WAEMRO’s approach to clinical decision support

1. WAEMRO’s approach to clinical decision support Professor Peter Sprivulis MBBS PhD FACEM FACHI

2. The clinical decision problem in healthcare • There is a plethora of resources available to clinicians to help them make good clinical decisions • Despite this, us clinicians repeatedly ‘drop the ball’ • We forget to ask, examine or order things • We don’t integrate clinical decision tools into our work-a-day practice • We don’t follow and don’t explain why we don’t follow simple guidelines for good practice • Patients suffer and our health system suffers because of these human frailities

3. An illustration, atrial fibrillation….. • 50 year old presents with a first episode of atrial fibrillation lasting for four hours • Seven different emergency physicians or registrars will investigate and manage this patient in the same ED differently, just based on the options below: • K+ topped up or not • Mg++ topped up or not • IV or oral antiarrthythmic – several choices or none • IV or oral rate control – several choices or none • Electrical defibrillation

4. The consequences of variation • Of the seven variations of managing this patient used by the seven different experienced ED doctors: • Six variations will be safe • Of these, three variations will be effective • Of these three, one variation will be the cheapest • Constraining the amount of variation reduces costs, increases safety and ensures effectiveness • Provided we deliver the best variation reliably, despite being human!

5. 60% 50% Increased percentage of effective expenditure 50% 90% Increased reliability of service delivery Across an entire healthcare system, choosing the best management variation and reliably delivering it increases value geometrically

6. So how can we achieve this? * See for example http://www.ncbi.nlm.nih.gov/pubmed/17598674 ** See for example http://www.ncbi.nlm.nih.gov/pubmed/22041642 • We know that integrating the preferred management plan into the clinical documentation process reduces variation and increases reliability • At least when using cellulose clinical path documentation* • Also, clinicians HATE ‘pop up’ decision support windows that appear in the middle of something when using computerised decision support systems • But we can cope with checklists**

7. WAEMRO aims to integrate the ‘smarts’ as convenient and clinican friendly documentation. eg:

8. Later steps • WAEMRO will aim at integrating third party tools across the web with its CODI documentation templates • Embed the decision support • Flow data back to registries for research and quality improvement activities • Many examples of these: • National diabetes • National heart foundation • MIMIC chest pain registry

9. Take home messages • None of us is reliable • Well designed online tools can help • WAEMRO’s aims to integrate decision support as part of the everyday clinical work flow/documentation process • For more information, visit WAEMRO at www.waemro.net