1. Clinical Decision Support at Partners Healthcare Blackford Middleton, MD, MPH, MSc Corporate Director, Clinical Informatics R&D Chairman, Center for IT Leadership Partners Healthcare System Harvard Medical School Harvard School of Public Health

2. Overview: CDS Dimensions Provider workflow Provider workflow – Lookup – Alert – Interrupt – Actionable – Documentation- centric – Population (Cohort) Patient Relevance Patient Relevance – Non-specific – Specific/tailored Consumer Consumer – Lookup – Alert – Population (Cohort) Methods Methods – Inference methods (rules, etc.) – Temporal reasoning (protocols/pathways) – Values/Utilities (preferences: pt/provider) 5*2*3*3 = a minimum of 90 different approaches to CDS!

3. Partners CDS CPOE CPOE Alerts & Reminders Alerts & Reminders Actionable CDS Actionable CDS Documentation-centric CDS Documentation-centric CDS Population/cohort Population/cohort Patient-directed CDS Patient-directed CDS

4. Medication ordering -- main screen

5. KnowledgeLink in the Workflow

6. Secure Messaging Task Management Population Management Clinical Alerts Schedule Patient Lists Knowledge Links

7. CAD/DM Smart Form Smart View: Data Display Smart Assessment, Orders, and Plan Assessment and recommendations generated from rules engine Smart Documentation Lipids Anti-platelet therapy Blood pressure Glucose control Microalbuminuria Immunizations Smoking Weight Eye and foot examinations Lipids Anti-platelet therapy Blood pressure Glucose control Microalbuminuria Immunizations Smoking Weight Eye and foot examinations

8. CAD/DM Smart Form Medication Orders Lab Orders Referrals Handouts/Education

9. CAD Quality Dashboard Targets are 90 th percentile for HEDIS or for Partners providers Zero defect care: Aspirin Beta-blockers Blood pressure Lipids Zero defect care: Aspirin Beta-blockers Blood pressure Lipids Red, yellow, and green indicators show adherence with targets

10. Discrepancy Details

11. Serious Medication Error Rates Before and After CPOE Bates et. al. JAMA 1998.

12. Preliminary Results: Smart Form On Treatment Analysis <0.001 0.05 0.004 0.006

13. Patient Journal Causes Provider Activation Grant RW et al. Practice-linked Online Personal Health Records for Type 2 Diabetes: A Randomized Controlled Trial. Arch Intern Med. 2008 Sep 8;168(16):1776-82..Arch Intern Med. More medication changes in visits after diabetes journal submission:

14. An external repository of clinical content with web-based viewer Search Criteria Content Type… Specialty

15. Community (”Crowd”)Medical Professional Personal Health Information Network Science Rule builder Knowledge respository Rule engine Clin. Inf. System Petter K. Risøe HSPH HPM512 2009 ’Crowdsourcing’ Knowledge Engineering Patient

16. “I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.” Clem McDonald, MD NEJM 1976 Thank you! Blackford Middleton, MD bmiddleton1@partners.org www.partners.org/cird www.citl.org Where are we?