Integrated Outcomes TM

1. Integrated OutcomesTM Unprecedented Capture of Outcomesfor Outpatient Interventions with Easy Work-flow Integration Duane Steward, DVM, MSIE, PhD Stewardd@saic.com duane@medg.csail.mit.edu 321 939-7912 cell: 407 230-6081

2. What is it? • Method for Managing Results • Based on a Simple Fundamental Technology • Product and a Service

3. Agenda • What • Why • How

4. Architecture of Integrated OutcomesTM • Medical record entry as trigger (e.g., ICD10 code) • Knowledge-based System for construction of inquiry • Timely inquiry • Patient responses in medical record • Knowledge-based System for provider response recommendation • Role specific prompting for provider staff

5. Integrated OutcomesTM Diagrammed

6. Integrated OutcomesTM Diagrammed

7. Integrated OutcomesTM Diagrammed

8. Integrated OutcomesTM Diagrammed

9. Why Integrated OutcomesTM? • C Everett Coop • Outcomes Measurement • Influence medical decisions • Inform present with the past • Inform the future • Quality of Care • Changed with timely feedback • Reduce Uncertainty

10. Outcomes Capturing Precedent • Inpatient • Hospital • Office • Laboratory • Rehabilitation • Outpatient • Obituaries • Scant instances of ad hoc local efforts

11. Why Are Not More Outcomes Measured? • Cost of asking • Tedium • Consuming Time & Resources • Patient compliance • Most too intimidated to bother the provider unless severe • Manageability of response • Patient knowledge is not • Informed • Structured • Systematized • . . . therefore not reliable

12. What Can We Expect With Integrated OutcomesTM • Outpatients asked about outcomes • Well timed • Structured • Intervention specific • Consistent solicitation • Systematic • Impact on Statistics and Sample Size • Potential for Machine Learning & Analysis • Not Burdensome, Cost-effective • Better follow-up

13. Impact on Quality of Care • Unprecedented Information • More Consistency in Delivery and Follow-up • Earlier Notice • Highly Organized • Minimized Cost

14. Integrated OutcomesTM Technology • Reasoning Engine • Knowledge-base • Infrastructure Interfaces • E-mail (or Postcard) • Medical Records

15. Reasoning Engine • Expert System • Java Expert System Shell used for prototyping • Separate Knowledge-base from Inference Engine • Needs no modification or rebooting when Rules are added or modified in the Knowledge-base

16. Knowledge-base • Consists of Healthcare Provider Protocols • Questions asked of patients • Timing of patient inquiry • Responses of staff to outcomes • Nature of response • Role to respond • Tailored to Institution, Practice, Clinic, Provider or Specific Clinical Study • Extensible Knowledge-base w/o Modification of Infrastructure

17. Sample Rules (from proof-of-concept) (protocol (intervention "Recommendation to watch for redness, swelling or other systemic symptoms") (question "Which of the following have occurred?") (answers "Nothing; no evidence remains of the tick bite. I am still waiting to hear results of the blood work." "Nothing; no evidence remains of the tick bite. I was informed that the results of the blood work were negative." "Redness remains where the tick was removed." "The area of redness has grown larger than a dime where the tick was removed." "Swelling has occurred or remains where the tick was removed." "Redness and swelling both occurred or remain where the tick was removed." "Other skin lesions have arisen not located at the site where the tick was removed." "Any of the following symptoms have occurred: malaise, fever, fatigue, headache, or other flu-like symptoms." "Other symptoms that I did not expect have occurred."))

18. Sample Rules (from proof-of-concept) (protocol (intervention "doxycycline 100mg BID PO 10 days") (question "Please select one or more responses concerning your condition.") (answers "I have taken my medication twice daily every day for one week." "I have taken my medication almost regularly for one week (missed < two doses)." "I have missed more than two doses but am still taking medication after 7 days." "I have stopped taking my medication within seven days of starting." "The redness/swelling under my arm has improved or disappeared after one week on doxycycline." "The redness/swelling under my arm has worsened after one week on doxycycline." "One or more of the following symptoms: malaise, fever, fatigue, headache, etc., occurred while taking doxycycline for one week." "No change after one week of doxycycline." "Other - please explain."))

19. Sample Rules (from proof-of-concept) (respProtocol (feedback "Nothing; no evidence remains of the tick bite. I am still waiting to hear results of the blood work.") (actions "Call now and reassure results are on the way")) (respProtocol (feedback "Nothing; no evidence remains of the tick bite. I was informed that the results of the blood work were negative.") (actions "Email congratulations")) (respProtocol (feedback "Redness remains where the tick was removed.") (actions "Make follow-up appointment.")) (respProtocol (feedback "Other symptoms that I did not expect have occurred.") (actions "Call to ask about the unexpected symptoms.")) (respProtocol (feedback "The redness/swelling under my arm has improved or disappeared after one week on doxycycline.") (actions "Ask again in three days")) (respProtocol (feedback "The redness/swelling under my arm has worsened after 10 days on doxycycline.") (actions "Make follow-up appointment and extend prescription of doxycycline."))

20. Infrastructure • Automated • Construction of questions • Timing of inquiry • Recommendations for staff response • Effortless Medical Record Updates • Compiled Lists of Tasks for Staff

21. Service • Knowledge-base • Refinement • Extension • Maintenance • Analysis • Collected Data • Analysis of Data • Machine Learning and Induction of New Rules • Re-integration into Knowledge-base

22. Beneficiaries • Pharmaceutical Companies • Clinical Trial Outcomes and Monitoring • Health Maintenance Organizations • Ensure Cost Effective Care and Responses • Clinicians • Close Monitoring • Feedback on Practice • Employers • Optimized Healthcare Benefit Expenses • Maximized Productivity • Patients • Better Care, Better Response • Confidence in Personal Contributions & Provider Responsiveness

23. What is it? • Method for Managing Results • Based on a Simple Fundamental Technology • Product and a Service

24. Integrated OutcomesTM Unprecedented Capture of Outcomesfor Outpatient Interventions with Easy Work-flow Integration Duane Steward, DVM, MSIE, PhD Stewardd@saic.com duane@medg.lcs.mit.edu 321 939-7912 cell: 407 230-6081