Advisories: Logic and Scope
Brillians (formerly, SupraVISTA) provides a powerful, extensible and fully customizable “Advisory” system. All Advisories are automatically evaluated and displayed when the user load a patient into Brillians – zero effort. All this at the point of care, within 30-50 seconds, while the user continues to work in CPRS. Zero clicks. Zero time-cost to the user.
For example, if the patient has abnormal lung imaging (per ICD-10 code entry in medical record), Brillians checks for lung imaging (chest x-ray or CT Thorax) within the specified time-frame. If the expected imaging is not found, the clinician is “advised” to review the need for lung imaging.
The following table shows the spectrum of Brillians’ Advisories and their rationale. The Advisories help the clinicians reduce the risk of clinical errors due to commonly missed clinical findings. Though over 250 clinical issues are evaluated internally, only the items which need clinician’s attention are displayed on the Advisories list.
Note: The statements in the table below represent general principles for “safe” clinical practice. These are NOT specific guidelines and not everyone will agree with these statements. Brillians is designed to bring “clinical concerns” to the clinician’s attention, and leave the decision making to his/her judgment.
Do not confuse advisories with clinical reminders or View Alerts. Advisories provide critical information but do NOT require any action/work from the user.
Worth Repeating !
At the point-of-care, in 30-50 seconds, Brillians automatically analyzes the selected patient’s record for the issues listed in the table below.
Zero effort. Zero time-cost: No user action is needed because Brillians synchronizes with CPRS and does all the work in the background without interfering with the user’s normal workflow.
Though Brillians evaluates 100s of clinical issues, a typical patient generates only about 10-12 Advisories which can be reviewed within a minute or two.
Each Advisory represents an issue which the clinician should be aware of. But, we don’t stop there.
A click and a double-click on the Advisory shows a lot more information about the given issue.
Can I do this manually in 3-5 minutes during the busy clinic schedule? If not, are my decisions really data driven?
Clinical Concern Risk Category
Abnormal Imaging Follow-up Missed
Clinical Concern
Rationale and Remarks
Abnormal Lung imaging
(e.g., lung nodule)Periodic follow up imaging to ensure stability (e.g., CT Chest)
Typical periodicity – 3 to 6 months initially, less frequently later on.
End Point – 2 to 2.5 years from the date of initial finding, if the lesion remains unchanged/stable per radiologist's interpretation.
Asbestosis screening
(e.g., History of Asbestos exposure)Chest X-Ray
Typical periodicity – Annually.
End Point – Life-long or diagnosis of Mesothelioma.
Aortic Aneurysm CT or ultrasound imaging of Aorta
Typical periodicity – 6 to 12 months depending on size/severity.
End Point – Life-long or surgical correction.
Carotid stenosis Carotid Artery Imaging
Typical periodicity – 6 to 12 months depending on the severity.
End Point – Life-long (? How often to follow-up after surgical correction)
Endoscopic Follow-up Missed
Clinical Concern
Rationale and Remarks
Bladder Cancer (SP Treatment) Cystoscopy
Typical periodicity – every 6 to 12 months depending on findings.
End Point – Life-long, surgical correction, or limited life expectancy.
Colon Cancer Colonoscopy
Typical periodicity – every 6 to 12 months initially.
End Point – inoperable or limited life expectancy.
Colon Polyps
(or High risk for Colon Cancer)Colonoscopy
Typical periodicity – 3 to 5 years depending on the family history and polyp microscopy.
FOBT Positive Colonoscopy
A potential legal trap: Colonoscopy may be requested but is never done (e.g., patient no-shows); or an incomplete procedure due to technical difficulties is not followed up with a proper endoscopy or colon imaging (Capsule Colonoscopy, CT or Barium studies)
Standard of Care Recommendations Missed
Clinical Concern
Rationale and Remarks
Proactive Management of ACSC Patients Patients with known Ambulatory Care Sensitive Conditions (ACSC) are at a greater risk of emergency department visits and hospitalizations.
For better outcomes, the Advisory reminds the clinician about the needs for aggressive management of ACSC diagnoses.
Atrial Fibrillation and Anticoagulation Warfarin or a novel anticoagulant drug
Unless there is a specific contra-indication, all patients with Atrial Fibrillation should be on anticoagulation (consider CHAD-VASC-2 score).
CAD and Beta-blocker Prescribe a beta-blocker drug
Unless there is a specific contra-indication, all patients with coronary artery disease (CAD) should be considered for a beta-blocker Rx.
LDL < 100 mg% (or LDL < 70mg%) Consider LDL < 70 mg% for high risk patients, including those with certain comorbidities e.g., CAD, diabetes, CVA, TIA (high risk of CVA), carotid or renal artery stenosis, PVD and tobacco use
Micro-albuminuria in a diabetic patient ACE-I or ARB Rx
Unless there is a specific contra-indication, all patients should be on a ACE-I or ARB group medication.
Target Systolic BP < 130 and Diastolic BP < 80
if the patient has certain comorbidities.Diabetes, and possibly, history of CVA or TIA
Periodic Cancer Screening missed
Clinical Concern
Rationale and Remarks
Note
Many “Performance Measures” Advisories are also included in other categories. Generally, VHA does a very good job on these items.
Prostate cancer screening PSA
Periodic PSA testing for prostate cancer screening is controversial. PSA Velocity may be a more useful indicator, but it suffers from the same controversy. Periodic (12-24 months) monitoring may be appropriate in high-risk male patients in age group 55 to 69 (USPSTF). An Advisory is generated for the overdue and abnormal findings for PSA and for elevated PSA Velocity. The user should use (or disregard) this Advisory per prevailing guidelines and patient preferences.
Cervical cancer screening PAP Smear
Periodic screening per prevailing guidelines in the appropriate age group in female patients. An Advisory is generated to remind the clinician to review pap smear report. This Advisory is linked to cyto-pathology reports so that the clinician can quickly review the relevant data
Breast cancer screening Mammogram
Annual or biennial screening in the appropriate age group in female patients. An Advisory is generated to remind the clinician to review the breast imaging studies.
Preventive Lab Screening missed
Note
Many “Performance Measures” Advisories are also included in other categories. Generally, VHA does a very good job on these items.
Clinical Concern
Rationale and Remarks
Hemoglobin A1c monitoring Hemoglobin A1c
Monitor A1c every 6-12 months in diabetic patients. An Advisory is generated for overdue testing.
Lipid monitoring Lipid panel
Annual monitoring in the appropriate age group in both genders. Advisories are generated for overdue and abnormal findings.
Liver Panel in patients taking certain anti-lipid medication Liver Panel
Monitor every 6-12 months in such patients, especially new Rx and dose changes. The Advisory is generated for the overdue testing.
PSA PSA
Periodic PSA testing for prostate cancer screening is controversial (see "Prostate Cancer Screening" above).
Monitor annually in males in the age group 50-75. The Advisory is generated for overdue testing.
Clinical Errors: Concomitant use of certain drugs
Note
Normally, CPOE order checks would address these issues. Brillians evaluates ONLY a few common issues and is NOT a substitute for CPOE order checks built into nearly all EHRs.
Clinical Concern
Rationale and Remarks
SSRI And Tramadol Risk of serotonin syndrome.
Anticoagulant Rx And NSAIDs GI bleeding risk.
Lithium and NSAIDs Lithium level may be increased if NSAID is added. Monitor Lithium level 5-7 days after adding NSAID and then periodically. It is better to have regular NSAID use (and lithium dose adjusted to that) than episodic NSAID use.
Warfarin and Amiodarone Increased risk of Amiodarone toxicity. Both drugs have many drug-drug interactions and are considered "high risk" drugs requiring close monitoring.
Clinical Errors: Toxic drug monitoring missed
Clinical Concern
Rationale and Remarks
Amiodarone Requires periodic monitoring for Hepatic, pulmonary and ocular toxicity.
Methotrexate Monitoring for Hepatic toxicity and bone marrow suppression
Warfarin Close INR monitoring and awareness of numerous drug interactions.
Clinical Errors: Drug level monitoring missed
Clinical Concern
Rationale and Remarks
Digoxin
Dilantin
Lithium
Phenobarb
Tegretol
TheophyllineAt least annual monitoring is recommended (more frequent drug level monitoring should be performed after dose changes, suspected drug interactions, etc.)
The medical center can set periodicity for each drug level. Brillians generates an Advisory if the drug level is not found within the specified time frame.
Special cases of the disease-specific lab monitoring
Clinical Concern
Rationale and Remarks
Colon Ca (SP surgery) Monitor CEA annually. (Some controversy about its correlation with cancer recurrence.)
Hepatitis C (? also B) AND Cirrhosis Monitor AFP annually
(Presently, an Advisory reminds the user to check AFP every year if patient has Hepatitis C without regard to Cirrhosis because many such patients have undiagnosed/undocumented Cirrhosis of liver.)
Note: Some experts recommend periodic Hepato-Cellular cancer screening with liver ultrasound for patients with Cirrhosis and viral hepatitis.
Prostate Ca (SP treatment) (No special Advisory is needed as we continue to do routine PSA follow up and an alert is generated if the periodic PSA monitoring is missed.)
Awareness of the diagnoses which need close monitoring
Note
The healthcare team needs to remain vigilant for certain conditions for various reasons (need close monitoring, failure to follow-up, infectious exposure risk, inability to navigate the system, etc.) In co-managed patients, each provider may think the someone else is following the condition.
Clinical Concern
Rationale and Remarks
Bladder Cancer (treated or otherwise) Urology/Cystoscopic exams, Oncology, and lab follow up, etc.
Patient may have unmet social or emotional needs.
Many do not have family/social support to navigate the system.
Colo-rectal Cancer (treated or otherwise) GI/Endoscopic exams, Oncology, and lab follow up.
Patient may have unmet social or emotional needs.
Many do not have family/social support to navigate the system.
Hepatitis C (treated or otherwise) GI/Liver and lab follow up.
Ongoing monitoring and counseling regarding alcohol use.
HIV / AIDS (treated or otherwise) Infectious disease and lab follow up.
Extra precautions during injections and invasive procedures.
Patient may have unmet social or emotional needs.
Malignant Melanoma Regular dermatology follow up.
The clinician should not assume "someone else" is taking care of it. Verify and document if the patient is receiving appropriate follow up by an internal or outside provider.
Lung Cancer Pulmonary, imaging, Oncology, and lab follow up.
Patient may have unmet social or emotional needs.
Peripheral Vascular Disease Vascular follow up and risk factor mitigation.
Ongoing monitoring and management of risk factors (e.g., diabetes, hypertension and lipid control, and tobacco use counseling).
Prostate Cancer Urology, Oncology, and lab follow up.
Patient may have unmet social or emotional needs.
Many do not have family/social support to navigate the system.
Schizophrenia Understand patient's limitation. MH follow up.
Patient may have unmet social or personal safety needs.
Watch for risk of homelessness and the inability to obtain help when needed.
Patient Safety: Review Selected Labs and Vital Signs
Note
Changes in lab values may be an early indication of deteriorating organ health. Given the large number of labs, it is not possible to manually review status and trend of each lab. Brillians screens a large number of labs and informs the user about abnormalities as Advisories.
Similar logic applies to vital signs.
Clinical Concern
Rationale and Remarks
Review over 100 labs Brillians can show abnormal lab tests as Advisories. Each medical center can define the abnormal and critical levels for each lab irrespective of the normal range in CPRS
Review Vital Signs Brillians can show "out of range" Vitals (e.g., Systolic BP, Pulse Rate) as Advisories. Each medical center can define the abnormal and critical levels for each item.
Quality of Care: Important calculated values
Note
Frankly, the busy providers do not have time to calculate certain risks. Therefore, Brillians automatically calculates certain values and shows the respective Advisory if the value is above the preset threshold (e.g., high Cardiac Event Risk).
Clinical Concern
Rationale and Remarks
Body Weight Change (%)
(compared to patient's mean weight until a year ago).Unintentional, unexplained weight loss of > 7% may be an early, and sometimes only, indication of an occult malignancy.
Cardiac Event Risk
(according to ATP III Calculator)This is intended to draws the provider’s attention to the need for aggressive cardiovascular risk reduction measures.
Fibrosis-4 Score Fibrosis-4 score is an indirect measure of degree of fibrosis (cirrhosis) in liver. It correlates well with liver ultrasound for degree of fibrosis. It is especially useful in patient with chronic viral hepatitis.
Morphine Equivalent Daily Dose (MEDD)
(mg/day)Brillians automatically calculates MEDD using the ACTIVE medications' data in the patient's outpatient medications list (excludes liquid and injectables typically used in terminally ill/hospice patients). The MEDD value is displayed as na Advisories if it is above the specified threshold (e.g., over 15mg/day)
PSA Velocity
(units change per year)A rapid rise in PSA can be an early indication of Prostate cancer though the PSA value may still be “normal.” This is easily missed if the PSA, though rising, is still within normal limits.
PSA velocity is a measure of rate of change, regardless of absolute value of PSA