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Interview with 2015 Medicine Innovation Program grant winners: Integration of Predictive Models to Support Clinical Decision Making in the Routine Care of Patients Undergoing Percutaneous Coronary Intervention (Co-Sponsored by the Healthcare Transformation Lab).
Drs. Jason Wasfy, Robert Yeh (of Beth Israel Deaconess Medical Center) and colleagues will leverage an emerging technology to integrate point-of-care modeling of patient-specific risks into the consent process prior to percutaneous coronary intervention. This intervention will help clinicians and patients better understand patient specific risks and make informed decisions in this context. Grant funds will be used to support project implementation and quantify the impact of the intervention on physician decision-making, clinical outcomes and the cost-effectiveness of care. This project is co-sponsored by the Mass General Healthcare Transformation Lab.
Dr. Yeh: We started this project as a collaborative project working with the Massachusetts General Physicians Organization (MGPO). Creagh Milford, DO and Timothy Ferris, MD have been developing a tool that can be used not only in cardiology but across systems to measure appropriateness of procedures, and what we wanted to add to this was the ability to implement these sorts of complicated risk stratification models into the tool that the MGPO was already building. A lot of the ideas behind this concept were generated from one of my mentors, John Spertus, MD, who was at the American Heart Institute and worked with us on developing several of these models. We figured out that we could integrate those models into an existing tool called PRoE, and one of the real innovations behind PRoE was that you have to collect information and data from patients to build these risk models, say 7 to 10 risk factors for a model. That can be laborious, but we also partnered with the QPID group, which is a tool that was also built in-house at MGH. That facilitated the ability for this to be used in clinical practice without slowing down workflow. We started a year ago to develop and de-bug this technology platform to do exactly this, to be able to integrate risk prediction, to be able to pull in a semi-automated fashion from the electronic health record, and to be able to produce an individualized consent form that we give to patients that show their individual risk as well as a clinician worksheet that showed clinicians what the patient’s risks were, and give some suggestions for what they might do differently for individual patients.
Dr. Wasfy: If you think about the way that medicine has evolved, the traditional model is a physician making decisions based on their experience and their gut that in many ways has a lot of value. But we know from a lot of the research that we’ve done, that the risks and outcomes can be predicted relatively well in models that have integrated lots of variables. We are not smart enough to integrate a model of seven variables; it’s too complicated for the human brain. So what happens is, just like all humans, we revert to our gut. The problem with your gut is that it’s biased by all kinds of history. That is cognitive bias. We’ve also done research with national databases and we’ve found evidence of systematic mis-estimation of risk. We hope that integrating these types of calculators into clinical practice will change the way that doctors make decisions in ways that address cognitive bias in decision making.
The nice thing about these kinds of tools is that it will not only better align our clinical decisions with meaningful risks and benefits for individual patients, but it will also be a more fundamentally right way of sharing information with patients.
Perry Band: I’m a project specialist in a group called the Healthcare Transformation Lab and we are focused on proving the value in experience of health care through collaborative innovation. The MIP approached us about this particular project because they felt it really aligned with our goals. The Healthcare Transformation Lab was born in the Heart Center so this was a natural project for us to take. I provide support on the project and the MIP is providing a portion of funding to help implement this project.
PRoE is a tool that is already used in many different departments, but in Percutaneous Coronary Intervention (PCI), it was not in practice, so part of this was developing this for PCI. So where it stands right now, the risk models are ironed out and we’re working on cosmetic aspects and adoption for actual utilization in the cath lab.
Project Next Steps:
Perry Band: There are two parts to this: At our last meeting we talked about Phase I, get fellows to universally use this before consenting patients and Phase II, once we feel like adoption has stabled to start determining the right workflow for this PCI timeout, and encourage care teams to record and discuss the anatomical vessel findings and the resulting clinical decision.
Value of Medicine Innovation Program Funding:
Dr. Wasfy: [MIP funding has] been essential for a number of different reasons. It’s paid for a lot of the computing resources that we need to analyze the effects of our intervention. It’s important for us to not only do things to make things better here, but share those results with the outside world as that can help improve health care more broadly.
Perry Band: Another thing that I found valuable was that the MIP has quarterly meetings with all of the different grant winners. I went to one of those and shared our progress and it was really helpful to have that community to debrief about what’s working well and what’s not working well and to have a sounding board to get advice, opinions, and commiserate on the progress of these projects.
Dr. Yeh: I think it gave a lot of structure to the effort and through this grant from the MIP and Healthcare Transformation Lab that the real value that we got was the insights we got from people like Perry and Drs Christiana Iyasere and Mark Poznansky who put us on a timeline, helped us to structure things and stay on task. To push these ideas through takes a lot of effort on multiple people’s parts. It’s not just a clinician with an idea, it’s really the implementation that’s challenging. That’s where that group has been incredibly helpful in pushing things through. I think that’s one of the reasons why we are active now.
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