Clinical Decision Support Consortium

Transcription

1 Clinical Decision Support Consortium

2 Agenda 1. Welcome, introductions and study overview (Blackford Middleton, subcontract PI, 10 min) 2. Recommendations and site visits (Dean Sittig, Co-investigator and KMLA and Recommendations Team Lead, 10 min) 3. CDSC customers experience (20 min) PHS (Adam Wright, PI and Demo Team Lead) Regenstrief Institute (Brian Dixon, Research Scientist) NextGen (Sarah Corley, MD, CMO) 4. Knowledge Layers, Knowledge Authoring Tool and Health edecisions (Aziz Boxwala, Co-investigator and KTS Team Lead, 10 min) 5. Wrapping AHRQ contract and CDSC V2 (Lana Tsurikova, Co-investigator, RPM and Research Management Team Lead, 15 min) 6. Discussion (All, 55 min)

3 CDS Consortium Study Overview Blackford Middleton, MD, MPH, MSc Subcontract Principal Investigator Chief Informatics Officer and Professor of Biomedical Informatics, and of Medicine (with tenure) at Vanderbilt University

4 CDSC Overview Clinical Decision Support Consortium (CDSC) Base Year One and Two: March 2008 June 2010 Optional Year One: July 2010 July 2011 Optional Year Two: July 2011 July 2012 Optional Year Three: July 2012 July 2013 Participating Organizations: Started from 11 entities Currently includes 31 organizations 8 healthcare institutions 9 academic institutions 14 vendors AHRQ contract HHSA

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6 CDSC Goal and Significance Goal: To assess, define, demonstrate, and evaluate best practices for knowledge management and clinical decision support in healthcare information technology at scale across multiple ambulatory care settings and EHR technology platforms. Significance: The CDS Consortium will carry out a variety of activities to improve knowledge about decision support, with the ultimate goal of supporting and enabling widespread sharing and adoption of clinical decision support. 2. Knowledge Specification 1. Knowledge Management Life Cycle 3. Knowledge Portal and Repository 4. CDS Public Services and Content 5. Evaluation Process for each CDS Assessment and Research Area 6. Dissemination Process for each Assessment and Research Area

7 Timelines We are here

8 CDSC Headlines Preview CDS Web Services work at Scale across multiple sites and multiple EMRs An Enhanced CCD can serve as the Patient Data Payload (with some limitations) Knowledge Artifacts Can Be Collaboratively Authored and Shared Across Diverse Care Delivery Organizations in an Open Knowledge Repository

9 CDSC Next Steps: v 2.0 Future research and development roadmap to focus on extensions to patient data payload, additional content areas, and generalizing the approach to create CDS Ecosystem Additional content areas (MU, Pharmacogenomics, care coordination, chronic care management) Additional functional areas (Order sets, infobuttons, documentation templates) Individual sites developing rules services (for $) The CDSC collectively exploring v 2.0 options (more to follow)

10 Recommendations Summary Dean Sittig, PhD Co-investigator and KMLA and Recommendations Team Lead

11 Recommendations for HIT Vendors Expand use of CCD standard Continue support for Gov t-approved controlled clinical vocabularies Continue to work with and support the on-going HL7 knowledge representation initiatives Support the HL7 Infobutton standard Implement standard data triggers Provide appropriate insertion points in the clinical workflow for CDS interventions to be delivered Facilitate selective filtering or tailoring of rules through EHRs

12 Comparison of Clinical KM Capabilities Commercially-available and leading internallydeveloped electronic health records. Qualitative research program: barriers and facilitators to successful adoption and use Reviewed teaching facilities with long-standing EHR R&D programs Are commercially-available EHRs capable clinical knowledge management features, functions, tools, and techniques required to deliver and maintain the CDS interventions required to support the recently defined meaningful use criteria

13 Comparison of Clinical KM Capabilities (cont.) 17-question survey about the vendor s EHR, CDSrelated system tools and capabilities that each vendor provides, and clinical content. Majority of the systems were capable of performing almost all of the key knowledge management functions we identified The transformation of the healthcare enterprise is achievable using commercially-available, state-of-theart EHRs. BMC Med Inform Decis Mak Feb 17;11:13. doi: / J Am Med Inform Assoc Nov-Dec;19(6): doi: /amiajnl J Am Med Inform Assoc May 1;18(3): doi: /amiajnl BMC Med Inform Decis Mak Feb 14;12:6. doi: /

14 Site Visit to Vendors and Vendors Customers Implementing CDSC Services Dean Sittig, PhD Co-investigator and KMLA and Recommendations Team Lead

15 We First Visited CDS Content Vendors Zynx Health, First Databank, UpToDate Focus was on CDS in general Big themes were We are in this together [with clinical organizations and the EHR industry] so need to work together We are like Switzerland [we do not practice medicine] Ash JS, et al. Studying the vendor perspective on clinical decision support. AMIA Annual Symposium Proceedings. 2011;2011:

16 Virtual Site Visits with EHR Vendors NextGen, GE and UMDNJ sites Focus was on service oriented architecture for CDS Big themes were SOA is the future The challenges are great, including lack of interest in CDS among customers and standards issues

17 Study Updates and Demo Results Adam Wright, PhD Principal Investigator and Demo Team Lead

18 Input (CCD) ECRS Recc Rule Authoring SMArt VMR Open EHR Translations / Normalization

19 Partners HealthCare EHR

20 Partners Trial Results Trial running since May 2010 Currently active in 2 out of the original 4 clinics Calls have been consistently high Service was not running between Dec 2010 and May 2011 Ongoing advanced analysis of the data Clinical & Execution performance

21 Partners Trial Results (cont.)

22 Regenstrief Institute CDSC Experience BRIAN E. DIXON, MPA, PHD, FHIMSS ASSISTANT PROFESSOR OF HEALTH INFORMATICS, IUPUI SCHOOL OF INFORMATICS AND COMPUTING RESEARCH SCIENTIST, REGENSTRIEF INSTITUTE RESEARCH SCIENTIST, CENTER FOR IMPLEMENTING EVIDENCE-BASED PRACTICE, DEPARTMENT OF VETERANS AFFAIRS, HEALTH SERVICES RESEARCH & DEVELOPMENT SERVICE

23 Two Independent Phases Phase 1 Limited Pilot July December primary care physicians Display of reminders in general inbox Phase 2 Expanded Pilot June December primary care physicians (all docs at 2 clinics) Display of reminders in CPOE module of EHR

24 Phase 1

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26 Phase 2

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28 Lessons Learned CDSC Service is analogous to homegrown reminders Recent analysis found strong correlation; article for review Technical integration into EHR straightforward Not easy but manageable Works better with SOA/modular CPOE Challenges remaining Terminology mapping CDA generation / consumption performance

29 Implementing CDSC Web Service NextGen and WVPHA Sarah Corley, MD, FACP, FHIMSS Chief Medical Officer, NextGen Healthcare

30 Background NextGen EHR/CDSC web service integration completed in 2012 Client site testing with test patients completed and ready to move to production Project was taken on as a proof of concept project from NextGen s perspective

31 Initial Challenges Legal agreements NextGen had to perform mapping from ICD-9 to SNOMED codes and NDC to RxNorm initially Some diagnoses were interpreted narrowly for CDSC Eclampsia does not represent a pregnant patient Diabetes in pueperium, baby delivered does not represent diabetes

32 Initial Challenges Allergies had to be mapped from UNII to RxNorm Structured PE findings had to be codified Diabetic foot exam The pregnancy information was in a CCD dedicated section rather than a subsection of the problem list The patient data needed to be deidentified

33 Workflow Challenges CDS in NextGen EHR is comprehensive & actionable How to best display CDSC recommendations within workflow? Who should see recommendations How to pass requests efficiently

34 Future Development Imported recommendations need to be actionable Duplicate recommendations need to be stripped if they are already in EHR More high value CDS needs to be provided Radiology appropriateness indicators Cardiology appropriateness indicators

35 NextGen EHR/CDSC Web Service Integration Details

36 Schematic of NextGen/CDSC Integration NextGen template is populated by user Stored procedure is called Interface calls CDSC server with NextGen data CDSC data returned

37 Schematic of NextGen/CDSC Integration NextGen template is loaded Check if CDSC data is present No Yes CDSC button hidden Display CDSC button on template

38 Screenshots

39 Screenshots

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41 Screenshots

42 Harmonization of Standards MU2 set a broader scope of vocabulary standards The ccda has expanded standardized content and should be used Transport and display of content should be standardized e.g. Direct for transport E.g. wrapped CDA for content coming back These will reduce barriers to wider vendor participation

43 Actionable CDS Consider using MU requirements for reconciliation as a tool to import recommendations for medications now with goal for importing lab tests and diagnostic studies in the future as structured data so it can be imported into EHR and ordered without transcription.

44 NextGen Next Steps Move to production server Barriers have been interoperability staff constraints due to MU 2 Pilot of catch-up immunizations with HeD

45 Questions???

46 Knowledge Layers, Knowledge Authoring Tool and Health edecisions Aziz A. Boxwala, MD, PhD on behalf of the Knowledge Translation and Specification Team

47 Overview CDSC Knowledge Layers CDSC Knowledge Authoring Tool Health edecisions update

48 Knowledge Representation Approach Goals Rapid translation of evidence into CDS knowledge Implementable in different settings and using different CDS tools and technologies Multilayered knowledge representation framework Increasing structure and refinement in successive layers

49 Multilayered Framework Published Guideline knowledge evoke: Arden Syntax Rule Semi-structured data: Structured Recommendation Recommendation Semi-Structured Recommendation PCP Structured := read { }; Recommendation Executable Rules BPRecordedInLastYear := read last{table= RES, code= } Meta data Title: Screening Meta data for High Blood Pressure Reaffirmation Title: Recommendation Screening Adult for := High ; Statement Blood Pressure Narrative Developer: Guideline Developer: U.S. Preventive CDS Consortium Services Task Screening for High Force Blood (USPSTF) Pressure Derived from: logic: USPSTF BP Screening Semistructured Rec. Reaffirmation Recommendation Strength of recommendation: Statement if (adult is Grade false) then A U.S. Preventive Services Task Applicable Force (USPSTF) Scenario conclude false; Clinical Scenario: Data Mapping: if (BPRecordInLastYear BPRecordedInLastYear: is null) Observation then = VitalSign-> Order Sets in Patient age select(code.equals(bploinccode) 18 years conclude true; and vsdatatime.within(12, CPOE months)) system The U.S. Preventive Blood Services pressure Task not obtained Force in the last year (USPSTF) recommends screening Logical Condition: for action: high BPRecordedInLastYear->notEmpty() blood pressure Clinical adults Action: aged 18 and Write older. Patient has not had a blood pressure screening in the last year (This is a grade Obtain "A" recommendation) and Recommended record blood pressure PCP ; Action: VitalSign(code: BPLoincCode)

50 Preliminary Assessment Survey of 19 CDS experts from Partners, Kaiser, VA, Regenstrief Assessed impact of layered model on five dimensions of GLIA: decidability, executability, presentation, flexibility, and computability The results suggest that structured actions are more implementable than semi-structured ones. This effect was not seen for clinical scenarios

51 Knowledge Document Structure (L3) CDS Knowledge Document Knowledge Module: Reminder Rule Knowledge Module: Order Set Knowledge Module: Documentation Template Knowledge Module: Info Button Knowledge Module Metadata Action Behavior Presentation Data

52 Knowledge Authoring Tool

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56 KAT Status Currently deployed on the web in test mode If you would like to check it out, please contact Lana Tsurikova or me In-progress Terminology search using BioPortal Planned Support for Health edecisions

57 Health edecisions S&I Framework project To identify, define and harmonize standards that facilitate the emergence of systems and services whereby shareable CDS interventions can be implemented via: Standards to structure medical knowledge in a shareable and executable format for use in CDS, and (Use Case 1 CDS Artifact Sharing) Standards that define how a system can interact with and utilize an electronic interface that provides helpful, actionable clinical guidance (Use Case 2- CDS Guidance Services)

58 Status of Health edecisions Created a knowledge artifact schema (in part based on L3) that has been applied to Event-condition-action rules Order sets Documentation templates Balloted as HL7 DSTU in Jan 2013 Passed ballot Significant number of comments related to alignment with HQMF Updating the ballot materials for publication as DSTU Pilot projects started Use case 2 for CDS services currently being developed

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60 Thanks CDSC team members Agency for Healthcare Research and Quality Health edecisions team members and community

61 Wrapping up AHRQ Contract CDSC Chapter 2 Lana Tsurikova, MSc, MA Co-investigator and Research Management Team Lead

62 AHRQ Asked Us Implementation Demonstration Evaluation Dissemination

63 Accomplishments CDS Services 8 clinical sites 5 EHR systems 1.7M CDS transactions 240 users WVP Health Authority (NextGen), Salem, OR Kaiser Roseville UC Davis Kaiser Sacramento Kaiser San Rafael Kaiser San Francisco California UMDNJ (GE) Wishard Hospital Newark, NJ Indianapolis, IN Cincinnati Children s Children s s Hospital Colorado Nationwide Children s Ohio NYP NY PHS

64 Accomplishments Knowledge Management 11 clinical rules 50+ classification rules 375 immunization schedule rules

65 Accomplishments Dissemination 24 published papers 16 papers in progress 11 sets of recommendations

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67 CDS Grand Challenges Manage large clinical knowledge databases Create an internet-accessible, clinical decision support repository Disseminate best practices Create an architecture for sharing executable CDS modules Prioritize CDS content development and implementation Sittig et al., J Bio Inf 2008

68 Additional Challenges Lack or ambiguity of standards Terminology alignment Reluctance to share

69 Additional Products Legal Framework 2 Years Clinical Governance Committee Hongsermeier et al., AMIA Annu Symp Proc Turechek et al., AMIA Annual Symposium; 2010

70 What It Took $6.5M AHRQ Contract # HHSA Tools and Time 90+ Researchers and Collaborators In-kind Contribution

71 Clinical Outcomes CDS services perform well Sites aim to increase participation by adding clinics or clinicians SOA-based approach to CDS is feasible Paterno et al., AMIA Annu Symp Proc. 2012

72 The CDSC Influence - Standards The Health edecisions (HeD) Knowledge Artifact Schema was largely based in large part on the CDSC L3 artifact; i.e., the approach of using one schema to express different types of CDS artifacts such as rules, order sets, and documentation templates HeD also uses concepts from L3 such as behavior, action groups and actions, and various elements from the metadata

73 Wrapping up CDSC V1 7/8/2013 Final report Complete existing and new demonstrations Continue work on publications

74 Reflections Leadership Pre-competitive R&D Ecosystem

75 CDSC Chapter 2 What s next Clinical content Standards Integrations Meaningful Use Stage 2 Novel approaches for providing CDS

76 Future Members 1. Healthcare service providers 2. EHR and content vendors 3. Insurance companies 4. HIT community, guidelines developers, specialty societies 5. Non-profit foundations

77 CDSC Chapter 2 How PHS CDS Lab Academic-Industrial Collaborative CDS Institute or CDS National Center for Excellence

78 Acknowledgements Principal Investigator (PI): Adam Wright, PHD (2/2013-7/2013) Subcontract PI: Blackford Middleton, MD, MPH, MSc (3/2008 2/2013) CDSC Team Leads: Research Management Team: Lana Tsurikova, MSc, MA KMLA/Recommendations: Dean F. Sittig, PhD Knowledge Translation and Specification: Aziz Boxwala, PhD KM Portal: Tonya Hongsermeier, MD, MBA CDS Services: Howard Goldberg, MD CDS Demonstrations: Adam Wright, PhD CDS Dashboards: Jonathan Einbinder, MD Evaluation: David Bates, MD, MSc Content Governance Committee: Saverio Maviglia, MD, MSc

79 Where are we? Thank you! Lana Tsurikova, MSc, MA