1. PHS / Department of General Practice Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn Clinical Prediction Rules as a basis for Clinical Decision Support HISI Conference, Dublin, 18 th November 2010 Derek Corrigan, Borislav D. Dimitrov, Tom Fahey

2. PHS / Department of General Practice Overview Brief overview of work HRB Centre for Primary Care Research What is a Clinical Prediction Rule (CPR)? What is a Clinical Decision Support System (CDSS)? What role can Clinical Predication Rules play in a CDSS? What form might a state of the art CPR based system look like? What are the challenges to achieving this state of the art?

3. PHS / Department of General Practice HRB Centre for Primary Care Research On-Going Work –Clinical and health informatics staff working on compiling a definitive register of Clinical Prediction Rules (CPRs) for use in Primary Care based on systematic reviews of clinical literature Ultimate Aim – e-Register –Provide an electronic register of CPRs suitable for Primary Care –Fully searchable –Fully documented

4. PHS / Department of General Practice Definitions – Clinical Prediction Rule Clinical Prediction Rule –Formalised clinical tools that quantify the contribution of Patient History – e.g. History of high blood pressure Physical Examination – e.g. Fever Diagnostic Tests – e.g. Blood count tests –Stratify patients diagnosis Probability of having target disorder based on scoring system –Outcome can be in terms of diagnosis, prognosis, referral or treatment

5. PHS / Department of General Practice An Example – CRB 65 Rule - Pneumonia Confusion, Respiratory Rate >= 30 /min, BP : SBP< 90 mm Hg or DSP <= 60 mm Hg, Age >= 65 years 0 1 OR 23 OR 4 Mortality Low Mortality Intermediate Mortality High Likely Home Treatment Likely Hospital referral and assessment Urgent Hospital CRB Score Rule Criteria Risk Decision

6. PHS / Department of General Practice

7. Definitions - Clinical Decision Support System Clinical decision support system (CDSS) –I.T. based systems that are designed to improve clinical decision making by suggesting possible clinical actions/interventions based on an underlying clinical evidence base CDSS Types –Diagnostic systems – diagnose appendicitis –Reminder systems – generate patient letters –Disease management systems – diabetes management –Drug dosing/prescribing – insulin, warfarin

8. PHS / Department of General Practice CDSS – The Electronic Patient Record The Electronic Patient Record (EPR) has long been viewed as a holy grail in Health Informatics Some conflicting debate about what the quantifiable benefits of the EPR are, if any Tend to view EPR in the context of a single patient Doesn’t always take into account the potential when EPRs are looked at collectively from a research perspective – this may be their real power!

9. PHS / Department of General Practice CDSS – Maintaining the Evidence Base Huge potential evidence base in EHRs in primary care e.g. General Practice Research Database in UK (GPRD) Create clinical trials/ epidemiological studies from primary care data May be used to amend an existing CPR i.e. the inclusion of additional symptoms/signs identified by data analysis as potential diagnostic cues May be used to create new CPR’s based on new diagnostic cue combinations Evidence base becomes “self-learning” and adds or refines the list of CPR’s used as the evidence base

10. PHS / Department of General Practice Implementation of Research Evidence

11. PHS / Department of General Practice The TRANSFoRm Project “Translational Research and Patient Safety in Europe” 5 Year EU funded research project – just started 17 Participant bodies including the HRB Centre Leading Work Package 4 – “Decision Rules and Evidence” Bridge clinical research and primary care practice – will involve validation in Irish GP sites

12. PHS / Department of General Practice TRANSFoRm Work Packages

13. PHS / Department of General Practice The TRANSFoRm Project

14. PHS / Department of General Practice 1 CPR Repository Clinical Prediction Rules Service TRANSFoRm Services 5 CPR Data Mining and Analysis 3 Research Study Designer 2 Distributed GP EHRs With CDSS CPR Analysis & Extraction Tool CP Classifier CP Rules Manager Study Criteria Design Find Eligible Patient 4 Research Study Management Recruit Eligible Patient Study Data Management

15. PHS / Department of General Practice Define Study Eligibility Criteria – Electronic Primary Care Research Network (Epcrn)

16. PHS / Department of General Practice Gather Study Data - Case Report Forms - ePCRN

17. PHS / Department of General Practice How can this improve Patient Safety? Diagnostic error is the major threat to patient safety in the context of the primary care setting TRANSFoRm uses CPRs to broaden the evidence base considered by GPs to support inclusion / exclusion of diagnostic hypotheses for any particular case – not just previous patient history By implication, decreasing the possibility of diagnostic error will improve patient safety Bridges the gap between implementing evidence based care research in the primary care setting

18. PHS / Department of General Practice TRANSFoRm Challenges The EPR –Still a huge amount of work to be done just to create usable EPRs System Interoperability – consistent representation of clinical data using technologies –Health Level 7 (HL7), OpenEHR – pool and share clinical data by allowing systems to ‘talk together’ Semantic Interoperability – being able to interpret clinical concepts contained within data in a consistent way –Clinical Coding Terminologies such as SNOMED-CT, ICPC, ICD

19. PHS / Department of General Practice In Summary CPRs have huge potential as a form of evidence in CDSS A number of technical challenges exist – system/semantic interoperability Future directions - develop the Electronic Patient Record and incorporate research tools to generate and update the evidence base – “self-learning”

20. PHS / Department of General Practice Thank You Discuss!