Clinical Decision Support Technologies for Oncologic Pathology

Transcription

1 Clinical Decision Support Technologies for Oncologic Pathology Brian H. Shirts Assistant Professor, Department of Laboratory Medicine University of Washington, National Cancer Policy Forum Improving Cancer Diagnosis and Patient Care Workshop Feb 12, 2018

2 Clinical Decision Support (CDS) Information presented to assist clinicians in appropriately interpreting and acting on diagnostic testing results. knowledge and person-specific or population information, intelligently filtered or presented at appropriate times, to foster better health Osheroff et al, JAMIA

3 CDS for Guidelines and Appropriate Use Guidelines can take years to disseminate Even with effective dissemination, implementation may be variable Clinical decision support can be an ideal way to: Educate Remind Assist

4 Passive and Active CDS Passive require user effort to access or interpret Reference ranges Dose or risk calculators URLs with links to additional information Infobuttons Active situation or action specific triggers Flags Pop-ups Diagnostic Management Teams

5 Passive Clinical Decision Support

6 What makes clinicians use passive CDS? In general passive CDS used infrequently Accessed for abnormal findings more often Accessed for unusual situations more often % reports downloaded normal Accessed more often when there are changes in process abnormal Shirts et al. (2009) Am J. Clin Path. Dec;132(6): Shirts et al. (2012) J Pathol Inform. 2012;3:26.

7 Active Clinical Decision Support

8 Barriers to Active CDS Physician Acceptance Coding molecular and pathology information for electronic health record Interoperability B A C Cost

9 Physican Acceptance 52% - 96% override rate Active Clinical Decision Support Alert fatigue Sijs et al, 2006 JAMIA

10 Not All Alerts are Created Equal Process Questions Do alerts cause providers to change medication or management? What percent of providers override alerts? Usability Questions What do providers like/dislike about CDS alerts? What makes a CDS alert more likely to be used? Nishimura et al Genet Med Nov;17(11):

11 Quality Active CDS Specificity Good design Stakeholder Acceptance Clinical Evidence Ash et al, JAMIA Hartzler et al 2014

12 Coding for Active CDS.AATGCTAATG Patient Genetic Test Sequence Read-out Automated Filtration Geneticist Annotation Expert Panel Review Care Provider Passive Decision Support Report Generated (Print/PDF format) 806C>T CYP2C19*17 Actionable variant identified Active Decision Support CDS Rules Engine Results stored in EHR Submitted as Lab Result (Machine Readable) Nishimura et al. Curr Genet Med Rep Dec 1;2(4):

13 Results/Orders/ADT/Billing ``` NWH Authentication A Interoperability for Active CDS B C Interoperability is the ability of different information technology systems and software applications to communicate, exchange data, and use the information that has been exchanged. Enterprise Departmental Clinical Systems PACS Archive (GE Offsite Storage) Infection Control (Theradoc) Radiation Oncology (Impac) Discharge Planning (ECIN) Cardiology (GE MUSE) Pathology (PowerPath) Laboratory System (Sunquest Flexilab) Dietary (CBORD) Radiology Information System (GE-Rad) Results/Orders/ADT/Billing HL7 Router (Orders/Results) Patient Admin/Billing Systems MINDscape HL7 Router (Billing) HL7 Router (ADT) Coding (3M) multiple systems Clinical Data Warehouse (Amalga) Cloverleaf Scheduling (Epic Cadence) ADT Professional Billing (Epic Resolute PB) ADT (Epic Prelude) Ambulatory EHR (EpicCare) EpicCare Enterprise Clinical Systems Registration (Epic Prelude) Hospital Billing (Epic Resolute HB) Master Patient Index (Epic Identity) Retail Pharmacy (Cerner Etreby) Data Warehouses (Epic Chronicles, Clarity, Caboodle) Provider Directory (Epic SER) Systems Authentication External Provider Directories Pharmacy (Cerner PharmNet) Inpatient EHR (Cerner / ORCA) Clinical Research Grants, Budgets and Billing (CRBB) Cerner/Siemens Soarian EHR (NWH) School of Medicine Systems Research Repository (I2B2 / Redcap) ITS Authentication (ITS LDAP/AD) PICIS ED/ICU (NWH) SOM Administrative (Morrisey, GMEtab) Provider Database (PUMA) Departmental Domains, Ads, and File Servers Notes: 1) Valley systems are not included 2) Total applications in UWM >500. 3) Only major systems are shown. Author: David Chou, MD External Provider Database Departmental Clinical Systems NWH PACS (GE Centricity) NWH Anesthesia (McKesson) Other Departmental Systems UWMC PACS (GE Centricity) UWMC Anesthesia (IBM/Merge) Endoscopy (Olympus) HMC PACS (GE Centricity) HMC Anesthesia (IBM/Merge) Cardiology (Xcerlera) Billing NWH Surgery Mgmt (McKesson) HMC Surgery Mgmt (McKesson) UWMC Surgery Mgmt (McKesson) NWH Materials Mgmt (McKesson) HMC Material Mgmt (McKesson) UWMC Materials Mgmt (McKesson) NWH General Ledger (McKesson) HMC General Ledger (McKesson) UWMC General Ledger (McKesson) McKesson Performance Manager McKesson Business Insight Supply Chain / ERP Systems AMC File Servers Timekeeping (Kronos) UW Payroll and Personnel (Workday) UW Authentication (NetID) Learning Management (SumTotal) Office 365 (Exchange, OneDrive, Sharepoint, Lynx) UW Campus Systems External Data from Affiliates HRP Systems UW Medicine Administrative Systems Cloud Services (AWS/Azure)

14 A Interoperability for Active CDS B C CCD/CDA Hospital System 1 Hospital System 2 Health Information Exchange Community Providers Figure courtesy of David Chou

15 Draft 10 Year CMS/ONC Interoperability Roadmap B A C Connecting Health and Care for the Nation, A Shared Nationwide Interoperability Roadmap, October, 2015;

16 Active CDS costs What was the estimated development, implementation, and maintenance cost for active pharmacogenetic CDS at the University of Washington expressed as cost per alert? $ 0 $46 $460 $4,600 $46,000 Mathias et al. AMIA Jt Summits Transl Sci Proc Jul 20;2016:60-4

17 Active CDS costs Mathias et al. AMIA Jt Summits Transl Sci Proc Jul 20;2016:60-4

18 Take Home Points Most pathology reports, including molecular pathology reports, are currently not formatted to facilitate pathology data sharing and effective electronic clinical decision support. Improvements are needed. The costs of building and maintaining clinical decision support networks are often ignored or minimized; however, these costs can be substantial, especially if clinical decision support is implemented independently at each health care institution. Dramatic improvements in data interoperability and inter-institution collaboration will be necessary to drive decision support costs down.