Knowledge Management Challenges in the Healthcare Delivery Market

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6 Νοε 2013 (πριν από 3 χρόνια και 9 μήνες)

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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 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 Team

Physicians, Nurses, Pharmacists, Clinical Systems Architects

Medication Safety Steering Committee

Chief Medical Officer, Chief Nursing Officer, Chief Information Officer, Chief Quality Officer

Knowledge

Application

Knowledge

Discovery

Knowledge

Asset Management

Knowledge Management: The Core Processes

A Continuum of Clinical Decision Support

and Knowledge Discovery*


Monitoring
patient
data with
passive
decision
support


Intercepting

incorrect

clinical

decisions


Making the
right
decisions
the easiest
decisions


Predictive
Modeling


Case
-
based
Reasoning


Learning
Knowledge
Repository

Reference
Knowledge

Linking


Event
Monitori
ng


Safety
Net

Anticipati
on

Understan
ding and
Predicting

Performan
ce


Surveillance


Interactive


Proactive


Learning

*modified from the First Consulting Group Model of Clinical Decision Support

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, Drug
-
Allergy, 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


Improvisation

Patient Preferences

User Personalization

End
-
user workflow preferences

Learning and User
-
defined

Clinical Standardization

Standards of Practice,

Role/Venue Requirements

Billing/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


Intercepting

incorrect

clinical

decisions


Making the
right
decisions
the easiest
decisions


Predictive
Modeling


Case
-
based
Reasoning


Learning
Knowledge
Repository

Reference
Knowledge

Linking


Event
Monitori
ng


Safety
Net

Anticipati
on

Understan
ding and
Predicting

Performan
ce


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

Knowledge

Repository

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 Workflow

Applications and

Services

Signature Initiatives and

Sub
-
Committees set

Enterprise
-
wide Strategy,

Clinical Standards and

Performance Measures

Knowledge

Building Blocks

Information

Model

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/Rx

Decision Making

Order Fulfillment,

Communication and
Coordination

Knowledge Asset Management:

Translating Goals into a Knowledge Repository Taxonomy

Goal Framework: Safety, Quality, Efficiency, Research

Data/Knowledge
Seeking

Requirements

Assessment

Billing

Reporting

Medical Management, Research, and Reporting


Care Applications


and Knowledge Bases


CORE 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 Venue
Clinical Domain
Role-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 Unit
Fever 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 PROCESSES
MODE OF INFORMATICS
APPLICATION
Admission
Results Review
Surgical Service Lines
Non-Surgical Service Lines
Patient Scheduling and Tracking
Notifications
Cardiac (surgical)
Cardiac (medical)
Clinical Data Review
Interactive Decision Support
Cardiac (interventional)
Endocrinology
Clinical Knowledge Retrieval
Reminders
General Surgery
Gastroenterology
Patient Assessment
Clinical Messaging
Gynecology
General Medicine
Diagnostic/Therapeutic Ordering
Order Sets
Orthopedic
Hematology
Order Fulfillment
Clinical Documentation
Transplant
Oncology
Results Reporting
Vital Signs, Intake and Output
Trauma
Newborn/ Neonatology
Billing
Reports
Urology/ Renal (Genitourinary)
Neurology
Patient Transfer/Hand-off
Dashboards
Vascular Surgery
Infectitious Disease
Care Oversight
Pediatric Surgery
Respiratory/ Pulmonary
Medical Management
Colorectal Surgery
Rheumatology/Immunology
Population Management
Neurosurgery
Behavioral Health
VENUES
WORKFLOWS
Patient Safety
Disease or Risk Management
Medication Safety
Diabetes
Medical-Surgical
Physicians
anticoagulation management
Congestive Heart Failure
Coronary Care Unit
Nurses
sedation management
Hypertension
Surgical Intensive Care Unit
Pharmacists
renal/electrolyte management
HIV
Medical Intensive Care Unit
Medical Technicians
elderly medication management
Immune Compromised
Post-operative Care Unit
Case Managers
pediatric medication management
Coronary Artery Disease
Thoracic Care Unit
Social Workers
Hyperlipidemia
Emergency Department
Respiratory Therapists
Nosocomial Infection Prevention
Elderly/Geriatric Status
Operating Room
Occupational Therapists
Antibiotic Management
Dementia or Alzheimer's Disease
Cardiac Catheterization Lab
Physical Therapists
Wound and Catheter Management
Transition Management
Rehabillitation Ward
Speech Therapists
Ventilator Management
Multiple Sclerosis
Subacute Care Unit
Chart Abstracter
Rheumatoid Arthritis
Psychiatric Care Unit
Risk Manager
Other Bedside Safety
Ambulatory Care
Administrative Support
Falls Prevention
Home Care
Quality Improvement
Decubitus Ulcer Prevention
Self Care
Patient/Consumer
Restraints Management
CLINICAL DISCIPLINES
Sample High
-
level Example Taxonomy for Knowledge Assets

Center for Clinical Knowledge Engineering

HEDIS

Content search

Welcome to the National Knowledge Engineering Repository

Go

Advanced Search Filters (press Ctrl to select more than one):

Cardiothoracic Surgery

Interventional Cardiology

Orthopedics

Etc.

Clinical Discipline: Surgical

Cardiovascular

Endocrinology

Gastroenterology

Etc.

Clinical Discipline: Non
-
Surgical

Nosocomial Infection Control

Medication Safety

Decubitus Ulcer Prevention

Etc.

Clinical Discipline: Safety

Congestive Heart Failure

Multiple Sclerosis

Etc.

Clinical Discipline: Disease Management

Diabetes Mellitus

Interactive Rules

Surveillance and Notifications

Documentation Templates

Etc.

Informatics Mode

Adult

Pediatrics

Neonate

Etc.

Age

Nurse

Physician

Case Manager

Etc.

Role

Ambulatory Care

Emergency Department

Etc.

Venue

CCU

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:


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:





JohnSmith@Safehospital.org

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/
hypok
alemia 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
: Lin
k

Knowledge Specifications

For Encoded Knowledge

Vs

Meta
-
knowledge about

The knowledge

Future State KM Model

Workflow Applications

Knowledge Repositories

Information Model

Meta
-
Knowledge

Repository

Collaborative

Knowledge

Authoring

Tools

Portal

Knowledge
-
based Services

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?