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PROBLEM-INTRODUCTION Identify High Risk Area Make It Easy to do Right Thing at Right
Time Standardized, Structured, and Reliable
Approach
Venous Thromboembolism (VTE) Prevention
PREVALENCE 200,000 people per year develop
venous thrombi with 50,000 going on to develop a pulmonary embolism (PE)
1 in 10 of the 2 million patients per year that develop PE will die
Incidence is 80 cases/100,000 patients
STRATIFICATION & TREATMENT Stratification levels
High, Moderate and Low
TreatmentEarly and frequent ambulationPharmacologicMechanical
CONTRAINDICATIONS Pharmacologic
Absolute Active hemorrhage, severe trauma to head or spinal
cord with hemorrhage in last 4 weeks Relative
Intracranial hemorrhage within last year, craniotomy or intraocular surgery within 2 weeks, gastrointestinal, genitourinary hemorrhage within last month, thrombocytopenia or coagulopathy, end stage liver disease, active intracranial lesions/neoplasm, hypertensive urgency/emergency and post-operative bleeding concerns
Mechanical Known DVT, previous immobility, severe arterial
insufficiency
ADMINISTRATIVE RELEVANCE Cost Regulatory
National Quality Forum (NQF)Centers for Medicare and Medicaid Services
(CMS) Clinical Measures Never Events EHR Incentive Program
Meaningful Use Clinical Quality Measures
EXISTING TOOLS Showed Impact/Improvement however…
Not comprehensive enoughNot proactiveNot fully incorporated into workflow
CLINICAL GOALS Automation of risk stratification Streamlined and automated process for:
Recommendation of prophylaxis based on stratification
Mechanical prophylaxis order for placement and/or
Pharmacologic prophylaxis order Associated safety processes
Incorporated into workflow
ADMINISTRATIVE GOALS Cost Reduction Meet regulatory and quality assurance
requirementsNational Quality Forum (NQF)Centers for Medicare and Medicaid Services
(CMS) Clinical Measures Never Events EHR Incentive Program
Meaningful Use Clinical Quality Measures
MODEL – CDS RULERule Category VTE Intervention protocol
Rule Title Stratify the patient’s level of VTE risk and prompt clinicians to intervene.
Risk Group Definition Age >= 70 (demographic data);Obese ((the weight in kilograms divided by the square ofthe height in meters) >= 30) OR ICD9 code of 278.0;Bed Rest or Immobility (found through NLP of nursing documentation);Female Hormone Replacement Therapy or oral contraceptives (found on active medication list);Major Surgery (any surgery lasting over 1 hour);Active Cancer (ICD9 149.0 to 172.99, 174.0 to 209.9);Prior VTE (ICD9 415.1, 415.19, 453.8, 453.9, and 671.31 to 671.50);Hypercoagulability (presence of factor V Leiden, lupus anticoagulant, andanticardiolipin antibodies);
Trigger Condition Admission of Hospitalized patient;During normal activities of patients stay (time and data driven);During discharge;
Displayed Message This patient has been identified as having a risk for venous thromboembolism (VTE). Based on his recent medical/surgical history, his risk level is (LOW|MED|HIGH). His contra-indications for potential interventions are: (list indications). Based on both his risk status and his contra-indications, the following interventions are appropriate for this patient: (list any pharmacological and any mechanical interventions that are still appropriate)
Coded Responses A. Order early and frequent ambulationB. Order suggested pharmacological intervention;C. Order suggested mechanical intervention;D. Acknowledge alert, but take no action; (Reason Required )
MODEL – CONTRAINDICATIONS Active hemorrhage (Boolean) Severe trauma to head or spinal cord with hemorrhage in the
last 4 weeks (Boolean) Intracranial hemorrhage within last year (Boolean) Craniotomy within 2 weeks (Boolean) Intraocular surgery within 2 weeks (Boolean) End stage liver disease (Boolean) Thrombocytopenia (<50k) of prothrombin time > 18 seconds)
(Boolean) Hypertensive emergency (Boolean) Allergic to warfarin (Boolean, and severity) Allergic to un-fractionated heparin (UFH) (Boolean, severity) Allergic to low molecular weight heparin (LMWH) (Boolean,
severity) Has skin lesions on left leg (Boolean) Has skin lesions on right leg (Boolean)
MODEL - RESPONSE Alert trigger time (date/time) Alert ignored / cancelled (Boolean) Risk group pre-selected on alert by CDSS
(enumeration: Low, Med, High) Pharmacological intervention selected (enumeration:
UFH, LMWH, warfarin) Pharmacological intervention dosage (unsigned
integer) Early and frequent Ambulation Pharmacological intervention rate in hours (unsigned
integer) Mechanical intervention selected (enumeration:
(sequential compression device, leg hose) Mechanical intervention area: (enumeration: left leg,
right leg, both)
MODEL – KNOWLEDGE REPOSITORY CDS rule to be coded using standard
terminology and stored in KR.Semantic shiftBetter criteria for ruleNew / different coding schemes.
LayeringDepartment specific contraindications
(OB/GYN) Analytics / Reports
SYSTEM - COMPONENTS
End User Interface EMR Analysis and Data Mining Module Knowledge Base Interface Knowledge Base Module Active Integrated NLP-CDS inference engine
SYSTEM - STANDARDS
HL7: Will be used for the exchange, integration, sharing, and retrieval of electronic health data.
XML: Will be used document storage and data integration. CDA: For specifying encoding, structure, and semantics of
clinical documents for exchange. LOINC: For identifying medical laboratory observations. SNOMED: To help index, store, retrieve, and aggregate the
data. CCOW: To enable the disparate applications in our
organization to synchronize in real-time. HIPPA: To ensure patient confidentiality when patients are
transferred to other healthcare providers and hospitals. ICD-9: To classify diseases, injuries, and cause of death.
SYSTEM - INTERFACES
Interface Engine Interfacing with internal systems Interfacing with external systems
EVALUATION Implementation Settings and Test Environment Utilizing Plan, Do, Study and Act
(PDSA) Challenges