IMPLEMENTING IMPERFECT GUIDELINES: GEM MEETS WEB SERVICES
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1 Children s Hospital Of Philadelphia Robert Grundmeier, MD Dean Karavite, MS Technical Expert Panel 2010 IMPLEMENTING IMPERFECT GUIDELINES: GEM MEETS WEB SERVICES 1
2 Objectives Describe an approach to using webservices to deliver guidelines in a vendorsupplied electronic health record Describe the experience using guidelines element markup (GEM) to implement guidelines Case study: retinopathy of prematurity Children s Hospital of Philadelphia 2
3 A Mixture of Urban and Suburban 4 Urban Primary Care Centers 1 Faculty Practice 26 Urban/Suburban and Rural Kids First Practices 8 Specialty Care Centers with 3 Ambulatory Surgical Centers 1 Hospital Practice Cultures Children s Hospital of Philadelphia 3
4 Pediatric Research Consortium (PeRC) at CHOP System-wide EHR (Epic) to identify eligible participants, facilitate collection of data, and to allow implementation of decision support tools Over 638,000 total ambulatory visits in 2009 provided to about 200,000 patients 169 physicians and 22 nurse practitioners 39 active projects All practices currently participating in a minimum of 3 active research studies Children s Hospital of Philadelphia 4
5 Care Assistant: A Web-Service Framework Children s Hospital of Philadelphia 5
6 Web Service Components: EHR Server Process for registering the web services URL of the service Data payload to deliver Specify data storage elements Data access methods Billing and problem list diagnoses Medications, orders, and immunizations Flowsheet data, etc Children s Hospital of Philadelphia 6
7 Web Service Components: EHR Workstation Provides Care Assistant a custom plug-in that can be inserted in the clinical workflow In Epic terms: Visit Navigator Section and Activity Acts as a relay station to forward the data payload from the EHR server to the web service Children s Hospital of Philadelphia 7
8 Web Service Components: EHR Workstation Completely asynchronous does not interrupt workflow Our style choice: no pop-ups just prominent positioning Dynamic HTML methods are used to display the guideline content Children s Hospital of Philadelphia 8
9 Workstation Integration Care Assistant can provide links to launch Order Sets Standard reports Data capture forms Additional web services Our style choice: all data storage is provided by the EHR The web-services are stateless Children s Hospital of Philadelphia 9
10 The Web Service Itself The Care Assistant framework as we have defined it is primarily a message protocol The web service itself: Listens for requests to process data payloads (e.g. an immunization history) Responds with HTML content, formatting, and JavaScript functionality to render the user interface (e.g. a forecast of upcoming immunizations) Children s Hospital of Philadelphia 10
11 Asthma Assistant Children s Hospital of Philadelphia 11
12 Immunization Assistant Children s Hospital of Philadelphia 12
13 Growth and Development Assistants Children s Hospital of Philadelphia 13
14 From Guideline to Executable Rules via GEM Retinopathy of prematurity guidelines Section on Ophthalmology, American Academy of Pediatrics American Academy of Ophthalmology American Association for Pediatric Ophthalmology and Strabismus Pediatrics 2006 Children s Hospital of Philadelphia 14
15 Retinopathy of Prematurity Children s Hospital of Philadelphia 15
16 Part I: Not So Bad Children s Hospital of Philadelphia 16
17 Rules for Part I: Not So Bad! Children s Hospital of Philadelphia 17
18 But Did You Notice? Gestation age 30 vs 32 Guideline wording: 32 weeks or less We interpret as < 33 weeks (or <= 32 6/7) Supporting table footnotes gestational age 31 and 32 weeks with the words [screen] if necessary Children s Hospital of Philadelphia 18
19 Part II: Weasel Words Children s Hospital of Philadelphia 19
20 Rules for Part II: A Work in Progress Children s Hospital of Philadelphia 20
21 Mutually Exclusive Criteria The guideline attempts to define two nonoverlapping sets BW < 1500 or GA <= 30 or 32 (depending on where you look in the guideline) vs. BW 1500 to 2000 or GA > 30 They probably meant: Cohort #1: BW < 1500 or GA <= 30 6/7 Cohort #2: BW 1500 to 2000 and not in cohort 1 Children s Hospital of Philadelphia 21
22 AND vs. OR Normal humans use AND to imply the union of two sets Infants with gestational age 30 or less AND infants with birth weight under 1500 grams are at risk Programmers use OR to imply union If (GA < 31 OR BW < 1500) then recommend(rop_screen) Children s Hospital of Philadelphia 22
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