Information Integration to Support Medication Management (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 8, 2008, Jonathan R. Nebeker, MS, MD, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (2.1 MB).

Slide 1

Information Integration to support Medication Management

Jonathan R. Nebeker, MS, MD
VA Salt Lake City GRECC
University of Utah

Slide 2

Acknowledgements

• Charlene R. Weir, PhD
• Frank Drews, PhD
• Molly Leecaster, PhD
• Rand Rupper, MPH MD
• Kenneth Boockvar, MD
• Kevin Meldrum
• Sandi Geary
• Mike Lincoln, MD
• Chris Nielson, MD PhD
• Brittany Mallin, MS MPH
• AHRQ R18 HS017186
• VA Salt Lake City GRECC
• VA Salt Lake City IDEAS Center

Slide 3

Overview

• The Electronic Health Record (EHR) context
  • Current
  • Future
  • How theory gets us to future
• Theoretical Framework
• Demonstration

Slide 4

Current Computerized Patient Record System (CPRS) Veterans Health Information Systems & Technology Architecture (VistA)

• Access, presentation, and inputs:
  • Tables, charts, lists, graphs, text fields
• Logical relationships:
  • Reminders
• Storage of basic clinical information:
  • Lab, pharmacy, vitals, reports/notes, demographics
• Emphasis on access
• Information siloed in tabs
• Physician centric
• Patient excluded
• No interface for control

Slide 5

Future CPRS VistA

• Access, presentation, and inputs:
  • Integrated tables, charts, lists, graphs, controls, text fields
• Logical relationships:
  • Diagnoses and supporting evidence; treatments, conditions, and goals; prescriptive decision support
• Storage of basic clinical information:
  • Ontologies of lab, pharmacy, vitals, reports/notes, demographics
• Emphasis on control
• Information integrated
• Supports all healthcare professionals and the patient

Slide 6

Progress

• The Electronic Health Record context
• Theoretical Framework:
  • Joint Cognitive Systems or Cognitive Systems Engineering
  • Contextual Control Model
• Demonstration

Slide 7

Cognitive System Engineering

• Contextual Control Model (CoCoM)
• Understanding/Sense making
• Goal reconciliation
• Feedback/Feed Forward Control
• Sharp-end efficiency, resiliency
• Assistive decision support

Slide 8

Decision Support v. Sense Making

• Computerized decision support is typically normative and targets the right decision.
• The CPRS of the future will emphasize an information-rich environment that targets sense making to support higher quality decisions in the highly variable context of patient care.

Slide 9

Contextual Control Model (CoCoM)

• Performance in context
• Different types of behaviors predict better outcomes
• Functional not structural approach:
  • Not about information processing models: Memory, programs, etc.
• Used in engineered systems:
  • ABS at Saab
  • Nuclear Power Plants

Slide 10

Control Cycle in Healthcare

The flowchart shows the healthcare of a patient.

• What is going on?
• Physician, Patient, Nurse, Pharmacist, Social Worker, etc., construct/shared understanding of patient health:
  • Determines
  • Action/care plan
  • Produces
  • Events/Feedback:
    • Disturbances can have inpact
  • Modifies

Slide 11

Control Modes

• Scrambled:
  • Lack of purposeful activity
• Opportunistic:
  • Addressing salient characteristics
• Tactical:
  • Following procedure, limited scope
• Strategic:
  • Broader scope and higher-level goals

Slide 12

Preliminary Conclusions

• CoCoM translates well to chronic disease care.
• High-mode characteristics have face validity for predicting better outcomes.
• Implications for software design:
  • Need to support efficient, rich reconstruction of mental model of patient
  • Need to highlight interaction of goals and therapies
  • Need to increase time horizon including feed forward

Slide 13

Demonstration

The slide shows an image of a rectangle with various icons.

• Click icon to add content.
• The icon includes:
  • Insert table
  • Insert chart
  • Insert clipart
  • Insert picture
  • Insert diagram or organizational chart
  • Insert media clip

Slide 14

Example of Integrated Control

The colored photograph shows Star Trek characters Capt. Kirk, Dr. McCoy, and Spock watching over a sleeping Vulcan character in the medical wing.

Slide 15

Building up to Understanding

Slide 16

Snapshot of condition

The table is repeated from the previous slide showing how particular interventions are used to treat a condition and the goal(s) attained.

• Intervention use of Apironolactone 50 mg po qday-MPR 100%; Carvedilol 25 mg bid-MPR 80%; Hydrochlorothiazide 25 mg po qday-MPR 30%; Lisinopril 40 mg po qhs-75%; and Terazosin 5 mg po qhs-MPR 80%
• Treats the condition of Hypertension
• Goal is to raise systolic blood pressure (SBP):
  • Raises K+
  • Raises Creat

Slide 17

The table is repeated from the previous slide, along with two graphs, one charting the daily status and range of Systolic blood pressure, Diastolic blood pressure, and K+ (Goals), and the other, daily uses and prescribed amounts of Lisinopril, Spironolactone, and Hydrochlorothiazide (Interventions).

Slide 18

The table and graphs from the previous page are repeated along with a screen shot of a drop screen for Spironolactone.

• The screen includes Spironolactone's:
  • Dose
  • Route
  • Frequence
  • Medication possession ratio (MPR)
  • Days supply/refills/arrival/cut pills? (for savings purpose)
  • Special instructions
  • Dispensed as
  • Reasons for change
  • Auto generated note

Slide 19

This slide is identical to the slide with the table and 2 charts (Slide 17), but instead shows the lowering of Spironolactone to 25 mg po qday-100% and raising Hydrochlorothiazide 25 mg po qday-to 100%. The 2 graphs chart the new measurements of the daily status and range of Systolic blood pressure, Diastolic blood pressure, and K+ (Goals), and daily uses and prescribed amounts of Lisinopril, Spironolactone, and Hydrochlorothiazide (Interventions).

Slide 20

The 2 graphs from the previous slide are repeated with a box open showing the doctor's name/date and Adverse Effect Management: Reduce spironolactone from 50 mg po qd to 25 mg po qd, to reduce potassium from 5.5 mmol/dl.

Slide 21

The 2 graphs from the previous slides are repeated but now also show the projected measurement status and range of Systolic blood pressure, Diastolic blood pressure, and K+ with lowering the dose of Spironolactone.

Slide 22

Advantages of Contextual Control

• Simplification of current systems:
  • Medication reconciliation
  • Alerts
• Allows for shared mental model of care plan by all professions and the patient:
  • Provides natural coordination of care
  • Reduces errors?
  • Facilitate the relevance of nursing documentation

Slide 23

Summary

• Theory-driven design (human factors)
• Reintegrates patient and system
• Patient-centric outcomes
• Assistive decision support
• Facilitates geriatric-style care