Collaborative Authoring of Decision Support Knowledge: A Demonstration

1. Collaborative Authoring of Decision Support Knowledge: A Demonstration Tonya Hongsermeier, MD, MBA Corporate Manager, Clinical Informatics R&D, Partners HealthCare System Vipul Kashyap, PhD Senior Medical Informatician, Clinical Informatics R&D, 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 Clinical Informatics Research and Development

2. 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

3. 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

4. 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

5. 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 doesn’t 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

6. Clinical Content Committee: Prioritizes and Sponsors Operational Stewardship of Content Safety Quality Disease Management Trend Management Primary Care Disease Areas Pharmacotherapy Imaging Studies Adult, Geriatrics, Pediatrics, Women’s Health CAD/CHF, Diabetes, Heme-Onc, Asthma, ID/HIV, Nephrology, Psych Medication Knowledge Committee PCHI P&T MGH ROE BWH Precipio SME Groups Knowledge Analysts facilitate Knowledge Editors update Production Knowledge Repositories

7. 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)

8. 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

9. DEMO of Knowledge Management Portal

10. KM Portal: Taxonomy based Navigation

11. KM Portal: Filter-based Search

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

13. 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

14. KM Generation 2: Architecture Internet Explorer Internet Explorer Content Switch Documentum Infrastructure IIS 6.0 IIS 6.0 IIS 6.0 Content Server Published Content (Production) 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

15. 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

16. 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

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

18. E-ROOM DEMONSTRATION: Geriatric Subject Matter Expert Review of Enterprise Geriatric Dosing Module

22. Votes

25. Other poll approaches

27. 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

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

30. 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…

37. Example LifeCycle of Functional Knowledge Spec. Edited State Review State Start Publish State Archive State

38. Medication Services Editors New Order Entry Editors New Documentation Editors Medication Svs Repositories Order Entry Repositories Documentation Repositories Legacy Editors Ilog Rule Editor Legacy Repositories Ilog Rule Repositories Health Language Inc Terminology Editors Complex Definition Editors Complex Definitions Repository Terminology Repository Roadmap: Proposed Sequence of Rearchitecting Editors with Documentum:A 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

39. 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