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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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