Is It Time for the Customizable Infobutton?

Infobuttons are intended to provide links to context-sensitive information in online resources to support clinical decision making. In this issue, we discuss challenges that impact the maximal effective use of Infobuttons. We also suggest methods to facilitate the role of Infobuttons as a tool to support optimal use of medications.The medication use process can be negatively impacted by inappropriate patient selection for drug therapy, nonscientific ordering behaviors, incorrect preparation procedures, inaccurate administration, and poor follow-up procedures. The process is further complicated when patients demand therapeutic interventions and providers believe that medication use is appropriate, even when there is no scientific evidence to support these treatment decisions. Access to information can aid clinical decision making and avoid the problems affecting the medication use process.HL7 International Context-Aware Information Retrieval standard (the HL7 “Infobutton” standard) has been widely adopted since 2007. Infobuttons are decision support tools that provide links within electronic medical record (EMR) systems to online information. Many practitioners are discovering that the Infobutton is defaulting to a static, tertiary reference monograph that is intended to guide decisions for all who participate in the medication use process. But decision support information is seldom a one-size-fits-all proposition. We believe that the Infobutton should be customizable for an individual health system’s use.Every guideline that is distributed to health systems gets vetted by a clinical review committee prior to being placed online for general use. We worked on a project where such a guideline was distributed to 128 hospitals and nearly every hospital found something to tweak in the guideline. We believe that Infobuttons could appropriately publish checklisted, evidence-based decision support to prompt both experienced and naïve users throughout the medication use process. Infobutton use could also lead to more updates, as feedback is gained from the use of specific medications and problems emerge in actual practice.The Agency for Healthcare Research and Quality considers a checklist to be “an algorithmic listing of actions to be performed in a clinical setting” with the intended goal being “to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement.”¹ Patient safety movements continue to promote the benefit of checklist-based approaches. Although mistakes can happen, slips are very preventable with the appropriate use of this tool.Clinicians are pressed for time due to the emergent conditions of their patients and their total patient loads. Under this pressure, they must make decisions about the safe use of drug interventions for which they may have little or no prior experience. This situation is not exclusive to physicians; it occurs across the medication use process. Therefore, the ideal Infobutton should allow systematic access and concurrently allow users to drill down to the precise nugget of information that is needed. We recommend navigation options that include links to these nuggets but also provide the ability to expand and collapse sections of extensive monographs to aid the rapid access to the desired decision support.When calculations about medications are required, it would be ideal to have patient demographics and lab values accessible and integrated to the Infobutton so that values can be verified and calculations can be made from prepopulated data. When integration is not available, data entry should be supported through checkboxes, radio buttons, pull-down lists, and controlled keyboard/touchscreen inputs. Instructions that require preparation procedures for drug products should utilize video demonstrations or illustrated steps that demonstrate how to achieve optimal results. Infobuttons should be designed to prevent errors by requiring users to start with a checklist that has been cleared automatically from any previous user. Additionally, print capabilities and download capabilities should make the Infobutton materials available for in-service education when desired.The use of checklists and other decision-support tools is not without controversy. Many clinicians see them as time robbers and yet another distraction to their thought processes. This viewpoint may indicate the need for a shift in organizational culture to put safety first, employing procedures, policies, and tools to enable a unified focus. A shift to a culture of safety often advances the use of decision-support tools. It may be necessary to hold providers accountable when they fail to use these tools when working with either new medications or medications that have known safety implications and have created problems in the medication use process. The ability for an individual health system to customize decision-support tools may help providers feel that they have ownership of the approach and may undercut their criticism that guidelines promote cookie-cutter medicine. Each Infobutton would be available on every screen in the EHR any time a medication consideration is being addressed. Thus, no provider would have to pull out a smart phone or go to another program outside of the EHR to access information.We found out through an advisory board that many drug products are associated with expert users in health systems. A further customization of an Infobutton would be to add a list of these experts and their contact information that would be available for clinicians when they experience difficulty with the use of these products or procedures. Most pharmaceutical companies also provide additional support in the form of 24-hour medical information hotlines and product-specific Web sites. We believe that the best customizable Infobutton would have a controlled editing environment that would allow US Food and Drug Administration–approved content to be displayed initially and would have the capacity for additional helpful information to be added through editing of the distributed information button content. The restoration of the original text back to the distributed document would also be a desirable feature for this content.We are excited that the opportunity for the receipt of just-in-time information continues to be enhanced. Although we know that errors and mistakes will occur, time-proven methods such as checklists can make the medication use process increasingly safe. We encourage your comments and questions to either Bill at ude.nrubua@gbeklef or Brent at ude.nrubua@nerbxof. We would enjoy continuing this conversation.     

How Population Health Management and Big Data Can Rock Your World

Hospitals and health systems like yours have been aggressively pursuing a range of information systems over the last several decades. Cited goals are often efficiency, lower costs, better decisions, and better patient outcomes. But how do these systems purportedly lead to population-level improvements in care? In this column, we address the connections that are anticipated as well as challenges to be expected along the way.Let’s start with some definitions. Population health management, according to a leading outcomes management provider, is the “aggregation of patient data across multiple health information technology resources, the analysis of that data into a single, actionable patient record, and the actions through which care providers can improve both clinical and financial outcomes.”¹ While we like this definition because systems are used in a way that patient care is provided to individual patients, we think that the intelligence gained from each patient encounter can concurrently be applied throughout the continuum of care for any population being served. Big data is a buzzword in health care, even though other industries have been using the analysis of huge quantities of digitized data for many years. In health care, the rapid adoption of the electronic health record (EHR) provides an opportunity to finally having a real chance for improving health outcomes and controlling costs.The definition of big data varies, but we will define it as the “ability to access and analyze information that holds the key to more efficient, higherquality health care while significantly shortening the time between research and translation into practice.”² Big data is made possible because health care is now moving toward being a real digital enterprise to leverage the collective power of information. In our examination of health system technology devices that have been deployed for the last 10 years, we discovered that some had the ability to be networked but many were not. The EHR can now be the data hub for providers while supporting care provision by consolidating and analyzing these digital warehouses of real-time data to discover trends and make predictions.In a previous column, we described these processes as enterprise performance management. At a strategic level, a health system would generate critical success factors and key performance indicators that would lead to outcomes improvement. At an operational level, data would be gathered as a byproduct of rendering patient care to determine how well these indicators of success were being met. The system would generate e-mails to managers to give them feedback on any success factors assigned to them. Exception reports could include deficiencies, meeting of goals, and exceeding expectations. When best practices were identified within the enterprise, the methods being utilized to exceed expectations could then be used to address the problems experienced in units where expectations were not being met.In our experience, niche industries are being generated by the inability of EHR vendors to address both the developmental needs to improve their core product for its primary purpose of patient care and to add all of the population health and data analysis capabilities required. Add to this the fact that the individuals who are needed at the health system level to work with data analysis are the same people that Google and Microsoft are recruiting as quickly as possible. Thus, entrepreneurs look at the needs of health care and bring the skills and expertise necessary to the task. The expectation is that the EHR vendors who are going to cooperate by providing the needed data will eventually wrap the capabilities of these consultants into the everyday functions found in their systems.The complexity inherent in population health management is quite high. The data sources and their divergent information standards bring about the first challenge. Again, starting with a specific EHR, integration or interfaces must be established with any ambulatory electronic medical record being utilized by employed or affiliated providers. Each of these medical records could utilize one of 10 standards to include HL7, CCR, CCD, and so on that will need to be translated and normalized to be of any use for analysis. Next, we have separate computerized prescriber order entry systems, labs, imaging, health information exchanges, payers, and claims data. Each of these data sources must be integrated and normalized before they provide any real utility.Now we need to talk about clinical decision support systems. As a provider, you are probably already aware of the problem we call flag fatigue where alerts and warnings interrupt your provision of care for your patients. The challenge for an enterprise decision support system will be to ensure that the right provider is involved in the appropriate intervention at the appropriate point in the care process in the appropriate facility for the appropriate patient at the appropriate time. Get your mind around this complexity. Now think about multidisciplinary care team coordination and communication. How are we going to know who did what, when, and how?Alerts that are needed in population health management can also start when care gaps are identified. They can start when a patient steps on a digital scale that transmits a 10-lb weight gain due to heart failure–related edema. The alert may take place because patient outreach is indicated and an assignment for this task must be made. Action may be needed due to a patient’s entry in a notes section of a patient portal. Alerts may occur because quality reporting is either missing or the values entered have triggered the need for a response.Right now, we’re spending most of our time putting these data in and straddling the current reimbursement system that is so heavily based on fee-forservice care provision while preparing for anticipated, future ways of providing care. To understand how life will be different as these changes take place, look at those health systems that have already gone through significant population health management transitions and who use big data routinely to improve their operations.We have been attending presentations by health systems that have started with the care provision of their own employees as a way to get some small population experience in the area and then moved on to larger populations they were able to attract. Just Google “population health management” and explore testimonials on how care provision has changed among these frontrunners. Some will definitely rock your world or at least give you a few “ah-ha” moments. We would enjoy hearing your comments and questions on this topic. You can reach Bill at felkebg@auburn.edu or Brent at foxbren@auburn.edu.     

IT Maximization for Population Health Management

Those of you who have been in the health-system setting for several decades have seen many changes. Some of the changes originate within the care setting, whereas many others are brought on by external circumstances. Even those who have been in health systems for only 5 years can recall a recent change in the organization that greatly impacted pharmacy. More change is coming. In this installment, we explore critical technology-related changes of which you should be aware.Health systems are increasingly finding themselves involved in something they describe as “straddling.” They are straddling current reimbursement drivers and practices while concurrently getting ready for population health strategies to replace what has been the norm for decades. We have been saying for years that we cannot imagine a scenario where we will use less technology in any foreseeable future. When it comes to operating a health system focused on managing populations, we cannot imagine anything more important than the effective use of the following top 5 technologies.     

Is there a role for warfarin or aspirin therapy in heart failure?

Despite recent advances in pharmacologic therapy of heart failure, mortality remains high. There is growing evidence that thromboembolic events may contribute to these events. There is evidence for platelet activation, hypercoagulability and endothelial dysfunction in heart failure. The incidence of overt thromboembolism in heart failure is low. Ischemic events are a frequent prelude to heart failure. Thus, subclinical embolism and ischemic events may be contributing factors to the morbidity and mortality in heart failure patients. The role of antithrombotic therapy with warfarin or aspirin needs to be systematically investigated to determine if such therapy can reduce mortality in heart failure. Such information is particularly essential because non-randomized data have raised the possibility that aspirin may interfere with the beneficial effects of angiotensin converting enzyme inhibitors. This review summarizes available data on warfarin and aspirin therapy in heart failure.     

Clinical, haemodynamic, and antiarrhythmic effects of long term treatment with amiodarone of patients in heart failure

Twenty two patients with heart failure were studied in a double blind crossover trial to compare amiodarone (200 mg/day) with placebo. Each agent was given for three months. Extrasystoles and complex ventricular arrhythmias were common during ambulatory electrocardiographic monitoring and during exercise testing at entry to the study. Breathlessness and tiredness as assessed by visual analogue scores and duration of treadmill exercise did not become worse during amiodarone treatment. During the placebo and amiodarone phases of the study left ventricular ejection fraction and cardiac index determined by first pass radionuclide ventriculography were similar, both at rest and during upright bicycle exercise. Exercise induced ventricular tachycardia was abolished and simple and complex ventricular arrhythmias observed on 24 hour ambulatory monitoring were greatly diminished during amiodarone treatment. Three patients died, all suddenly, during the placebo phase. In two patients amiodarone was withdrawn after a further myocardial infarction in one and a worsening of symptoms of ventricular arrhythmia in the other. In contrast with other antiarrhythmic agents amiodarone is effective in suppressing ventricular arrhythmias in heart failure without causing adverse haemodynamic effects. Because frequent ventricular arrhythmias are known to be associated with a poor prognosis in heart failure, these data suggest that amiodarone may improve the poor prognosis in patients with heart failure.     

Clinical trials update from the European Society of Cardiology Heart Failure meeting and the American College of Cardiology: darbepoetin alfa study, ECHOS, and ASCOT-BPLA

This article provides information and a commentary on landmark trials presented at the European Society of Cardiology Heart Failure meeting held in June 2005, relevant to the pathophysiology, prevention and treatment of heart failure. All reports should be considered as preliminary data, as analyses may change in the final publication. The erythropoiesis stimulating protein, darbepoetin alfa, increased haemoglobin levels, improved quality of life and showed a trend for improved exercise duration in anaemic patients with symptomatic chronic heart failure. In the ECHOS study, the selective dopamine agonist nolomirole (CHF1035) showed no benefit in heart failure patients. Preliminary results of the ASCOT-BPLA study, which were reported at the American College of Cardiology meeting in March 2005, showed that in hypertensive patients, treatment with a calcium antagonist plus an ACE inhibitor was more effective at reducing cardiovascular outcomes than atenolol plus a diuretic.     

Implantable left ventricular assist systems (LVAS): recent results. A report from a series of meetings sponsored by the Study Group on Advanced Heart Failure of the Working Group on Heart Failure

Implantable left ventricular assist systems (LVAS) consist of implantable pumps with small control consoles and power sources that can be worn externally. These systems provide far greater patient mobility and independence than external pumps with bulky control consoles. Patients with implantable LVAS can be discharged from hospital and are able to return to work and resume active sports. Most patients have received these systems as a bridge to heart transplantation. Clinical status and quality of life improve dramatically after device implantation and survival on support (60-70% after approx. 100 days of support) is acceptable compared with transplant candidates on medical therapy. Patient selection and adverse events, primarily bleeding, thromboembolism and infection, are important issues with LVAS. In the future, long-term support and bridging to myocardial recovery may become important indications for LVAS.     

The views and attitudes of general practitioners and smokers toward provision of smoking cessation advice: a qualitative study.

Objectives: To identify common themes between general practitioners (GP's) and patients on smoking cessation in primary care in order to inform the development of acceptable guidelines, thus maximising the chance that recommendations will be received positively and implemented. Design: Qualitative study using focus groups and individual interviews with GPs and patients. Setting: North East Scotland. Subjects: 10 general practitioners and 20 patients (10 smokers and 10 patients who described themselves as ex-smokers). Results: Both general practitioners and patients agreed that the GP has a key role in providing a range of advice and support for smoking cessation. Both parties expressed views at variance with current guidelines but agreed that, for support and advice to be successful, it needs to comply with four of the five main themes identified; that it should be practical, pertinent to the consultation, personalised to the smoker's clinical need, and should emphasise the positive health gains from quitting. Conclusion: The considerable concordance between the perceptions of GPs and their patients about smoking cessation care suggests potential for a more positive partnership in working towards reduction of smoking in the UK.