Overview'of'Clinical'Decision'Support'and'Knowledge'

Management'Roberto'A.'Rocha,'MD,'PhD,'FACMI'

Clinical'Informa9cs'Director,'Partners'eCare,'Partners'Healthcare'System'

Assistant'Professor'of'Medicine'Division'of'General'Internal'Medicine'and'Primary'Care,'Department'of'Medicine,'Brigham'and'Women’s'Hospital,'Harvard'Medical'School'

Big%Data%in%Healthcare:%The%Impact%on%Healthcare%Quality,%Cost%and%Access%in%China%=%April%18=19,%2016%=%%

Overview'

• Background'– Clinical'Decision'Support'(CDS)'modali9es'

– Examples'from'Partners'HealthCare'

• Knowledge'Management'(KM)'

– KM'program,'challenges,'opportuni9es'

– Assets'and'tools'used'at'Partners'HealthCare'• Conclusions'

– Successful'program,'care'workflow,'sharing'

Modalities'of'CDS'

•  Reference'knowledge'selec%on(and'retrieval(–  e.g.,'infobuQons,'crawlers'(indexing)'

•  Informa9on'aggrega%on(and'presenta%on(–  e.g.,'summaries,'reports,'dashboards'

•  Data'entry(assistance(–  e.g.,'forcing'func9ons,'calcula9ons,'evidenceRbased'templates'for'

ordering'and'documenta9on'

•  Event(monitors(–  e.g.,'alerts,'reminders,'alarms'

•  Care'workflow(assistance(–  e.g.,'protocols,'care'pathways,'prac9ce'guidelines'

•  Descrip%ve(or'predic%ve(analy9cs'–  e.g.,'diagnosis,'prognosis,'treatment'planning,'treatment'outcomes'

3(

CDS:(infobu?ons(

Informa9on'about'

“Depression”'

CDS:'alerts'for'medication'ordering'

5(

CDS:'interruptive'alert'with'action'

Clinician'must(cancel'current'order'or'discon9nue'preRexis9ng'order'

CDS:'geriatric'medication'dosing'

7(

CDS:'preventive'care'reminders'

8(

CDS'key'challenges'

•  Reliable'change(management(– Revisions'with'preserva9on'of'dependencies'–  Efficient'propaga9on'of'changes'

–  Preserva9on'of'meaning'(intent)'

•  High'scalability(– Ability'to'handle'mul%ple(clinical'condi9ons'with'reasonable'development'and'maintenance'costs'

– Adop9on'of'distributed'and'collabora%ve(cura%on(framework'(easy'to'create'and'deploy)'

– Maximize'reusability'and'maintainability'

KNOWLEDGE'MANAGEMENT'(KM)'

KM'Program'

•  Systema%c(and'sustainable(acquisi9on,'adapta9on'(localiza9on),'and'management'of'knowledge'assets'for'different'“modali9es”'of'CDS'

•  Includes'the'adapta%on(of'“reference”'knowledge'to'reflect'local'and'ins9tu9onal'requirements,'

resources,'and'priori9es'

•  Follows'a'wellRdefined'lifecycle,'including'specific'stages'for'documenta9on,'tes9ng,'and'monitoring'–'supported'by'integrated'set'of'tools'and'resources'

Rocha'RA,'Maviglia'SM,'Sordo'M,'Rocha'BH.'Clinical'knowledge'management'program.'In:'Greenes'RA,'editor.'Clinical'Decision'Support'R'The'Road'to'Broad'Adop9on'(Second'Edi9on).'Burlington:'Academic'Press;'2014.'p.'773R817'

Implementation'of'CDS'modalities(

CDS'modality( Types'of'Knowledge'Assets(

1.'Information'selection'and'

retrieval'Reference'

2.'Information'aggregation'and'

presentation' Actionable'3.'Data'entry'

assistance'

4.'Event'monitors'

Executable'

5.'Care'workflow'assistance'

6.'Descriptive'or'predictive'modeling'

Cost'

Ava

ilability'

Complex

ity'

Maint

aina

bility'

12(

Scope'(assets)'@'Partners'

Inventory'of'Knowledge'Assets'Managed'Centrally'at'Partners'(1/2)'

Rocha'RA,'Maviglia'SM,'Sordo'M,'Rocha'BH.'Clinical'knowledge'management'program.'In:'Greenes'RA,'editor.'Clinical'Decision'Support'R'The'Road'to'Broad'Adop9on'(Second'Edi9on).'Burlington:'Academic'

Press;'2014.'p.'773R817'

Inventory'of'Knowledge'Assets'Managed'Centrally'at'Partners'(2/2)'

Rocha'RA,'Maviglia'SM,'Sordo'M,'Rocha'BH.'Clinical'knowledge'management'program.'In:'Greenes'RA,'editor.'Clinical'Decision'Support'R'The'Road'to'Broad'Adop9on'(Second'Edi9on).'Burlington:'

Academic'Press;'2014.'p.'773R817'

Knowledge'Engineering'challenges'

•  LaborRintensive'acquisi%on(process'(SMEs)'

•  Inability'to'achieve'proper'domain(coverage(•  Rudimentary'tools(&'resources(•  Costly(and'inefficient(maintenance'

•  WellRtrained'personnel'equipped'with'efficient'tools'and'

processes'

•  Distributed'and'collabora%ve(ac%vi%es(–'i.e.'coopera9on'across'teams'and'ins9tu9ons'

–  Common'tools,'processes,'and'standards'

Implementation'challenges'

•  Data(availability'•  Data'not'coded,'coded'inconsistently,'not'enough'detail'(codes)'

•  Large'number'of'dependencies'(frequency'of'changes)(•  Data'defini9ons,'classifica9ons,'EHR'configura9on,'new'evidence'

•  Rudimentary'tools((edi9ng)'•  Incorrect'logic,'missing'values,'related'rules,'automated'valida9on'

•  Labor'intensive'tes%ng(•  Posi9ve'and'nega9ve'tests,'regression'tes9ng,'automated'tes9ng'

•  EHR(system'or'integrated'CDS'engine'

•  Limited'integra9on'op9ons,'complex'configura9on,'peculiar'features'

Rocha'RA,'Maviglia'SM,'Sordo'M,'Rocha'BH.'Clinical'knowledge'management'program.'In:'Greenes'RA,'editor.'Clinical'Decision'Support'R'The'Road'to'Broad'Adop9on'(Second'Edi9on).'Burlington:'Academic'Press;'2014.'p.'773R817'

Basic'KM'scenario:'Portal'

• WebRbase'portal'(intranet/Internet)'

• Open(access(to'a'complete'inventory'of'knowledge'

assets'created'and/or'used'(mul9ple'types)'

•  Asset'metadata,'including'iden9fica9on,'provenance,'lifecycle,'designa9ons'(labels'and'names),'and'classifica9ons'

•  Essen9al'documenta%on((detailed'specifica9ons)'•  Enables'process'transparency(and'effec9ve'collabora%on((including'reuse)'

Portal'Overview'

CONCLUSIONS'

CDS:'Care'workflow'assistance'(Registra%on)'

(Triage)(knowledge'retrieval,'data'entry'assistance,'event'monitors'

(Ini%al(Assessment)(data'entry'assistance,'knowledge'retrieval,'order'entry'assistance,'event'monitors'

(Complete(Assessment)'informa9on'presenta9on,'data'entry'assistance,'knowledge'retrieval,'event'monitors'

(Analysis(&(Plan)'knowledge'retrieval,'order'entry'assistance,'informa9on'aggrega9on,'data'entry'assistance,'event'monitors'

Clinician(preference(

Pneumonia(protocol(

2nd(Episode(

Protocol(stra%fica%on(

Appropriate(Abx(

Pa%ent(preferences(

Protocol(eligibility(

CoTmorbidi%es(

CDS'has'to'follow'the'patient'

• Clinical'systems'might'have'very'similar(CDS(features,'but'are'frequently'not'configured'the'same'way'

– CDS'triggered'in'one'segng'may'not'be'confirmed'

or'reRenacted'in'subsequent'segngs'

• Without'con9nuity'and'consistency'across'

segngs'and'ins9tu9ons,'interven9ons'have'

decreased(effec%veness(for'dissemina9ng'

evidence'and'reducing'unwarranted'variability'

Knowledge'Exchange'is'vital'

Home(

Ambulatory(Visit(

Hospital(

Procedure(

Rehabilita%on(

Phase(

CDS?(

CDS?(CDS?(

CDS?(

Shared(Repository?(

Integrated(KM(Programs?(

CDS'overview'

•  CDS'known'to'improve(care(– BeQer'with'more'complex(CDS'– But'has'to'follow(the'pa9ent'

• US'EHR'incen%ves(require'CDS'use'– Dependency'on'available'structured'data'– High'data(quality(and'consistency(is'a'essen9al'– Alignment'with'quality'&'safety'measures''

•  Knowledge'is'constantly'growing(–  Exis9ng'knowledge'assets'quickly'obsolete'– Must'evolve'toward'individualized(decisions(– Must'combine'evidence(&'personal(preferences(

Successful'KM'Program''

• Enables'health'care'ins9tu9ons'to'effec9vely'u9lize'knowledgeTdriven(computer'systems'

– Improve'care'safety'and'quality'

– Keep'pace'with'frequent'scien9fic'advances'– Embrace'new'care'delivery'models'

– Promote'con9nuous'learning'

• Overcome'knowledge(engineering(and'implementa%on(challenges'

Acknowledgements(

Saverio'Maviglia'

Margarita'Sordo'

Beatriz'Rocha'

Eileen'Yoshida'

Charles'Lagor'

Priyaranjan'(Raj)'Tokachichu'

Christopher'Vitale'

Dan'Bogaty'

Other'members'of'the'Clinical(Informa%cs(Team(at'Partners'

Thank(you!(

Roberto A. Rocha, MD, PhDrarocha@partners.org

http://scholar.harvard.edu/rarocha

This'work'by'Roberto'A.'Rocha'is'licensed'under'a'Crea9ve'Commons'AQribu9onR

NonCommercialRShareAlike'4.0'Interna9onal'License'