Tonya Hongsermeier, MD, MBA

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Collaborative Authoring of Decision Support
Knowledge A Demonstration

• Tonya Hongsermeier, MD, MBA
• Corporate Manager, Clinical Informatics RD,
  Partners HealthCare System
• Vipul Kashyap, PhD
• Senior Medical Informatician, Clinical
  Informatics RD, Partners HealthCare System
• Robert Masson
• EMC/Documentum
• With assistance from
• Judith Colecchi, RN, MS
• Corporate Team Lead I
• Cathyann Harris
• Project Manager
• Paul Rapoza
• Application Developer
• Muffie Martin, RN, MSN
• Senior Project Specialist
• Eileen Yoshida, MS Pharm, MBA
• Pharmacy Knowledge Engineering Team Lead 2
• Blackford Middleton, MD, MPH, MSc
• Director

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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

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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

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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

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Content Life-Cycle Challenges
Committee, Department, Researcher, or Other
Proposes to Implement Content

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

Guideline is Defined and Validated

• 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

Functional Knowledge Specification For Encoding
is Designed and Validated

• 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 doesnt help maintain data about content

Specification is Engineered into Production
Generating a Technical Specification

• 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

Ongoing Revisions or Eventual Sunset Of Encoded
Guideline
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Clinical Content Committee Prioritizes and
Sponsors Operational Stewardship of Content
Safety
Quality
Disease Management
Trend Management
Disease Areas
Primary Care
Pharmacotherapy
Imaging Studies
CAD/CHF, Diabetes, Heme-Onc, Asthma, ID/HIV,
Nephrology, Psych
Adult, Geriatrics, Pediatrics, Womens Health
PCHI PT
Medication Knowledge Committee
BWH Precipio
MGH ROE
SME Groups
Knowledge Analysts facilitate
Knowledge Editors update
Production Knowledge Repositories
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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)

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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

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• DEMO of
• Knowledge Management Portal

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KM Portal Taxonomy based Navigation
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KM Portal Filter-based Search
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• Documentum Content Management System (CMS)
• Provides order to unstructured and structured
  information by managing processes for
• creation
• processing
• delivery
• archival 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.

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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

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KM Generation 1 Architecture
KM Portal
Internet Explorer
Content Switch
Upload Control
Internet Explorer
IIS Web Server 1
IIS Web Server 2
IIS Web Server 3

• keyword based search
• filter based search
• taxonomy based browsing

KM Portal/Win 2003
KM Portal/Win 2003
KM Portal/Win 2003
synchronized copy
Goes Away
Verity Web Server
Shared SQL Server Database

• stored procedures
• SQL queries

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KM Generation 2 Architecture
Internet Explorer
Internet Explorer
Content Switch
Documentum Infrastructure
IIS 6.0
IIS 6.0
IIS 6.0
Published Content (Production)
Content Server
ASP Scripts
ASP Scripts
Collaboration Server
Content Intelligence Server
Verity Search Server
KM Portal
Content Repository
Content Management
Metadata Transformation and Publication
Collaboration
Shared RDBS
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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
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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

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Partners maintains a geriatric dosing database
that supports either default dosing more
appropriate for geriatric population or
substitution recommendations
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• E-ROOM DEMONSTRATION
• Geriatric Subject Matter Expert Review
• of Enterprise Geriatric Dosing Module

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Votes
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Other poll approaches
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E-room report illustrating aggregation of expert
input, dramatically improves efficiency for
subject matter experts and medication services
design teams
Vioxx alert shared, removed from database
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Knowledge Engineer updates the content in the
Gerios editor A new cut of Gerios is posted to
the portal.
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Now, we move the Content Management interface to
upload the new cut of Gerios to the Portal And
apply appropriate metadata filters and taxonomy
tags
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Example LifeCycle of Functional Knowledge Spec.
Edited State
Review State
Start
Publish State
Archive State
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Roadmap Proposed Sequence of Rearchitecting
Editors with DocumentumA Knowledge Event
Management Architecture
Transaction Systems and Services
2007
Propagation Inheritance
2006
Documentum
2007
Knowledge Management Portal
eRoom and Portal Repositories (metaknowledge about
the knowledge)
2006
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Conclusions

• Now that two groups have used it on Documentums
  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 cant achieve
  enterprise-wide clinical standards in our
  clinical decision support content without such
  tools