Acute Myocardial Infarction

(AMI) Treatment and the

Promise of Clinical Decision
Support (CDS)

May 27, 2009

Medical Informatics 406
Kenyetta Cole
Derrick Hawkins
Rozmin Pirwani
Candyce Thompson
INTRODUCTION
Problem Space
• US Institute of Medicine estimates up to 98,000 Americans
die each year as a result of preventable medical errors
• Nationwide audit review of 439 quality measures
determined that adults receive only about half of the
recommended care
• Gap exists between medical science and the care patients
actually receive

• Purpose:
– Usage of clinical decision support (CDS) to improve care
and health outcome for patients with acute myocardial
infarction (AMI)
Uncertainties
• Conflicting, incomplete, and untimely data
• Outcome of any action
• Adverse reactions
• The evaluation of acute chest pain
remains challenging, despite many insights
and innovations over the past two decades
• Impact on workflow
Challenges
• Knowledge of symptoms may not be enough to
promote prompt action in the event of an AMI

• Cognitive and emotional processes, individual

beliefs and values, and the influence of the
context of the event should also be considered
in individual interventions

• Use of fax facility and decision tree improves

decision making regarding thrombolysis in AMI

http://www.bmj.com/cgi/content/full/324/7344/1006
http://heart.bmj.com/cgi/content/abstract/78/2/198
Relevant Developments
• Missed diagnoses of acute coronary syndromes
(ACS) in the ER is a continuous challenge

• Several options are now available to recanalize an

occluded coronary artery, including thrombolytic
agents, percutaneous coronary angioplasty, and
cardiac surgery

• The efficacy of these strategies and have concluded

that early vessel recanalization significantly reduces
in-hospital mortality

• Early vessel recanalization is the primary goal of

therapy in acute myocardial infarction
Gold Standards
• EKG - Do EKG within 5 min as soon as patient arrival.
Electrocardiogram is the diagnostic tool of first choice in AMI.
However; it has a sensitivity of only 55-75 %

• CK-MB levels AMI depends largely on cardiac markers in

blood such as Creatinine kinase-MB isoenzyme (CK-
MB). CK-MB is the most appropriate test for diagnosis of
AMI. Done within 30 min of patient arrival via point of
care (POC)

• Troponin level Cardiac Troponin shown to have a consistently

higher sensitivity and specificity for identifying
myocardial necrosis than traditional markers. Done within 30
min of patient arrival via point of care (POC)

http://www.biomedres.org/journal/pdf/312.pdf
Relevant Prior Articles
• Primary PCI for Myocardial Infarction with
ST-Segment Elevation, Ellen C. Keeley,
M.D., and L. David Hillis, M.D., New
England Journal of Medicine, January 4,
2007

• Detection and Risk Stratification of

Myocardial Damage: The Troponin Story,
Duke Clinical Research Institute
Objective
• Usage of clinical decision support (CDS) to
improve care and health outcome for
patients with acute myocardial infarction
(AMI)
THE MODEL
Model Design
• “to ensure that optimal, usable and effective
clinical decision support is widely available to
providers, patients, and individuals where and
when they need it to make health care
decisions” for AMI patients

Osheroff, J. A., J. M. Teich, et al. (2007). "A roadmap for national action
on clinical decision support." Journal of the American Medical
Model Design (cont’d)
• Model Framework
– Arden Syntax
• Response to the inability to share
medical knowledge among different
institutions
• Defines a modular guideline
– Medical Logic Modules (MLM)
– Focuses on the “sharing of simple
modular and independent guidelines”
– Current version is Arden 2.0

de Clercq, P. A., J. A. Blom, et al. (2004). "Approaches for creating

computer-interpretable guidelines that facilitate decision support."
Model Design (cont’d)
• Medical Logic Modules
– Each makes a single decision
– Each is an ASCII file

• Contains 3 categories of slots

– Maintenance
– Library
– Knowledge

de Clercq, P. A., J. A. Blom, et al. (2004). "Approaches for creating

computer-interpretable guidelines that facilitate decision support."
Model Design (cont’d)
• Maintenance slot
– File name, author, version, institution, etc
– Testing, research, production

• Library slot
– For documentation purposes
– Contains detailed explanation
– Keyword

• Knowledge slot
– Actual medical knowledge is stored
• Type, data, evoke, logic and action
 Conceptual
Model Design

Presentation – Jane Brokel, “Improving Quality of Care for Vulnerable

Populations Through HIT” – AHRQ 2008 Conference
 maintenance:
title: Alert on high cholesterol;;
filename:high_cholesterol;;

Sample version: 1.00;;

institution: KDRC
author: Jane Doe, MD (jdoe2@dmc.org);;

MLM
specialist: ;;
date: 2009-05-20;;
validation: testing;;

library:
purpose: Alert clinician of high cholesterol;;

explanation: Whenever a lipid profile is ordered and resulted, the

cholesterol level is checked to verify whether it is above 239.;;

keywords: cholesterol; lipid profile;;

knowledge:

type: data-driven;;

data:
lipid_results_storage := event {‘ lipid profile ’};
cholesterol := read last {‘ cholesterol ’};;

evoke: lipid_results_storage;;

logic:
/* check that the cholesterol is a valid value */
if cholesterol is not number then
conclude false;
endif;

if cholesterol >= cholesterol >239 then

conclude true;

endif;;

action:

write “The patient’s cholesterol level (“|| cholesterol ||”) is high”;;

Knowledge Engineering
• Knowledge Acquisition
– A Roadmap for National Action on Clinical Decision
Support
• AMIA for ONC
– Trinity Health
– Cecelia Montoye
• Director of Quality @ MI Heart and Vascular
Institute
– Dr. Kim Eagle
• Clinical Director for Cardiology Center @
University of MI Health System
– Paul A. de Clercq
• Department of Medical Informatics @ University of
Masstricht
Knowledge Engineering
• Knowledge Maintenance
– Automatic update of multiple external
knowledge bases

– Date and time of update will always be

displayed

– Clinicians will develop new MLMs

– New versions will coincide with central

knowledge base
SYSTEM DESCRIPTION
Types of CDSS Architectures
• Stand Alone systems
• Integrated systems
• Standards-based systems
• Service architectures
• Service-oriented Architecture for NHIN
Decision Support (SANDS)
• EON
Types of Decision Support
• Checklists
• Reminders & Alerts
• Defaults, Order sets, Integrated tools
• Point-of-care (bedside) information
• Aids for differential diagnosis
Common Components of a CDSS
• Knowledge base
• Rules engine or inference engine
• User interface

Inference
Engine
User Interface

Knowledge Base
The Knowledge Base
• Is usually a relational or OLAP database

• Allows input from user or the EMR (EcMR)

• Essential that it be up to date

• Able to perform multiple queries

simultaneously

• Stores raw data in the form of

multidimensional cubes or tables
The Knowledge Base (cont’d)
• Use data mining technique to turn raw
data into information

• Receives queries from the inference

engine

• Collection of real world facts

• Created with the help of a knowledge

engineer
The Inference Engine
• Provides intelligence to search
knowledgebase
• Uses if <conditions> then <actions>
• Logic is made of algorithms and routines
– AND Gates, flip flops, logic arrays,
algorithm
– Arden Syntax (clinical knowledge coding
standard)
• Designed using a programming language
such as Java, C, or Pascal
• Outputs results of queries to user
User Interface
• Virtually always in the form of graphical
user interface (GUI)
• Sometimes web based for ease of
deployment
• Can also be thick client and provide native
input and output screens
• Input screen contains check boxes, radio
buttons, and text boxes
• Serves as input and output mechanism
• Output can be redirected
EVALUATION
Evaluation of CDSS Model –
Ongoing Improvement
Diagram of the CDS Evaluation Cycle

Steady State

Create Verify and Monitor Evaluate

Interventions validate and effectiveness
measure

Acquire After every If problems identified, Quarterly if

knowledge and change if e.g. adversely affect not working as
enter into errors clinicians, reliability or planned
system. identified. response time.
Requires
collaboration
Modify and
between
maintain
clinicians
informaticians,
and IT
professionals.
As needed, may
require revisions of
knowledge, encoding
or system design.
 Use and Usability Log
Intervention Name Usage and Usability Issues Date Noted Remediation Plan Priority
Aspirin in post-assessment order
1-M ay-09 N/A N/A
set Avg. 17 uses/ day; no issues noted
Avg. 17 firings/ day; high user Analysis in progress, nurses
Aspirin 325 mg reminder alert 1-M ay-09 M edium
dissatisfaction feel this is redundant, part
of order set
Analysis in progress, nurses
ACEI/ ARB prescribed in discharge
Avg. 19 uses/ day; 30% rejection
1-M ay-09 feel this is redundant,High
only
order
rate. Some user dissatisfaction used w ith A M I patients w ith
Avg. 18 uses/ day; 25% rejection
Lipid Profile order set 1-M ay-09 Analysis in progress M edium
rate. High user dissatisfaction
Avg. 18 firings/ day; 25% rejection
Lipid profile result alert 1-M ay-09 Analysis in progress M edium
rate. Some user dissatisfaction
Avg. 19 uses/ day; 20% rejection Analysis in progress,
PCI/ STE-M I order set 1-M ay-09 High
rate. Some user dissatisfaction consider re-w ork
Beta blocker prescribed in
1-M ay-09 N/A N/A
discharge order Avg. 7 uses/ day; no issues noted

Beta-blocker in order set 1-A pr-09 N/A N/A

Avg. 10 uses/ day; no issues noted
Beta-blocker administration on
1-M ay-09 N/A N/A
documentation form Avg. 7 uses/ day; no issues noted

Beta-blocker reminder alert 1-A pr-09 N/A N/A

Avg. 7 firings/ day; no issues noted
Adult Smoking Cessation
1-M ay-09 N/A N/A
Performance Against Objectives
CDSS Program Enhancement Plan
DISCUSSION
Drawbacks and Shortcomings
• Inference engine may • The anomaly
experience insolvability
issues or infinite loops
• Errors could result in
delays, frustration or
endanger patient
health
• Violate Hippocratic
Oath “Above all, do no
harm”
• Out of date information
Implementation
• Can be client/server or closed end system
• Open Source platform such as Linux contains
all components
• Oracle or Microsoft SQL server database
provides more robust database capabilities
• Can be used in emergency room, battle field
triage, remote locations with scarce medical
personnel, teaching hospitals
• Indian University uses MS Access for HIV
CDSS
Future Extensions
• Collect real-time samples of bioterrorism
information

• Interface with portable lab units for

specimen identification and diagnosis
 Decision Support Architecture

Electronic Health Record

Hospital
Database EBM Scripts

Patient Guideline Links

Data Structured Messages
Interactive forms
Patient Data
Decision
Decision Support Drug indications
Support Engine
Component Decision Support Contraindications

Drug interactions
Decisio Local Scripts
n
Suppor
t
Knowledge in computer-readable form
is probably more easily translated, shareable
and divided into modules than full guidelines
EMR
workstation
Patient presents Medical data manually entered
and symptoms or its pulled from EMR
collected

Inference Engine (Rules Engine)

Arden Syntax, Bayesian,

SQL model

Protocols
Treatments
Advice K no w le d g e b a s e
Information
Output

CDSS High Level System

Workflow
Results of the Queries
• Triggers: Events in a clinical system which
invoke a clinical decision support inference,
(e.g., ordering a medication).
• Data elements: Patient-specific information
used for decision support such as a medication
list, problem list or lab result.
• Intervention: The action a decision support
system takes in response to some clinical
situation, such as notifying the user or logging
an event.
• Response Action: The action a user takes in
response to a notification, such as canceling an
order or overriding the rule.

Wright, A. and D. F. Sittig (2008). "SANDS: a service-oriented architecture for clinical decision
support in a National Health Information Network." J Biomed Inform 41(6): 962-81.
References
• Optimal Inference Engine, N. L. Griffin and F. D. Lewis,
Department of Computer Science, University of Kentucky
• Fleisher, H. and Maissel, L.I., “An Introduction to Array Logic”,
“IBM J. Res. And Dev.(1975)
• Kuperman GJ, Gardner RM, et al. Help: a dynamic hospital
information system. New York: Springer-Verlag; 1991.
• Clinical Decision Support Software for Chronic Heart Failure,
Stephen J. Leslie, PhD, FRCP,* and Martin A. Denvir, PhD,
FRCP†
• Journal of the American Medical Informatics Association
Volume 8 Number 6 Nov / Dec 2001
• Electronic Medical Records: An Introductory Tutorial, William
Tierney, MD, Atif Zafar, MD
Questions