Clinical decision support track fhir dev days 2016

© 2013 HL7 ® International. Licensed under Creative Commons. HL7 & Health Level Seven are registered trademarks of Health Level Seven International. Reg. U.S. TM Office.

Clinical Decision Support Track

Bryn RhodesNovember 16, 2016


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


3

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.


4

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.

http://wiki.siframework.org/Health+eDecisions+Use+Case


5

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


6

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?


7

CDS - Management


8

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


9

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


10

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

http://jamia.oxfordjournals.org/content/18/Supplement_1/i132.long


11

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

http://gem.med.yale.edu/default.htm

http://cds-hooks.org/

https://www.healthit.gov/techlab/testing_and_utilities.html


12

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)


13

Zika Virus WorkflowSimplified, showing only part 1 of branch for all pregnant patients


14

Clinical Reasoning Module

Representation, Distribution, Evaluation of Clinical Knowledge Artifacts

Event-Condition-Action Rules Order Sets Documentation Templates Quality Measures etc


15

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


16

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


17

Zika Virus ArtifactsSimplified, showing only part 1 of branch for all pregnant patients

Questionnaire

Actions

Conditions


18

Zika Exposure Assessment


19

ActivityDefinition


20

Condition Logic


21

Building the PlanDefinition


22

Other Conditions


23

ECA-Rules


24

Zika Virus ImplementationSimplified, showing only part 1 of branch for all pregnant patients

Questionnaire

Actions

Conditions


25

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


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", ...}


EHR CDS Service


CDS Service Logic



EHR CDS Service

HTTP 1.1/ 200 OK

{ "cards": [ { "summary": "Example card", "indicator": "info", "source": { "name": "Demo CDS Service”}}]}


29

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

http://demo.primedimensions.com/

http://prime-dimensions-zika.herokuapp.com/resetdb

http://prime-dimensions-zika.herokuapp.com/resetdb


30

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


31

Questions?

http://build.fhir.org http://wiki.hl7.org/index.php?title=FHIR

http://build.fhir.org/

http://wiki.hl7.org/index.php?title=FHIR


32

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/

https://oncprojectracking.healthit.gov/wiki/display/TechLabSC/CQF+Home

https://oncprojectracking.healthit.gov/wiki/display/TechLabSC/CQF+Home



http://hl7.org/fluentpath/

Healthcare

Clinical decision support track fhir dev days 2016