at partners healthcare (phs) · 10/7/2016 · partners ecare, partners healthcare system assistant...
TRANSCRIPT
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EvolutionoftheKnowledgeManagementProgram
atPartnersHealthCare(PHS)
RobertoA.Rocha,MD,PhD,FACMIClinicalInforma9csDirector,
PartnerseCare,PartnersHealthcareSystemAssistantProfessorofMedicine
DivisionofGeneralInternalMedicineandPrimaryCare,DepartmentofMedicine,BrighamandWomen’sHospital,HarvardMedicalSchool
LearningHealthSystem(LHS)Seminar
-October7,2016-
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Overview
• History– Goals,typesofassets,ini9alchallenges,tac9cs
• Currentstate– Program,principles,typesofassets– Newchallenges,revisedtac9cs
• Implementa9onframework– Levelsofsupport,areasoffocus
• Futuredirec9ons• Conclusions
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HISTORY
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KnowledgeManagement
• Establishedin2003asaformalfunc9onwithintheClinicalInforma9csR&Dgroup–clinicalteamwithinInforma9onSystems
• Responsibilityfordesigning,developing,andsuppor9ngprocesses,tools,andassets–e.g.governance,lifecycle,authoring,deployment
• Enterprisecontentareas–e.g.terminologies,catalogues,rules,referencesources,etc.
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OriginalStrategicGoals
• Reducethecostandincreasethespeedofknowledgeacquisi9onandmaintenancefordecisionsupport
• Speedtransla2onofclinicalinnova9onandevidenceintoclinicalprac9ce• Proac2ve,an2cipatorydecisionsupportarchitecturetosetfounda9onfor
personalizedmedicine–avoid“interrup9ve”decisionsupport• ImprovePartners’organiza2onaleffec2venessasalearningorganiza9on
throughorganiza9onalalignmentanddata-drivenperformanceimprovement
• Alignknowledgeassetswithbusiness,regulatory,safetyandqualityrequirements
• Onlybuildwhatwecannotbuy• Partnershascreatedsomeofthebestdecisionsupportinproduc9onin
theworld,thegoalhereistokeeptheknowledgeuptodate
SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)
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ContentExamplesatPHS
• Medica2onDataDic9onarywithdefaultdoses,weight-baseddoses,dosestrings,anddrug-druginterac9onchecking–mul9pleapplica9onsandpopula9onsviaCommonMedica9onServices
• GeriosandNephrosforproac9vedosingforelderlyand/orrenalinsufficient
• Drug-labmonitoring,duplicatedrugchecking,drug-groupchecking,drug-diseasechecking,drug-pregnancychecking
• Primaryandsecondarypreven9vehealthreminders• ResultsManager(abnormaltestresults)• Inpa9entandoutpa9entordersets• Inpa9entinterac2verules(applica9onspecific,hard-coded)• Conceptdic2onaryandproblemlist• Pa9entmonographs• Radiologyorderingdecisionsupport• Outpa9entdocumenta2ontemplates
SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)
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ContentLife-CycleChallenges
SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)
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ClinicalContentCommittee
SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)
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DeployedTactics(2008)
• TransparencyandGovernance(2004)– Documentlibraryportalofdecisionsupportknowledgespecifica9onsin
produc9on§ 600documentsrepresen9ng10sof1000sofrules
– Newgovernanceandsubjectma`erexpertpanels
• Collabora2onandContentLife-cycleTools(2005)– Collabora9onPortalsalignedwithgovernanceandbusinessgoalsofPartners
§ 60spacestodate,Documentum’seRoom
– ContentManagementinfrastructureforsharing,versioning,audi9ng,scheduling,tracking§ Documentum’sContentManagementServices
• ContentEdi2ngRe-architecture(2006)– Oncedecisionismadeforknowledgetochange,changewillbeimplemented
rapidlyatalltouch-points– PrimaryfocusofKMdevelopmentgoingforward
SlidecreatedbyTonyaHongsermeier,MD,MBA(2008)
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List Ingredient(s)?
Get Request
Research Med (if applicable)
Choose Ingredient/
Ingredient Set
Select Type of Entry
Commercially Available (default)
Select Route Grouping
AssignAllowable Route(s)
Preview GCNSEQNO
return list((optional)
Select or free text Strength(s) (if applicable)
Select or free text Dose Form(s) (if applicable)
Select or free text Indication(s)
(if applicable)
Assign/create Internal Name
Assign/create External Name
“Empty” list of Brand names
ID Drug / Compound
Choose Ingredients)
Yes
NoYes
View list of Brand names
Create new Synonym(s)
Select none, 1, or more; or create
new Synonym(s)
Assign other defining
characteristics?No
ID Drug / Compound
Assess DDIs
Similar to pre-existing
concept?
Labs data applicable?
Incorporate into DDI KBYes
Flag for DDI reviewNo
Yes
DDIs applicable?
ID Drug with Ingredient(s)?
Compond with Ingredient(s)?
ID Drug without
Ingredient(s)?
KM Comments needed?
No systemic absorption
Commercially Available Drug
Enter Labs dataYes
Enter CommentsYes
No Select Population
Accept or override
Frequency listNo
Accept or override
Dose+Unit(s) list
Chemo drug?
Dispensing Advice
needed?
Prescribing Advice
needed?
Enter textYes
Enter textYes
No No
Enter Rounding Increment
Enter Max Dose (Daily)
Select Max Dose (Daily) calculation
Yes Enter Max Dose (Weekly)
Select Max Dose (Weeky)
calculation
Enter Max Dose (Lifetime)
Select Max Dose (Lifetime)
calculation
Administration Advice
needed?
Patient Advice
needed?
Enter textYes
Enter textYes
No No
No
Review Summary/Preview screen
SAVE as Enterprise
Version
Input site-specific
data
Select Rounding Increment units
Other Population(s)?
Yes
ENTERPRISE
No
FDIs applicable?
Assess FDIs
Flag for FDI review
Similar to pre-existing concept
or FDB has data?
Yes
Nephros applicable?
Assess Nephros
data
Flag for Nephros review
Similar to pre-existing concept
or FDB has data?
Yes
Gerios applicable?
Assess Gerios data
Flag for Gerios review
Similar to pre-existing concept
or FDB has data?
Yes
No No
Linked to “external” editors
Create Generic Name
Use as chemo? Yes
No
MedicationDictionary:KMWorkflow
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KMsoftwaretools
10-15looselyconnectedtoolsusedjusttomaintainMeds
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CURRENTSTATE
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CKMProgram
• Systema2candsustainableacquisi9on,adapta9on(localiza9on),andmanagementofknowledgeassetsfordifferent“modali9es”ofCDS
• Includestheadapta2onof“reference”knowledgetoreflectlocalandins9tu9onalrequirements,resources,andpriori9es
• Followsawell-definedlifecycle,includingspecificstagesfordocumenta9on,tes9ng,andmonitoring–supportedbyintegratedsetoftoolsandresources
RochaRA,MavigliaSM,SordoM,RochaBH.Clinicalknowledgemanagementprogram.In:GreenesRA,editor.ClinicalDecisionSupport-TheRoadtoBroadAdop9on(SecondEdi9on).Burlington:AcademicPress;2014.p.773-817
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Programguidingprinciples@PHS
• Objec9velyimprovessafety,quality,andefficiency• Supportedbyevidence,clinicalbestprac2ces,andsoundclinicalthinking
• Alignswithandpromotesclinicalandbusinessgoals• Acceptabletoprac9cingendusers(workflowintegra9on)
• Adherestoinforma9csandknowledgemanagementbestprac2ces
• Bestu9lizestalent,resources,andcapitalofPartners• SupportsresearchandteachingmissionsofPartners
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InventoryofKnowledgeAssetsManagedCentrallyatPartners(1/2)
RochaRA,MavigliaSM,SordoM,RochaBH.Clinicalknowledgemanagementprogram.In:GreenesRA,editor.ClinicalDecisionSupport-TheRoadtoBroadAdop9on(SecondEdi9on).Burlington:AcademicPress;2014.p.773-817
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InventoryofKnowledgeAssetsManagedCentrallyatPartners(2/2)
RochaRA,MavigliaSM,SordoM,RochaBH.Clinicalknowledgemanagementprogram.In:GreenesRA,editor.ClinicalDecisionSupport-TheRoadtoBroadAdop9on(SecondEdi9on).Burlington:AcademicPress;2014.p.773-817
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CKMLifecycle@PHSRequest
(neworupdate)
Authorize&Priori9ze
Design
ImplementTest&Deploy
Monitor
Evaluate
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Ongoingactivities@PHS
• Transi2on!– PartnerseCare:implementa9onofEpic
§ SystemisliveatBWH,MGH,NWH,MEEI,andPCPO
– Migra9on(andpreserva9on)oflegacyassets– EvolvingunderstandingofwhatEpiccan/cannotdo
• Implemen9nganaly9csplakormforClinicalKM– Monitoringandevalua9onofCDSinterven9ons– Op9miza9onofKMac9vi9es
• CompletednewKMsolwareplakorm(CKMS)– Repository+Portal+Authoring+SMECollabora9on– SystemlivesinceFebruary2015
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PartnerseCare
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Programmilestones@PHS
ü Establishgovernancestructurewithclearguidingprinciplesü Definepriori2esconsideringongoingprograms&ini9a9vesü Catalogfeatures&contentavailableinlegacysystemsü Assimilatefeatures&contentavailableinnewEHRsystemü Resolveormi9gateiden9fiedgaps(features&content)ü DefineworkplanalignedwithEHRimplementa9on9melineü ImplementKMlifecycle(availabletools)ü Implementmonitoringprocess(CDSinterven9ons)o Replaceisolatedtoolswithintegratedinfrastructureo Exposeassetsandprocessestousersandstakeholderso Expandmonitoringprocess(KMlifecycle&CDSevalua2on)o Engageandcollaboratewithotherorganiza9ons
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CDSMonitoringPortal
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CDSMonitoring:Example
Revision(Nov)
Releasedac2ve(Dec)
Releasedsilent(Sep)
Remindertodocumentaprincipalproblem09/15/15-Releasedsilentformonitoring;firingwasexcessive11/17/15-Revisedtofireonlyonadmi`edpa9ents(excludeEDpa9ents)12/22/15-Ac9vated;~200pa9ent-alerts/day
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CKMsoftwareplatform(CKMS)
• Integra2on– Completelifecycle:authoring,collabora9on,andpublica9on– (Replaceandconsolidatelegacyeditorsandrepositories)
• Extensibility– Coresetofknowledgetypesandlifecycleswithrichmetadata– Configurableextensionstosupportlocalandreferenceassets
• Integrity– Versioninganddependencymanagementacrossknowledgetypes– Configurablevalida9onpa`ernsandrules(globalortype-specific)
• Interoperability– Extensivesetofwebservices– Import&Exportassetsandtypedefini9ons(simpleXMLformat)
• Seman2c“intelligence”– Decisionsupportforknowledgecurators– Preventerrorsandsuggestop9ons:sustainablelong-termmaintenance
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ContentSources(e.g.,EHRcontent,Opensourcecontent,Licensedcontent,etc.)
IMPORT(XMLformatcompa2blewithavailablestandards–e.g.,CTS2)
ContentConsumers(e.g.,Clinicalapplica2onsandservices,EHRsystems,etc.)
Publication
Authoring
Linking Validation
Review & Vetting
ETL
CKMS
EXPORT(sameXMLformatusedforImport)
ETL
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IMPLEMENTATIONFRAMEWORK
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Levelsofsupport
• Reac9veSupport– Troubleshoo9ngandmaintenanceofexis9ngassets– Preserva9onoforiginalscope:quan9tyandcoverage
• PeriodicImprovement– Sporadicimprovementsbeyondiden9fiedproblems– Limitedexpansionoforiginalscope
• Con9nuousImprovement– An9cipatoryiden9fica9onofproblemsandneeds– Expanded(dynamic)scope,includingnewdatatypes– Scalableandcost-effec9veprocessesandinterven9ons
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WhyContinuousImprovement?• NewEHRsystemincludesasignificantlylargercollec2onofdata&
knowledgeassets,es9matedat4to59mesthenumberofassetspreviouslymanaged/curated
• Levelofintegra9onofthenewEHRsystemgreatlyincreasesthenumber&complexityofinterdependenciesbetweenassets,aggravatedbyimportantlimita9onsof“internal”configura9ontools
• Sitesaredemandingsite-specificcustomiza2on&filteringofassets,givendisparateneeds,targetpa9entpopula9ons,resources,andprocesses
• Needfortargeted&con2nuousCDSinterven2onsincreasesasmoreemphasisismadetomanagehigh-riskpopula9onsandepisodes,takingintoaccountdifferentpayercontractsanduniquepa2entcharacteris2cs
• Needforconsistentdatadefini2onsalignedwithstandardsisevenmorecri9calgivenincreaseddemandforInteroperability,CDS,andAnaly9cs
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Complexitychallenge
0100020003000400050006000700080009000
10000
0 500 1000 1500 2000 2500
Interdependenciesvs.NumberofAssets
Assumingthatagivenassetistypicallyconnectedto3otherassets
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CDSframework
• ClinicalDecisionSupport(CDS)– Ac2vi2es:analysis,design,specifica9on,build,tes9ng,monitoring,and
troubleshoo9ng;evaluateandreporttheeffec9venessofinterven9ons;integra9onwithuserworkflowsandrepor9ng;dependenciesmanagement
– Assets:alerts,reminders,medwarnings,duplica9onwarnings,therapeu9calterna9ves,infobu`ons,ordersets,smartlists,etc.–mul9pleapplica9ons
– Supportenterprise,site-specific,andresearch/innova2onefforts
Reac9veSupport
• Alerts,reminders,andInfobu`ons
• +800interven9onsforEnterpriseneeds
PeriodicImprovement
• Alerts,reminders,Infobu`ons,warnings
• +1,200interven9onsforEnterpriseandSite-specificneeds
Con9nuousimprovement
• AllCDS,includingpa9entsanddevices
• +2,000interven9onsforEnterprise,Site-specific,Research&Innova2onneeds
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WhyClinicalDecisionSupport?
• Opportunity– CompleteCDSinterven9ons–advancedprotocols,riskstra2fica2on,
managementofcomorbidcondi9ons– Extendtopa2entsandalliedhealthcareprofessionals– Devices,genomic,pa2entgenerateddata,preferences– Performancedatatocon9nuouslyimproveinterven9ons
• Challenges– Numerousinterven9ons–somestakeholdersnotrepresented– Op9malimplementa9on–limitedEHRfeatures,maintenance– Poordesignrejectedbyusers–nega9vepercep2onaboutEHR
reliabilityandu9lity– Interdependencies–isolatedtools,resourceintensiveprocess,
fragmenta2on,inconsistencies
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DataDefinitionsframework
• DataDefini2ons– Ac2vi2es:selec9on,analysis,mapping;managementoflocalextensions;
defini9onofreferencemodelsforhighpriorityclinicaltopics;integra9onwithuserworkflows,CDS,andrepor9ng;dependenciesmanagement
– Assets:dataelements,localextensions,andstandardreferencemodels– Supportenterprise,site-specific,andresearch/innova2onefforts
Reac9veSupport
• Datadefini9ons,localextensions,andreferencemodels
• +20clinicaltopicsforEnterpriseneeds
PeriodicImprovement
• Datadefini9ons,localextensions,andreferencemodels
• +40clinicaltopicsforEnterpriseandSite-specificneeds
Con9nuousimprovement
• Datadefini9ons,localextensions,andreferencemodels
• +100clinicaltopicsforEnterprise,Site-specific,Research&Innova2onneeds
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WhyDataDefinitions?
• Opportunity– Datadefinedwithstandardreferencemodels–consistency,
completeness,andinteroperability– Sustainableprocess–newdomains,singleelectronicrecordforall
sedngsanddisciplines
• Challenges– Datadefini9onsnotsharedacrossEHRmodulesorserngs–similar
datastoredandencodeddifferently– Largelibrariesofdefini9ons–promoteinconsistency,dis9nc9onsnot
documented,overlappingdomains/topics– Manualverifica9on–constantlyevolvingdatacollec9ontools(e.g.
forms,flowsheets,templates,macros,etc.)– Poordataquality–affec9ngCDS,reports,registries,etc.
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Additionalframeworks
• Dataclassifica9on• Terminologies(dic9onaries)• Solwareinfrastructure• Processanaly9cs
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FUTUREDIRECTIONS
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KMopportunities(1/2)
• Individualizedinterven9ons– Integra9onandeffec9veuseof"new"datasources–e.g.devices,genomic,pa9ententered,preferences
• Minimizefa2gueandmaximizeu2lity– Detailedrepresenta9onofcontextandstate–e.g.interven9ontarge9ngandcon9nuouslearning
• Preventmalfunc2ons– Decisionsupporttoassistknowledgeengineers–e.g.automateconfigura9on,customizevalida9onrules
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KMopportunities(2/2)
• Proac9vemaintenance– Automateddetec9onofmalfunc9ons
–e.g.con9nuouslymonitorac9veinterven9ons,detec9onalgorithms
• Localizedknowledgetransla2ons– Automateddetec9onofnewevidence(fromdata)
–e.g.evidenceaugmentedbypa`ernsofuse,concurrentinterven9onswithprospec9veevalua9ons
• Mi9gatecomplexity– Adoptnewdecisionsupportmethodsandtools
–e.g.combineinferencemethods,“dynamic”knowledgeassets
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CONCLUSIONS
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Challenges–implementation
• Dataavailabilityandquality• e.g.datanotcoded,codedinconsistently,notenoughdetail(codes)
• Rudimentarytools(edi9ng,versioning,linking)• e.g.incorrectlogic,missingvalues,relatedelements,automated
valida9on;contentmanagementtoolsarenotasolu9on
• Laborintensivetes2ng• e.g.posi9veandnega9vetests,regressiontes9ng,automatedtes9ng;
crea9onandmaintenanceofusefultestdata/pa9ents
• Prolifera9onofCDSvendors• e.g.singlevendorwillnotfulfillallyourneeds,overlapping
interven9ons(reconcilia9on)notiden9fiedasasignificantproblem
• Internal(EHR)versusexternalservice• e.g.immaturestandards,complexconfigura9on,peculiarfeatures
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Challenges–largescale
• Labor-intensiveacquisi2onprocess(SMEs)• Inabilitytoachieveproperdomaincoverage• Rudimentarytools&resources• Costlyandinefficientmaintenance
• Well-trainedpersonnelusingefficientprocesses• Distributedandcollabora9veac9vi9es–i.e.coopera2on
acrossteamsandins2tu2ons• Commontools,processes,andstandards
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CDShastofollowthepatient
• ClinicalsystemsmighthaveverysimilarCDSfeatures,butarefrequentlynotconfiguredthesameway– CDStriggeredinoneserngmaynotbeconfirmedorre-enactedinsubsequentserngs
• Withoutcon9nuityandconsistencyacrossserngsandins9tu9ons,interven9onshavedecreasedeffec2venessfordissemina9ngevidenceandreducingunwarrantedvariability
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Acknowledgements
SaverioMavigliaEileenYoshidaCharlesLagor
MargaritaSordoChristopherVitale
Priyaranjan(Raj)TokachichuAllmembersoftheClinicalInforma2csTeamatPartners
BeatrizRochaDanBogaty
TonyaHongsermeierBlackfordMiddleton
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Thankyou!Roberto A. Rocha, MD, PhD!
[email protected] !http://scholar.harvard.edu/rarocha!
!! !
ThisworkbyRobertoA.RochaislicensedunderaCrea9veCommonsA`ribu9on-NonCommercial-ShareAlike4.0Interna9onalLicense