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Education and Clinical Decision Support: Reuniting Twins Separated at Birth Jerry Osheroff, M.D. Thomson Healthcare University of Pennsylvania.

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Presentation on theme: "Education and Clinical Decision Support: Reuniting Twins Separated at Birth Jerry Osheroff, M.D. Thomson Healthcare University of Pennsylvania."— Presentation transcript:

1 Education and Clinical Decision Support: Reuniting Twins Separated at Birth Jerry Osheroff, M.D. Thomson Healthcare University of Pennsylvania

2 Objectives Outline the need for a joint model for education and clinical decision support Outline the need for a joint model for education and clinical decision support Describes how the two can be used together to achieve outstanding care delivery and outcomes. Describes how the two can be used together to achieve outstanding care delivery and outcomes.

3 Healthcare is Broken Safety 1 medication error/inpatient/day – IOM 1 medication error/inpatient/day – IOM >500K preventable ADE deaths/injuries (outpt) – IOM >500K preventable ADE deaths/injuries (outpt) – IOMQuality 55% chance of appropriate care – McGlynn/NEJM 55% chance of appropriate care – McGlynn/NEJM 17 years: effective treatment ->routine – Balas/IMIA 17 years: effective treatment ->routine – Balas/IMIAAffordability $ 44 billion waste recoverable w/CPOE (outpt) - CITL $ 44 billion waste recoverable w/CPOE (outpt) - CITL $ 3.5 billion from inpatient ADEs – IOM $ 3.5 billion from inpatient ADEs – IOM

4 Education What should I know and do? Clinical Decision Support What should I do now? Part of the Solution

5 Orthopedic Surgery VTE prophylaxis schema for hip and knee arthroplasty and hip fracture surgery Any CONTRAINDICATIONS to pharmacologic prophylaxis? High risk of bleeding Active bleeding Systemic anticoagulation INR 1.5 or aPTT ratio 1.3 Platelet count < 50,000 Yes Use TEDs/SCDs until contraindication no longer present. Consider serial duplex surveillance or vena caval filter in high-risk orthopedic patients (Hip or knee arthroplasty-particularly with VTE risk factors, Hip fracture surgery, major trauma, spine surgery with risk factors) No Creatinine clearance < 30 ml/min No Hip surgery with VTE risk factors? Previous DVT/PE Cancer Thrombophilia Major trauma Fondaparinux 2.5 mg sc qday X 14 days (Start 6 hours post-op) Enoxaparin 30 mg sc q12h X 14 days (Start hours post-op; PREFERRED enoxaparin regimen) Enoxaparin 40 mg sc qday X 14 days (Start 12 hours pre-op, next dose at least 12 hours post-op) Warfarin 5 mg po qday (adjust to INR2-3) (Begin day of surgery) (Use 2.5 mg for age>75, CHF or liver disease, interacting meds) Consider extended prophylaxis for 28 days post-op with Fondaparinux 2.5 mg sc qDay or Enoxaparin 40 mg sc qDay or Warfarin (INR 2-3) (with at least weekly INR) Yes Complete 14 days of prophylaxis No Yes Enoxaparin 30 mg sc q24h X 14 days (Start hours post-op) Warfarin 5 mg po qday (adjust to INR2-3) (Begin day of surgery) (Use 2.5 mg for age>75, CHF or liver disease, interacting meds) May add SCDsFoot pumps Hip surgery with VTE risk factors? Previous DVT/PE Cancer Thrombophilia Major trauma Complete 14 days of prophylaxis Consider extended prophylaxis for 28 days post-op with Warfarin (INR 2-3) (with at least weekly INR) Yes No Not in order set

6 Goal of Education Existing knowledge New knowledge Provide cognitive framework, skills, and beliefs necessary for practice.

7 Tools of Education DIDACTICEXPERIENTIAL InformationCasePractice BasedBasedBased -Informational -Fictional-Apprenticeship text & graphics or real -Quality -Books cases Improvement -Lectures-Virtual -Point of care patients

8 Goals of CDS Providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care.Providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented at appropriate times, to enhance patient care. Includes and builds on whats already being done on a daily basis in healthcare organizations… Includes and builds on whats already being done on a daily basis in healthcare organizations… NOT just rules and alerts… NOT just rules and alerts…

9 Tools of CDS Documentation templates: pt hx, visit note Documentation templates: pt hx, visit note Relevant data presentation: flowsheets, audits Relevant data presentation: flowsheets, audits Order creation facilitators: order sets Order creation facilitators: order sets Protocol support: pathways Protocol support: pathways Reference information: infobuttons Reference information: infobuttons Unsolicited alerts: proactive warnings Unsolicited alerts: proactive warnings

10 Must do items clearly identified Help with order selection, core measures identified Links to drug info from every medication order C Acute MI Order Set

11 Drug information at a glance

12 Knowledge Needs What I know that I dont know (Recognized need) What I know that I know What I dont know that I dont know (Unrecognized need) What I dont know that I know COMPETENCE CONSCIOUSNESS

13 Links to synoptic disease information

14 Reunion Drivers CME Accreditation changes CME Accreditation changes Improve physician competence, performance, patient outcomes*Improve physician competence, performance, patient outcomes* Continuous improvement: knowledge, strategies, and performance-in-practice**Continuous improvement: knowledge, strategies, and performance-in-practice** Point of care learning Point of care learning Leverages decision support tools and adds reflective componentLeverages decision support tools and adds reflective component Responds to learning needs from patients clinical problems ***Responds to learning needs from patients clinical problems *** Quality improvement Quality improvement Broader examination of quality gapsBroader examination of quality gaps Integrated into Maintenance of CertificationIntegrated into Maintenance of Certification * ACCME, Updated Accreditation Citeria, 2006 ** Regnier et al., JCEHP 2005 *** Davis and Willis, JCEHP 2004

15 5 Rights: Joint Model for Education and CDS CDS and Education should provide: the right information (ebm),the right information (ebm), to the right person (clinicians and patients … ),to the right person (clinicians and patients … ), in the right intervention format or activity (alert, answer, virtual patient, assessment, reflection),in the right intervention format or activity (alert, answer, virtual patient, assessment, reflection), at the right point in time (relative to workflow and other interventions)at the right point in time (relative to workflow and other interventions) through the right systems and people (cds and education professionals, multimodal solutions)through the right systems and people (cds and education professionals, multimodal solutions) to improve health care delivery and outcomes. to improve health care delivery and outcomes.

16 Keys to Joint Model Comprehensive user needs assessment Comprehensive user needs assessment Diverse development team (clinical experts, informaticians, educators) Diverse development team (clinical experts, informaticians, educators) Multiple interventions and modalities Multiple interventions and modalities Integrated perspective/action Integrated perspective/action

17 A Question in Practice Physician Performance In Practice Physician Competence Strategy Wisdom Judgment Information Analysis Data Synthesis Knowledge Regnier et al, JCEHP, Fall 2005 Assessment Education Decision Support = Added Continuing Professional Development

18 Implementing the Joint Model Work with colleagues in CDS or Education Work with colleagues in CDS or Education Understand the tools available Understand the tools available Look at clinical systems for needs assessment data Look at clinical systems for needs assessment data Analyze root causes of poor performance Analyze root causes of poor performance Create interventions fully appropriate for needs Create interventions fully appropriate for needs Education + CDS = Best Healthcare Outcomes

19 Discussion Thank you! Thank you! Comments? Questions? Comments? Questions? Contact info: Contact info:


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