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Northwestern University School of Continuing g Studies MED_INF 406 March 13, 2013 T Team M3C

Martin Coyne

Charan Dhanoa

Mik N Mike Nowak k

M tth Matthew Tran T

CDSS Presentation
Gastric Cancer Clinical Decision Support System

Background g

An estimated 22,000 gastric cancer cases diagnosed each year resulting in 11,000 deaths. Lack of complete p information at the Point of Care impacts p the delivery of appropriate treatment options to patients. Patient preferences for quality of life are not factored into p treatment options. Poor documentation on staging Cancer patients. There is a need to develop a standard workflow for physicians. Goal is to develop an inference engine that can automatically generate decisions based on scientific data and provide patient with cost-effective treatment options.

Stakeholders, , Goals, , and Objectives

Stakeholders

Chief of Oncology Chief Information Officer Chief of Nursing (Oncology) Provide recommendation for treatment Integrate with EHR system C Complement the clinical i i workflow f Include patients QoL assessment

Goals

Objectives

System y Inventory y

Inputs

Demographic Information Lab Information Radiological Information Pathological Information Patient Questionnaire Epic based EMR S Separate systems for f Lab, Radiology i and Pathology Separate database for patient questionnaire

Infrastructure

Intervention and Workflow

Intervention

Is there an effective intervention for gastric cancer? Can the intervention be operationalized? Is the intervention cost effective? Can the intervention be supported by the workflow? Can the workflow be captured by data? Can the workflow be captured in a DSS?

Workflow

Workflow Diagram g

Change g Management g

Proposed changes

QoL assessment Decision support recommendation Develop Change Team Communicate Communicate, Communicate, Communicate Communicate Identify Super Users Train, Use, Retrain

Change plan

Decision Model

Analysis Decision tree analysis with different options of treatment Partial gastrectomy with either radiation or chemotherapy Total gastrectomy as sole treatment Each treatment judged by 1 Survival probability based on review of scientific literature 1.

2. Quality of Life score subjectively determined by patient preference scale and physician determined QoL score based on clinical experience

Design g

Requirements

Intervention strategy Data should be presently available Data easily accessed Manageable workflow

Impact

Will help physicians make treatment recommendations Will i be patient i centered Will be cost effective

Design g Diagram g

Content

Information Delivery

Treatment Recommendations

Based on probabilities Unbiased Tailored to patient Sensitive to patients feelings on mortality and morbidity

Information on patient perspective

User Interface

DSS Program

Ability to run scenarios Customize Uses currently available data for decision tree

Data input

EMR Specialty systems: Lab, Radiology & Pathology

Requires manual input of patient responses Treatment Recommendations based on decision tree Results of patient questionnaire

Data output

Knowledge g Management g

Initial Design of Knowledge Database Domains Gastroenterology Oncology Sources Scientific published studies controlled studies registries data Expert opinion Ongoing management Expiration date on data Expert annual review

Evaluation

Verification Pre-treatment survey for Patient and Physician Does CDS recommendation correspond to patient expectation to physician clinical expertise

Validation Post-treatment survey Patient satisfaction Physician i i satisfaction i f i

Discussion
Assumptions Decision tree depends on subjective preferences Patient and Physician QoL Limitations Knowledge database limited by small number of high quality studies Future knowledge iteration limited by small number of cases in US of gastric cancer Implementation Plan Oncologists design decision tree under direction of academic steering committee Piloting of CDS at one oncology center After validation and verification, rollout to 6 centers

Discussion

Vision

First CDS for oncology management that builds into it patient expectations and values A model for future CDS for management of other oncology diagnoses

Conclusion

50% of deaths occurring from those diagnosed each year Developing a system that generates decisions based on evidence based medicine and scientific data will:

help physicians in providing efficient care and most effective treatment Improved clinical work flow Improved patient quality of life Reduce the number of deaths occurring each year

References

National N ti lC Cancer Institute. I tit t (2013) (2013). Cancer C T Topics i . Retrieved R t i d 2013, 2013 from f National Cancer Institute at the National Institutes of Health: http://www.cancer.gov/cancertopics/types/stomach National Cancer Institute. ( (2013). ) SEER Stat Fact Sheets: Stomach. Retrieved 2013, from Surveillance Epidemiology and End Results: http://seer.cancer.gov/statfacts/html/stomach.html Mackenzie, M., Spithoff, K., Jonker, D., & Group, G. C. (2010). Systemic therapy for advanced gastric cancer. cancer Cancer Care Ontario Ontario. Toronto: Agency for Healthcare Research and Quality. Sherman, K., Merkow, R., Bilimoria, K., Wang, C. E., Mulcahy, M., Benson, A., et al. (2012). Treatment Trends and Predictors of Adjuvant and Neoadjuvant Therapy for Gastric Adenocarcinoma in the United States . Annals of Surgical Oncology . Smith, R., & Shinohara, E. (2011). Gastric Cancer: The Basics. The Abramson Cancer Center of the University of Pennsylvania.