1. Family Medicine Residency Program
STFM Spring Conference, May 1, 2008
Wouldn’t It Be Nice If . . .
Information Tools That Automate Common Clinical Practices
Gregory Sawin MD, MPH
Allen Shaughnessy, PharmD
Intro - - “What brought you to this session?”
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2. Family Medicine Residency Program
Choose your adventure
What the *?%!# are they talking about?
Why should I care?
How do I build/use these tools in practice?
What’s possible? To infinity and beyond!
Take the temperature of our audience to decide which direction to take our presentation.
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3. All Questions Welcome Here
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4. Family Medicine Residency Program
“Work Smarter, not harder.”
Scrooge McDuck
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5. How can these systems help
Computer systems – EHR
Point-of-care information
Engaging your patients
Communicating risks and benefits
Building Clinical Teams
2. POC Info - Ely JE. Analysis of questions asked by family doctors regarding patient care. BMJ 1999;319:358-61
Average 1 question for every other patient
They’re important
Only 1 in 3 questions pursued
Found “answer” 80% of time
Guess at 70-80% of information needs!
Journals only used to answer 2 of 1101 questions in busy practice
Books, colleagues used most often
½ of the time <60 seconds was devoted to answering the question
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6. Family Medicine Residency Program
Nearly all of these things will require us to leave our comfort zones.
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7. Pushing and Pulling Information
“Work Smarter, not harder.”
Scrooge McDuck
Ask audience to define difference between pushing and pulling information and start pointing to thinking about new ways to get information, i.e. “beyond the book”
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8. What makes a system work?
Automated decision support as part of clinician workflow
Gives recommendations rather than just assessments
Decision support at the time and location of decision making
Computer based decision support
Meta-analysis with 70 studies. Studies were assessed for statistically and clinically significant improvement in clinical practice and for the presence of 15 decision support system features whose importance had been repeatedly suggested in the literature.
Decision support systems improved clinical practice 68% of the time.
30/32 (94%) of studies with all 4 factors improved clinical practice.
direct experimental justification was found for providing periodic performance feedback, sharing recommendations with patients, and requesting documentation of reasons for not following recommendations.
Kawamoto,K.; Houlihan,C.A.; Balas,E.A.; Lobach,D.F. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ, 2005, 330, 7494, 765
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9. Smarter Electronic Health Records
Automated calculation of BMI
Documentation of obesity (BMI ≥ 30) improved from 31% to 71%
Documentation of treatment of obese patients also improved, from 35% to 59%
EHR – replacing paper charts but doing more. Doing things with your data fields.
What else would be helpful to have automatically calculated: Peak flows, NCEP cholesterol goals, Framingham Heart Data?
Automated reminder systems have shown improved delivery of preventive care and immunization.
Richard Bordowitz, MD, MPH; Kimberly Morland, PhD; Douglas Reich, MD
The Use of an Electronic Medical Record to Improve Documentation and Treatment of Obesity. Family Medicine. April 2007
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10. Family Medicine Residency Program
UVA Discount Formulary
Christakis et al. A Randomized Controlled Trial of Point-of-Care Evidence to Improve Antibiotic Prescribing Practices for Otitis Media In Children. Pediatrics. 201;107.
Results. Intervention providers had a 34% greater reduction in the proportion of time they prescribed antibiotics for <10 days. Intervention providers were less likely to prescribe antibiotics than were control providers
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11. Family Medicine Residency Program
“Pushed” recommendations based on diagnosis - - see yellow boxes making recommendations for this diabetic.
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12. Family Medicine Residency Program
Beware TMI!!
Beware the Pop-up. Avoid annoyance with Too Much Information (TMI)
With point of care information goal should be to have things just 1 click away - - or as few clicks as possible.
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13. Family Medicine Residency Program
Talking about risk →
Essential Evidence Plus
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14. Family Medicine Residency Program
Should we leave both Happy face examples in? Maybe this first one to introduce the concept since it has the nice boxes telling folks what it means, then use the Abx in ear infection next.
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15. See: http://www.nntonline.net or http://www.npci.org.uk/
Children with ear pain after days, without treatment
Children with ear pain after 2 – 7 days, with treatment
Additional children experiencing diarrhea, vomiting, or rash during treatment
This is for treatment of Acute Otitis Media right?

16. Family Medicine Residency Program
Do I have Strep Throat?
Who should fill this in?
Doctor
Nurse
Tech
Front Desk
Mom
Patient
Simple algorithm many of us do in our heads when we see patients with sore throat – but could someone else do it for us? Nurse, MA, Even patient themselves.
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17. Building Clinical Teams
“Work Smarter, not harder.”
Scrooge McDuck
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18. Family Medicine Residency Program
Screen shot of Epic Health Maintanence fields - aka “prevention to-do list” based on patient’s age, sex and diagnoses.
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19. Family Medicine Residency Program
Registry
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20. There is no box ~ think liberally
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21. Thanks for your participation!
Gregory Sawin MD, MPH
Allen Shaughnessy, Pharm.D.
Family Medicine Residency Program