regenstrief institute’s new medical gopher: a next-generation open-source physician order entry...
TRANSCRIPT
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Regenstrief Institute’s New Medical Gopher:
A Next-Generation Open-Source Physician Order Entry System
Jon D. Duke, MD, MSBurke Mamlin, MD Doug Martin MD
MedInfo 2013
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Gopher• Gopher grew from a single clinic to over
1000 workstations, inpatient, outpatient, ED• 25+ years of iterations has resulted in robust
functionality and efficiency• Served as the research platform for many of
the seminal studies in healthcare computing
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1984 2010
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• In 2009 Regenstrief Institute began rebuilding its core clinical information system platform
• In 2010, we began work on a new web-based version of the venerable Gopher
• This system was designed using the knowledge gained from the past 25 years of Gopher as well as from the evolving literature on CPOE system design
Developing the new Gopher
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Started with a Blank Slate
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Improve User Satisfaction
Support Patient Safety
Improve Quality of Care
Promote Provider Efficiency
Guiding Principles
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Set Gravity in the Right Direction
Leverage Metaphors
Constrain Then Innovate
Design Strategies
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LeverageMetaphors
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Leveraging Metaphors
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Leveraging Metaphors
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Leveraging Metaphors
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E-Commerce
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Workflow Wizards
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Smart Autocompletion
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ConstrainThen Innovate
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140 characters
hashtagsretweetsurl shortenersbrevity
InstagramVineYammerWaze
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Screen Real Estate
• At outset of development process, set aside an untouchable area of screen real estate
• That area– the InfoPanel– was not utilized for >1 year into development but has become a critical asset
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Set Gravity in the Right Direction
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Right Thing
Wrong Thing
UserUser
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Formulary Recognition
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Allergy Entry
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Fitt’s Law
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What’s inside the new Gopher?
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Major Functions
• Order entry• Documentation / note writing• Medication / problem / allergy management• Results viewing• Research• Clinical decision support
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Advancements in New Gopher
• Context-Driven Dynamic Alerts• Adaptive Learning• Real-time Natural Language Processing• Multimedia Alerts• Advanced Rule Authoring
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Advancement #1: Dynamic Alerts
• Gopher has embedded mechanics to dynamically change alert display based on context– Patient– Physician– Institutional
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Alerting Zones
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Relevance Adjustment Module
• Every alert has a baseline relevance level which determines its display location
• For example, for DDI alerts, about 40% are interruptive and 60% non-interruptive
• The RAM can adjust this default level
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DDI Alert Service
DDI Alert Service
TRIAMTERENE Interacts with LISINOPRILRisk of HyperkalemiaSeverity: Moderate
Relevance: 5 (Average)
TRIAMTERENE Interacts with LISINOPRILRisk of HyperkalemiaK 5.3*, Cr 1.3, GFR 55Relevance: 7 (High)
Lisinopril Order
Related ConceptsRelated
Concepts
Hyperkalemia Has Relevant Labs: K, Cr, GFR
DataRepository
DataRepositoryK, Cr, GFR
Relevance Adjustment ModuleRelevance Adjustment Module
Original Alert Final Alert
Patient has lab values:K 5.3*, Cr 1.3, GFR 55
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DDI Alert Service
DDI Alert Service
TRIAMTERENE Interacts with LISINOPRILRisk of HyperkalemiaSeverity: Moderate
Relevance: 5 (Average)
TRIAMTERENE Interacts with LISINOPRILRisk of HyperkalemiaK 3.3, Cr 0.8, GFR 114
Relevance: 3 (Low)
Lisinopril Order
Related ConceptsRelated
Concepts
Hyperkalemia Has Relevant Labs: K, Cr, GFR
DataRepository
DataRepositoryK, Cr, GFR
Relevance Adjustment ModuleRelevance Adjustment Module
Original Alert Final Alert
Patient has lab values:K 3.3, Cr 0.8, GFR 55
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Relevance Adjustment Module
• RAM can also make changes based on provider characteristics
• For example, can make particular alerts non-interruptive for certain specialties
• Conversely, for medical students all alerts can be made interruptive
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TM Nintendo
Advancement #2:Gopher is a Learning System
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Advancement #2:Gopher is a Learning System
• Gopher can track user actions and activity such as– Number of logins– Frequently selected orders– Responses to previous alerts
• Can customize system behavior based on individual user history
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Alerts That Learn
• Picture of learning message, then another of the small alert
Diazepam
Diazepam 5 MG
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Alerts That Learn
Diazepam
Diazepam 5 MG
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Advancement #3: Natural Language Processing
• Gopher can analyze notes in real-time• Can determine section (e.g., FHx, PMH) to give
context to the concepts retrieved• Multiple services may be run simultaneously
(e.g.,CDS, quality metrics, study recruitment)• Results may be displayed as alert or used for
background data capture
Section header detection thanks to SecTag from Vanderbilt University:http://knowledgemap.mc.vanderbilt.edu/research/content/sectag-tagging-clinical-note-section-headers
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Order Detection
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Study Reminders
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Natural Language Processing
• Can be used as a CDS trigger• Can be used to enhance structured
documentation for ‘meaningful use’• Can be used for clinical research• Integrated with our Advanced Rule Authoring
environments
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Advancement #4: Multimedia Alerts
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Adherence Information
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Research Study Eligibility
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Advancement #5: Advanced Rule Authoring
• The Rule Authoring and Validation Environment (RAVE) is a rule authoring tool within Gopher
• The RAVE is designed to empower stakeholders to create complex, rule-based actions using a simple graphical interface
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Rule Authoring
• Rules are necessary to drive decision support logic as well as other system actions
• Rule authoring is generally a complex task requiring code-like syntax
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Good artists copy.Great artists steal. - Pablo Picasso
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ifttt.com
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Great Artists Steal
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RAVE = IFTTT for EMRs
• Built a variety of channels for EMR activities• Channels may server as
– Triggers (If)– Actions (Then)– Both
• Additionally, we added a ‘For’ component to specify when the rule should be run
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Rule Authoring and Validation Environment
• Picture HERE
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Rule Authoring and Validation Environment
• Picture HERE
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Rule Authoring and Validation Environment
• Picture HERE
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RAVE Channels
If Channels• Orders• Diagnoses• Allergies• Note NLP• Chart Actions• Observations• ADT• HL7
Then Channels• Alerts• Email / SMS• Logging• Observations
For Channels• Patient• User
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FOR: Patient Channel
• Picture HERE
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IF: Diagnosis Channel
• Picture HERE
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THEN: Alert Channel
• Picture HERE
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RAVE Output
• Picture HERE
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RAVE Output
• Picture HERE
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RAVE DROOLS Syntax
• Picture HERE
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Rule Authoring and Validation Environment
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RAVE = Customizability
• Can mix and match channels to create a remarkable array of functionality without need for programmer intervention
• Can write rules just for yourself or (with permission) your clinic, specialty, or all users
• Rule syntax is generated automatically in a standard rules syntax (Drools)
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Gopher Demo
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Gopher and Open Source
• Regenstrief is philosophically and contractually committed to release of the new Gopher platform as open source software
• We are looking for partners to take part in both software development and community building around this effort
• Please let us know if this is something you would be willing to commit time and energy to pursuing
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Acknowledgements• Chris Beesley• Chris Bonham• Mike Brehm• Jason Cadwallader• Joshua Castagno • Vidhya Chari• Parishkar Chauhan • Ling Cheng• Sireesha Chilukuri • Cyril Colvard• Jonathan Cummins • Alex Franken • Cindi Hart • Charity Hilton • Joshua Jones • Warren Killian • Jeremy Leventhal
• Allen Logan • Ernesto Maldonado • Burke Mamlin• Andrew Martin • Doug Martin• Jim Meeks-Johnson • Pat Milligan • Justin Morea• Chris Power• Linas Simonaitis• Kenneth Spry• Jeff Stroup• Blaine Takesue• David Taylor • Jeff Warvel • Jennifer Weatherspoon • Chen Wen