km challenges in healthcare hongsermeier
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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: [email protected] 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?