1. Using the Electronic Health Record to Encourage Evidence-Based Practice Jonathan S. Einbinder, MD, MPH Partners HealthCare (jseinbinder@partners.org)jseinbinder@partners.org August 22, 2006

2. Outline Meeting information needs – the challenge Potential of electronic health record (and cautions) Partners HealthCare Signature Initiative Smart Forms Registries

3. 24 doctors and students observed 5 clinical questions per patient 74% concerned patient care --Osheroff 1991 Patient care information needs in a teaching hospital

4. Usefulness of medical information Usefulness = relevance x validity work to access --Shaughnessy, Slawson, Bennett 1994

5. The role of technology (the $64 question) How can informatics applications: identify information needs? provide useful information? change clinician behavior? change patient behavior?

6. A good place to start is basic management of information to help us do things that we know we should do. Make sure that patients reliably receive interventions known to be beneficial, leading to improved outcomes.

7. Getting past 55% performance… -- EA McGlynn et al. NEJM 2003;348:2635-2645

8. Established patient care strategies are not used Random sample of adults in 12 metro areas Survey and medical records review 439 indicators of quality of care for 30 acute and chronic conditions, as well as preventive care Key finding: Participants received 54.9% of recommended care -- EA McGlynn et al. NEJM 2003;348:2635-2645

9. Impediments to using current best evidence in clinical practice When to look for new evidence Where to locate relevant information How to synthesize it to determine optimal approach --Haynes et al., JAMIA 1995 Technology (electronic health record) can facilitate effective use of information

10. Diabetes Population Management Intervention: “Novel” population management software (registry) NP used weekly and emailed suggestions to PCPs. Results: More testing (A1C and LDL) at intervention clinic. No significant effect for med prescription, LDL and A1C levels. Grant et al. Diabetes Care 2004;27(10):2299-2305 But, consider the following examples:

11. OnCall: Population Management for Diabetes

13. Intervention: Evidence-based cardiac care suggestions, approved by a panel of local cardiologists and general internists, were displayed to physicians and pharmacists as they cared for enrolled patients. Results: The intervention had no effect on physicians' adherence to the care suggestions (23% for intervention patients versus 22% for controls). Tierney et al. J Gen Intern Med. 2003;18(12):1060-1. Computerized reminders for CHF/CAD

14. Computerized reminders for diabetes and CAD Intervention: Computerized reminders. Results: Diabetes reminders resulted in the recommended action in 19% of patients in the intervention group versus 14% of patients in the control group. Annual cholesterol testing HR 1.41, 95% CI 1.15–1.72 ACE inhibitors HR 1.42, 95% CI 0.94–2.14 Statin use – NS Annual eye exam - NS Sequist et al. J Am Med Inform Assoc. 2005;12:431–437.

15. LMR Summary with diabetes reminders

16. Problem: Proven effective medical interventions are not uniformly applied across health care settings. Goal: Set standards, improve clinical performance, and achieve national leadership levels of performance reliably across the system. Acute Myocardial Infarction (AMI) Congestive Heart Failure (CHF) Diabetes Pneumonia Smoking cessation Partners Signature Initiative III Goals and Scope

17. EMR Framework Adoption Get an EMR and use it Adoption Get an EMR and use it Effective Use Use key EMR features fully Effective Use Use key EMR features fully Smart Use Leverage EMR decision support Smart Use Leverage EMR decision support

18. Diabetes Decision Support Team Goal: Increase the number of providers using and patients with diabetes being managed with standard evidence-based decision support. How: Develop and deploy an integrated suite of information system tools to assist providers in caring for their diabetic patients. Specifically, this suite will include the Diabetes Smart Form, the Diabetes Registry, and the Diabetes Population Manager.

19. What are Smart Forms? Composite application for clinicians, combining documentation, orders, decision support Use by clinician during an office visit Support efficient workflow with decision support Built upon a foundation of clinical applications and services Data review Documentation Actionable decision support and orders

21. Decision Support: Highlights

22. Actionable decision support and orders

23. Smart Form origins AHRQ Smart Forms and Quality Dashboards grant 3 year, $1.2M project to evaluate Smart Forms for acute respiratory infection (ARI) and coronary artery disease (CD) in a randomized trial Signature Initiative 3 Potential of Smart Forms to promote adherence to evidence- based guidelines for diabetes. Smart Form for diabetes will be evaluated in randomized trial, along with ARI and CAD.

24. Smart Forms: Clinical and Quality Opportunity Address a critical obstacle to effective use of the EMR: integration of documentation and actionable decision-support in a streamlined workflow Positively impact clinical processes and outcomes Positively impact attainment of performance targets in reimbursement contracts Provide mechanism to help achieve goals and objectives for patient safety, disease management, and trend management (in ambulatory care settings)

25. Knowledge Management: Current Clinical Content and Guidelines Functional Knowledge Specification For ARI, CAD, DM: Iterative, painstaking, manual process involving clinical sponsors, developers, analysts – shepherded by KM. Able to build first Smart Forms Needs, issues became apparent Knowledge Specification approach defined. Technical Knowledge Specification Codes Rules Templates Logic

26. Knowledge Management: Future Over next year, infrastructure and processes will evolve: Tools Concept Dictionary Order Catalogue Template Editors Rule Editor Processes Guideline approval Functional knowledge spec. Technical knowledge spec. Maintenance and updating Clinical Content and Guidelines Functional Knowledge Specification Technical Knowledge Specification Codes Rules Templates Logic