Agile Clinical Decision Support


Nov 8, 2017 - ... Willett, MD, MS. Epic XGM 2017 ... o Understandable to developers, stakeholders, and users o Focuses on ... evidence-based, suitable to guide action, pertinent to ... e.g., through EHR, patient portal, or more general ...

Agile Clinical Decision Support Mujeeb A Basit, MD, MMSc Vaishnavi Kannan, MS DuWayne Willett, MD, MS Epic XGM 2017

Disclosure • We and our partners have no relevant relationships with commercial interests to disclose.

2

UT Southwestern Health System William P. Clements Jr. University Hospital

604 Beds

1700 Physicians

West Campus Professional Building 1

40+ Clinics

23,132 Admissions

40,813 ED Visits

Radiation Oncology Facility

7947 Inpatient Surgeries

Academic Medical Center in Dallas Partnered with Texas Health Resources Moncrief Medical Center at Fort Worth 3

Clinical Decision Support (CDS) • Types of CDS • Alerts

• Effective CDS Guiding principle “Do CDS with users, not to users”

o Clinical practice alerts o Med alerts o Duplicate alerts

• • • • •

Order sets Health maintenance reminders Order questions Reports Reference information

4

Challenges Faced in Creating Clinical Decision Support Tools • Differing understanding of intended solution among stakeholders

• Complexity • Evolving requirements

5

Agile Methods for Clinical Decision Support Development

6

Benefits of Agile CDS Development • Shared understanding

• Rapid-cycle time-boxed development • Agility in responding to evolving requirements

7

Lightweight Requirements with User Stories • A user story is a brief statement of intent that describes something the system needs to do for the user. Story Title:



As a



I want



so that



• Some advantages: o Short, easy to read o Understandable to developers, stakeholders, and users o Focuses on customer and value to be delivered: • “who”, “what”, and “why” in one sentence.

8

Acceptance criteria for a CDS User Story • Acceptance criteria o “conditions of satisfaction” for customer o Definition of success

• Can be any/all of: o simple bulleted list o set of Acceptance Tests o CDS “Five Rights”

• CDS “Five Rights” o The right information evidence-based, suitable to guide action, pertinent to circumstance

o to the right person considering all care team members, patients, and their caretakers

o in the right CDS intervention format Alert, order set, documentation tool, data display/report, reference information

o through the right channel e.g., through EHR, patient portal, or more general channel such as a website or mobile app

o at the right time in workflow when it is most needed to make a decision or take action 9

Example: Prompt to Prescribe DMARDs for Rheumatoid Arthritis User Story

Acceptance Criteria

As a specialist caring for patients with Rheumatoid Arthritis, I want to be alerted when such a patient is not on DMARD so that I can increase the percentage of my patients on optimal medical treatment for rheumatoid arthritis.

• Alert to prompt ordering of DMARD on patients with rheumatoid arthritis • Alert fires for patients with rheumatoid arthritis on their Problem List in the EHR (based on SNOMED) • Alert does not fire if a DMARD medication is already on their active medication list • Alert allows designation of reasons why the patient is an exception, and should not be on a DMARD currently • Tipsheet to train on use of alert

10

Agile Modeling

11

Agile Modeling • Why Model? o To understand o To communicate

• ‘Agile Modeling’ goal: high value for degree of model creation effort expended • Agile Modeling core practices include: o Active Stakeholder Participation o Model With Others o Apply the Right Artifact(s) o Use the Simplest Tools o Model in Small Increments o Create Simple Content

BPA Trigger criteria met (provider, Rheumatology)

Rheumatoid Arthritis on the problem list Yes On DMARD

No Yes

Don’t display BPA

No

Display BPA to prompt ordering of DMARD

12

Rheumatoid Arthritis: CDS (Best Practice Advisory) BPA Trigger criteria met (provider, Rheumatology)

Rheumatoid Arthritis on the problem list Yes On DMARD

No Yes

Don’t display BPA

No

Display BPA to prompt ordering of DMARD

13

Use Case Diagram for an Osteoporosis Registry: Data Collection Purpose: • Show “verbs” (uses) of the system, organized by role. • No sequence or timing implied. • A graphical table-of-contents of Use Cases.

14

Solution Object Diagram

Purpose: Depict the software objects (records) to be built or employed in our EHR, and how they relate to one another, as a road-map for understanding the detailed design 15

Useful tools • Requirements Discovery: what’s the destination? Question

Tool

Who, what, and why?

User Story

Rest of CDS “5 rights”, other success descriptions

Acceptance Criteria

• 4 practical “agile modeling” goals & tools: what’s the map to the destination? Question

Tool

Where does this CDS fit in the bigger picture?

Swimlane or Use case diagram

Under what circumstances should it appear?

Decision tree

Once displayed, what happens when used?

UI mockup with Use case text

What do you need to build in your EMR?

Object diagram

16

Acceptance Test-Driven Development

17

Test-Driven Development • What it is o Specify software behavior first, in a testable manner o Then build until the test(s) pass o “Make it work, then make it better”: “Red-Green-Refactor”

• Encourages o Simple design o Confidence

• Builds up a regression test suite automatically • Acceptance Test-Driven Development = “Executable Requirements”

18

FIT and FitNesse FIT = Framework for Integrated Testing

FitNesse is a HTML wiki based open-source “front-end” to FIT

Guarantee business rules

19

Automated Acceptance Testing and FitNesse User Story As a ___, I want to be able to ____ so that ____.

Fit Table (Test Case)

Expected Output = Actual Output Expected Output ≠ Actual Output

Clarity database

dbFit (free) runs SQL queries from Test Case

http://www.fitnesse.org/FitNesse.FullReferenceGuide.UserGuide.FitNesseWiki.MarkupLanguageReference.MarkupPicture

20

No BPA

Pre-Build

BPA with Errors

Initial Build

Correct BPA

Final Build

CKD CDS FitNesse

21

Fault Handling

Parent Incident FIT Name

Initial Records 2017,06 2017,07 2017,08 Total Trend

INC0653546

FIT0653546:OR Procedure records without SHx/EAP value

INC0656674

FIT0656674:Test patients but do ont conform to ZZZTEST as the last name

2012

0

0

0

2012

88

0

0

0

88

INC0656678

FIT0656678:Patients with a last name like test but not marked as test patient

INC0657263

1

0

0

0

1

FIT0657263:Individual statin medication records not in groupers that identify whether med is high/moderate/low 3 0 intensity 0 statin 0

3

INC0657288

FIT0657288:E-Prescribe flag set to "Y" for ordering 25 or more prescriptions in Epic for last 150 days 18

INC0678844

FIT0678844:Radiology departments missing vital items - facility, center, rev location, report grouper27, or default 0 POS0ID

0

3

INC0683631

FIT0683631:Test of POS Business Rule

INC0683633 INC0683635 INC0683641 INC0683645 INC0683647

3

1

0

47

30

0

0

8

51

FIT0683633:Test to find out if 205 = 14 or if 5012 = 76 or 99 for Radiology procedures

1

0

0

0

1

FIT0683635:Test to find Visit Types that are active but not attached to a correct EAP record

0

0

0

0

0

FIT0683641:Test of PRL Business Rule

114

0

0

0

114

FIT0683645:Test of POS Business Rule

27

0

0

0

32

FIT0683647:Test of PRL Business Rule -HCM Metadata records

0

0

0

0

0

INC0699493

FIT0699493:MSDRG Grouper 1 check

0

0

0

0

0

INC0700559

FIT0700559:Billing providers with grouper 9

0

0

0

0

0

22

CDS Monitoring

23

CDS Failure Under expression

CDS displaying for patient that it is not supposed to (false positive)

CDS not displaying for patient that it is supposed to (false negative)

Number of Views

Number of Views

Overexpression

Date

Date

24

Alert Display Data Model • Grain: 1 row per Alert Display Event • Event context of interest: Alert Date

User

Alert Display Event

Primary User Response

Triggering Event

Location/ Unit

o o o o o o o

Date? Which alert? Which user? In what patient location? What encounter type? How was it triggered? With what user response?

Encounter Type

25

Power BI Dashboard: “Top 10 Alerts”

26



I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.

~ Clem McDonald, MD NEJM 1976

27

Rheumatoid Arthritis: Quality Measurement & Improvement

Measure Performance Rate (%)

100

80

DMARD Compliance 96.3 → 98.6 3.7 → 1.4 Defect

60

CDAI Assessment 42.7 → 80.9

40

20

CDAI Score Severity: Low Disease Activity (> 2.8 and 22) 0

13.7 → 10.1

28

Provider Dashboard

29

Summary Agile Methods

Modeling

As a ___, I want to be able to ____ so that ____.

Monitoring

Automated Acceptance Testing

30

Questions • Contact us at: o [email protected] o [email protected] o [email protected]

• Thank you!

31

Recommend Documents
Nov 8, 2017 - Requirements Discovery: what's the destination? Question. Tool. Where does this CDS fit in the bigger picture? Swimlane or Use case diagram. Under what circumstances should it appear? Decision tree. Once displayed, what happens when use

Explain benefits of employing agile principles and practices during new CDS ..... Project characteristics that favor agile development methodologies over ...

Clinical Decision Support Systems and How Critical ..... Executive Vice President, Business Solutions ...... The first computer-operated clinical decision support.

antibiotic therapeutic drug monitoring, alert, rules, pharmacy, infection. ABStRACt. Clinical decision support tools are important components of the electronic ...

Review online at www.gastro.org/lynchsyndrometool. AGA GUIDELINE FOR. Diagnosis and Management of Lynch Syndrome. CLINICAL DECISION SUPPORT ...

5-biopsy Sydney system in 1 jar. Biopsies for. GVHD** or OIs. Routine special stain not warranted. Routine special stain not warranted. Normal duodenum.

Nov 6, 2008 - Clinical Decision Support (CDS) has emerged over the ... of bone mineral density evaluation, no diagnosis or treatment for osteopenia or.

Cost of budesonide. • Patient preference. 2nd Line Medical Therapy. • Bismuth subsalicylate. • Prednisone (prednisolone). • Mesalamine. Budesonide 9mg daily.

Apr 15, 2015 - EMR and synthesize those into potential best practices for dissemination amongst their .... “No administrative regulations exist to delineate the.

have licensed the clinical decision support functionality. Your administrative super user or you, if you have the needed security access, can add the CDS tab to ...