Antimicrobial Computerized Decision Support System CDSS in CPRS

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Antimicrobial Computerized Decision Support
System (CDSS) in CPRS
VeHU 2007 211

• Eric Geurkink PharmD
• Kristian Johnson RN, CAC

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Also Known As
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Educational objectives

• Session participants will
• Understand the development process involved in
  creating the antimicrobial CDSS menus
• Learn how CPRS menu order dialogs can be adapted
  to provide decision support at the point of entry
  in CPRS
• Understand the flexibility and limitations of
  antimicrobial decision support within CPRS
• Appreciate how the implementation and
  incorporation of the antimicrobial CDSS varied
  among VISN 23 sites

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What is the CDSS?

• Computer Decision Support System
• A tool within CPRS that offers empirical
  antimicrobial prescribing advice to clinicians at
  the point of order entry

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Why is this important?

• Guideline-concordant therapy improves outcomes

• Guideline-concordant pneumonia mortality 65-75
  of controls (Tennessee Medicare data) 1
• Antimicrobial therapy is suboptimal about half of
  the time
• In 2004, 55 of MVAMC Medicine Service
  inpatients received suboptimal antimicrobial
  therapy2
• Antimicrobial Resistance is increasing and is
  expensive
• Annual cost of nosocomial infections with
  resistant organisms 4.0 billion3
• Total cost of antibiotic resistance 30 to 100
  billion per year3

1Gleason, Arch Int Med 1999 159 2562 2Johnson
JR, et al. Unpublished data 3cited in Protecting
the Crown Jewels of Medicine A strategic plan to
preserve the effectiveness of antibiotics. 1998.
Center for Science in the Public Interest
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Potential Benefits

• Patients
• Better infectious disease outcomes
• Fewer ADE
• Shorter stays
• Less resistant flora
• Hospitals
• Better outcomes
• Lower costs
• Antimicrobial stewardship
• Less resistant flora
• Happier staff

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Strategies to Influence Prescribing Behavior

• Education
• Personalized Feedback
• Rules and Limitations
• Academic Detailing
• Incentives
• Guidelines
• System Change
• Reminders
• Computer Decision Support

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Strategies to Influence Prescribing Behavior

• Education
• Personalized Feedback
• Rules and Limitations
• Academic Detailing
• Incentives
• Guidelines
• System Change
• Reminders
• Computer Decision Support

CDSS highlights these strategies
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Methods for Improving Antimicrobial Prescribing

• Incorporate guidelines into clinical practice
• Incorporate computerized decision support into
  clinical practice
• Provide incentives for providers
• Antimicrobial CDSS uses all of these methods

FromInfectious Diseases Society of
AmericaClin Infect Dis 200744 159
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Goals of the CDSS project

• Improve patient outcomes
• Optimize costs
• Prevent adverse drug effects
• Reduce antimicrobial resistance
• Improve life for prescribers

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Project Personnel
Project Director
Clinical Applications Coordinator
Evaluation Specialist
Pharmacist

• - All other VISN sites encouraged to form a
  similar team
• Every prescriber and pharmacist is encouraged to
  contact the team with questions or suggestions

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Decision Support Content Process

• CDSS team physician and pharmacist review
  literature and develop recommendations
• These recommendations are reviewed with local
  experts in the pertinent fields
• e.g. Intra-abdominal abscess General Surgery,
  GI, ER, ICU, Infectious Disease, Pharmacy
• Content revised and finalized after consensus is
  reached

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Updating Process

• Each site has own customized CDSS
• Significantly different prices and suggested
  content changes from CDSS team are disseminated
  ANNUALLY
• Each site can accept or reject the changes
• Emergent changes are dealt with ASAP
• (e.g. gatifloxacin removed from market)

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Schematic Diagram
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Example Cholecystitis
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Example Uncomplicated Cystitis
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Example Prosthetic Valve Endocarditis
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Example Diverticulitis
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• Example
• Specific pathogen
• Klebsiella pneumoniae

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• Pathway to specific pathogen Klebsiella

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• Links to internal and external information sources

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Antimicrobial CDSS Technical Requirements
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Antimicrobial CDSS - Technical Requirements
The Raw Numbers (Really Dirty Harry)
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Antimicrobial CDSS - Technical Requirements
1 Year Development Time 200 Outpatient
Medication Quick Orders 200 Inpatient
Medication Quick Orders 1600 Order Menus 20 URL
Links in Generic Orders
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Antimicrobial CDSS - Technical Requirements
Some amount of local programming was done to
enhance the capabilities of the CDSS project.
NOTE Those enhancements are NOT required for
the CDSS to be successful!
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Antimicrobial CDSS - Technical Requirements
A local quick code program created a new file
in fileman that allows for tracking of CDSS
program usage.
Captures Patient name and SS Ordering
provider Time Drug Location Primary vs.
alternative drug
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Antimicrobial CDSS - Technical Requirements
Two data objects were built that called up the
local routine. We named these data objects ZZ
QUICK ORDER AUDIT and ZZ QUICK ORDER
AUDIT(ALT) We placed the data object into the
comments section of the medication quick orders.
This is the text that is entered ZZ QUICK
ORDER AUDIT ZZ QUICK ORDER AUDIT (ALT)
The object methods for the data objects S
XAUDANAZQUIC(DFN,"P") S XAUDANAZQUIC(DFN,"
A")
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Antimicrobial CDSS - Technical Requirements
The data objects return a comment that includes a
confirmation number.
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Antimicrobial CDSS - Technical Requirements
A local VistA routine was created for pharmacy.
Pharmacists can go into a menu option and type in
the confirmation number returned by the quick
order. This tells them whether or not the order
was placed using the CDSS.
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Antimicrobial CDSS - Technical Requirements
Quick Audit Record Inquiry
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Antimicrobial CDSS - Technical Requirements
Nightly Background Job to capture the actual
orders that are filled.
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Antimicrobial CDSS - Technical Requirements
A local report was created for tracking
antimicrobial orders
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Antimicrobial CDSS - Technical Requirements
Importing the CDSS and Non-CDSS report into Excel
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Antimicrobial CDSS - Technical Requirements
Moving the CDSS System into other VistA Databases
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Antimicrobial CDSS - Technical Requirements
Our local programmer built a new VistA option for
creating quick orders and menus. This option
allows new order dialogs to be assigned a much
higher sequence number than what currently exists.
When the order dialogs are copied into another
system, the higher number prevents the new order
dialogs from overwriting existing dialogs.
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Antimicrobial CDSS - Technical Requirements
Considerations for Copying Dialogs into Another
VistA System
All order menus and quick orders were given a
unique namespace (up to the first 30 characters)
that was different from any existing namespaces.
Menus are copied into the new system intact, but
quick orders must all be remapped to the local
orderable item (medication or consult service).
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• Additional Benefits
• And Features

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Help and Links throughout CDSS

• Site-specific antibiograms
• Allergy information and desensitization protocols
• Consults
• Information on how to contact the CDSS team
  (phone, email, pager)

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Alternative antimicrobial needed?

• Our system provides alternatives for MOST
  clinical scenarios
• If you want to select an alternative, we ask that
  you provide a reason, in order to help us improve
  our recommendations

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Important Drug Properties

• Concise, pertinent drug information
• Links to more complete resources
• Micromedex, Up-to-date
• Pharmacist contact information

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Usage data
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Minneapolis
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Central Iowa
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CDSS outcomes data in UTIKothari NJ, et al,
unpublished data

• 274 cases of acute urinary tract infection for
  which antibiotics were prescribed. CDSS was used
  in 75 of these cases (27.3)
• Antibiotics prescribed with CDSS were less likely
  to have been prescribed for asymptomatic
  bacteriuria (15) than those prescribed without
  CDSS use (27) (p0.037).
• Prescribers using CDSS are more likely to
  prescribe first line agents fluoroquinolones and
  TMP-sulfa, than those who do not use CDSS (64
  vs. 40, p0.001).

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Summary

• CPRS offers great possibilities for incorporating
  decision support into routine care.

• Implementation of decision support systems
  requires buy-in, work, and feedback from
  providers, CACs, and pharmacy.

• Promotion and educational efforts are key to
  achieving sustained usage.

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Questions ??
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Thank You!