Tonya Hongsermeier, MD, MBACorporate Manager, Clinical Informatics R&D, Partners HealthCare System

Vipul Kashyap, PhDSenior Medical Informatician, Clinical Informatics R&D, Partners HealthCare System

Robert MassonEMC/Documentum

With assistance from:Judith Colecchi, RN, MS

Corporate Team Lead I

Cathyann HarrisProject Manager

Paul RapozaApplication Developer

Muffie Martin, RN, MSNSenior Project Specialist

Eileen Yoshida, MS Pharm, MBAPharmacy Knowledge Engineering Team Lead 2

Blackford Middleton, MD, MPH, MScDirector

Clinical Informatics Research and Development

Collaborative Authoring of Decision Support Knowledge: A Demonstration

Outline

• Knowledge Management: Strategic Goals

• Steps for a Knowledge Management Solution KM Portal Implement Collaboration and Content

Management Tools from Documentum Integrate New and Legacy Content Editors with

Document Content Management Services

• Case Example: Maintenance of a Geriatric Dosing Database

• Conclusions

Knowledge Management: Strategic Goals

• Reduce the cost and increase the speed of knowledge acquisition and maintenance for decision support

• Speed translation of clinical innovation and evidence into clinical practice

• Proactive, anticipatory decision support architecture to set foundation for personalized medicine – avoid “interruptive” decision support

• Improve Partners’ organizational effectiveness as a learning organization through organizational alignment and data-driven performance improvement

• Align knowledge assets with business, regulatory, safety and quality requirements

• Only build what we cannot buy

• Partners has created some of the best decision support in production in the world, the goal here is to keep the knowledge up to date

Content Examples maintained at Partners Healthcare System

• Medication Data Dictionary with default doses, weight-based doses, dose strings, and drug-drug interaction checking (multiple applications and populations via Common Medication Services)

• Gerios and Nephros for proactive dosing for elderly and/or renal insufficient

• Drug-lab monitoring, duplicate drug checking, drug-group checking, drug-disease checking, drug-pregnancy checking

• Primary and secondary preventive health reminders • Results Manager • Inpatient and outpatient order sets• Inpatient interactive rules (application specific, hard-coded)

• Concept dictionary and problem list• Patient monographs • Radiology ordering decision support• Outpatient documentation templates

Content Life-Cycle Challenges:

Committee, Department, Researcher, or Other

Proposes to Implement Content

Guideline is Defined and Validated

Functional Knowledge SpecificationFor Encoding is

Designed and Validated

Ongoing Revisions or Eventual Sunset

Of Encoded Guideline

•Prioritization mechanism not always clear•Stewardship processes not always clear•Lack of coordination

•Unclear mechanism for subject matter expert participation…Who says so? Friend of Researcher?

•No budgetary model to reimburse experts… •No tools to support efficient collaboration – 3000 row tables•Little or no audit trail of decisions made

•Project competition with other engineering projects, prioritization processes unclear•Knowledge editors typically do not enable content auditing, knowledge editors siloized, no support of inheritance or propagation•Little or no documentation about content in production •MS Office doesn’t help maintain data about content

•Little analytic data available on decision support content orimpact on clinical outcomes impact to direct updating•Tendency to rely on query of transaction systems•No content management tools to support process and ensure timeliness

Specification isEngineered into Production Generating

a Technical Specification

Clinical Content Committee: Prioritizes and Sponsors Operational Stewardship of Content

Safety

CAD/CHF, Diabetes, Heme-Onc, Asthma, ID/HIV, Nephrology,

Psych

Disease Areas

Adult, Geriatrics,Pediatrics,

Women’s Health

Primary Care

PCHIP&T

Pharmacotherapy

Quality Disease Management Trend Management

SMEGroups

MedicationKnowledgeCommittee

BWHPrecipio

Imaging Studies

MGHROE

Production Knowledge Repositories

Knowledge Analysts facilitate

Knowledge Editors update

How we are evolving our knowledge management infrastructure:

Knowledge Management Generation 1 (2004):• Build and deploy a document library to provide enterprise wide

access to specifications of decision support knowledge

• Inventory all structured knowledge in production at Partners

• Create and develop a knowledge repository

Knowledge Management Generation 2 (2005):• Implement tools to support collaborative content consensus,

iterative drafting of guidelines and conversion to functional knowledge specifications

• Knowledge repository expanded to support browsing of pre-production and “in-production” knowledge

• Implement tools to support content management processes using lifecycles and workflows (knowledge maintenance)

Knowledge Management Generation 3 (2006):• Integrate legacy and new content authoring tools with content

management infrastructure (knowledge editing)

Knowledge Management Generation 1 Functionality

• A Partners-wide repository of documentation on clinical decision support knowledge

• Knowledge organized based on:— Well defined metadata and filters

• E.g., entity, content type, clinical descipline, application— Well defined taxonomic categories

• E.g., disease management, patient safety, signature initiative areas

• Search and lookup by:— Free text, key word based search

• E.g., Get me all order sets that contain the word “cardiovascular”— Metadata and filter based search

• E.g., Get me all order sets that were created at BWH for cardiology in the BICS system

— Taxonomy based browsing• E.g., I want to explore and iteratively all knowledge associated with

Patient Safety

• Content upload tool (internally developed) enabled— Mapping of clinical knowledge to filters and taxonomic concepts— Creation and management of taxonomies and metadata filters

DEMO of

Knowledge Management Portal

KM Portal: Taxonomy based Navigation

KM Portal: Filter-based Search

Documentum Content Management System (CMS):

• Provides order to unstructured and structured information by managing processes for:creationprocessingdeliveryarchival of any content according to user-defined business rules.

• Establishes relationships between pieces of content, allowing the same content to be used in different contexts and renditions and supporting propagation of key content relationships and dependency management.

• Natively supports XML content creation and authoring

• Adds intelligence, creating categorization schema and metadata that make search and retrieval faster and more efficient.

•Automates the processing of content through its life cycle.

• Facilitates publication of content through multiple channels

• Promotes integration between departments and systems that previously worked within silos.

• Enables access control security so that permissions for who can view, edit and manage content are controlled at the user and role level

Knowledge Management Generation 2 Functionality

Tools for content management• Creation and management of different types of clinical content metadata and

(with configuration and/or customization) the content for transaction systems• E.g., Order Sets, Clinical Rules, Documentation Templates

• Definition and Enforcement of Content Lifecycles• Support for Content Dependency and Propagation

• Definition and Enforcement of Content Workflows• Support for different roles, e.g., Knowledge Engineer, Administrator, etc.• Support for Content Auditing processes

• Metadata and Taxonomy Management

Tools for collaboration• Enable vetting and refinement of clinical knowledge

• Support for different roles, e.g., Subject Matter Expert, Coordinator, etc.• Expertise Location Functionality

Search and Retrieval of Content• Keyword and filter-based search• Taxonomy-based browsing

KM Generation 2: Architecture

InternetExplorer

IIS 6.0

Collaboration Server

Content Repository

InternetExplorer

ContentSwitch

IIS 6.0 IIS 6.0

ASP Scripts ASP Scripts

VeritySearch Server

PublishedContent(Production)

KM Portal

Collaboration

Content Management

ContentServerContent

IntelligenceServer

Shared RDBS

MetadataTransformationand Publication

Documentum Infrastructure

Problem of Lost Knowledge and Lack of Collaboration Support:Setting aside the challenge of “who decides on content”, this screenshot shows a common way for clinical guideline spec management:MS office folders, documents related by title and common location only,Difficult to know what changed from one version to next or why, people move on to new jobs and folders get lost…..

Solution: Structured tools for content collaboration lifecycle management

Gerios: Case Example Collaborative Content Development using E-Room

• New Business Incentive for Geriatric Prescribing at Partners

• Gerios in production in BICS for several years, already planned for move into LMR

• Content reviewed for current categories, however, not complete coverage of relevant drugs for elderly, many gaps

• With added drugs, became a 160+ Row Decision Table• Geriatric expert panel chartered to work with our

Medication Services Knowledge Engineering team to update the Geriatric Content and create a new version called Gerios- Version 2 with a plan to standardize for all CPOE utilizing common services

Partners maintains a geriatric dosing database that supports either default dosing more appropriate for geriatric population or substitution recommendations

E-ROOM DEMONSTRATION:

Geriatric Subject Matter Expert Review

of Enterprise Geriatric Dosing Module

Votes

Other poll approaches

E-room report illustrating aggregation of expert input,dramatically improves efficiency for subject matter expertsand medication services design teams

Vioxx alert shared, removed from database

Knowledge Engineer updates the content in the Gerios editor……A new cut of Gerios is posted to the portal….

Now, we move the Content Management interface to upload the new cut of Gerios to the PortalAnd apply appropriate metadata filters and taxonomy tags…

Example LifeCycle of Functional Knowledge Spec.

Start

Edited State

Review State

Publish State

Archive State

Roadmap: Proposed Sequence of Rearchitecting Editors with Documentum:A Knowledge Event Management Architecture

Documentum

eRoom and PortalRepositories (metaknowledge

about the knowledge)

KnowledgeManagementPortal Health Language Inc Terminology Editors

Terminology Repository

Legacy Editors

LegacyRepositories

Medication Services Editors

Medication SvsRepositories

New Order Entry Editors

Order EntryRepositories

New Documentation Editors

DocumentationRepositories

Transaction Systems and

Services

Ilog Rule Editor

Ilog RuleRepositories

2007

2006

2006

Complex Definition Editors

Complex Definitions Repository

2007

Propagation& Inheritance

Conclusions

• Now that two groups have used it on Documentum’s hosted site, we have a lot of pent up demand, rollout begins in December on hosted environment

• These are volunteer Subject Matter Experts, incentives are being developed to reward contribution, however, current participants describe it as fun and intellectually rewarding

• The rollout of the rooms must be carefully designed, every room needs a dedicated administrator who tees up the content for review, shepards the content through the lifecycle

• Leadership well recognizes that we can’t achieve enterprise-wide clinical standards in our clinical decision support content without such tools