EvolutionoftheKnowledgeManagementProgram

atPartnersHealthCare(PHS)

RobertoA.Rocha,MD,PhD,FACMIClinicalInforma9csDirector,

PartnerseCare,PartnersHealthcareSystemAssistantProfessorofMedicine

DivisionofGeneralInternalMedicineandPrimaryCare,DepartmentofMedicine,BrighamandWomen’sHospital,HarvardMedicalSchool

LearningHealthSystem(LHS)Seminar

-October7,2016-

Overview

•  History– Goals,typesofassets,ini9alchallenges,tac9cs

•  Currentstate–  Program,principles,typesofassets– Newchallenges,revisedtac9cs

•  Implementa9onframework–  Levelsofsupport,areasoffocus

•  Futuredirec9ons•  Conclusions

HISTORY

KnowledgeManagement

•  Establishedin2003asaformalfunc9onwithintheClinicalInforma9csR&Dgroup–clinicalteamwithinInforma9onSystems

•  Responsibilityfordesigning,developing,andsuppor9ngprocesses,tools,andassets–e.g.governance,lifecycle,authoring,deployment

•  Enterprisecontentareas–e.g.terminologies,catalogues,rules,referencesources,etc.

OriginalStrategicGoals

•  Reducethecostandincreasethespeedofknowledgeacquisi9onandmaintenancefordecisionsupport

•  Speedtransla2onofclinicalinnova9onandevidenceintoclinicalprac9ce•  Proac2ve,an2cipatorydecisionsupportarchitecturetosetfounda9onfor

personalizedmedicine–avoid“interrup9ve”decisionsupport•  ImprovePartners’organiza2onaleffec2venessasalearningorganiza9on

throughorganiza9onalalignmentanddata-drivenperformanceimprovement

•  Alignknowledgeassetswithbusiness,regulatory,safetyandqualityrequirements

•  Onlybuildwhatwecannotbuy•  Partnershascreatedsomeofthebestdecisionsupportinproduc9onin

theworld,thegoalhereistokeeptheknowledgeuptodate

SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)

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)

ContentLife-CycleChallenges

SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)

ClinicalContentCommittee

SlidecreatedbyTonyaHongsermeier,MD,MBA(Mar2006)

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)

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

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“Empty” list of Brand names

ID Drug / Compound

Choose Ingredients)

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NoYes

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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

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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

KMsoftwaretools

10-15looselyconnectedtoolsusedjusttomaintainMeds

CURRENTSTATE

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

Programguidingprinciples@PHS

•  Objec9velyimprovessafety,quality,andefficiency•  Supportedbyevidence,clinicalbestprac2ces,andsoundclinicalthinking

•  Alignswithandpromotesclinicalandbusinessgoals•  Acceptabletoprac9cingendusers(workflowintegra9on)

•  Adherestoinforma9csandknowledgemanagementbestprac2ces

•  Bestu9lizestalent,resources,andcapitalofPartners•  SupportsresearchandteachingmissionsofPartners

InventoryofKnowledgeAssetsManagedCentrallyatPartners(1/2)

RochaRA,MavigliaSM,SordoM,RochaBH.Clinicalknowledgemanagementprogram.In:GreenesRA,editor.ClinicalDecisionSupport-TheRoadtoBroadAdop9on(SecondEdi9on).Burlington:AcademicPress;2014.p.773-817

InventoryofKnowledgeAssetsManagedCentrallyatPartners(2/2)

RochaRA,MavigliaSM,SordoM,RochaBH.Clinicalknowledgemanagementprogram.In:GreenesRA,editor.ClinicalDecisionSupport-TheRoadtoBroadAdop9on(SecondEdi9on).Burlington:AcademicPress;2014.p.773-817

CKMLifecycle@PHSRequest

(neworupdate)

Authorize&Priori9ze

Design

ImplementTest&Deploy

Monitor

Evaluate

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

PartnerseCare

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

CDSMonitoringPortal

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

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

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

IMPLEMENTATIONFRAMEWORK

Levelsofsupport

•  Reac9veSupport–  Troubleshoo9ngandmaintenanceofexis9ngassets–  Preserva9onoforiginalscope:quan9tyandcoverage

•  PeriodicImprovement–  Sporadicimprovementsbeyondiden9fiedproblems–  Limitedexpansionoforiginalscope

•  Con9nuousImprovement–  An9cipatoryiden9fica9onofproblemsandneeds–  Expanded(dynamic)scope,includingnewdatatypes–  Scalableandcost-effec9veprocessesandinterven9ons

WhyContinuousImprovement?•  NewEHRsystemincludesasignificantlylargercollec2onofdata&

knowledgeassets,es9matedat4to59mesthenumberofassetspreviouslymanaged/curated

•  Levelofintegra9onofthenewEHRsystemgreatlyincreasesthenumber&complexityofinterdependenciesbetweenassets,aggravatedbyimportantlimita9onsof“internal”configura9ontools

•  Sitesaredemandingsite-specificcustomiza2on&filteringofassets,givendisparateneeds,targetpa9entpopula9ons,resources,andprocesses

•  Needfortargeted&con2nuousCDSinterven2onsincreasesasmoreemphasisismadetomanagehigh-riskpopula9onsandepisodes,takingintoaccountdifferentpayercontractsanduniquepa2entcharacteris2cs

•  Needforconsistentdatadefini2onsalignedwithstandardsisevenmorecri9calgivenincreaseddemandforInteroperability,CDS,andAnaly9cs

Complexitychallenge

0100020003000400050006000700080009000

10000

0 500 1000 1500 2000 2500

Interdependenciesvs.NumberofAssets

Assumingthatagivenassetistypicallyconnectedto3otherassets

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

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

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

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.

Additionalframeworks

•  Dataclassifica9on•  Terminologies(dic9onaries)•  Solwareinfrastructure•  Processanaly9cs

FUTUREDIRECTIONS

KMopportunities(1/2)

•  Individualizedinterven9ons–  Integra9onandeffec9veuseof"new"datasources–e.g.devices,genomic,pa9ententered,preferences

•  Minimizefa2gueandmaximizeu2lity–  Detailedrepresenta9onofcontextandstate–e.g.interven9ontarge9ngandcon9nuouslearning

•  Preventmalfunc2ons–  Decisionsupporttoassistknowledgeengineers–e.g.automateconfigura9on,customizevalida9onrules

KMopportunities(2/2)

•  Proac9vemaintenance–  Automateddetec9onofmalfunc9ons

–e.g.con9nuouslymonitorac9veinterven9ons,detec9onalgorithms

•  Localizedknowledgetransla2ons–  Automateddetec9onofnewevidence(fromdata)

–e.g.evidenceaugmentedbypa`ernsofuse,concurrentinterven9onswithprospec9veevalua9ons

•  Mi9gatecomplexity–  Adoptnewdecisionsupportmethodsandtools

–e.g.combineinferencemethods,“dynamic”knowledgeassets

CONCLUSIONS

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

Challenges–largescale

•  Labor-intensiveacquisi2onprocess(SMEs)•  Inabilitytoachieveproperdomaincoverage•  Rudimentarytools&resources•  Costlyandinefficientmaintenance

•  Well-trainedpersonnelusingefficientprocesses•  Distributedandcollabora9veac9vi9es–i.e.coopera2on

acrossteamsandins2tu2ons•  Commontools,processes,andstandards

CDShastofollowthepatient

•  ClinicalsystemsmighthaveverysimilarCDSfeatures,butarefrequentlynotconfiguredthesameway–  CDStriggeredinoneserngmaynotbeconfirmedorre-enactedinsubsequentserngs

• Withoutcon9nuityandconsistencyacrossserngsandins9tu9ons,interven9onshavedecreasedeffec2venessfordissemina9ngevidenceandreducingunwarrantedvariability

Acknowledgements

SaverioMavigliaEileenYoshidaCharlesLagor

MargaritaSordoChristopherVitale

Priyaranjan(Raj)TokachichuAllmembersoftheClinicalInforma2csTeamatPartners

BeatrizRochaDanBogaty

TonyaHongsermeierBlackfordMiddleton

Thankyou!Roberto A. Rocha, MD, PhD!

rarocha@partners.org !http://scholar.harvard.edu/rarocha!

!! !

ThisworkbyRobertoA.RochaislicensedunderaCrea9veCommonsA`ribu9on-NonCommercial-ShareAlike4.0Interna9onalLicense