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LEVERAGING CLINICAL IT
FOR DENGUE: OPPORTUNITIES
     FOR TOMORROW

               SlideShare.Net/Nawanan



     Nawanan Theera-Ampornpunt, M.D., Ph.D.
Outline

 Background
 Clinical Management of Dengue

 Roles of Health IT in Dengue

 Summary
Dengue: Epidemiology

 Most rapidly spreading mosquito-borne
  viral disease in the world
 30-fold increase in incidence in the last

  50 years
 Epidemic dengue spread to new areas

 Substantial burden on health sector &

  economy

    WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Dengue: Prevention & Control

 Dengue surveillance
 Case management

 Outbreak response

 Integrated vector management

 Social mobilization & communication

 Research

    Resolution SEA/RC61/R5 of WHO Regional Committee for South-East Asia (2008)
    WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Dengue: Clinical Management




   WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009),
                                                        adapted from Yip (1980)
Dengue: Clinical Decisions

 Diagnosis & differential diagnosis
 Investigations

 Phase & severity

 Disposition: To send back home or to admit

 Monitoring of patient status

 Fluid management & transfusion decisions

 Management of complications
Dengue: Differential diagnosis
Febrile Phase
 Flu-like syndromes

 Illnesses with a rash

 Diarrheal diseases

 Illnesses with neurological manifestations

Critical Phase
 Infectious

 Malignancies

 Others (e.g. acute abdomen, metabolic conditions,
  hematologic disorders)

      WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Dengue: Admission Criteria




   WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Dengue: Management Guidelines




   WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Fluid Management in Compensated Shock




     WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Fluid Management in Hypotensive Shock




     WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
Imagine This Scenario
   Not enough sleep




                        Image Source: aafp.org
“To Err Is Human”
 Lack of attention
 Easily distracted

 Limited memory

 Difficulty putting relevant information together

  (information overload?)
 Inappropriate decisions (lapses, cognitive errors)

 Poor decisions under pressure (emergencies)

 Difficulty in monitoring & triage of patients
Roles of Health IT

 Assists in documentation & assessments
 Reminds or alerts

 Servers as external memory

 Better visualizations / information
  presentations
 Suggests management options

 Guidelines at the point of care

 Patient monitoring
Example of “Alerts & Reminders”
Clinical Decision Support Systems
                     PATIENT


                    Perception
CLINICIAN

                    Attention


Long Term Memory                 External Memory
                     Working
                     Memory
 Knowledge   Data                Knowledge    Data


                    Inference


                    DECISION
Roles of Health IT in
    Dengue Clinical Management
 Online templates for complete patient
  assessment & documentation
 Alerts & Reminders

 Decision support tools to offer
  recommendations in case management
 Electronic disease reporting

 Information integration for early detection

  of an outbreak
Clinical Decision Support Systems
                              PATIENT
              Improved                             Guidelines &
            information      Perception             References
CLINICIAN presentations                    Alerts &
         (graphs, tracking   Attention    Reminders,
             tools, etc.)                 Templates

Long Term Memory                             External Memory
                              Working
                              Memory
 Knowledge    Data                           Knowledge    Data


                             Inference       - Differential Dx
                                             - Treatment
                             DECISION        Recommendations
Google Flu Trends




Source: Google.org/FluTrends
Disease Surveillance

   Google Flu Trends uses search engine
    keywords (non-clinical data)
     Accuratefor practical purposes of detection
     of possible outbreaks (not confirmation)
   Imagine how it would be if we use clinical
    data (e.g. chief complaints, diagnoses in
    ER/clinics). Would it help us respond faster?
Opportunities for Tomorrow

 Dengue management relatively
  straightforward, easy to implement as logic
 Improved IT infrastructure within hospitals &
  clinics
     Hospital information systems & electronic
      health records common (high adoption)
     Can be leveraged for better dengue
      management within those settings
Infrastructure:
22
     EHR Adoption in Thai Hospitals




                              Theera-Ampornpunt (2011)
Adoption Estimates: THAIS 2011
23




      Estimate (Partial or Complete Adoption)       Nationwide
     Basic EHR, combined inpatient & outpatient       49.8%
     settings
     Comprehensive EHR, combined                       5.3%
     order entry of medications, combined              90.2%
     order entry of all orders, combined               79.4%




                                                  Theera-Ampornpunt (2011)
Current State of IT Use in Dengue

 Focus more on IT use in surveillance &
  outbreak detection
 Some uses in patient education,
  teleconsultations, predictive modeling, &
  basic research
 Few studies on use of health IT to manage
  dengue in clinical settings
Summary (1)

 Dengue is an important epidemic
 Management involves various steps
  & criteria, maybe complicated for
  non-experts
 Errors inevitable for inexperienced
  providers
Summary (2)

 Health IT can be used to provide
  better care, e.g. through decision
  support
 Opportunities exist for use of IT in
  dengue
 Call for more focus on development
  & evaluation of IT uses in clinical
  management of dengue

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Leveraging Clinical IT for Dengue: Opportunities for Tomorrow

  • 1. LEVERAGING CLINICAL IT FOR DENGUE: OPPORTUNITIES FOR TOMORROW SlideShare.Net/Nawanan Nawanan Theera-Ampornpunt, M.D., Ph.D.
  • 2. Outline  Background  Clinical Management of Dengue  Roles of Health IT in Dengue  Summary
  • 3. Dengue: Epidemiology  Most rapidly spreading mosquito-borne viral disease in the world  30-fold increase in incidence in the last 50 years  Epidemic dengue spread to new areas  Substantial burden on health sector & economy WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 4. Dengue: Prevention & Control  Dengue surveillance  Case management  Outbreak response  Integrated vector management  Social mobilization & communication  Research Resolution SEA/RC61/R5 of WHO Regional Committee for South-East Asia (2008) WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 5. Dengue: Clinical Management WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009), adapted from Yip (1980)
  • 6. Dengue: Clinical Decisions  Diagnosis & differential diagnosis  Investigations  Phase & severity  Disposition: To send back home or to admit  Monitoring of patient status  Fluid management & transfusion decisions  Management of complications
  • 7. Dengue: Differential diagnosis Febrile Phase  Flu-like syndromes  Illnesses with a rash  Diarrheal diseases  Illnesses with neurological manifestations Critical Phase  Infectious  Malignancies  Others (e.g. acute abdomen, metabolic conditions, hematologic disorders) WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 8. Dengue: Admission Criteria WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 9. Dengue: Management Guidelines WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 10. Fluid Management in Compensated Shock WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 11. Fluid Management in Hypotensive Shock WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control (2009)
  • 12. Imagine This Scenario  Not enough sleep Image Source: aafp.org
  • 13. “To Err Is Human”  Lack of attention  Easily distracted  Limited memory  Difficulty putting relevant information together (information overload?)  Inappropriate decisions (lapses, cognitive errors)  Poor decisions under pressure (emergencies)  Difficulty in monitoring & triage of patients
  • 14. Roles of Health IT  Assists in documentation & assessments  Reminds or alerts  Servers as external memory  Better visualizations / information presentations  Suggests management options  Guidelines at the point of care  Patient monitoring
  • 15. Example of “Alerts & Reminders”
  • 16. Clinical Decision Support Systems PATIENT Perception CLINICIAN Attention Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference DECISION
  • 17. Roles of Health IT in Dengue Clinical Management  Online templates for complete patient assessment & documentation  Alerts & Reminders  Decision support tools to offer recommendations in case management  Electronic disease reporting  Information integration for early detection of an outbreak
  • 18. Clinical Decision Support Systems PATIENT Improved Guidelines & information Perception References CLINICIAN presentations Alerts & (graphs, tracking Attention Reminders, tools, etc.) Templates Long Term Memory External Memory Working Memory Knowledge Data Knowledge Data Inference - Differential Dx - Treatment DECISION Recommendations
  • 19. Google Flu Trends Source: Google.org/FluTrends
  • 20. Disease Surveillance  Google Flu Trends uses search engine keywords (non-clinical data)  Accuratefor practical purposes of detection of possible outbreaks (not confirmation)  Imagine how it would be if we use clinical data (e.g. chief complaints, diagnoses in ER/clinics). Would it help us respond faster?
  • 21. Opportunities for Tomorrow  Dengue management relatively straightforward, easy to implement as logic  Improved IT infrastructure within hospitals & clinics  Hospital information systems & electronic health records common (high adoption)  Can be leveraged for better dengue management within those settings
  • 22. Infrastructure: 22 EHR Adoption in Thai Hospitals Theera-Ampornpunt (2011)
  • 23. Adoption Estimates: THAIS 2011 23 Estimate (Partial or Complete Adoption) Nationwide Basic EHR, combined inpatient & outpatient 49.8% settings Comprehensive EHR, combined 5.3% order entry of medications, combined 90.2% order entry of all orders, combined 79.4% Theera-Ampornpunt (2011)
  • 24. Current State of IT Use in Dengue  Focus more on IT use in surveillance & outbreak detection  Some uses in patient education, teleconsultations, predictive modeling, & basic research  Few studies on use of health IT to manage dengue in clinical settings
  • 25. Summary (1)  Dengue is an important epidemic  Management involves various steps & criteria, maybe complicated for non-experts  Errors inevitable for inexperienced providers
  • 26. Summary (2)  Health IT can be used to provide better care, e.g. through decision support  Opportunities exist for use of IT in dengue  Call for more focus on development & evaluation of IT uses in clinical management of dengue