Judy Ozbolt, Asli Ãzdas, Lemuel R. Waitman, Janis B. Smith, Grace V. Brennan, Randolph A. Miller ... [I]f wisely used, these improved statistics would tell.
MEDINFO 2004 M. Fieschi et al. (Eds) Amsterdam: IOS Press © 2004 IMIA. All rights reserved
Decision Support for Patient Care: Implementing Cybernetics Judy Ozbolta, Asli Özdasb, Lemuel R. Waitmanb, Janis B. Smithc, Grace V. Brennand, Randolph A. Millerb aSchool
of Nursing and Department of Biomedical Informatics, School of Medicine c Department of Biomedical Informatics, School of Medicine Systems Support Services, dInformatics Center Vanderbilt University, Nashville, Tennessee USA
b
Judy Ozbolt, Asli Özdas, Lemuel R. Waitman, Janis B. Smith, Grace V. Brennan, Randolph A. Miller
[2-9]. Evolution toward an electronic health record (EHR) based on widely adopted standards for terminology, information models, messaging, and databases offers opportunities for realizing this vision. At Vanderbilt University Medical Center (VUMC), we are beginning to use informatics resources and clinical and management processes to make this vision a reality.
Abstract The application of principles and methods of cybernetics permits clinicians and managers to use feedback about care effectiveness and resource expenditure to improve quality and to control costs. Keys to the process are the specification of therapeutic goals and the creation of an organizational culture that supports the use of feedback to improve care. Daily feedback on the achievement of each patient’s therapeutic goals provides tactical decision support, enabling clinicians to adjust care as needed. Monthly or quarterly feedback on aggregated goal achievement for all patients on a clinical pathway provides strategic decision support, enabling clinicians and managers to identify problems with supposed “best practices” and to test hypotheses about solutions. Work is underway at Vanderbilt University Medical Center to implement feedback loops in care and management processes and to evaluate the effects.
Methods This paper describes the opportunities we identified to introduce cybernetic mechanisms to improve patient care, the modifications required to enable our informatics resources to provide timely feedback, and the changes in clinical and organizational processes necessary to make use of the information. Defining Cybernetic Care Processes Patient Care without Cybernetics
Keywords
Greatly simplified, a typical patient care process follows a predictable course. For example, a patient with Congestive Heart Failure in decompensation is admitted to the hospital. A physician performs the history and physical examination and writes orders. Nurses develop a care plan, execute the plan and the physician orders, and document care and observations, including a record of fluid intake and output. The physician periodically reviews laboratory results, signs and symptoms, and fluid intake and output. When the physician is satisfied that the patient’s condition is sufficiently improved, the physician discharges the patient.
Decision Support Systems, Clinical; Decision Support Systems, Management; Cybernetics; Communication Barriers
Introduction “There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life; . . . . In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to. . . . [I]f wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present They would enable us, besides, to ascertain the influence of the hospital . . . upon the general course of operations and diseases passing through its wards; and the truth thus ascertained would enable us to save life and suffering, and to improve the treatment and management of the sick . . . .”
In the typical care process, every clinician is striving to provide high quality care. Even with the best of intentions, however, orders and care plans are often formulated ad hoc from the knowledge and expertise the clinician is able to bring to bear in a cognitively challenging clinical environment. Therapeutic goals are rarely specified, and failure to achieve goals may go unnoticed. Abnormal findings are reported, but the timeliness and effectiveness of communication vary. Furthermore, work processes for retrieving, communicating, and using evolving information may be poorly defined. The typical care process, in fact, is one that in the United States infamously leads to an estimated 48,000 to 98,000 deaths per year from medical errors [10]. The status quo is not acceptable. Priorities for corrective action
-- Florence Nightingale, Notes on Hospitals, 1863 [1] From Florence Nightingale onward, health care professionals, managers, and researchers have pursued the vision of providing feedback from the data of everyday clinical practice to improve the quality of care, enhance patient outcomes, and contain costs
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These applications perform many functions needed for cybernetic systems of care management and improvement. PathworX contains template clinical pathways, or comprehensive, interdisciplinary plans of care developed by teams of clinical experts using the best evidence available. With PathworX, nurses select the appropriate template pathway for each patient and customize it for the individual. Each pathway specifies the therapeutic goals for every phase of care, and at least once every 24 hours, a nurse records whether or not each current goal has been achieved. Every pathway has a corresponding set of physician orders stored as a template in WizOrder and available to physicians as a starting point to create the orders for an individual patient. Decision-support functions in WizOrder consult patient data in StarChart to create alerts and reminders to the physician and to warn of possible contraindications to orders.
include “cross-cutting systems interventions” [11] supported by electronic health records [12]. Patient Care with Cybernetics Norman Wiener coined the word “cybernetics” from the Greek word for “steersman” and defined it to mean “the science of communication and control in animal and machine” [13]. Cybernetic systems use feedback to regulate processes to achieve equilibrium or to reach goals. By extension, cybernetic patient care systems use feedback about selected variables to improve achievement of therapeutic goals and to optimize resource utilization. Using the example above, a cybernetic care process differs from the typical care process in important ways. A patient with Congestive Heart Failure in decompensation is admitted to the hospital. A physician performs the history and physical examination and customizes orders from an evidence-based order set. A nurse assigns and customizes a clinical pathway and therapeutic goals. Nurses execute the pathway and the physician orders and document care and observations, including a record of fluid intake and output and achievement of therapeutic goals. The physician periodically reviews laboratory results, signs and symptoms, fluid intake and output, and goal achievement. The clinical team adjusts care as needed to enhance goal achievement. When the clinical team verifies that the patient has achieved the therapeutic goals, the physician discharges the patient. Periodically, the clinical team uses aggregate data about goal achievement from many patients to modify the template pathway and order set.
Why, then, were feedback loops missing? WizOrder and PathworX had been developed by separate teams who had focused more on the internal functions and robustness of each application than on needs for communication between them. Consequently, clinicians using each system made decisions in the absence of knowledge contained in the other system—or even contained in the same system but not readily retrievable. For example, although evidence-based order sets corresponding to pathways existed in WizOrder, there were no pointers to these order sets and nothing to distinguish them from literally hundreds of other order sets composed idiosyncratically by individual physicians over a period of years. Faced with a glut of order sets with no obvious distinguishing characteristics, most physicians simply composed orders one by one based on their current knowledge, recall, and judgment. They had no way of identifying the evidence-based pathway and order set that would best serve the patient. Valuable knowledge contained within the system was not readily retrievable and so was not used. Meanwhile, nurses were independently placing patients on pathways and referring to a “comprehensive plan of interdisciplinary care” that differed from physician orders. Patients were not getting the benefit of well-integrated, evidence-based care.
In cybernetic care systems, clinicians implement evidence-based care as clinical pathways and order sets with defined therapeutic goals. They use feedback about goal achievement to fine-tune care, averting costly complications. They use aggregate data to test hypotheses, generate new evidence, and refine pathways and order sets. The feedback loops of cybernetic systems provide the missing links in the process of quality improvement. Examining the Vanderbilt Case
The Solution: The Admission Wizard
At Vanderbilt University Medical Center in early 2003, many of the elements of a cybernetic patient care system were in place, but the feedback loops were not functioning. To diagnose and correct the problems, we examined informatics resources and clinical and management processes. The method was to compare actual processes to the ideal cybernetic processes as outlined in the examples above.
Once we had described the problem, the solution was apparent: point the physician toward the appropriate evidence-based pathway. Experience provided two caveats: Minimize disruption to the clinical workflow and avoid confounding business rules (how to find the pathway-related order set) with evolving knowledge (content of pathways and order sets). The appropriate time for assigning a pathway and choosing an order set is most often at admission, so the new functionality was dubbed “the Admission Wizard.” In the established course of writing admission orders, the resident physician routinely types into WizOrder, “Admit to Dr. [Attending Physician]’s service.” At that point, the Admission Wizard presents a pop-up window listing the pathway-oriented order sets associated with that attending physician’s clinical service and inviting the resident physician to select one. This solution avoids complex knowledge-based algorithms to match the precise order set to information about the patient—a process with many pitfalls and prone to change with evolving knowledge—while presenting the resident physician with a manageable choice from 10 to 15 alternatives. The
Results Resolving Information Silos The Problem: Inaccessible Information The first issue in using feedback to improve care is the availability of the information. How effective were our information resources in providing evidence-based guidelines for care and feedback about goal achievement? At VUMC, three locally developed applications play key roles in managing clinical information. WizOrder provides real-time decision support for clinician orders at the point of care. PathworX assists nurses to plan and document care. StarChart contains patient-specific data.
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that case managers can get a quick update on the patients for whom they are responsible.
physician can edit the selected order set as needed for the patient. Preliminary findings on pilot units show a significant increase in the use of the appropriate pathway-oriented order set for patients with acute myocardial infarction. We are tracking deviations from the template order set to assess their impact on goal achievement and other outcomes.
To communicate goal achievement status to physicians required collaboration with the teams responsible for StarChart and WizOrder. PathworX is being modified to export goal achievement reports to each patient’s record in StarChart, making the reports viewable by authorized users from any computer (including palm-sized personal digital assistants) with access to StarChart. In addition, the code in WizOrder that generates “Current Meds and Results Reports” for resident physicians preparing for rounds is being modified to import goal achievement reports from StarChart and to include them with other current data that physicians use when assessing a patient’s progress.
Intervention Before
After
Total
Used
53
38
91
Not Used
45
11
56
Total
98
ACS Order Set
Statistical Test: χ2 Significance: p
