senior leadership

Barrier: Operationalizing evidence

Strategies: • Flexibility in decision support with required

feedback about reasons for non-compliance and barriers to compliance

• Local review of compliance with local solutions (tailored training)

• Add autonomy in other areas: e.g., guideline input, self-review, link to reference materials

Barrier: Threats to provider autonomy

• rapid monitoring and feedback for evidence-based practice

• recommend appropriate treatment (reminders), track actual treatment and results, provide ongoing analysis of effectiveness

• Support analysis and review at different levels and contexts

Priority 2: Reporting/Evaluation Functions

Strategies: • More automation of data (e.g., link

diagnosis to test)• Review and monitoring of data

quality• Linkages to other information in EHR

so provider doesn’t have to reenter (e.g., test results)

Barrier: Data issues

Reporting complexity requires specialized knowledge

Strategies: • Use OLAP cubes to simplify user

generation of reports

Barrier: Reporting complexity

Reporting function on existing patient care system eats system resources, slows response time

Strategies: • Move reports off system – put analytical

tools on a system separate from pt care system

Barrier: System resources

• Aspects of the information system are based on prior care models

• Current methods of data collection may not match business process or support evidence-based practice

Priority 3: Information system needs to evolve with health care system

Strategies:• Develop patient-centered data

collection methods, core data elements, and system capacity for patient-based health data sets

• Encourage basic research on capturing home care data for all stakeholders

Barrier: Emphasis on provider-level activities and provider-

entered data

• Focus on outcomes (maintaining/improving functional status of the patient), not workload

• encourage “just in time” rather than “just in case” visits, collect interim data remotely

Barrier: Emphasis on workload rather than care received by

patient

Some Summary Remarks

• Technology must be tailored to providers’ needs• Fit into workflow in real time• Minimize request for additional information• Meet need for speed• Elicit feedback and respond• Tracking mechanisms needed to support research