Towards The Collaborative Development of Evidence-Based IT in Electronic Order Entry CMET 5

1. Towards The Collaborative Development of Evidence-Based IT in Electronic Order Entry CMET 5

2. Goals & Objectives • Bayside Health & Austin Health to work together • Implement & foster clinical practice change • Using evidence based Clinical Decision Support in an electronic orders entry system • Develop a template for clinical decision support • Develop a model for evidence based review • Utilise intellectual capital of medical staff to assist with training and evidence based review

3. Initial Liaison & Planning • Austin Health & Bayside Health met in Jan 2003 • Existing work regarding order sets & decision support reviewed • Research at Austin /Bayside discussed • Decision support protocols developed according to most impact eg. most prevalent DRG & problem areas • Ideas for clinical decision support & evidence based practice templates tabled.

4. Information Shared • ICU order sets -Bayside, ED order sets - Austin • ED survey questionnaire & research results -Austin • AMI protocols research - Bayside • Observation of MedTrak™ & Cerner™ at each health service • Learnings from each implementation • Serum Troponin protocol - Austin • Clinical decision support template - Austin • Methodology for evidence based practice - Bayside

5. Template Development • Literature search for decision support methodology • Arden Syntax model chosen as the basis for template • Reviewed & modified for project use • Tested with protocols • Structured English language eliminated • Logic flow chart now in place • Hyperlinks to evidence based practice • Audit function included • Review process

6. Maintenance The maintenance category specifies the information unrelated to the health knowledge in the MLM. These slots are used for MLM knowledge base maintenance and change control. Maintenance Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Title (Required Fields are highlighted in blue) Title Contrast Nephropathy Filename: - MLM's unique identifier - letter; then letters, digits, underscores (_) - length 1 to 80 - not a regular file (can have more than 1 MLM per file) Filename: austin-contrast-nephropathy; Version: - revision number (increment on each change) - a number = 1.00 with two decimal places version: Version:3.00

7. Maintenance Maintenance Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Institution: - origin of the MLM - free text - makes filename unique across institutions Institution: Austin Health Author/s: - who wrote the MLM – First Name, Middle Name, Last Name, Suffixes and Degrees Optional email address in parentheses Where MLMs are authored by special interest groups (SIG) or committees, the name of the committee precedes the names of the committee members Author/s: Rinaldo Bellomo MD Heather Davis RN Graeme Hart MD Frank Ierino MD Mark Brooks MD Jennifer Johns MD Mark Horrigan MD

8. Maintenance Maintenance Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Authorised By: - person, committee or special interest group in the institution (with the authority) who approved the MLM - same format as author/s - always blank on sharing specialist: Please note! This section should be left blank when transferring MLMs from one institution to another. Authorised By: Dir Nephrology Dir Radiology Dir ICU Dir Cardiology Clinical Governance

9. Maintenance Maintenance Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Responsible - person, committee or special interest group in institution who is responsible for ongoing review and maintenance of MLM Responsible Clinical Protocols Committee Date: date first authored date of last change date for review date expired Format for date is - YYYY-MM-DD also 1993-01-01T02:12:34.5 (ISO 8601) Date: First Authored 1995-09-11 Last change 2003-06-17 Review 2004-05-06 Expires 2004-09-30

10. Maintenance Maintenance Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Validation: production = approved for clinical care research = approved for clinical research testing = only for debugging, sharing expired = no longer in use review = under review If sharing between institutions Validation= testing Validation: Testing

11. Library The library category contains the slots pertinent to knowledge base maintenance which are related to the MLM's knowledge. These slots provide health personnel with predefined explanatory information and links to the health literature. They also facilitate searching through a knowledge base of MLMs. Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Purpose: Motivation for using the MLM - free text • Purpose: • Reduce incidence of contrast induced nephropathy. • Issue alert when physician orders Imaging study with contrast in patient with renal impairment

12. Library Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Explanation: How the MLM works, in detail - free text - can be displayed to the clinical users Explanation: If a physician orders an Imaging Study contrast, this rule retrieves most recent serum creatinine. If there is no recent creatinine the system issues an alert to the physician and asks if they want to order one and advises physician of risk criteria.If the last creatinine value is > 0.11 and < 0.18, the system issues an alert to the physician to consider the possibility that his/her patient has impaired kidney function and to consider using other contrast dyes or ordering another test. If the last creatinine is > 0.18 the system issues a warning to the physician that there is a significant risk of contrast nephropathy and if they still consider the test essential to invoke contrast nephropathy protocol or order an alternative test.There are a series of audit check boxes for the physician to fill in to account for exceptions

13. Library Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Keywords: Descriptive terms for indexing an MLM KB - list of terms delimited by semicolons - MeSH or UMLS terms preferred Keywords: creatinine, urea, renal failure, kidney failure, cat scan, ct scan, angiography, nephropathy, iodinated, contrast, prophylaxis,Angiogram, Angioplasty, Myelogram, Arthrogram,

14. Library Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) • Citations: • Support for the MLM in the literature • "Vancouver style" • " Harvard style" • Citations must be numbered serving as specific references. They can be web links or scanned documents in Adobe Format and can be assigned a type . • The types are: • Support: (S)these support, verify or validate the algorithm • Refute: (R) These refute or offer alternatives to the algorithm Citations: 1, S, Level I Barrett BJ, and Carlisle EJ: Meta analysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media. Radiology 1993; 188: 171-178 2, R, Level 1 Tippins RB. Torres WE. Baumgartner BR. Baumgarten DA. Are screening serum creatinine levels necessary prior to outpatient CT examinations?. Radiology. 216(2):481-4, 2000 Aug.

15. Library Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Citations: Level Of Evidence: Degree of support for the MLM in the literature based upon the level evidence. This will be based on the levels of evidence defined by the NHMRC Please click on the link to view: …\CDS Documents\NHMRC Levels of Evidence.doc 3, S, Level II Moore RD, Steinberg EP, Powe NR, et al: Nephrotoxicity of high-osmolality versus low-osmolality contrast media: randomized clinical trial. Radiology 1992; 182: 649-655

16. Library Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) • Internal Links: - institution-specific links to other information - eg: • electronic textbook • education modules • case studies • protocols • guidelines • procedures • expert searches (links) InternalLinks: http://armcpath/index.htm Protocol for Renal Protection from Intravenous Radiocontrast Nephropathy.doc http://armcnet/Departments/Radiology/patient_prep_sheets.htm

17. Library Library Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) External Links: - external links to other infomation - eg, electronic textbook, education modules, case studies, protocols, guidelines, procedures, expert searches – optional External Links: http://www.rcpa.edu.au/pathman/creatini.htm

18. Knowledge The Knowledge Category specifies what the Medical Logic Module (MLM) does. This module defines the terms used in the MLM (Data), the context in which the MLM should be evoked (evoke), the condition to be tested ( logic) and the action to take should the condition be true (action) Knowledge Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Type: - Specifies which slots are contained in the knowledge category, it is a required code. Eg Data-Driven (derived from the database in the computer system) Type: - Data Driven Data:Terms must be mapped to a database by a read statement. Can have operators such as first, last, min, max, count, average sum, if, then Data: Last_creat = read last {"creatinine level"}

19. Knowledge Knowledge Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Priority: Specifies relative order in which MLMs are evoked ( 99 is highest priority and is evoked first, 1 is lowest priority and is evoked last. If not specified the default value is 50 Priority: priority: 50 • Evoke: The evoke slot defines trigger/triggers an MLM eg: • The occurrence of an event • Timed execution after an event • Periodic repetition after an event • Direct call from another MLM Evoke: An order for {"CT Scan, Angiogram, Angioplasty, Myelogram, Arthrogram, etc”}

20. Maintenance Logic: Set of medical criteria Logical algorithm (Flow Chart) Ends with a “Conclude Statement” Conclude (True or False, Yes or No) Please note: The logic for this algorithm is to be represented in flow chart format. Eg. Please click on this link to view flow chart: CDS Documents\Logic Flow Contrast Nephropathy3.doc

21. Knowledge Knowledge Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) • Action:Carries out action if logic slot concludes true: • Write a message to screen • Generate hyperlink to file • Store a message in a file • Call another medical logic module Action: Write alert -text to screen is (1) is true/yes (1) “ last Creatinine > 0.13 consider impaired kidney function when ordering contrast studies” • AuditCarries out audit function if logic slot concludes false: • Write a check box to screen • Write a questionnaire to screen • Audit • Write check box to screen if (1 or 4) is false/no "Indicate Reason • Emergency • External Creatinine Results • Patient Choice • Clinician Overide"

22. Knowledge Knowledge Definition (Required Fields are highlighted in blue) Example (Required Fields are highlighted in blue) Urgency: Determines importance of action if the MLM concludes true 1 (Low urgency) to 99 (High urgency) Urgency: 70

23. Evidence Review Process

24. Suggested Approval Process

25. Approval Process Second Stage

26. Learnings • System must be user friendly • Decision support more helpful for the inexperienced • Educational support a must • Physician buy- in difficult • Personal approach works best • Extensive clinical consultation required • Protocol implementation & testing resource intensive • Protocol development can be complex • Protocol review requires automation

27. Approval Committee Role

28. Learnings • System must be user friendly • Decision support more helpful for the inexperienced • Educational support a must • Physician buy- in difficult • Personal approach works best • Extensive clinical consultation required • Protocol implementation & testing resource intensive • Protocol development can be complex • Protocol review requires automation

29. Change Management • Planned program • Knowledge management tools • User group involvement - whole of hospital approach • Change ownership- user own knowledge • Training & awareness communications utilising intranet • Ongoing support through clinical governance, IT & clinician education • Management buy in imperative