Integrated Asthma Decision Support System Med Info 406 – Winter 2009 Joan Baird Nudrat Hassan James Ellzy

Overview Chronic inflammatory condition Estimated cost $14 billion by NHLBI National Asthma Education and Prevention Program (NAEPP) guidelines Patient and practitioner compliance low

CDSS goals Provide patients with consistent, high quality, safe asthma care Fewer visits to ED/physicians Minimal missed work/school PHR portal for patient input Access to current clinical practice guidelines, clinical pathways Disease management through ICD-10, NDC codes & order sets

Stakeholders

Change Management Assess “Current State” Envision / Design “Future State” Perform gap analysis Confirm future state – design phased strategy for implementation and rollout Implement, evaluate, and recommend improvements Continually review for process improvement and IT enabler opportunities Perform before and after evaluation-metrics

Current State of Asthma DSS Non integrated approaches Paper based “cheat sheets” Internet-based CDSS Currently no approaches that directly alert users of an EMR are available.

Chosen Model CDSS to assist clinical team and patients in maximizing management of chronic asthma System assists in choosing the appropriate Action for Treatment by Systematically classifying both Asthma Severity and Asthma Control Alerting the provider if chosen treatment plan does not agree with clinical practice guideline recommendations

Assess Asthma Severity Intermittent Persistent Mild Persistent Moderate Persistent Severe Well Controlled Not Well Controlled Poorly Controlled ADJUST THERAPY: Well controlled – maintain current step Not Well controlled – step up 1-2 steps Poorly controlled – consider steroids and step up 1-2 steps Well Controlled Not Well Controlled Poorly ControlledWell Controlled Not Well Controlled Poorly ControlledWell Controlled Not Well Controlled Poorly Controlled Assess Asthma Control National Asthma Education and Prevention Program: Guidelines for the Diagnosis and Management of Asthma Asthma patient presents for f/u

Asthma Severity National Asthma Education and Prevention Program: Guidelines for the Diagnosis and Management of Asthma

Asthma Control National Asthma Education and Prevention Program: Guidelines for the Diagnosis and Management of Asthma

ADULTS

System Architecture Assumptions Clinician - EMR system in place Ordering – Medications Documentation Plans of Care Reporting Centralized Patient Data Repository Patient - PHR Health History Self Assessment Forms Disease Management Guidelines Web-Interface

Input into the System Inputs Data from EMR Severity Control Therapy Data from PHR Symptom Reporting Self Assessment Aggregate Data from Reporting Engine

Output from the System Alerts Unsolicited Provided when therapy does not match severity and control Logic for adjustment of therapy provided End-User is able to override or by-pass alert

Evaluation – Verification/Validation Verification Was it built right? Does the system alert when needed? Does it unnecessarily alert? Validation Was it the right thing to build? Is it changing decision makers to follow clinical guidelines? Are users following alerts?

Evaluation – Clinical Efficacy Fewer asthma exacerbations Improve appropriateness of overall workup and treatment plan for a given situation Fewer ER visits for asthma exacerbation because patients are appropriately managed Optimize treatment of chronic conditions over time Fewer asthma office visits because asthma is appropriately addressed at all visits Improved compliance with care guidelines Improved patient functional level Less sick days because patient complies with self treatment plan

Discussion: Limitations Classifying asthma severity and monitoring asthma control System must address age groups-limitations Chronic disease management Patient engagement critical

Discussion: Implementation Assumptions/scope Outpatient clinic Follow-up visit Workflow integration EMR/PHR Future extension Integration with long-term or inpatient care

Questions?