Integrating Healthcare Information Technology (HIT) into Clinical Practice

1. Integrating Healthcare Information Technology (HIT) into Clinical Practice David K. Ahern, PhD, Thomas C. Bailey, MD, Charles B. Eaton MD, MS, David C. Goff, Jr, MD, PhD, Jeffrey Rothschild, MD For the Innovative Strategies Writing Group

2. Objectives • Illustrate approaches using information technology to improve adherence to guidelines • Identify selected barriers and facilitators for these approaches • List some of the preliminary lessons learned

3. Study Approaches Using HIT Project Project description Technology Assisted Academic Detailing (Bailey) Automated ID of inpatient candidates for primary and secondary CHD prevention to facilitate academic detailing Cholesterol Education And Research Trial (Eaton) Waiting room patient activation software combined with PDA-based decision support for cholesterol management Guideline Adherence for Heart Health (Goff) PDA-based decision support and academic detailing for cholesterol management Transfusion CDS (Rothschild) CPOE-based decision support for inpatient transfusions

4. TAAD, CEART, GLAD, T-CDS CEART Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4.

5. Technology Assisted Academic Detailing (TAAD) Bailey et al • Automated identification of inpatient candidates for CHD prevention medications, coupled with pharmacist-mediated academic detailing to improve adherence to: • CHD secondary prevention guidelines for patients with AMI • Cholesterol lowering guidelines for patients with diabetes • Patient identification using automated screening • CHD/AMI – troponin-based screening • DM – algorithm based on prior ICD-9, glucose, HA1c, medications

6. Alert generated from patient data Pharmacist reviews alerts and evaluates for intervention Pharmacist approaches physicians with intervention

7. Barriers to TAAD • Workflow issues • Timing of alert generation, response • Short lengths of stay • Screening/alert to intervention time must be efficient • Personnel issues • Prospective intervention requires personnel to handle alerts

8. Facilitators of TAAD • IT infrastructure • Flexibility to adapt to workflow • Efficient methods of candidate identification • Dedicated pharmacist resources • Pre-existing pharmacist and physician culture • High profile issues of recognized importance • Both external and internal pressures to succeed

9. Lessons Learned from TAAD • Technical efficiencies make the impossible possible • Resource and workflow constraints are critical considerations • In asynchronous mode of decision support, must make sure physicians follow through • A pharmacist champion coupled with regular performance feedback is key

10. Cholesterol Education and Research Trial(CEART) Eaton, et al Pt activation tool

11. PDA Decision Support Tool with Patient Education Screen

12. Barriers to CEART & GLAD • Some patients were not technology oriented and wouldn’t use computer kiosk (CEART) • Varying physician experience with PDAs and technology for decision support • Physician workflow (and apparel) issues

13. Facilitators to CEART & GLAD • Design and development of tools based upon qualitative and formative research with patients and physicians • Training and reinforcement in use of tools • Academic detailing regarding guidelines • Inclusion of other software (e.g, ePocrates) • Mobility and efficiency of PDA as a platform for decision support tool • Appeal and ease-of-use of patient activation tool (CEART)

14. Lessons Learned from CEART & GLAD • Both patients and physicians need training and reinforcement in use of technology • Both technical and organizational challenges need to be addressed • Clinical decision support enabled by HIT requires integration with workflow

15. Questions ?