Epic as a platform to launch clinical decision support tools

E p ic a s a P la t f o r m L a u n c h in g
D e c is io n S u p p o r t T o o ls :
www.CenterForUrbanHealth.org

Im p lic a t io n s f o r R e s e a r c h a n d P o p u la t io n
QI
Yiscah Bracha, MS
Minneapolis Medical Research Foundation
Robert Grundmeier, MD
The Children’s Hospital of Philadelphia

Epic Research Advisory Council Meeting
April 1, 2009

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
Sherry 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)
Y i s c a h B r a c h a , M S (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); R o b e r t
G r u n d m e i e r , M D (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)

T h e P r o b le m :

• Docs practice within an information
avalanche
• Impossible for any human to keep up

W h a t is a b u s y p h y s ic ia n t o
do? www.CenterForUrbanHealth.org

B e c o n f id e n t .

B e c onc e rne d.

B e o b liv io u s .

M e d ic a l in f o r m a t ic s t o t h e
re s c ue ! www.CenterForUrbanHealth.org

• Provide decision support during care,
while doc viewing pt electronic record
• Developmental generation beyond:
 URL to PDF of guidelines on screen
(clinicians don’t go there)
 Automatic reminders & alerts (clinicians suffer
from “alert fatigue”)

T a s k -b a s e d d e c is io n
s upport www.CenterForUrbanHealth.org

• Types of support
 Which diagnostic tests to use
 How to initiate therapy
 How to adjust therapy over time
• Electronic data:
 EHR data automatically populate decision
algorithms
 Results from algorithms automatically
populate patient data record

D e c is io n S u p p o r t & E p ic :
C urre nt mode l

Epic
Electronic decision Electronic decision
support for: Information on support for:
interface interface
engine Individual Patients engine
Asthma Which diagnostic
imaging tech?

Clarity

Information for
ASTHMA Populations IMAGING
REGISTRY REGISTRY
Asthma info for Imaging info for
Populations Populations

C u rre nt mo d e l a nd d a ta
w a r e h o u s in g :

Epic
interface interface
imaging tech?

Clarity
ASTHMA
REGISTRY Information for
ASTHMA Asthma info for Populations IMAGING
REGISTRY Populations REGISTRY

C u rre nt mo d e l a nd d a ta

Epic
interface interface
imaging tech?

ations
Popul fo for
Clarity Imagin
g in
RY
REGIST
Information for
G
IMAGIN
Populations
ASTHMA
REGISTRY
Asthma info for
Populations

B u ild in g t h e W a r e h o u s e :

ations
Popul fo for
g in
Imagin
RY
REGIST
G
IMAGIN
ASTHMA
REGISTRY
Asthma info for
Populations

Th e Wa re h o u s e D re a m :

HIV REGISTRY DIABETES REGISTRY COLONOSCOPY
HIV info for Diabetes info for
REGISTRY
Populations Populations Colonoscopy info
Populations

ASTHMA REGISTRY IMAGING REGISTRY STENT REGISTRY
Asthma info for Imaging info for Stent info for
Populations Populations Populations

T h e a n a ly t ic d r e a m :

REGISTRY
Populations


O u r a n a ly t ic r e a lit y :

WHY?
RY
I ST
R EG r
ES fo
T o
BE inf ns
IA es io
D e t la t
ab u
Di Pop

HI V
RE
GIS
HIV TR
Y
Po info
pu fo r
la t
ion
s

Ima
P in

IMA
op g info
g
ula

GIN
tio for

GR
ns

EG
IST

ASTHMA REGISTRY
RY

Asthma info for
Populations

T h e p r o b le m w it h t h e
c u r r e n t m o d e l:

Epic
interface interface
imaging tech?

Clarity

Information for
REGISTRY REGISTRY

H a r d t o b u i l d ….

Epic
support for: interface Information on interface support for:
Individual Patients
Asthma engine engine Which diagnostic
imaging tech?

Clarity

Information for
REGISTRY REGISTRY

H a r d t o m a i n t a i n ….

S o m u c h e ffo rt fo c u s e d o n
in t e r f a c e *:

Epic

Electronic decision
interface Information on interface
Individual Patients Electronic decision support

engine engine
support for:
for:

Asthma
Which diagnostic imaging
tech?

Clarity

ASTHMA
Information for IMAGING
REGISTRY Populations REGISTRY

Asthma info Imaging info
for for

* Building complex decision support within Epic is
just as much effort as interface

N o re s o u rc e s fo r d a ta
mg mt: www.CenterForUrbanHealth.org

R Y
I ST
EG
SR fo
r
TE o
BE inf ns
IA es io
D e t la t
ab u
Di Pop

HI V
RE
GIS
HIV TR
Y
Po info
pu fo r
la t
ion
s

Ima
P in

IMA
op g info
g
ula

GIN
tio for

GR
ns

EG
IST

ASTHMA REGISTRY
RY

Asthma info for
Populations

A lo w -c o s t a lt e r n a t iv e t o
c u r r e n t m o d e l: www.CenterForUrbanHealth.org

1. Support provided by external applet
2. Applet invoked through Intranet hyperlink
3. Hyperlink opens applet in new window
4. Applet provides decision support
5. Applet saves data to its own database
6. User returns to Epic

E x a m p le : H IT A s t h m a
P r o je c t www.CenterForUrbanHealth.org

• Java Applet, called e-AAP, provides
administrative & clinical decision support*
• Invoked from Epic:
 Create new Asthma Action Plan (procedure order)
 View existing Asthma Action Plan
 from Order Results
 from asthma detail in problem list
• Invocation sends @ 20 encrypted live Epic data
elements to applet through URL
• New asthma data saved to SQL server database
* Support based on NAEPP-3 Guidelines, August 2007

e -A A P C lin ic a l D e c is io n
S u p p o rt: www.CenterForUrbanHealth.org

• For new asthma patients
 Assess severity
 Initiate treatment given age & severity
• For currently treated asthma patients
 Assess control
 Modify treatment given age, control, current
treatment, pt adherence
 Step-based treatment
 Supports user in calculating current step

e -A A P A d m in is t r a t iv e
S u p p o rt: www.CenterForUrbanHealth.org

• Document severity and/or control
• Generate printable asthma action plan
 Patient-specific
 Patient-friendly (tested for literacy)
 Records all JHACO-required data
• Document production of AAP
• Generate:
 Template of asthma progress note that user can
paste into patient’s chart
 List of selected meds & instructions for use

La unc he d a s proc e dure
o r d e r in E p ic : www.CenterForUrbanHealth.org

Clicking here launches applet..

Highlighted data transferred in URL.

L iv e d a t a p a s s e d t o A p p le t
in U R L : www.CenterForUrbanHealth.org

Web link defined by print group

Launches web browser with
“garbled” pt data in URL

L in k in g c o d e r e q u ir e d :

Cache routine: Cache global:
Delivers hyperlink Provides configuration

1s t s c r e e n u s e r s e e s :

User automatically logged in; audit trail initiated;
patient data transferred directly from Epic.

A p p le t g e n e r a t e s d a t a . Whe re
d o the y g o ?

• Individual patient data:
 Saved to underlying database
 Applet generates asthma progress note that
doc can paste into record
• Population data:
 All Applet data stored to underlying registry
 Clarity data extracted & merged with Applet
data in registry

In d iv id u a l p t d a t a :

Patient & user
context thru
URL

Epic
ASTHMA APPLET
Saved to SQL
Information for server database
Asthma info for Individual Patients
Individual (registry)
patients

Clarity

Information for
ASTHMA Populations
REGISTRY
Asthma info for
Populations

P o p u la t io n d a t a :

Patient & user
context thru
URL

Epic
ASTHMA APPLET
Relevant data
Information for extracted from
Individual Clarity, merged
patients
with Applet data
in registry
Clarity

Information for
ASTHMA Populations
REGISTRY
Asthma info for
Populations

D e c is io n S u p p o r t & E p ic :
A lt e r n a t iv e m o d e l

Patient & user
context

Epic
ASTHMA APPLET
Information for
Individual
patients

Clarity

Information for
ASTHMA Populations
REGISTRY
Asthma info for
Populations

H o w a r e a p p le t d a t a
r e t r ie v e d ? www.CenterForUrbanHealth.org

• Individual patient data:
 Previously created e-AAPs easily found &
reviewed from Applet.
 If user pasted asthma progress note,
available in EHR.
• Population data:
 Extracted from underlying registry
 Registry populated with Applet data and
relevant data from Clarity

T o v ie w in d iv id u a l p t d a t a :

To see previous AAPs,
user clicks here

P o p -u p a p p e a r s :

User clicks on desired PDF

H y p e r lin k o p e n s a p p le t :

T o v ie w p o p u la t io n d a t a :

Patient & user
context thru
URL

Epic
ASTHMA APPLET
Information for
Individual
patients

Clarity

Information for
ASTHMA Populations
REGISTRY
Asthma info for
Populations

M u lt ip le s u c h r e g is t r ie s
p o s s ib le :

Patient & user Patient & user
context context

Epic
ASTHMA APPLET Imaging Applet
Information for
Imaging info for
Asthma info for Individual Patients Individual
Individual
Patients
patients

Clarity

Information for
ASTHMA Populations Imaging
REGISTRY Registry
Asthma info for
Populations Imaging info for
Populations

A lt e r n a t e m o d e l a n d d a t a

context context

Epic
Information for
Imaging info for
Individual
Patients
patients

Clarity

ASTHMA Information for
ASTHMAREGISTRY Populations Imaging
REGISTRY Registry
Asthma info for
Asthma infoPopulations
for
Populations HIV info for
Populations

A lt e r n a t e m o d e l a n d d a t a

context context

Local EHR
HIV APPLET
Information for
HIV info for
Individual
Patients
patients

G
IN Y
EHR Data AG ISTR for
IM G fo s
Repository RE g in tion
n
a gi u l a
Im Pop
Information for ASTHMA
Populations REGISTRY
Asthma info for
Populations

N o m a jo r in t e r f a c e t o b u ild
o r m a in t a in !

context context

Local EHR
interface Information for interface HIV info for
Individual engine engine Individual
Patients
patients

EHR Data
Repository
ASTHMA Imaging
Information for
REGISTRY Registry
Populations
Asthma info for
Populations Imaging info for
Populations

M a yb e w e c a n !

REGISTRY
Populations


Project supported by the
Agency for Health Research and Quality.

Contract No. HHSA290200600020, Task Order No. 5

The findings and conclusions are the responsibility of the authors, not the AHRQ.

Q u e s t io n s ?
Clinical informatics at HCMC: Asthma details about applet:
Dr. Kevin Larsen Dr. Gail Brottman
(kevin.larsen@hcmed.org) (brott004@umn.edu)

Invoking applet from Epic: Project direction & all other Qs:
Dr. Robert Grundmeier Yiscah Bracha, MS
(grundmeier@email.chop.edu) (shate001@umn.edu)

E x t r a S lid e s

• URL to live application demo
• Why not build in Epic
 Logical complexity
 Volume of clinical material

W h y n o t b u ild it in E p ic ?

• Logical complexity
 Existence of relevant data
 Validity of relevant data
 User choices
 Patient age, adherence
• Volume of up-to-date clinical info required
 @37k med combos in guidelines
 Guidelines contain @ 2% of all possibilities

e -A A P : H ig h -le v e l p r o c e s s
2. Identify patient
f lo w : 3. Peak flow,
triggers, weight.
4. Classify severity or assess control . 1. Classify Severity

Live data transfer Live data transfer www.CenterForUrbanHealth.org
Age 0-4 Age 5-11 Age 12+
from EHR & registry 4a. Existing record of
severity 4b. No existing record of
Registry & user (From EHR or registry , if exists ) severity
Lookup in registry (From registry, if exists )
entry

2.
Verify Level Of
Severity
1. Authenticate 1. Assess Control
BEGIN
user Choose next
Age 0-4 Age 5-11 Age 12+ step.
Live data transfer
from EHR
No existing
Log in by user & treatment record Existing treatment record
system check.

3. Identify current Not 3. Validate meds in
asthma meds validated record

Validated .
Return user to EHR system
Closure

END
Return user to
operating system
Disease mgmt 4b. Current meds 4a. Current meds
do not map to map to
component recognized plan recognized plan

4. Choose next step. 1. Choose Treatment Plan
New values of variables and
PDF of AAP to registry
Saves.
New values of variables and
PDF of AAP to registry
2. Choose daily controllers

HIT Asthma.
Model workflow for an outpatient asthma visit 3. Choose quick relievers
Consistent with recommendations in
2007 NEAPP Guidelines. 2. View/Print
Asthma Action Plan. 4. Choose burst meds
EHR-compatible version 1. Next Visit Info
Selected meds (for exacerbations)
Desktop version Visit Summary

D is e a s e m a n a g e m e n t
c o mp o ne nt: www.CenterForUrbanHealth.org

T r e a t m e n t d e c is io n s in
g u id e lin e s : www.CenterForUrbanHealth.org

T r e a t m e n t d a t a in A p p le t :

Epic as a platform to launch clinical decision support tools

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