Beyond BPAs - Dynamic Clinical Decision Support with an awareness of human factors and UX design

Beyond BPAsDynamic Clinical Decision Support with an awareness of human factors and UX design

Russ Cucina, MD, MSProfessor of MedicineVP & Chief Health Information OfficerUCSF Health

Aparna Sashikanth, MSMartin KoenigClinical Systems Orders Team,UCSFMC

PermissionsAll material is Copyright © Russ Cucina, 2014, except where attributed otherwise.

Screenshots of Epic Systems software are Copyright © Epic Systems, Inc, 2014, and used with permission.

With the exception of Epic screenshots, you are welcomed to reuse this content with attribution for noncommercial purposes, under the Creative Commons Attribution-Noncommercial License.

https://creativecommons.org/licenses/by-nc/4.0/

Roadmap

1. Principles of clinical decision support

2. Case studyI would like a BPA that alerts physicians when they are trying to transfuse red blood cells in a patient with a hemoglobin > 8 gm/dL that their order is outside the clinical guidelines.

3. Human factors relevant to CDS

4. Transfusion CDS beyond BPAs

5. Principles of UI design – how does the transfusion intervention stack up? (time permitting)

6. Questions

The Five Rights of Clinical Decision Support

1. Right information – evidence-based, pertinent to the circumstance, and actionable

2. Right person – action, authority, and responsibility (often, housestaff vs. attendings)

3. Right format – an order set, reference information, or an alert?

4. Right channel – again with attention to actionability

5. Right time – exactly when actionable, neither sooner nor later

How would this BPA do?

Roadmap

1. Principles of clinical decision support

2. Case studyI would like a BPA that alerts physicians when they are trying to transfuse red blood cells in a patient with a hemoglobin > 8 gm/dL that their order is outside the clinical guidelines.

3. Transfusion CDS beyond BPAs

4. Principles of UI design – how does the transfusion intervention stack up?

5. Questions

Ordering Blood Products at UCSFMCA comprehensive, and therefore complex, order set with lots of imbedded text intended to guide the ordering physician

• At least 3 screens of scrolling

• Minimum of 11 clicks for the simplest case of PRBC transfusion

Copyright © Epic Systems Inc. 2014, used with permission

Ordering Blood Products at UCSFMC

• 3 screens of scrolling• 11 clicks

Epic “Best Practice Alerts” for orders do not fire until after the physician has clicked “Sign”

• If BPA is ‘obeyed’, 6 clicks to back out the work already completed

17 clicks to accomplish nothing

The Five Rights of Clinical Decision Support

1. Right information – evidence-based, pertinent to the circumstance, and actionable

2. Right person – action, authority, and responsibility (often, housestaff vs. attendings)

3. Right format – an order set, reference information, or an alert?

4. Right channel – again with attention to actionability

5. Right time – exactly when actionable, neither sooner nor later

How would this BPA do?

Relevant Human Factors in Informatics

• Retrogressive Inhibition– Humans resist undoing work they have already completed or redoing

work already done

• Divestiture Aversion (also called “endowment effects”)– Humans over-value courses of action they have already invested in,

or objects they already possess

• Alert Fatigue– Human attention is finite, and repeated alerts of any kind result in

decreased attention to alerts of all kinds– UCSF has already had a severe AE due in large part to alert fatigue

Each of these are intrinsic features of human cognition, and are not unique to physicians, health care, or UCSF.

Furthermore –

• UCSF, like all EHR (or other technology) users, has a problem with alert fatigue

• Alerts in Epic already have poor PPV

In summary – a BPA is rarely the best way to get anything done

Better Clinical Decision Support• Dynamically present an ordering interaction

depending on the patient’s hemoglobinIf Hgb < 6.0

Copyright © Epic Systems Inc. 2014.Used with permission.

Better Clinical Decision Support• Dynamically present an ordering interaction

depending on the patient’s hemoglobinIf Hgb = 6.0 – 6.9

Copyright © Epic Systems Inc. 2014.Used with permission.

Better Clinical Decision Support• Dynamically present an ordering interaction

depending on the patient’s hemoglobinIf Hgb = 7.0 – 7.9

Copyright © Epic Systems Inc. 2014.Used with permission.

Better Clinical Decision Support

• Dynamically present an ordering interaction depending on the patient’s hemoglobin

If Hgb >= 8.0

Copyright © Epic Systems Inc. 2014.Used with permission.

Better Clinical Decision Support

• Dynamically present an ordering interaction depending on the patient’s hemoglobin

– NO Hgb in the last 48 hours:

Copyright © Epic Systems Inc. 2014.Used with permission.

Better Clinical Decision Support

• Only for Adult patients

• No changes for now to the Accelerated Admin section, on the assumption this should always only be used in actively bleeding patients.

– We will monitor change in usage patterns

• No changes to the Malignant Hematology transfusion order set

Principles of User Experience Design -How do you grade the Transfusion CDS?

• Structure

• Simplicity

• Visibility

• Feedback

• Tolerance

• Reuse

A

B+

B+

C

A

C

Beyond BPAs

Questions?

Russ Cucina, MD, MSProfessor of MedicineVP & Chief Health Information OfficerUCSF Health

Aparna Sashikanth, MSMartin KoenigClinical Systems Orders Team,UCSFMC