Pharmacy OneSource_Drools in Healthcare Bootcamp Oct 2011

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Speed Saves Lives

Leveraging a Massively Parallel Expert System for Patient Surveillance

Pharmacy OneSource

•9 SAAS healthcare applications

•1 in 3 hospitals in the U.S. utilize our applications

•Active community of > 44,000 of pharmacy professionals.

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Sentri7 Clinical Workflows

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Surveillance

Intervention

Documentation

Reporting

What do we mean by…

Surveillance: Actively monitoring patients to identify opportunities for intervention

Intervention: changing patient care to improve outcomes

Outcomes:

Quality & Safety

Efficacy

Efficiency

Cost effectiveness

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Electronic Medical Records

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Visit

Order Tests

Surgeries

Lab resu

lts

EMR

Observations

Patient Clinician

Lab technician

Medications

Diagnoses

Vitals

Enhancing the EMR

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EMRClinician

Sentri7

• Activating data• Intelligent Decisions

Reasoning in real time

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On Demand

Event Driven

Event Stream Processing

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Receive Transform Update Complex Events

Surveillance

Rule T-N

Rule T-2

Rule T-1

Rule U-N

Rule U-2

Rule U-1

Rule CE-N

Rule CE-2

Rule CE-1

Rule S-N

Rule S-2

Rule S-1

Extract meaning with rules

HL7 standard open to interpretation

•Discrete and non-discrete data elements

•Variance between vendors & systems

•IDNs, Sites, and departments

Understanding the clinical meaning of a message

•Patient admission & discharge

•Active/visible medications

•Estimated creatinine clearance

•MDRO classification

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What does it mean?

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MSH|^~\&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1817457|D|2.5|

PID||0493575^^^2^ID 1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^|19480203|M||B|254 MYSTREET AVE^^MYTOWN^OH^44123^USA||(216)123-4567|||M|NON|400003403~1129086|

NK1||ROE^MARIE^^^^|SPO||(216)123-4567||EC|||||||||||||||||||||||||||

PV1||O|168 ~219~C~PMA^^^^^^^^^||||277^ALLEN MYLASTNAME^BONNIE^^^^|||||||||| ||2688684|||||||||||||||||||||||||199912271408||||||002376853

Data

Facts

Determine relevance with rules

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•Clinical outcomes & risk define time windows

•Active alerting

•Daily/weekly routines

•Criteria may exclude portions of the patient model or patient populations

•Admission/discharge

•Location, patient status.

Event Lifespan

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Observed

Reported

Received

Analyzed

Archived

Event Relevance Window

Patient surveillance with rules

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Active drug order for

"Piperacillin"

Last Estimated Creatinine

Clearance > 40 ml/min

Estimated Creatinine

Clearance < 40 ml/min in the last 10

days

Sentri7 surveillance rule builder

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Iterative refinement in computer systems

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Any automated system has this cycle

Agile attempts to reduce cycle time

Rule engine performance

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Facts X Rules = Evaluations

1 Patient 550 X 57 = 31,428

1 Hospital 605,000 X 57 = 34,571,428

350 Hospitals

211,750,000

X 20,000

= 4,235,000,000,000

F x R = P

How does reasoning time affect patient care?

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•Perception of responsiveness

•Time sensitivity of outcomes

Perception of responsiveness

1. Speed is everything—this is what information system users value most.

2. Anticipate needs and deliver in real time—deliver information when needed.

-“Ten Commandments for Effective Clinical Decision Support” American Medical Informatics Association, 2003

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Time sensitivity of outcomes

Simple, low risk. Therapeutic substitution.

“Nexium IV substituted to protonix”

Show all patients that have an active drug order where the drug name contains the phrase "Pantoprazole Sodium" and route is IV

Complex, high risk. Sepsis.

“At Very high risk for Severe Sepsis with shock”.

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At very high risk for severe sepsis with shock

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Group A

-Pulse > 90

-Resp < 20

-PaCO2 < 32 mmHg

-Temp not in the range 96.8 F to 100.4 F

Group B

-WBC Count not in the range 4 thou/uL to 12 thou/uL

-Band > 10 %

Group C-Lactic Acid >= 3.5 mmol/L-Serum Creatinine > 2 mg/dL-Estimated Creatinine Clearance < 50 ml/min-Platelet count < 80 thou/uL-Active Drug Order where Drug Name is not in the list ("WARFARIN SODIUM", "ENOXAPARIN SODIUM", "HEPARIN SODIUM, PORCINE") AND has one of the following:

-PT (INR) > 1.5-aPTT > 60 sec

-BILIRUBIN TOTAL > 2 mg/dL AND ALT (SGPT) >114 U/L-VENOUS O2 SATURATION (VO2HB) < 70%-pH < 7.30-PaO2 < 80 mmHg-pH < 7.35 AND PaCO2 < 50 mmHg

Group D-SYSTOLIC BP < 90-SYSTOLIC BP has decreased 28%

Show all patients that have at least one match from each of the following groups in the last 24 hours.

Impact of Sepsis on Patient Health

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Angus DC et al. Crit Care Med 2001;29(7):1303-1310.

Patient Lives

• > 200,000 deaths per year in the US

• Mortality from severe sepsis is between 28-50% (with standard care)

Hospital Costs

• $16.7 billion in total annual U.S. costs

• Average cost = $22,100 - $29,900

• Average LOS = 19.6 - 23.3 days

Space-Based Architecture

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GigaSpaces XAP – Elastic Application Platform

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DATA PROCESSING EVENTS & MESSAGING WEB APPLICATIONSUPPORT

MANAGEMENT & MONITORING

HIGH AVAILABILITY ELASTICITY CLOUD READINESS

GigaSpaces + Drools

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Performance Collocate rules with the data allowing extreme low latency rules

execution

Rules Management Dynamically load/unload rules leveraging GigaSpaces & Drools APIs

Ultra Scalable Parallel rules execution across the different data-grid partitions

Elasticity Scale- up/down, in/out system and leverage extra resources on-

demand within private cloud or public cloud.

High-Availability Continuous availability running rules 24X7 without any downtime

Scaling our decision support system

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Massively Parallel Expert System

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Clinica

l

Decisi

on

Supp

ort

Surveillanc

e Rules

GigaSpaces Grid + Drools

Surveillance Results

Lessons Learned

•Accelerate through partners

•Procedural vs Declarative

•Open Source

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