Knowledge Management Challenges in the Healthcare Delivery Market

Tonya Hongsermeier, MD, MBACorporate Manager, Clinical Decision Support and Knowledge Management,

Clinical Informatics Research & Development

Partners HeatlhCare System, Inc.

Agenda About Partners Healthcare Knowledge Management and Informatics

Knowledge Application Knowledge Discovery Knowledge Asset Management

Challenges in Healthcare Delivery Weak Organizational Alignment Weak Investment in Asset Management Implications for Clinical R&D Implications for Personalized Medicine

Partners HealthCare Massachusetts General Hospital, Brigham and

Women’s Hospital and several other hospitals in the network

Licensed Beds 3196 Births 18,478 Admissions 134,991 Patient Days 871,321 Average LOS 5.31 Total Outpatient Visits 2,324,073

Partners Information Systems

Much published on innovative use of informatics in healthcare (Bates, Teich, Glaser, Kuperman, Barnett, Chueh, and many others)

800 applications 520 active projects 680 employees based in 19 locations FY02 operating budget of $92.3M FY02 capital budget of $47M These are relatively generous numbers as a

percentage of operating expenses

Some Current Clinical Knowledge Assets Developed at Partners Medication Data Dictionary and DDIs Inpatient alerts and interactive order rules Gerios and Nephros for proactive filtering of drug doses

for elderly and/or renal insufficient Radiology Ordering decision support Preventive health reminders Outpatient lab result decision support Outpatient documentation templates Piloting outpatient drug-lab, drug-disease interactive

reminders

Current State Challenges Typical of Many Academic Healthcare Delivery Organizations

7 homegrown and 2 commercial CPOE systems, plan to evolve to “next generation CPOE” in next 5 years

Limited implementation of structured (encoded) clinical documentation

Proprietary approaches to knowledge encoding Not re-usable or sharable Much updating/maintenance is bottlenecked by

resource constraints Research datawarehouse in place, but struggle to

expand in face of fragmented clinical systems environment

Typical Committee and Project Structures Related to Medication Safety Illustrate

Organizational Alignment Problem

Physician Order Entry Team

Clinical Data Repository Team

Pharmacy System Team

Clinical Documentation Team

Electronic Medication Adminstration Team

Information Technology Projects

Pharmacy and Therapeutics

Patient Safety Quality or Performance

Improvement Policies and

Procedures Formulary Infection Control

Committees and Departments

Medication Use Process Organization

Physician Order Entry Team

Clinical Data Repository Team

Pharmacy System Team Clinical Documentation

Team Electronic Medication

Administration Team

Information Technology Projects

Pharmacy and Therapeutics

Patient Safety Quality or Performance

Improvement Policies and Procedures Formulary Infection Control

Committees and Departments

Interdisciplinary Medication Use Process Advisory TeamPhysicians, Nurses, Pharmacists, Clinical Systems Architects

Medication Safety Steering CommitteeChief Medical Officer, Chief Nursing Officer, Chief Information Officer, Chief Quality Officer

KnowledgeApplication

Knowledge Discovery

KnowledgeAsset Management

Knowledge Management: The Core Processes

A Continuum of Clinical Decision Support and Knowledge Discovery*

Monitoring patient data with passive decision support

Interceptingincorrect clinicaldecisions

Making the right decisions the easiest decisions

Predictive Modeling

Case-based Reasoning

Learning Knowledge Repository

Reference KnowledgeLinking

Reference KnowledgeLinking

Event Monitoring

Event Monitoring Safety NetSafety Net AnticipationAnticipation

Understanding and PredictingPerformance

Understanding and PredictingPerformance

Surveillance Interactive Proactive Learning

*modified from the First Consulting Group Model of Clinical Decision Support

Medication Decision Support Categories at PartnersREFERENCE INFORMATION Drug-information knowledge linking via info

button adjacent to drug name Partners handbook provides access to

numerous drug information databases Planned drug-information knowledge linking

via info button in electronic medication administration record in FY 04

SURVEILLANCE AND MONITORING Drug-induced abnormal lab result notification

of physician Drug-induced abnormal lab result notification

of pharmacist Renal function decline in patient on renally

excreted drug notification of physician and pharmacist

INTERACTIVE DECISION SUPPORT FOR PHYSICIAN AND PHARMACIST:

Drug-allergy checking Drug-drug interaction checking Drug-food interaction checking Drug-herb interaction checking Drug-disease interaction checking

INTERACTIVE DECISION SUPPORT FOR PHYSICIAN ORDER ENTRY ONLY:

Drug-lab interaction checking Consequent order recommendations Relevant lab display Indication-required orders Height, weight, allergy update required

notification Dose calculation tools Intravenous to oral conversion recommendation

on renewal of intravenous order when patient receiving other oral medications

Formulary substitution alerts Antibiotic restriction alerts

PROACTIVE DECISION SUPPORT Gerios for elderly patient medication dosing Nephros for dosing in renal insufficiency Preventive health reminders Problem-linked order sets

Laboratory Notification with consequent order recommendations

Alternate Procedures, Redirects, Drug-Allergy, Drug-Drug, Drug-Lab etc.

Gerios: Dose-filters for ageNephros: Dose-filters for renal function

Inappropriately sedated elderly inpatients on average incur $5600 excesscosts over expected for severity of illness

Preventive Reminders

Problem-level anticipatory decision support Today, order sets and documentation templates are static

which means that clinician must change them to personalize them to patient

We plan to use inferencing to dynamically generate problem-driven order sets and documentation templates that account for multiple co-morbidities

Must be able to incorporate future onslaught of gene diagnostic and prognostic data

Knowledge Application must anticipate these dimensions of the clinical encounter

ImprovisationPatient Preferences

User PersonalizationEnd-user workflow preferences

Learning and User-defined

Clinical StandardizationStandards of Practice,

Role/Venue RequirementsBilling/Regulatory Requirements

Poly-hierarchical inferencing with actionable advice – surveillance, interactive, or proactive mode

This is an example from clinical decision support company called Theradoc

A Continuum of Clinical Decision Support and Knowledge Discovery

Monitoring patient data with passive decision support

Interceptingincorrect clinicaldecisions

Making the right decisions the easiest decisions

Predictive Modeling

Case-based Reasoning

Learning Knowledge Repository

Reference KnowledgeLinking

Reference KnowledgeLinking

Event Monitoring

Event Monitoring Safety NetSafety Net AnticipationAnticipation

Understanding and PredictingPerformance

Understanding and PredictingPerformance

Surveillance Interactive Proactive Learning

*modified from the First Consulting Group Model of Clinical Decision Support

Current Initiatives Quality data warehouse with Clinician

Dashboards Early identification of patients at risk for case

management Longer term knowledge discovery goals to use

performance data to enhance knowledge repository

Need to evolve towards non-human dependent modes of knowledge acquisition

Knowledge Asset Management Infrastructure: Analysis of clinical performance data to understand where

knowledge deficits are to support performance goals Authoring and support of virtual, asynchronous collaborative

authoring by knowledge editors and leaders of research, safety and quality improvement initiatives (reference knowledge specs for encoding

Knowledge acquisition from commercial/etc knowledge bases Validation and audit trail maintenance (meta-knowledge) Inventory (knowledge librarian) Publishing and Sharing Reference information and knowledge model

What are the challenges today:

Healthcare delivery organizations purchase systems but don’t invest in knowledge asset management, they install plumbing

Vendors sell knowledge editors, not knowledge management support infrastructure

There is no repository of “best clinical IT practices” at a national level, few among the vendors

No knowledge encoding and representation standards to facilitate knowledge sharing

Partners-Wide Knowledge Management Model

KnowledgeRepository

Data Warehouse

KNOWLEDGE ASSET MANAGEMENT

DECISION SUPPORT(APPLIED KNOWLEDGE)

PERFORMANCE and OUTCOMES(KNOWLEDGE DISCOVERY)

Applications for Virtual Collaborative Knowledge Authoring and Maintenance

Decision Support Design Teams direct the design of cross-functional knowledge to be encoded

Clinical WorkflowApplications and

Services

Signature Initiatives andSub-Committees set

Enterprise-wide Strategy, Clinical Standards andPerformance Measures

KnowledgeBuilding Blocks

InformationModel

Common Services Knowledge Editors

Subject Matter Expert (SME) Panels Advise on Entity, Venue, Role, Specialty, Primary Care, Disease Management, and

Safety related requirements for application function and knowledge bases

Partners Genetics Computing Platform

Performance Feedback to Leaders, SMEs, Committees, and End-users

Care Applications (Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS,

Measurement) and Knowledge Bases

Care Applications (Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS,

Measurement) and Knowledge Bases

Dx/RxDecision Making

Order Fulfillment,Communication and

Coordination

Reference Information Model

Knowledge Asset Management: Translating Goals into a Knowledge Repository Taxonomy

Goal Framework: Safety, Quality, Efficiency, Research

Data/Knowledge Seeking

Requirements

AssessmentBilling

Reporting

Medical Management, Research, and Reporting

Care Applications

and Knowledge Bases

CORE CARE PROCESS AUTOMATION TAXONOMYCORE CARE PROCESS AUTOMATION TAXONOMY

Transfer/Handoff

Clinical Knowledge for Personalized Medicine Taxonomy

Role and Venue Domain Taxonomy

MEDICATION USE PROCESS: Acetaminophen in a 2.5 Kg Premature Infant

Patient VenueClinical DomainRole-based workflow

Physician Orders Pharmacist Dispenses

Nurse Administers Nurse Assesses

Physician Order Entry with Pediatric dosing calculation engine

Pharmacy Verification and Dispensing System

Electronic Medication Administration Record with Calculation Engine

Clinical Documentation

Medication Knowledge

Acetaminophen, 10 mg/kg PO Q 6 hrs

Infant Acetaminophen 100mg/ml solution

Acetaminophen, 0.25 ml PO Q 6 hours

Desired Outcome is fever abated

Neonatal Intensive Care UnitFever Management

Informatics Support

Clinical Data Repository with longitudinal patient information such as gestational age, height, weight, allergies, active and historical orders, assessment data, laboratory data, and other diagnostic data

CORE CLINICAL PROCESSESMODE OF INFORMATICS

APPLICATION

Admission Results Review Surgical Service Lines Non-Surgical Service LinesPatient Scheduling and Tracking Notifications Cardiac (surgical) Cardiac (medical)Clinical Data Review Interactive Decision Support Cardiac (interventional) EndocrinologyClinical Knowledge Retrieval Reminders General Surgery GastroenterologyPatient Assessment Clinical Messaging Gynecology General MedicineDiagnostic/Therapeutic Ordering Order Sets Orthopedic HematologyOrder Fulfillment Clinical Documentation Transplant OncologyResults Reporting Vital Signs, Intake and Output Trauma Newborn/ NeonatologyBilling Reports Urology/ Renal (Genitourinary) Neurology Patient Transfer/Hand-off Dashboards Vascular Surgery Infectitious DiseaseCare Oversight Pediatric Surgery Respiratory/ PulmonaryMedical Management Colorectal Surgery Rheumatology/ImmunologyPopulation Management Neurosurgery Behavioral Health

VENUES WORKFLOWS Patient Safety Disease or Risk Management Medication Safety Diabetes

Medical-Surgical Physicians anticoagulation management Congestive Heart FailureCoronary Care Unit Nurses sedation management HypertensionSurgical Intensive Care Unit Pharmacists renal/electrolyte management HIVMedical Intensive Care Unit Medical Technicians elderly medication management Immune CompromisedPost-operative Care Unit Case Managers pediatric medication management Coronary Artery DiseaseThoracic Care Unit Social Workers HyperlipidemiaEmergency Department Respiratory Therapists Nosocomial Infection Prevention Elderly/Geriatric StatusOperating Room Occupational Therapists Antibiotic Management Dementia or Alzheimer's DiseaseCardiac Catheterization Lab Physical Therapists Wound and Catheter Management Transition ManagementRehabillitation Ward Speech Therapists Ventilator Management Multiple SclerosisSubacute Care Unit Chart Abstracter Rheumatoid ArthritisPsychiatric Care Unit Risk Manager Other Bedside SafetyAmbulatory Care Administrative Support Falls PreventionHome Care Quality Improvement Decubitus Ulcer PreventionSelf Care Patient/Consumer Restraints Management

CLINICAL DISCIPLINES

Sample High-level Example Taxonomy for Knowledge Assets

Center for Clinical Knowledge Engineering

HEDISContent search

Welcome to the National Knowledge Engineering Repository

Go

Advanced Search Filters (press Ctrl to select more than one):

Cardiothoracic SurgeryInterventional CardiologyOrthopedicsEtc.

Clinical Discipline: Surgical

CardiovascularEndocrinologyGastroenterologyEtc.

Clinical Discipline: Non-Surgical

Nosocomial Infection ControlMedication SafetyDecubitus Ulcer PreventionEtc.

Clinical Discipline: Safety

Congestive Heart FailureMultiple SclerosisEtc.

Clinical Discipline: Disease Management

Diabetes Mellitus

Interactive RulesSurveillance and NotificationsDocumentation TemplatesEtc.

Informatics Mode

AdultPediatricsNeonateEtc.

Age

NursePhysicianCase ManagerEtc.

Role

Ambulatory CareEmergency DepartmentEtc.

Venue

CCU

Search File Hierarchy

Knowledge Asset Management ToolkitLink to references, survey instruments, diagrams, descriptions, process flow diagrams, etc on Partners and VA approaches to asset management

Submit Content to Editor

About Us

ABRIDGED SAMPLE KNOWLEDGE SPECIFICATION

INVENTORY INFORMATION:

TITLE: Digoxin Order Abnormal Lab Result INFORMATICS MODE: INTERACTIVE CPOE FILE NAME: BICS_DIGORDER_LAB DATE LAST UPDATED: 12/03/2003 DATE FIRST ACTIVATED: 03/02/2001 AUTHORS: John Smith, Jane Doe CONTACT: JohnSmith@Safehospital.org VERSION ID: 001.005.003 SITE: Safe Hospital KNOWLEDGE EDITOR: Joe Brown STATUS: IN PRODUCTION

PURPOSE: Warn of potential digoxin toxicity when ordering digoxin in a patient w/ hypokalemia which predisposes patient to an adverse drug reaction EXPLANATION: Alert Evokes when digoxin is ordered. Recent chemistry values are checked for hypokalemia, Recent orders are also checked for current potassium supplements which would indicate the electrolyte problem is already being addressed. KEY WORDS: Digoxin, Potassium, K, Dig REFERENCES: Links to Articles DATA ON IMPACT: Links to Reports on Usability and Clinical Impact

SPECIFICATION INFORMATION

EVOKE: on DIGOXIN ORDER LOGIC: DIGOXIN ORDER and MOST RECENT POTASSIUM RESULT <3.4 WITHIN 30 DAYS and ACTIVE ORDERS DO NOT INCLUDE POTASSIUM CHLORIDE; POTASSIUM PHOSPHATE etc… ACTION: SEND NOTIFICATION RECOMMENDING POTASSIUM SUPPLEMENTATION etc….

SCREEN SHOTS: Link PROCESS FLOW DIAGRAM: Link

Knowledge SpecificationsFor Encoded KnowledgeVsMeta-knowledge aboutThe knowledge

Future State KM Model

Workflow Applications

Knowledge Repositories

Information Model

Meta-KnowledgeRepository

CollaborativeKnowledge Authoring

Tools

PortalKnowledge-based Services

Barriers to Success at the Intersectionof Clinical Informatics and KM

Leadership inadequately committed Products inadequate to support

processes Business case intangible Fear of exposure (technology increases

transparency) Few roadmaps to success are proven in

the healthcare arena

Market Drivers will Propel Progress Aging population: computer literate and population

growth will outstrip service capacity, informatics must support self-management

Business community will aid transition from commodity to value based purchasing by employers and consumers, they know that the current inflation rate of the commodity is untenable

Leapfrog and Government are beginning to purchase quality

Genomics: personalized medicine will require technologies for personalization, these same technologies will enable more user-friendly safety solutions

Where are we?