HIT Asthma. A tale of woe & enlightment,

H IT A s t h m a www.CenterForUrbanHealth.org

a t a l e o f wo e a n d
e n l ig h t e n me n t

Yiscah Bracha, M.S.
ybracha@CenterForUrbanHealth.org

AHRQ Annual Meeting
09SEP08

P r o je c t O b je c t iv e :
www.CenterForUrbanHealth.org

• Demonstrate use of HIT to improve
ambulatory asthma care
• Two existing technologies:
 Interactive Asthma Action Plan (IAAP)
(developed by MN Dept of Health)
 Commercially available electronic health
record (EHR) (EpicSystems Inc.)

Wha t w e k ne w :

• For asthma, IAAP beats Epic in user and
patient friendliness
• Difficult for Epic user to get to IAAP
• Untapped potential to use EHR data to
support QI

Wha t w e w a nte d to
propos e : www.CenterForUrbanHealth.org

• Make IAAP available from within Epic-
driven workflow
 Brings guidelines to the point of care
• Use IAAP database as asthma registry
 Evaluate effect of QI initiatives
 Identify at-risk patients
 Generate reports required by external
agencies

O n e s m a ll p r o b le m …

• Existing IAAP based on guidelines
released in 2002
• 2007 guidelines soon to be released
• Our project would link the EHR system to
a soon-to-be-obsolete tool

W h a t w e a c t u a lly
propos e d: www.CenterForUrbanHealth.org

• Update IAAP to be consistent with 2007
guidelines
• Make updated IAAP available from within Epic-
driven workflow
 Brings new guidelines to the point of care
• Use IAAP database as asthma registry
 Evaluate effect of QI initiatives
 Identify at-risk patients
 Generate reports required by external agencies

E x p e c t e d c h a lle n g e s

• Accessing IAAP from Epic
 Pushes boundaries both technically &
organizationally
• Creating & using asthma registry
 Technology well-understood; organizational
barriers to readiness
• Updating IAAP
 Trivial technically; no impact organizationally

3 m o n t h s a f t e r p r o je c t
in c e p t io n : www.CenterForUrbanHealth.org

• IAAP-EHR interface:
 Technical boundaries identified
 Organization is ready within those boundaries
• Registry
 Organizational barriers quickly overcome
 Demanding to establish what fields to pull, but
a well-understood task.
• Update IAAP ….

F a m o u s la s t w o r d s :

• “It will be simple to update the existing
IAAP to make it consistent with the new
guidelines”

Oops :

• Original IAAP contained:
 Out-of-date, unsupported version of Java
 Database not designed to support analysis
 List of meds not designed to be updated
• “Update” of any kind not possible
 Radical shift in perspective from 2002 to 2007
 FROM: Treating acute symptoms
 TO: Managing chronic disease

T h e s t r u g g le :

• Clinicians try to convert guidelines directly
into screens:
 They get trapped in logical circles from which
they cannot escape
• Analytically-minded Project Director tries
to display their thinking in flow diagrams
 Clinicians can’t follow the diagrams
• Many expressions of frustration
exchanged!

S ome c onc e rns :

• Close scrutiny of guidelines reveals:
 Ambiguous and/or internally inconsistent
recommendations:
 Inadequate dosing instructions for young children
 Recommendations for formulations not available
commercially
 Recommendations for off-label uses of drugs
 Drugs for young children not approved by FDA

More c onc e rns :

• Even with close scrutiny, no answers to
front-line clinical questions:
 What should the dosing instructions be in the
“red zone” of the asthma action plan?
 How can we determine the current treatment
step for a new patient who is already
receiving asthma care?

A n d m o r e s t r u g g le s :

• Enormous effort required to communicate
needs to software development company
• Even with that effort, still uncertainty that
they really understand what’s required

T h e t a le o f w o e …

• We are failing at our most trivial task
 AHRQ will give up on us
 We will disappoint the users whose
expectations we have raised
• We have over-extended ourselves and our
budget trying to cope with this
• If we succeed, who will be responsible for
harm that may arise because we delivered
vague guidelines to the point of care?

T h e t a le o f e n lig h t e n m e n t :

• Bob* (unexpectedly) says:
 This is very interesting!
 Let’s reduce your anxiety … there are lots of
ways to make lemonade here
 We have an agency interest in alternative
ways to disseminate guidelines
 Document these issues
 Analyze them
 Make recommendations to future expert panels

* Bob Mayes, our AHRQ Task Order Officer


F r o m:
E x p e r t P a n e l G u id e lin e s
To :
E le c t r o n ic C lin ic a l D e c is io n
S u p p o rt:

W h a t a r e t h e P r im a r y
C h a lle n g e s ? www.CenterForUrbanHealth.org

• Logical complexity
• Volume of therapeutic choices
• Different languages used by:
 Academic experts
 Front-line clinicians with limited time
 Patients responsible for self-management

T h e P r im a r y C h a lle n g e s

 Academic experts

T h e h u m a n m in d :

• Do I know this patient?
• Is the patient already being treated? How
aggressively? Is the patient being treated
the right way?
• How is the patient doing? Is the therapy
adequate? Is the patient using the
therapy as prescribed?
• What might happen if I changed the dose?

T h e s o f t w a r e m in d …
1. System displays all known values , as
shown on UI screen.

2. User accepts or changes value for weight

3a. 3b.
4b. System changes value for date of
User accepts value User changes value
last weight to current date.
for weight for weight

5. User accepts or changes value for height.

6a. 6b. 7b. System changes value for date of
User accepts value User changes value last height to current date. System
for height for height changes value of predicted peak flow .

M o r e p e a k s in t o t h e
s o f t w a r e m in d … www.CenterForUrbanHealth.org

1.
IAAP Screen_03_01. (User Interface_03_01)
User opts to establish asthma control or severity.
User opts to infer level, or to enter known level.
To User Interface
_03_01

Clinicians : How
do you want to
handle this choice
and/or this screen
if there is an
existing value for
3b. USER CHOOSES: severity in the
3a. USER CHOOSES: 6. USER CHOOSES:
Enter severity level system?
Infer severity from ASSESS CONTROL
as known.
symptoms

8. System check:
If neither current
treatment step nor
pharmacy order for
4b.
10. asthma meds
4a. System calculates
System transfers user to available, then
System transfers user to [step_recommend],
‘Determine Control ’ POPUP
process that classifies based on severity and
interface.
severity from symptoms patient age.

To Pop-Up_03_
To Process Flow_04S To Function_04. Step
recommend. To Process Flow_04C

H u m a n vs s o ftw a re
“ m in d s ” : www.CenterForUrbanHealth.org

Huma ns S o ftw a re
Fast, unarticulated Series of nested and
thought processes explicit if-then statements
“Gestalt” Linear, step-by-step
Counterfactuals Counterfactuals not
entertained possible
Approximate Precise meaning of words
meanings of words OK required
Can tolerate ambiguity No tolerance for ambiguity

T h e n e g o t ia t io n c h a lle n g e :

• Clinicians must:
 Clearly explicate their thought processes
 Force themselves to use precise vocabulary
 Think linearly
• Software developers must:
 Obtain necessary initial values without
burdening users
 Replicate clinical “flow”

S o f t w a r e D e v e lo p m e n t
C h a lle n g e s www.CenterForUrbanHealth.org

• Bridging languages
 Academic medical expertise

F r o m t h is ….

…t o t h is

C o m b in a t o r ia l v o lu m e

• > 23,000 possible combinations of
 Age
 Step
 Preferred vs. alternative
 Instructions for use
 Brands
• Some combinations are impossible, or
unsupported by evidence, or contradict FDA
• Changing all the time
 New drugs
 New delivery mechanisms
 New evidence

C h a lle n g e s p o s e d b y
v o lu m e : www.CenterForUrbanHealth.org

• Effort required to capture all possibilities
• Likelihood of errors & inconsistencies
increase with volume
• Deciding when to stop, when every month
something new comes out
• Responsibility for on-going maintenance

S o f t w a r e D e v e lo p m e n t
C h a lle n g e s www.CenterForUrbanHealth.org

 Academic medical experts

D if f e r e n t w o r d s f o r s a m e
id e a s : www.CenterForUrbanHealth.org

A c a d e m ic : C lin ic a l: O r d in a r y :
Long-acting
Daily controller Purple inhaler
beta agonist
What you can
FEV1 actual vs. My top number
and should be
predicted on the meter
able to blow
I thought my
Exacerbation ED visit
child would die

B e c a u s e o f d if f e r in g
v o c a b u la r y : www.CenterForUrbanHealth.org

• Text in guidelines doesn’t work on screen
 Guidelines: “Step up one”
 Clinician question: “What is the current step?”
 (Patient question: What is a step?)

B e c a u s e o f d if f e r in g

• On-screen text for clinical users doesn’t
work in asthma action plan.
 Drug example:
 Clinician: Fluticasone MDI (44 mcg/puff)
 Patient: Fluticasone inhaler 44 mcg
 Condition example:
 Clinician: Best peak flow, predicted peak flow
 Patient: Peak flow

T h e c h a lle n g e p o s e d b y

• Anticipating who the user/consumer is
• Testing vocabulary with users to make
sure it works
• Resolving conflicts between need for
specificity among one group of users vs.
need for simplicity among another

S o m e p r e lim in a r y
c o n c lu s io n s

P o lic y Q s t h e p r o c e s s
r e v e a ls : www.CenterForUrbanHealth.org

• At what point in guideline development
should “codification” be considered?
 By the expert panel while deliberating?
 After the text of the guidelines released?
• Who is responsible for resolving textual
inconsistencies and ambiguities?
 Expert panel?
 Software developers?
 Front-line clinicians?

A d d l p o lic y Q s t h e p r o c e s s
r e v e a ls : www.CenterForUrbanHealth.org

• What should the “update” process be?
 Reconvene expert panel every xxx years?
 Regular software maintenance?
• Should users be enabled to maintain their
own lists of therapeutic choices?
 Pros: Can be customized to site (e.g. locally
supported formularies)
 Cons: Induces site-to-site variability in
dissemination of latest evidence

S u s t a in a b ilit y q u e s t io n s

• Who bears the costs of development?
 Original guidelines
 Original software for guideline-based decision
support
• Who bears the costs of maintenance?
 Guidelines
 Software, especially when software and
clinical expertise are seldom the same

O u r w o r k c o n t in u e s :

• Conveying user requirements to software
developers, where requirements include:
 Adherence to interpreted guidelines
 “Smooth” & supportive clinical workflow
• Documenting issues we encounter in
attempting to achieve that goal
• Preparing our sites for implementation,
albeit a year late

And:

• Sharing process & results with all of you!

Im p r o v in g A s t h m a C a r e in a n In t e g r a t e d
S a f e t y N e t t h r o u g h a C o m m e r c ia lly A v a ila b le
E le c t r o n ic M e d ic a l R e c o r d

Prime contractor: D e n v e r H e a l t h a n d H o s p i t a l A s s o c i a t i o n .
Subcontractor: M i n n e a p o l i s M e d i c a l R e s e a r c h F o u n d a t i o n . Project site: H e n n e p i n C o u n t y
M e d ic a l C e n t e r , M p ls M N
AHRQ Contract No. H H S A 2 9 0 2 0 0 6 0 0 0 2 0 , T a s k O r d e r N o . 5

Staff – Denver Health and Hospital Association
Sheri Eisert, PhD (Director, Health Services Research)
Michael (Josh) Durfee (Research Projects Coordinator, Health Services Research)
Staff and contractors – Minneapolis Medical Research Foundation
Gail Brottman, MD (Chief, Pediatric Pulmonology, HCMC)
Kevin Larsen, MD (Chief Medical Informatics Officer, HCMC)
Yiscah Bracha, MS (Research Director, Center for Urban Health)
Cherylee Sherry, MPH (Project Manager, Pediatric Research & Advocacy HCMC )
Touch Thouk (Administrative Manager, Center for Urban Health)
Angeline Carlson, PhD (Principle, Data Intelligence Inc.)
Contributors of Ideas, Information & Effort:
Michael Barbouche (University of Wisconsin Medical Foundation); Robert Grundmeier, MD
(Children’s Hospital of Philadelphia); Michael Kahn, MD, PhD (Denver Children’s Hospital)
Donald Uden, PharmD (University of Minnesota), Faith Dohman, RN (Hennepin Faculty
Associates); Susan Ross, RN (Minnesota Department of Health)

…a nd now , B ob www.CenterForUrbanHealth.org

M a ye s o u r Ta s k
O r d e r O f f ic e r

HIT Asthma. A tale of woe & enlightment,

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