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Real-Time Surveillance for Rapid Correction of Clinical Decision Support Failures Allison Beck McCoy, MS

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Introduction <ul><li>Increasing implementation of CPOE and EMRs </li></ul><ul><li>Addition of decision support reduces errors, but also introduces potential for failures </li></ul><ul><ul><li>Unjustified provider overrides </li></ul></ul><ul><ul><li>Error-producing conditions within the technology </li></ul></ul><ul><li>Understanding of failures is critical </li></ul>

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Prior Surveillance Work <ul><li>Surveillance systems are often utilized to reduce errors </li></ul><ul><ul><li>E-mail notifications about patient conditions </li></ul></ul><ul><ul><li>Daily printouts or computerized monitoring by pharmacy of high-alert medications </li></ul></ul><ul><li>Real-time surveillance of decision support has not been implemented at the patient level </li></ul><ul><ul><li>Failures may not be apparent outside of the patient context </li></ul></ul><ul><ul><li>Technical failures and usage failures may be difficult to differentiate </li></ul></ul>

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Goal/Main Idea/Thesis (?) <ul><li>Common implementations of decision support for high-alert medications each have potential for failure and application for surveillance </li></ul><ul><li>Surveillance tool prototype </li></ul><ul><ul><li>Acts as a safety net for failures </li></ul></ul><ul><ul><li>Gives feedback to developers </li></ul></ul>

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Passive Alerts <ul><li>Interventions that display text without interrupting workflow </li></ul><ul><ul><li>Drug interactions </li></ul></ul><ul><ul><li>Changing lab values </li></ul></ul><ul><li>May be unnoticed or intentionally ignored </li></ul>

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Interruptive Alerts <ul><li>Interventions that interrupt workflow to display information and require an acknowledgment or response </li></ul><ul><li>Frequently overridden </li></ul>

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Order Sets <ul><li>Promote adherence to clinical guidelines </li></ul><ul><ul><li>Appropriate medications for a given condition </li></ul></ul><ul><ul><li>Appropriate drug monitoring </li></ul></ul><ul><li>May not be used or may be misused </li></ul>

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Complex Ordering Advisors <ul><li>Computerized tools that generate orders adhering to drug selection or dosing guidelines and protocols </li></ul><ul><ul><li>Dose calculations </li></ul></ul><ul><ul><li>Administration intervals </li></ul></ul><ul><ul><li>Appropriate monitoring </li></ul></ul><ul><li>May be confusing, or inputs may be incorrect or incomplete </li></ul>

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Surveillance Applications <ul><li>Safety net to prevent patient harm </li></ul><ul><li>Identification of frequent failures and generation of solutions </li></ul><ul><ul><li>User education </li></ul></ul><ul><ul><li>Redesign of decision support rules or method </li></ul></ul>

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Prototype <ul><li>Web-based dashboard </li></ul><ul><li>Available to developers, clinical pharmacists, and institutional leaders </li></ul><ul><li>Displays high-risk medication decision support usage across all adult units and services </li></ul><ul><li>Automatically populated at any point during a patient’s admission that targeted decision support is triggered </li></ul>

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Surveillance View <ul><li>Displays all currently admitted patients that have received decision support </li></ul><ul><li>Allows identification of patients at high risk for harm following multiple decision support failures </li></ul><ul><li>Allows identification of decision support with high failures rates </li></ul>

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Surveillance View

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Patient Detail View <ul><li>Displays a detailed timeline for an individual patient </li></ul><ul><ul><li>Orders, order administrations, lab values </li></ul></ul><ul><ul><li>Decision support interactions </li></ul></ul><ul><li>Allows understanding of provider actions and patient conditions in conjunction with decision support failures </li></ul>

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Patient Detail View

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Patient Detail View

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Requirements <ul><li>Electronic data </li></ul><ul><ul><li>Patient lab results </li></ul></ul><ul><ul><li>Ordering history </li></ul></ul><ul><ul><li>Decision support logs </li></ul></ul><ul><li>Monitoring staff </li></ul>

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Conclusions <ul><li>Surveillance team members can rapidly identify decision support failures, take actions to prevent further patient harm, and initiate improvement efforts </li></ul>

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Acknowledgments <ul><li>National Library of Medicine </li></ul><ul><ul><li>T15 LM 007450-07 </li></ul></ul><ul><li>PhD Committee </li></ul><ul><ul><li>Russ Waitman, Josh Peterson, Cindy Gadd, Bob Lobo, Jack Starmer </li></ul></ul>