Knowledge Management Challenges in the Healthcare Delivery Market

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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.

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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 RD
• Implications for Personalized Medicine

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Partners HealthCare

• Massachusetts General Hospital, Brigham and
  Womens 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

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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

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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

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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

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Typical Committee and Project Structures Related
to Medication Safety IllustrateOrganizational
Alignment Problem
Information Technology Projects
Committees and Departments

• Physician Order Entry Team
• Clinical Data Repository Team
• Pharmacy System Team
• Clinical Documentation Team
• Electronic Medication Adminstration Team

• Pharmacy and Therapeutics
• Patient Safety
• Quality or Performance Improvement
• Policies and Procedures
• Formulary
• Infection Control

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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
Committees and Departments

• Physician Order Entry Team
• Clinical Data Repository Team
• Pharmacy System Team
• Clinical Documentation Team
• Electronic Medication Administration Team

• Pharmacy and Therapeutics
• Patient Safety
• Quality or Performance Improvement
• Policies and Procedures
• Formulary
• Infection Control

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Knowledge Management The Core Processes
Knowledge Application
Knowledge Discovery
Knowledge Asset Management
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A Continuum of Clinical Decision Support and
Knowledge Discovery

• Proactive

• Surveillance

• Interactive

• Learning

Reference Knowledge Linking
Event Monitoring
Safety Net
Anticipation
Understanding and Predicting Performance

• Making the right decisions the easiest decisions

• Monitoring patient data with passive decision
  support

• Interceptingincorrect clinicaldecisions

• Predictive Modeling
• Case-based Reasoning
• Learning Knowledge Repository

modified from the First Consulting Group Model
of Clinical Decision Support
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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

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(No Transcript)
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Laboratory Notification with consequent order
recommendations
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Alternate Procedures, Redirects, Drug-Allergy,
Drug-Drug, Drug-Lab etc.
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Gerios Dose-filters for ageNephros
Dose-filters for renal function
Inappropriately sedated elderly inpatients on
average incur 5600 excess costs over expected
for severity of illness
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Preventive Reminders
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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

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Knowledge Application must anticipate these
dimensions of the clinical encounter
Clinical Standardization Standards of
Practice, Role/Venue Requirements Billing/Regulato
ry Requirements
User Personalization End-user workflow
preferences Learning and User-defined
Improvisation Patient Preferences
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Poly-hierarchical inferencing with actionable
advice surveillance, interactive, or proactive
mode
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This is an example from clinical decision support
company called Theradoc
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A Continuum of Clinical Decision Support and
Knowledge Discovery

• Proactive

• Surveillance

• Interactive

• Learning

Reference Knowledge Linking
Event Monitoring
Safety Net
Anticipation
Understanding and Predicting Performance

• Making the right decisions the easiest decisions

• Monitoring patient data with passive decision
  support

• Interceptingincorrect clinicaldecisions

• Predictive Modeling
• Case-based Reasoning
• Learning Knowledge Repository

modified from the First Consulting Group Model
of Clinical Decision Support
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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

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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

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What are the challenges today

• Healthcare delivery organizations purchase
  systems but dont 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

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Partners-Wide Knowledge Management Model
KNOWLEDGE ASSET MANAGEMENT
Signature Initiatives and Sub-Committees
set Enterprise-wide Strategy, Clinical Standards
and Performance Measures
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
Data Warehouse
Decision Support Design Teams direct the design
of cross-functional knowledge to be encoded
PERFORMANCE and OUTCOMES (KNOWLEDGE DISCOVERY)
Partners Genetics Computing Platform
Applications for Virtual Collaborative
Knowledge Authoring and Maintenance
Knowledge Repository
Clinical Workflow Applications and Services
Knowledge Building Blocks
Information Model
Common Services Knowledge Editors
DECISION SUPPORT (APPLIED KNOWLEDGE)
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• 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

Knowledge Asset Management Translating Goals
into a Knowledge Repository Taxonomy
Goal Framework Safety, Quality, Efficiency,
Research
Dx/Rx Decision Making
Order Fulfillment, Communication and Coordination
Data/Knowledge Seeking
Assessment
Billing Reporting
Transfer/ Handoff
CORE CARE PROCESS AUTOMATION TAXONOMY
Medical Management, Research, and Reporting
Clinical Knowledge for Personalized Medicine
Taxonomy
Reference Information Model
Role and Venue Domain Taxonomy
Requirements
Care Applications and Knowledge Bases
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MEDICATION USE PROCESS Acetaminophen in a 2.5 Kg
Premature Infant
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Sample High-level Example Taxonomy for Knowledge
Assets
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Center for Clinical Knowledge Engineering
Welcome to the National Knowledge Engineering
Repository
Go
HEDIS
Content search
Advanced Search Filters (press Ctrl to select
more than one)
Clinical Discipline Surgical
Informatics Mode
Cardiothoracic Surgery
Interactive Rules
Search File Hierarchy
Interventional Cardiology Orthopedics Etc.
Surveillance and Notifications Documentation
Templates Etc.
Knowledge Asset Management Toolkit
Link to references, survey instruments, diagrams,
descriptions, process flow diagrams, etc on
Partners and VA approaches to asset management
Clinical Discipline Non-Surgical
Age
Cardiovascular
Adult
Submit Content to Editor
Endocrinology Gastroenterology Etc.
Pediatrics Neonate Etc.
About Us
Clinical Discipline Safety
Role
Nosocomial Infection Control
Nurse
Medication Safety Decubitus Ulcer Prevention Etc.
Physician Case Manager Etc.
Clinical Discipline Disease Management
Venue
Diabetes Mellitus
CCU
Congestive Heart Failure Multiple Sclerosis Etc.
Ambulatory Care Emergency Department Etc.
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Knowledge Specifications For Encoded
Knowledge Vs Meta-knowledge about The knowledge
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Future State KM Model
Workflow Applications
Collaborative Knowledge Authoring Tools
Portal
Meta-Knowledge Repository
Knowledge-based Services
Knowledge Repositories
Information Model
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Barriers to Success at the Intersectionof
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

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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

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Where are we?