Integrating Clinical Decision Support with Point of Care Education:

Lessons from the OsteoporosisCare Initiative

Mr. Ray Saputelli, Executive Vice President, New Jersey Academy of Family Physicians

Mr. Matthew Lewis, Doctoral Candidate, Columbia University-Teacher’s College

Disclosures• This project was initiated through an educational grant

from the Alliance for Better Bone Health (P&G Pharmaceuticals and sanofi-aventis)

• Ray Saputelli: None

• Matt Lewis: This project was initiated in my previous professional capacity at P&G Pharmaceuticals. Though I am a current employee of Boehringer Ingelheim Pharmaceuticals, Inc’s CME department, the perspectives and opinions discussed herein are mine alone and do not necessarily reflect those of BIPI

Clinical Decision Support as Education

• Improving Clinical Outcomes

• The OsteoporosisCare Initiative

• Project Goals

• Tool Demonstration

• Key Learnings

Bridging the Gap between Theory and Practice: Are Guidelines the Answer?

• Clinical Practice Guidelines have been defined as: “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific circumstances”

• However, CPGs have been criticized for being:– Excessive in number– Poorly constructed– Obsolete– Difficult to apply to individual cases– Too rigid or complicated– Irrelevant for PCPs– Insensitive to time demands

Scott IA. Internal Medicine Journal. 2004; 34: 492-500

Capacity

“Physicians cannot keep all the information they need in their heads, and even if they could, medical knowledge changes so rapidly that acquired information quickly becomes obsolete.”

Haynes, B, et al. Ann Intern Med 1990

Point of Care Information Mastery

• What Determines a Clinician’s Interest in Accessing Medical Information?

Medical Information Usefulness=

(Relevance * Validity) Work

Shaughnessy AF et al. J Fam Pract. 1994; 39:489-99

Clinical Decision Support• Refers broadly to providing clinicians or patients

with clinical knowledge and patient-related information, intelligently filtered, or presented at appropriate times, to enhance patient care1

• “Considered to include: – Passive and Active Referential Information– Reminders– Alerts– CPGs”2

1Osheroff JA. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. HIMSS Publication, 2Bates DW. Journal of the American Medical Informatics Association. 2003; 10(6): 523-530

(Four of the)Ten Commandments for

Effective Clinical Decision Support

1. Speed is Everything

2. Anticipate Needs and Deliver in Real Time

3. Fit into the User’s Workflow

4. Simple Interventions Work BestBates DW. Journal of the American Medical Informatics Association. 2003; 10(6): 523-530

Didactic, “Traditional”, CME

Clinical Decision Support

Point of Care CME

Place of Access CLASSROOM, INTERNET, IPOD, HOME, TRAVEL

DURING PATIENT CARE

FOLLOWING PATIENT CARE

Time Demand HIGH LOW MEDIUM

Knowledge is… ACQUIRED APPLIED EXPANDED

Type of Learning Passive, Direct Active, Indirect Active, Direct

Makes Practical Recommendation

NO YES YES

Improves Clinical Performance

NO YES YES

OsteoporosisCare Initiative

NJ State Osteoporosis Survey• Developed by Past President of the New Jersey

Interagency Council on Osteoporosis, Dr. Jeffrey Levine

• IRB-approved investigation of educational needs, performance and barriers

• Distributed through NJAFP and NJDHSS to NJ State Family Physicians

• 17% Response Rate (347 FPs)

Family Physicians in NJ…

• Think osteoporosis management can be managed in the time they have

• But… the majority don’t know what to do at the point of care. They:– Are unsure how much calcium/vitamin D to recommend to their patients– Don’t know why patients need drug if they are on calcium and vice versa– Can’t identify which patients should be screened for bone loss– Think drugs don’t prevent fractures if patient has already fractured– Are not sure which pharmacologic agent to use for which patient type– Think drugs are unsafe for long-term use– Don’t know when or how to monitor patients on therapy

Why a PDA-based CDS solution?

• Multiple guidelines with conflicting recommendations

• Ineffectiveness of traditional, lecture-based, CME in changing practice behavior

• Growing clinical use of PDAs by Family Doctors

OsteoporosisCare Initiative• Goal: Improve the quality of care delivered to

patients at risk of osteoporosis by Family Physicians

• Solution:– Three-Phase, Interactive, Iterative CME Project led

by the New Jersey Academy of Family Physicians

1. Asynchronous, case-based education using CDS instrument

2. Use of Tool with 10-25 Patient Charts, and, in clinical practice

3. Traditional POC information resource

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With this POC Tool, Clinicians Can…

1. Determine whether their patient is a candidate for DXA testing and utilize the appropriate ICD-9 codes for insurance coverage and reimbursement

2. Calculate the level of risk their patient is at for fracture, whether they should be treated, and the appropriate pharmacologic options for that patient

3. Develop individualized patient strategies for bone health maintenance including nutritional supplementation, exercise and fall prevention

4. Learn about osteoporosis and gain CME credit

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What Does the Tool Really Do?

• Converts conflicting CPGs into practical recommendations

• Simultaneously teaches and supports decision making

• Increases confidence and attitudes towards treating osteoporosis

• Improves clinical skills necessary for recognizing fracture risk

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Main Menu

Does My Patient Need a DXA?

Recommendation

User Group Top 3 Reasons They Would Use the Tool :

1. Ease of Use/Short amount of time to use

2. Can Access Comprehensive Practical Information

3. Personalized Recommendations

Key Learnings

1. Design

2. Complexity

3. Resources

4. Connectivity

5. Partnership