Five Informatics Issues in Clinical Practice Topics in Clinical Management Course February 5, 2007 Daniel R. Masys, M.D. Professor and Chair Department of Biomedical Informatics Professor of Medicine Vanderbilt University School of Medicine

Biomedical Informatics Discipline that addresses “...the cognitive, information processing, and communications tasks of medical practice, education and research, including the information science and technology to support these tasks” (Greenes & Shortliffe, 1990) The art and science of organizing knowledge of human health and disease, and making it available and useful for problem solving.

Informatics vs. Information Technology (IT) and Data Processing Informatics uses Information Technology as an infrastructure, but is focused on the semantics of what information means E.g., a data processing system reports a serum K+ value; an informatics system knows that serum K+ has implications for cardiac & renal physiology, drug-drug interactions and drug dosing

Goals for Effective Healthcare Deliver the right services to the right patient at the right time. Do not deliver services that will not help the patient. Deliver services that are cost effective. Do nothing to harm patients or health care workers. Respect each patient’s unique needs and preferences. Why is this hard to do, and getting harder?

Issue 1: Too Much to Know

Growth of new information The Biomedical Literature Molecular Life Sciences                                                                  MEDLINE: 15 Million journal articles Growing at 576,000 new articles per year GENBANK as of Feb 2007: 2.47 million genes 85+ Billion DNA base pairs

Be diligent. Read two journal articles every night Be diligent. Read two journal articles every night. At the end of a year a you will be 1275 years behind the literature. Assume only 1% of the new literature is relevant to what any individual physician does. At the end of a year you are 12 years behind.

(Partial) solution: Just-in-Time Learning Issue 1: Too Much to Know (Partial) solution: Just-in-Time Learning Wireless-enabled PDA

Issue 2: Fallibility of your own memory and that of colleagues

The Two Sides of Errors Commission Omission 44,000+ hospital deaths due to medical error 50 adverse events/1000 outpatient pt-years (Gurwitz 2003) Patients receive 55% of recommended care (McGlynn, 2003) Commission Omission

Issue 2: Fallibility of your own memory and that of colleagues (Partial) solution: Consult the literature early and often

…we just don’t know which half Issue 3: Half of what you have learned in med school will be shown to be incorrect …we just don’t know which half (Partial) solution: Don’t assume that nothing has changed since the last time you saw a similar case. Refresh your knowledge a patient at a time

Issue 4: More factors bear on many clinical decisions than unaided human cognition is capable of handling Citation classic ref.: Human Problem Solving Simon and Newell, 1972 Observation: To solve problems that exceed 4-7 inputs, humans extinguish inputs to simplify the problem

The world of personalized, molecular medicine

Issue 4: More factors bear on many clinical decisions than unaided human cognition is capable of handling (Partial) solution: Seek practice environments that provide patient-specific clinical decision support. You will need it.

Clinical Decision Support

35 30 Errors per 100 Orders 25 20 15 10 5 pre-CPOE post-CPOE Computerized Provider Order Entry (CPOE) at Vanderbilt 35 30.1 30 25 Errors per 100 Orders 20 15 10 6.8 5 2.2 1.3 0.2 0.1 pre-CPOE post-CPOE Potential ADE's Medication Prescribing Errors Rule Violations Potts, A. et al. PEDIATRICS 2004;:113:59-63

RxStar Provides Guidance, Alerts and Reminders Dosing and allergy alerts Include some screen snapshots Serifed fonts (avoid)

Issue 5: Changing roles of providers: from captain of the ship to coach

MyHealth portal at Vanderbilt: 25,000 users, increasing 1K/mo 1500 sessions/day

Clinical Practice in the Information Age

Issue 5: Changing roles of providers: from captain of the ship to coach (Partial) solution: Stay flexible, learn new communications tools (e.g., patient portals) and roles, enjoy the ride

Summary

Five Informatics Challenges in Clinical Practice Issue (Partial) solution 1. Too much to know Develop skills in Just-in-Time learning 2. Fallibility of your own memory and that of colleagues Consult the literature early and often 3. Half of what you have learned in med school will be shown to be incorrect Don’t assume that nothing has changed since the last time you saw a similar case

Five Informatics Challenges in Clinical Practice, cont’d Issue (Partial) solution 4. More factors bear on clinical decisions than unaided human cognition is capable of handling Seek practice environments that provide patient-specific clinical decision support 5. Changing roles of providers: from captain of the ship to coach Stay flexible, learn new communications tools (e.g., patient portals), enjoy the ride

The only thing we know for sure about the future is that it will be different -Alan Kay

Vanderbilt can do it. We can help.