clinical decision support track fhir dev days 2016
TRANSCRIPT
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Clinical Decision Support Track
Bryn RhodesNovember 16, 2016
© 2014 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.
Objectives
Discuss CDS landscape Review an approach to distributing CDS Introduce the Clinical Reasoning Module Use the CRM resources to describe a
simplified Zika Virus Management Workflow Review Implementation Strategy Discuss Track Goals/Next Steps
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CDS - Definitions
Osheroff, et. al.: Clinical Decision Support is a process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.
Osheroff J, Teich J, Levick D, et al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. 2nd ed. Health Information Management Systems Society, 2012.
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CDS - Definitions Health eDecisions: CDS is the user facing representation
of clinical guidance. Effective CDS interventions require availability or computable biomedical knowledge, person-specific data, and a reasoning or inference mechanism that combines these elements to generate and present helpful and actionable information to clinicians, individuals, or caregivers in the right way --- at the right time.
Standards & Interoperability Framework. Health eDecisions: CDS Artifact Sharing Use Case. September 13, 2012. Available at: http://wiki.siframework.org/Health+eDecisions+Use+Case.
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Existing Approaches
“Baked” in to the EHR/Health Application CDS as a Service
Existing products don’t have a common API CDS Hooks is changing this
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Sharing Clinical Knowledge Various means for representing Clinical Knowledge in
an electronic format Measurement
Quality Measures (HQMF) Guidelines (GEM, PDF)
Decision Support (CDS-KAS) Event-Condition-Action (ECA) Rules Documentation Templates Order Sets
How can we enable computable representations so we can automate as much as possible sharing and implementation of clinical knowledge?
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CDS - Management
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CDS - ComponentsTrigger Input Data Element Intervention Offered Choices Order entered
Laboratory result stored
Outpatient encounter opened
User request
Time
Admission
Problem entered
Enter allergies
Enter weight
Laboratory result/observation
Drug list
Hospital unit
Diagnosis/problem
Age
Nondrug orders
Gender
Family history
Allergy list
Weight
Surgical history
Reason for admission
Prior visit types
Race
Notify
Log
Provide defaults/pick lists
Show guidelines
Collect free test
Get approval
Show entry template
Write order
Defer warning
Override rule/keep order
Cancel existing order
Cancel current order
Edit current order
Edit existing order
Set allergies
Write letter
Write note
Edit problem list
Enter weight, height/age
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CDS - Delivery
Narrative Semi-structured Structured ExecutableFormat Narrative text Organized text Coded and
interpretable by computer
Coded and interpretable by CDS systems; variety of formats
Sharability of knowledge
Broad Broad Broad Very limited
CDS modality and tool independent
Yes Yes Yes No
Site independent Yes Yes Yes NoAuthor Guideline
developerClinical domain expert
Knowledge engineer
CDS implementer
Purpose Communication of policy; synthesis of evidence
Recommendations for implementation in CDS
Precise communication, validation
Implementation for a particular site
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All Hazards Approach: CDS Delivery
Intent (Narrative)Semi-Structured Content
Diagram FormalismFormalism
(Structured / Executable)
Iterative Testing
Adapted from: Boxwala AA, Rocha BH, Mviglia S, et. al. A multi-layered framework for disseminating knowledge for computer-based decision support, J Am Med Inform Assoc. 2011;18:i132-i139. Available at: http://jamia.oxfordjournals.org/content/18/Supplement_1/i132.long
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All Hazards Approach: Zika Virus StatusIntent (Narrative)
CDC ContentEmergency Operations CenterMMWR PublicationsLocation Hyperlinks
Semi-Structured ContentClarify Clinical Workflow ProcessesAssure Binary Decision pointsLogicVocabularies
Diagram Simple AlgorithmBinary (where possible)Legend to describe links1) Vendors create logic in individual products2) Local organizations implement algorithm in existing EHR implementations
Iterative Testing
Guideline Elements Model: http://gem.med.yale.edu/default.htmCDS Hooks: http://cds-hooks.org/Clinical Quality Framework - ONC Tech Lab: https://www.healthit.gov/techlab/testing_and_utilities.html
Formalism (Structured / Executable)Options:
Data Model – Quality Information Clinical Knowledge (QUICK)Expression – Clinical Quality Language (CQL)Structure – Clinical Quality Framework on FHIR (CQF on FHIR) – structure for CDS, Measure, ReportGEM Cutter IICDS HooksInfoButtonNow in Place
Pilots / Options
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Artifact Types Event Condition Action Rules – Generally, the a trigger
(event) initiates an action and if the “rule” condition is true, the EHR performs the action
Order Sets – A pre-defined set of orders intended to standardize care related to a specific condition or venue of care containing diagnostic and therapeutic orders
Documentation Templates – A structured form for recording information on a patient into a set of pre-defined data fields (or slots)
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Zika Virus WorkflowSimplified, showing only part 1 of branch for all pregnant patients
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Clinical Reasoning Module
Representation, Distribution, Evaluation of Clinical Knowledge Artifacts
Event-Condition-Action Rules Order Sets Documentation Templates Quality Measures etc
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Clinical Reasoning Topics
Expression Logic How to use expression languages like FHIRPath
and CQL in FHIR Definitional Resources
ActivityDefinition - The “definition” counterpart of the “request” resources
Representing Knowledge Artifacts PlanDefinition – Resource to capture generalized
workflow including ECA rules, order sets, protocols
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Zika Virus Artifacts
Questionnaires – To capture information not present in the EHR directly
ActivityDefinition – To describe “offered choices” and “actions to be performed”
PlanDefinition – To describe Event-Condition-Action Rules
Library – To contain the expressions defining the logic involved
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Zika Virus ArtifactsSimplified, showing only part 1 of branch for all pregnant patients
Questionnaire
Actions
Conditions
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Zika Exposure Assessment
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ActivityDefinition
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Condition Logic
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Building the PlanDefinition
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Other Conditions
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ECA-Rules
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Zika Virus ImplementationSimplified, showing only part 1 of branch for all pregnant patients
Questionnaire
Actions
Conditions
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CDS HooksA vendor agnostic decision support specification
Initiated by Josh Mandel, architect of SMART
Open source (Apache) Emerging standard with
active development and widespread participation from stakeholders
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POST https://example.com/cds-services/example-service
EHR CDS Service
{ "hook": "patient-view”, "fhirServer": "http://fhir.example.com", "user": "Practitioner/789", "patient": "123", "encounter": "456", ...}
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EHR CDS Service
POST https://example.com/cds-services/example-service
CDS Service Logic
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POST https://example.com/cds-services/example-service
EHR CDS Service
HTTP 1.1/ 200 OK
{ "cards": [ { "summary": "Example card", "indicator": "info", "source": { "name": "Demo CDS Service”}}]}
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Zika Virus Reporting App
http://demo.primedimensions.com Demonstration maintains state based on
answered questions, to reset, use this link: http://prime-dimensions-zika.herokuapp.com/
resetdb
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Track Goals
Integrate CDS Evaluation and Workflow Augmentation w/ CDS Hooks Can work with Epic, Cerner, Allscripts Prime Dimensions is making their service available
for the track for testing Ingest CDS Descriptions
Use existing components (HAPI Server, CQL Engine, Measure Processing Component, Structured Data Capture) to create a CDS Service that implements Zika Virus
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Questions?
http://build.fhir.org http://wiki.hl7.org/index.php?title=FHIR
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Resources
ONC Tech Labs for CQF: https://oncprojectracking.healthit.gov/wiki/display/T
echLabSC/CQF+Home Clinical Quality Language Specification:
http://www.hl7.org/implement/standards/product_brief.cfm?product_id=400
FHIRPath (formerly known as FluentPath): http://hl7.org/fluentpath/