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Knowledge Management Challenges in the Healthcare Delivery Market Tonya Hongsermeier, MD, MBA Corporate Manager, Clinical Decision Support and Knowledge Management, Clinical Informatics Research & Development Partners HeatlhCare System, Inc. Agenda About Partners Healthcare Knowledge Management and Informatics Knowledge Knowledge Knowledge Application Discovery 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 Information Technology Projects Physician Order Entry Team Clinical Data Repository Team Pharmacy System Team Clinical Documentation Team Electronic Medication Adminstration Team Committees and Departments Pharmacy and Therapeutics Patient Safety Quality or Performance Improvement Policies and Procedures Formulary Infection Control Medication Use Process Organization Medication Safety Steering Committee Chief Medical Officer, Chief Nursing Officer, Chief Information Officer, Chief Quality Officer Interdisciplinary Medication Use Process Advisory Team Physicians, Nurses, Pharmacists, Clinical Systems Architects Information Technology Projects Physician Order Entry Team Clinical Data Repository Team Pharmacy System Team Clinical Documentation Team Electronic Medication Administration Team Committees and Departments Pharmacy and Therapeutics Patient Safety Quality or Performance Improvement Policies and Procedures Formulary Infection Control Knowledge Management: The Core Processes Knowledge Application Knowledge Asset Management Knowledge Discovery A Continuum of Clinical Decision Support and Knowledge Discovery* Surveillance Interactive Reference Knowledge Linking Event Monitori ng Safety Net Proactive Anticipati on Learning Understan ding and Predicting Performan ce Monitoring patient data with passive decision support Intercepting Making the right incorrect decisions clinical the easiest decisions decisions *modified from the First Consulting Group Model of Clinical Decision Support Predictive Modeling Casebased Reasoning Learning Knowledge Repository Medication Decision Support Categories at Partners REFERENCE 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, DrugAllergy, Drug-Drug, Drug-Lab etc. Gerios: Dose-filters for age Nephros: Dose-filters for renal function Inappropriately sedated elderly inpatients on average incur $5600 excess costs 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 Clinical Standardization Standards of Practice, Role/Venue Requirements Billing/Regulatory Requirements Improvisation User Personalization Patient Preferences End-user workflow preferences Learning and User-defined Poly-hierarchical inferencing with actionable advice – surveillance, This is an example from clinical decision support company called Theradoc A Continuum of Clinical Decision Support and Knowledge Discovery Surveillance Interactive Reference Knowledge Linking Event Monitori ng Safety Net Proactive Anticipati on Learning Understan ding and Predicting Performan ce Monitoring patient data with passive decision support Intercepting Making the right incorrect decisions clinical the easiest decisions decisions *modified from the First Consulting Group Model of Clinical Decision Support Predictive Modeling Casebased Reasoning Learning Knowledge Repository 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 (metaknowledge) 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 KNOWLEDGE ASSET MANAGEMENT Signature Initiatives and Sub-Committees set Enterprise-wide Strategy, Clinical Standards and Performance Measures Decision Support Design Teams direct the design of crossfunctional knowledge to be encoded Performance Feedback to Leaders, SMEs, Committees, and End-users 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 Applications for Virtual Collaborative Knowledge Authoring and Maintenance Knowledge Repository Knowledge Building Blocks Common Services Knowledge Editors Information Model Clinical Workflow Applications and Services DECISION SUPPORT (APPLIED KNOWLEDGE) Data Warehouse PERFORMANCE and OUTCOMES (KNOWLEDGE DISCOVERY) Knowledge Asset Management: Translating Goals into a Knowledge Repository Taxonomy Goal Framework: Safety, Quality, Efficiency, Research Data/Knowledge Seeking Assessment Dx/Rx Decision Making Order Fulfillment, Communication and Applications Coordination Billing Reporting Transfer/ Handoff Care (Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS, CORE CARE PROCESS AUTOMATION TAXONOMY Measurement) and Knowledge Bases Medical Management, Research, and Reporting Care Applications (Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS, Clinical Knowledge forMeasurement) Personalized Medicine Taxonomy and Knowledge Bases Role and Venue Domain Taxonomy Requirements Care Applications and Knowledge Bases MEDICATION USE PROCESS: Acetaminophen in a 2.5 Kg Premature Infant Patient Venue Clinical Domain Role-based workflow Informatics Support Neonatal Intensive Care Unit Fever Management Physician Orders Pharmacist Dispenses Physician Order Pharmacy Entry with Verification and Pediatric dosing Dispensing calculation engine System Nurse Administers Nurse Assesses Electronic Clinical Medication Documentation Administration Record with Calculation Engine 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 Medication Knowledge Acetaminophen, Infant Acetaminophen, 10 mg/kg PO Q 6 Acetaminophen 0.25 ml PO Q 6 hrs 100mg/ml solution hours Desired Outcome is fever abated Sample High-level Example Taxonomy for Knowledge Assets CORE CLINICAL PROCESSES Admission Patient Scheduling and Tracking Clinical Data Review Clinical Knowledge Retrieval Patient Assessment Diagnostic/Therapeutic Ordering Order Fulfillment Results Reporting Billing Patient Transfer/Hand-off Care Oversight Medical Management Population Management VENUES Medical-Surgical Coronary Care Unit Surgical Intensive Care Unit Medical Intensive Care Unit Post-operative Care Unit Thoracic Care Unit Emergency Department Operating Room Cardiac Catheterization Lab Rehabillitation Ward Subacute Care Unit Psychiatric Care Unit Ambulatory Care Home Care Self Care MODE OF INFORMATICS APPLICATION Results Review Notifications Interactive Decision Support Reminders Clinical Messaging Order Sets Clinical Documentation Vital Signs, Intake and Output Reports Dashboards WORKFLOWS Physicians Nurses Pharmacists Medical Technicians Case Managers Social Workers Respiratory Therapists Occupational Therapists Physical Therapists Speech Therapists Chart Abstracter Risk Manager Administrative Support Quality Improvement Patient/Consumer CLINICAL DISCIPLINES Surgical Service Lines Cardiac (surgical) Cardiac (interventional) General Surgery Gynecology Orthopedic Transplant Trauma Urology/ Renal (Genitourinary) Vascular Surgery Pediatric Surgery Colorectal Surgery Neurosurgery Non-Surgical Service Lines Cardiac (medical) Endocrinology Gastroenterology General Medicine Hematology Oncology Newborn/ Neonatology Neurology Infectitious Disease Respiratory/ Pulmonary Rheumatology/Immunology Behavioral Health Patient Safety Medication Safety anticoagulation management sedation management renal/electrolyte management elderly medication management pediatric medication management Disease or Risk Management Diabetes Congestive Heart Failure Hypertension HIV Immune Compromised Coronary Artery Disease Hyperlipidemia Elderly/Geriatric Status Dementia or Alzheimer's Disease Transition Management Multiple Sclerosis Rheumatoid Arthritis Nosocomial Infection Prevention Antibiotic Management Wound and Catheter Management Ventilator Management Other Bedside Safety Falls Prevention Decubitus Ulcer Prevention Restraints Management Center for Clinical Knowledge Engineering Welcome to the National Knowledge Engineering Repository Go Content search HEDIS Advanced Search Filters (press Ctrl to select more than one): Clinical Discipline: Surgical Cardiothoracic Surgery Interventional Cardiology Orthopedics Etc. Clinical Discipline: Non-Surgical Cardiovascular Endocrinology Gastroenterology Etc. Clinical Discipline: Safety Nosocomial Infection Control Medication Safety Decubitus Ulcer Prevention Etc. Clinical Discipline: Disease Management Diabetes Mellitus Congestive Heart Failure Multiple Sclerosis Etc. Informatics Mode Interactive Rules Surveillance and Notifications Documentation Templates Etc. Age Adult Pediatrics Neonate Etc. Role Nurse Physician Case Manager Etc. Venue CCU Ambulatory Care Emergency Department Etc. Search File Hierarchy Knowledge Asset Management Toolkit Link 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: Knowledge Specifications For Encoded Knowledge Vs Meta-knowledge about The knowledge TITLE: INFORMATICS MODE: FILE NAME: DATE LAST UPDATED: DATE FIRST ACTIVATED: AUTHORS: CONTACT: VERSION ID: SITE: KNOWLEDGE EDITOR: STATUS: Digoxin Order Abnormal Lab Result INTERACTIVE CPOE BICS_DIGORDER_LAB 12/03/2003 03/02/2001 John Smith, Jane Doe [email protected] 001.005.003 Safe Hospital Joe Brown 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 SUPPLEMENTATION etc…. SCREEN SHOTS: Link PROCESS FLOW DIAGRAM: Link RECOMMENDING POTASSIUM Future State KM Model Collaborative Knowledge Authoring Tools Portal Meta-Knowledge Repository Workflow Applications Knowledge-based Services Knowledge Repositories Information Model Barriers to Success at the Intersection of 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?
