Clinical Decision Support
A state of irritability, exhaustion, or bewilderment triggered in clinicians who have been exposed to too many alerts which cause the user to ignore some or all the alerts. American National Standards Institute (ANSI) ; coordinates for the development of Health bevel Seven’s Arden Syntax Standard. Bar Code Medication Administration (ABACA) ; An inpatient CADS to assist nurses with the five rights of medication administration. ; Provides warnings if any of the five rights are violated. ; It also requires the nurses to enter an override reason if he/she chooses to proceed.
Bar Code Medication Administration Health Level Seven (HAL) ; A standards development organization for health information technology (HIT) Look-Alike, Sound-Alike (ALAS) ; Drugs with similar spelling or pronunciation. ; Refers to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered or presented to appropriate times, to enhance patient care. ; Integrate patient-specific data with an available knowledge base in order to assist the clinician in selecting and delivering the safest and most effective therapies.
Clinical Decision Support System A system intended to provide CDC to clinicians, caregivers and health care consumers. ; An Automated CADS includes: 1. A Knowledge base 2. An Event monitor 3. A Communication system Take Note: ; CADS may be a stand alone system ; CADS may be integrated into other technology solutions (ex. Bar code scanning technology and e-Prescribing) General Attributes of CADS 1. Designed for three purposes: Improve the quality of clinical decisions Notify of potential change in patient status ;. Prevent errant action at the point of care a.
Error of commission b. Error of omission 2. Patient specificity 3. Context sensitive- relates directly to the work at hand 4. Integrated into workflow- convenient to use. 5. Timely- executes in real time 6. Pushes information to the clinician, care-giver or health care consumer 7. Intelligently filtered clinical information ; Information, advice or warning is relevant and meaningful ; CADS uses patient data to infer that the message is actually needed. ; CADS is customizable to clinical preferences. Types of Clinical Decision Support A. Patient-specific CADS B.
Non-patient specific CADS ; This type of CADS consist of three types f alerts 1 . Commercial drug-interaction alerting system 2. Commercial dose and dose-range checking alerts 3. Commercial clinical rules engine Commercial drug-interaction alerting system ; Most common in COPE and Pharmacy Information systems. ; Provides alerts for drug-allergy, drug-drug, drug-pregnancy and other interactions. ; Limitation is that severity levels Of drug interaction is pre-assigned by the vendor based on the anticipated adverse reaction and cannot be customized.
Four Possible Results from deterioration alerting system Alert Result Produces alert? Relevant? Clinician deeds to see? True Positive Yes True Negative NO No Positive False Yes but never gets the chance Commercial dose and dose-range checking alerts ; Currently, this is rudimentary using few patient data, usually only age. Therefore this systems only loosely fit paternalistic category. Commercial clinical rules engine ; These allow local development or customization of clinical content and programming logic. 2. 3. 4.
Data mining Informational notice Order sets Knowledge retrieval systems ; Provides population specific relationships and information. ; Encompasses numerous methods used to identify patterns and relationships in data. ; Usually just-in-time, product specific information. ; Examples: 1 . Provides alert for possible ALAS 2. In COPE, it might be order specific information such as the cost off lab test, or formula status of a drug. ; An organized set of patient care orders that are usually population, procedure or disease specific. It may be evidence-based such as clinical guideline. ; The KIRKS ; It could be: 1. Primary KIRKS ex. Google and 2. Secondary KIRKS (Harridan’s online) 3. Tertiary KIRKS (ASAP, Thomson Health care and How to maximize the benefits Of CADS? Maximizing the benefits 1. Ensure that the data available for decision-making is as comprehensive as possible. Data should be current and urge Larry updated. 2. Optimize the method by which the decision support information is delivered to the health care provider values of CADS ; Application of CADS in different current medical technologies available: 1.
COPE 2. OMAR(Getronics Medication Administration 3. Smart Pumps 4. Automated distribution cabinets CADS in COPE CADS integrated in COPE can: ; Reduce medication errors (any preventable event that may lead to inappropriate medication use or cause harm to he patient while the medication is in the control of a health care professional, patient or consumer) ; Improve compliance with recommended monitoring or adjunctive therapies. ; Improve efficiency by reducing the time spent clarifying incomplete orders. Screen for a variety or risks on the point of entry (ex. Duplicate therapy, drug-drug, allergic cross sensitivities) ; can reduced mathematical errors by automating weight-based and similar dosing calculations. ; can identify possible ALAS medications. Computerized Provider Order Entry CADS in Omar ; OMAR (Electronic Medication Administration Record) CADS integrated in Omar can: ; Can provide real time confirmation of the 5 rights of medication administration: 1. Right medication 2. Right dose 3. Right route 4. Right patient 5.
Right time ; Can screen for recent changes in laboratory parameters, vital signs, or allergy status which may interact with a scheduled medication and alert the nurse prior to administration. ; Ex: laboratory shows critical level of potassium thereby alerting the nurse before administering dioxin to patient. CADS in Smart Pumps ; Smart pump- a computerized infusion device that can be programmed to include specific set of data. CADS integrated in Smart Pumps can: ; Provide real time confirmation of the volume, rate and concentration of the solution being administered.
Smart Pumps CADS in Automated Dispensing Cabinets ; ADS- secure storage cabinets typically located decennially on patient care units capable of handling most unit-dose and multiple dose medications. ; CADS integrated in ADS can: ; Notify nurses of potential hypersensitivity or ADAIR when certain trigger medications are withdrawn for a patient. ; In pharmacy, can provide alerts when medication is withdrawn too early or too ate based on scheduled administration time. Automated Dispensing Cabinets Unintended consequences in CADS ; A. Alert fatigue ; 8. Delay in care ; C. System performance A.
Alert fatigue ; Tendency users to become overwhelmed and begin to ignore CDC messages due to a high quantity of alerts or a perception that the alerts have little perceived value. B. Delay in care ; The risk that interruptions in the workflow caused by clinical decision support alerts or system limitations may lead to a delay in delivery of patient care. C. System Performance ; The risk that the processor resources seed by the CADS will cause the hospital information system software to perform slowly. Arden syntax standard ; A programming language designed for clinicians to build clinical rules. Streamlined computer language based on Pascal. ; Developed in Columbia University Arden Homestead in 1989. ; This standard provides a method to construct clinical rules, such as alerts, reminders and recommendations, known as Ml. ; Provides a flexible and clinically way to develop Ml. What is Ml? Ml ; Means Medical Logical Modules ; Offers a suggestion or warning (alert, recommendation or reminder) regarding a alnico decision or action, or an informational notice to report a change in a patient’s clinical status.