Security Policy Development

1
Steps toward a System of Care and Personalized
Medicine
William W. Stead, M.D. Professor of Medicine and
Biomedical Informatics Associate Vice Chancellor
for Health Affairs Vanderbilt University October
14, 2004
Disclosures McKesson distributes WizOrder as
Horizon Expert Orders. I am a Director of
Healthstream Netsilica.
2
Road Map to the Talk

• My View of the Problem
• Vision of a System of Care
• Vanderbilts Building Blocks for Systematic
  Medicine
• Frameworks for the Future

3
The Gap Between Discovery Practice

• From Innovation to Practice - An Average of
  Six Years to 50 Adoption

Discovery Phase (3-5 yrs)
Acceleration of Medical Innovation Read 2
articles every night X 365 days/year At that
rate you will be 1,225 years behind by end of
year 1
Submit for Publication (6 mos)
Peer and Editorial Review (6 mos)
Time to Publication (6 mos)
Publication Reviewed by Specialty Societies (1 yr)
Invitation to Present Findings (6 mos)
Time until Conference (1-18 mos)
Practitioners Test (6 mos)
Payors Adjust Pmt Standard (1-18 mos)
Day 1 3Yr 4Yr 5Yr
6Yr
4
The Gap Between What We Know What We Do

• 6,712 Individuals in 12 Cities
• Only 54.9 received recommended care
• Only 54.9 received recommended preventive care
• Only 53.5 received recommended acute care
• Only 56.1 received recommended chronic care
• Examples Hip Fracture 22.8 (Range 6.2-39.5)
• Atrial Fibrillation 24.7
• Depression 57.2
• Senile Cataract 78.7 (Best performance)

McGlynn, et. al., NEJM 20033482635-45
5
Road Map to the Talk

• My View of the Problem
• Vision of a System of Care
• Vanderbilts Building Blocks for Systematic
  Medicine
• Frameworks for the Future

6
Vignettes of the Art of the Possible A System
of Care

• Putting the patient and practitioner on the same
  page

• Patient tracking own care against standard of care

• Instantaneous improvement in the standard of care

7
Communication as an Intermediary
Patient
Practitioner
8
Information-based Communication
Practitioner
Patient
Information Resources
Data Patient Record Learning Record Outcome Record
Knowledge Best Practice Trials Literature
9
Infrastructure for the New Model
Information Islands Discipline specific
information and records Task specific systems,
each with its own record Each note stands on its
own
10
Skills for the New Model

• Teamwork, problem solving and coaching

• Guiding a data-driven system of care

• Finding, assessing and applying just in time
  information

• Learning at teachable moments

• Privacy, confidentiality, security

• Managing change

11
Road Map to the Talk

• My View of the Problem
• Vision of a System of Care
• Vanderbilts Building Blocks for Systematic
  Medicine
• Frameworks for the Future

12
Vanderbilts 15 Yr Journey toward Systematic
Medicine

• Data driven care pathways
• Point of care literature access
• Provider order entry with decision support
• Electronic patient chart
• Enterprise data warehouse
• Clinical Informatics Consult Service
• Chronic disease management registries
• Information and tools for patients

13
Data Driven Care Pathways

• Highest volume
• Highest variation in resource utilization
• Specific cases from top and bottom
• Agree on best practice
• Represent as phases of care
• Track goal variance by system, provider, patient

14
Radical Retropubic Prostatectomy -
Standardization on Best Practice

• Laboratory
• Hematocrit/K on postoperative days 1,3
• No other laboratory studies unless clinically
  indicated
• Decreased utilization of autologous blood
  donation
• Pharmacy and medical supplies
• Single-dose preoperative antibiotic (cefazolin)
• Elimination of epidurals for postoperative
  analgesia
• Elimination of pneumatic compression stockings
• Operating room and anesthesia
• Standardization of case carts
• Minimization of disposable items (drains, clip
  appliers, catheters, etc)
• Routine Care
• Admission day of surgery
• Outpatient mechanical bowel preparation
• Target postoperative day 3 for discharge
• Early feeding, rectal suppositories
• Immediate ambulation

Koch MO, et al. Urology 199444(1)313
15
Vanderbilt University Medical Center Radical
Prostatectomy
DRG Number _____________ ELOS
____________________
2-3 days
Pre-Op (Outpatient)
Day of Surgery (OR RW)
Post Op Day One (RW)
Post Op Day Two (RW Home)
Post Op Day Three (RW Home)
Goals
Pre-op testing completed WNL Patient/family teac
hing completed Consent Signed
Bowel Sounds present, /- flatus Drain
Output lt100cc/day Possible D/C if tolerate
diet Remove drain if lt60cc and D/C planned today
Bowel Sounds present, passing flatus Follow up
appt. w/MD scheduled D/C drain if lt60
cc/24 Discharge home with Foley catheter D/C
teaching completed
Bowel Sounds present, no flatus Drain
Output lt150cc/day UOP gt 150cc over 4 hours
Labs
SMA 18 CBC w/plt TS
Hct
Tests
HP CXR EKG
Treatments
Consent Signed
VS q4x24, then q8 IO q 4 hrs Foley
catheter IMED Pump JP drain
D/C Possible D/C drain
D/C drain
16
Full Implemen-tation
p Value
Phase-in
Prestudy
87 13,783 6,009 2,327 2,510 65 184
2.1 963 32 5.7 3 10
12 10,723 5,245 1,866 1,814 64 148 1.2 819 33 5.0
0 17
17 8,149 4,290 1,384 1,262 63 131 0.9 917 33 3.6 0
0
lt0.0001 lt0.0001 lt0.0001 lt0.0001 lt0.0001 0.0001
lt0.0001
No. cases Total patient cost () OR anesthesia
cost () Pharmacy medicine cost () Routine
care () Mean patient age (y) OR time (min)
Tranfusion (units) Estimated blood loss
(mL) Hematocrit at discharge () Hospital stay
(days) Major complications () Minor
complications ()
Koch MO, et al. Urology 199444(1)315
17
Decision Support at Order Entry

• Guides to best practice are developed throughout
  the organization
• Patient Care Center Clinical Practice Teams
• Pharmacy Therapeutics Committee
• Care Improvement Committee
• Clinical Cost Effectiveness Committee

• WizOrder provides a single point to link guides
  into workflow

• Caregiver remains the decision maker

• Actual practice patterns provide feedback for
  iterative improvement

18
Methods Study Design

• Retrospective pre-post study
• Implemented in all 600 beds using WizOrder
• Pre-intervention
• 9 week period (9/30/00 12/4/00)
• Imaging studies ordered in WizOrder
  individually
• Post-intervention
• 8 week period (12/5/00 1/30/01)
• Study only means for generating relevant orders
• Decision support system remains in current use

Sanders D, et al. JAMIA Symposium Supplement
2001583-587
19
Implementation Acuity and Category Selection
20
Implementation Diagnostic Indication Selection
21
Implementation Ordering Page
22
Results Ordering Patterns
Sanders D, et al. JAMIA Symposium Supplement
2001583-587
23
Clinical Informatics Consult Service

• Librarians participate in clinical teams
• Digital library of common sources of evidence and
  past questions answers
• Patient Information Prescription
• Bring Evidence to Pathway Development
• Structured Searches for EBM Solutions and ACP
  PIER

24
Date created 2003-08-12Date modified 2003-08-12
IMPORTANT EBL librarians attempt to provide
accurate, inclusive, and informative reports
based on the information requests and relevant
data provided to them. All information is treated
with strict confidentiality, in keeping with
Vanderbilt policies. Librarians attempt to report
all points of view described in the literature,
selecting what they consider the most
representative examples of each. Summaries are
prepared for the convenience of the clinician,
and physicians should consult the attached
full-text reprints before taking action however,
the information provided is no substitute for
clinical judgement. It is possible that any given
search may omit some relevant information. More
extensive bibliographic references for any topic
are available upon request.
25
Summary
Current literature suggests bilirubin level can
go as high as 20 mg/dl before a blood transfusion
is necessary. Agrawal (2001) suggests transfusion
should be first considered at 15 mg/dl whereas
Cashore (2000) states that bilirubin of 12-18
mg/dl are well tolerated before exchange
transfusion should be considered in infants
weighing 500-750g and can go as high as 17-20
mg/dl for 1250-1500g infants.
26
References Reference 1 Agrawal R, Aggarwal R,
Deorari AK, Paul VK. Jaundice in the newborn.
Indian J Pediatr. 2001 Oct68(10)977-80.
This articles states that although exchange
transfusion was once the standard practice in
managing severe hyperbilirubinemia, today
phototherapy, at optimal efficacy, can control
the most severe jaundice. Of particular
importance are the sections on jaundice in
preterm babies, the sick newborn and prolonged
jaundice beyond two weeks. A 1000g infant should
receive phototherapy if bilirubin levels exceed
10 mg/dl and an exchange transfusion should be
considered at 15 mg/dl. Authors give phototherapy
guidelines, ie. blue tubes with the mark
F20T12/BB should be used at a distance of 15-20
cm from the infant, and a chart is included that
gives weight, phototherapy and exchange
transfusion indicators.
Reference 2 Cashore WJ. Bilirubin and jaundice
in the micropremie. Clin Perinatol. 2000
Mar27(1)171-9
27
(((((("Bilirubin/analysis"MeSH OR
"Bilirubin/bloodMeSH) OR ("Jaundice/etiologyM
AJR OR "Jaundice/therapyMAJR)) AND "Exchange
Transfusion, Whole Blood/methodsMeSH) OR
"Phototherapy/methodsMeSH) AND "Infant,
PrematureMeSH) AND EnglishLang)
28
(No Transcript)
29
Panel Management

• Master panel by provider with sub-panels for
  disease/work flow categories
• Alerts to new information missed goals
• Message baskets for intra-staff communication
• Tools to implement document actions
• Patient-provider messaging linked to electronic
  chart patient portal
• Key word and range search

30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
Road Map to the Talk

• My View of the Problem
• Vision of a System of Care
• Vanderbilts Building Blocks for Systematic
  Medicine
• Frameworks for the Future

34
Framework to Support Evolution to a System of Care
STEPS
EXAMPLES
Adherence to best practices, reduce errors,
reduce prescriptions, reduce redundant/
overlapping testing, increase compliance
Value
OUTCOMES
Systems that support safety, patient centered
care, disease management, evidence based decisions
-
Change in Practice
-
INTERVENTIONS
-
CPOE, eprescribing, closed loop medication
administration, retail pharmacy, notification
/escalation
Point of Information Systems
Patient index, lab results, medication dispensing
record
Data Interchange
INFRASTRUCTURE
Messaging, terminology, role based authorization
Standards
35
EBLs Framework of Library-based Services
36
Engaging the Patient
Consumer Web-site Patient Information
Prescription
37
Evidence-based System of Care
38
Regional Databank
Healthcare Entity Internal Systems
Vaults
Regional Index
Person 1 Composite ID Info
Link 1
Link 2
Hospital A
Entity Patient ID Info
Structured Documents

Person 2
Hospital B
Group Practice
Clinic
Nursing Home
Retail Pharmacy
Payer
39
Regional Databank
Healthcare Entity Internal Systems
Vaults
Regional Index
Integrated Patient Database
Person 1 Composite ID Info
Link 1
Link 2
Person 1 Problems, Lab Data, Med Data,
Hospital A
Entity Patient ID Info
Structured Documents

Person 2
Person 2
Hospital B
Group Practice
Clinic
Nursing Home
Retail Pharmacy
Payer
40
Learning to be a Life Long Learner
41
Personalized Medicine (Ex risk of colon cancer)
Steady-state Functions
DNA Sequence
Proteome
Array-based gene expression
Clinical phenotype
Time Varying Functions
Concept The power for solving for an unknown
parameter is augmented by including both
steady-state and kinetic (time-varying) data
42
Meta-Index
Classification Algorithms
StarChart Database
Index each Word and Number
Tier 3
Tier 2
Assemble by Patient
Tagged Text Blocks
Tagged Header with Pointer to Image
Tier 1
Sources
Systems (ADT, Lab, Radiology)
Note Capture Tools (Dictating, Structured Data)
Image (PACS, Wave Form, Scan)
43
(No Transcript)