Decision Support for Diabetes: Embedding Knowledge in Care Processes

1. Decision Support for Diabetes: Embedding Knowledge in Care Processes Dr Ann Wales, Programme Director for Knowledge Management. NHS Education for Scotland Ann.wales@nes.scot.nhs.uk

2. Who is involved? • Dr Ann Wales and Mr FaiyazShaik, NHS Education for Scotland • Dr Rebecca Locke and SCI-Diabetes Team, NHS Tayside. • Dr James Walker, NHS Lothian • Dr Nicholas Conway, University of Dundee • Digital Health Institute for Scotland. • No conflict of interest

3. Overview • Aim • Drivers • 3. Methods • Research question • Technical approach • Analysis and evaluation • Initial results • 5. Implications for future national decision support.

4. Aim • Improve safety and reliability in applying evidence-based guidelines for diabetes…..in a way that reflects the reality of clinical practice…. • in a context-sensitive manner • that responds to individual patient needs • including complex care needssuch as co-morbidities.

5. Drivers

6. Challenge of Long Term and Multiple Conditions • In the United Kingdom: • Long term conditions affect 1 in 5 people • 80% of general practice consultations • Costs £23.7bn per annum - 10% of NHS annual spend. • In Scotland: • 77% of people with diabetes in Scotland have co-morbidities. • 38% are taking more than 5 medications.

7. Limitations of Research Evidence • Classic research evidence, guidelines and pathways focus on single conditions and standardised study populations. Context: Overestimation of impact in research studies compared with real-life contexts. Ioannidis, 2011. Personalisation: Limitations in applying research results and guidelines to individual patients with complex needs. Kent, 2007; Lutgenberg, 2009.

8. New Paradigm for Evidence-Based Practice • We need to find innovative ways of integrating knowledge from research and practice into clinical workflow to: • Improve reliability of care • While • Contextualising and personalising care • Responding to complex care needs especially co-morbidity and polypharmacy.

9. NHSScotlandKnowledge into Action Strategy • help practitioners to applyknowledge in the realities of day to day frontline practice. • embed use of knowledge in healthcare improvement..

10. Methods

11. Research Questions • How does decision support derived from condition-specific, research-based guidelines need to be tailored and adapted for local contexts and individual patients with complex needs such as multiple conditions? • What factors influence implementation and spread of such tailored decision support across healthcare organisations? • Inform recommendations for decision support in NHSScotland.

12. Choice of Decision Support Platform • Requirements: • Capability to interact with multiple clinical systems. • Editing of decision support scripts and links. • Shared pool of decision support scripts. • Localisation of scripts. • Selection – EBMEDS from Duodecim

13. Technical approach • Integration in SCI-Diabetes – national electronic health record system for diabetes in NHSScotland. • Community of practice converted SIGN guideline recommendations into 17 decision support scripts, e.g: • TSH monitoring • UKPDS Risk Engine • Weight gain • Recall of patients for retinal screening • Mapping codes in patient record system to elements in scripts. • Prompts, reminders, alerts • Links to national evidence, local handbooks and pathways

14. Example: Glitazone Prescribing Script • Links: • Full message • Calculators, Formulary, Patient information.

16. Care Alerts/Reminders Care Alerts/Re

17. Quality Improvement Cycles Cycle 3 <COP> Sites 1-4 Spread Improvement Cycle 2 <COP> Sites 1-3 Improvement Cycle 1 <COP> Site 1 Case controls 1 5 10 15 Month

18. Evaluating Impact – Outcomes Chain • Case-control comparison of HBA1c, • blood pressure, cholesterol, UACR • Patient Reported Experience Measures Long-term Outcomes INDIRECT INFLUENCE • Case-control comparison of clinical processes. Practice change • Before-after comparison of system navigation data. Capacity & Capability DIRECT INFLUENCE Technology Acceptance Questionnaire Focus group and community feedback. Reach & Reaction Numbers of clinicians accessing prompts. Number of prompts accessed. Activities/ Outputs DIRECT CONTROL Inputs

19. Pre-intervention attitudes

20. Emerging Results – First Cycle • Unified Theory of User Acceptance of Technology (Ventaktesh, 2003; • Heselmans et al 2012)

21. Community of Practice Feedback • Has influenced some decisions – investigations, prescribing. • Script changes. • Overriding of prompts when in patients’ interests – e.g.co-morbidities; personal circumstances. • Facility to turn off individual scripts important. • Different prompts relevant to primary and secondary care. • No time to read underlying guidelines/evidence. • Full message needed in pop-up. • Interest in recording use for CPD.

22. Emerging Implications for National CDSS • Responsive and flexible system, continually adaptable to user needs. • Segmentation of clinician needs – generalist and specialist. • Facility to override, turn off prompts • Links across patient care pathways for multiple conditions. • Combined decision support for guidelines and medicines. • Link with CPD recording

23. Summary: “Adaptive” Evidence-Based Practice • Using quality improvement, programme evaluation and research methods to contextualise and personalise evidence-based practice for complex care needs. • Decision support as vehicle to combine knowledge from research, practice, patient and professional experience to improve quality of care.

24. Decision Support for Diabetes: Embedding Knowledge in Care Processes Dr Ann Wales, Programme Director for Knowledge Management. NHS Education for Scotland Ann.wales@nes.scot.nhs.uk