Clinical Decision Support Consortium

Clinical Decision Support

Consortium

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)

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

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

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.

1. Knowledge Management Life Cycle

2. Knowledge Specification

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

Timelines

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

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)

Recommendations Summary

Dean Sittig, PhD

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

Comparison of Clinical KM Capabilities

• Commercially-available and leading

internally-developed 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”

Comparison of Clinical KM Capabilities (cont.)

• 17-question survey about the vendor’s EHR,

CDS-related 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-the-art EHRs.

BMC Med Inform Decis Mak. 2011 Feb 17;11:13. doi: 10.1186/1472-6947-11-13.

J Am Med Inform Assoc. 2012 Nov-Dec;19(6):980-7. doi: 10.1136/amiajnl-2011-000705. J Am Med Inform Assoc. 2011 May 1;18(3):232-42. doi: 10.1136/amiajnl-2011-000113. BMC Med Inform Decis Mak. 2012 Feb 14;12:6. doi: 10.1186/1472-6947-12-6.

Site Visit to Vendors and Vendors’

Customers Implementing

CDSC Services

Dean Sittig, PhD

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.

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

Study Updates

and Demo Results

Adam Wright, PhD

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

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

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

Regenstrief Institute

CDSC Experience

Two Independent Phases

y

Phase 1 – Limited Pilot

{ 3 primary care physicians

{ Display of reminders in general “inbox”

y

Phase 2 – Expanded Pilot

{ 19 primary care physicians (all docs at 2 clinics) { Display of reminders in CPOE module of EHR

Lessons Learned

y

CDSC Service is analogous to homegrown reminders

y

Technical integration into EHR straightforward

{ Works better with SOA/modular CPOE

y

Challenges remaining

Implementing CDSC Web

Service –NextGen and

WVPHA

Sarah Corley, MD, FACP, FHIMSS

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

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

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

de-identified

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

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

NextGen EHR/CDSC Web

Service Integration Details

Schematic of NextGen/CDSC

Integration

Schematic of NextGen/CDSC

Integration

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

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.

NextGen Next Steps

• Move to production server

– Barriers have been interoperability staff

constraints due to MU 2

Questions

Knowledge Layers,

Knowledge Authoring Tool

and Health eDecisions

Aziz A. Boxwala, MD, PhD

on behalf of the

Overview

• CDSC Knowledge Layers

• CDSC Knowledge Authoring Tool

• Health eDecisions update

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

Multilayered Framework

Recommendation Executable Rules

Order Sets in CPOE system

Narrative Guideline

Screening for High Blood Pressure

Reaffirmation Recommendation Statement U.S. Preventive Services Task Force (USPSTF)

The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older. (This is a grade "A" recommendation)

Narrative Guideline

Screening for High Blood Pressure

Reaffirmation Recommendation Statement U.S. Preventive Services Task Force (USPSTF)

The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older. (This is a grade "A" recommendation)

Semi-Structured Recommendation

Meta data

Title: Screening for High Blood Pressure Reaffirmation Recommendation Statement

Developer: U.S. Preventive Services Task Force (USPSTF)

Strength of recommendation: Grade A

Clinical Scenario:

Patient age ≥18 years

Blood pressure not obtained in the last year

Clinical Action:

Obtain and record blood pressure

Semi-Structured Recommendation

Meta data

Title: Screening for High Blood Pressure Reaffirmation Recommendation Statement

Developer: U.S. Preventive Services Task Force (USPSTF)

Strength of recommendation: Grade A

Clinical Scenario:

Patient age ≥18 years

Blood pressure not obtained in the last year

Clinical Action:

Obtain and record blood pressure

Structured Recommendation

Meta data

Title: Screening for High Blood Pressure

Developer: CDS Consortium

Derived from: USPSTF BP Screening Semistructured Rec.

Applicable Scenario

Data Mapping: BPRecordedInLastYear: Observation = VitalSign-> select(code.equals(BPLoincCode) and vsDataTime.within(12, months))

Logical Condition: BPRecordedInLastYear->notEmpty()

Recommended Action: VitalSign(code: BPLoincCode)

Structured Recommendation

Meta data

Title: Screening for High Blood Pressure

Developer: CDS Consortium

Derived from: USPSTF BP Screening Semistructured Rec.

Applicable Scenario

Data Mapping: BPRecordedInLastYear: Observation = VitalSign-> select(code.equals(BPLoincCode) and vsDataTime.within(12, months))

Logical Condition: BPRecordedInLastYear->notEmpty()

Recommended Action: VitalSign(code: BPLoincCode)

Arden Syntax Rule

knowledge evoke: …

data:

BPRecordedInLastYear := read last{table=‘RES’, code=‘12345-0’} PCPemail := read {…};

Adult := …;

logic:

if (adult is false) then conclude false;

if (BPRecordInLastYear is null) then conclude true;

action:

Write ‘Patient has not had a blood pressure screening in the last year’ at PCPemail;

Arden Syntax Rule

knowledge evoke: …

data:

BPRecordedInLastYear := read last{table=‘RES’, code=‘12345-0’} PCPemail := read {…};

Adult := …;

logic:

if (adult is false) then conclude false;

if (BPRecordInLastYear is null) then conclude true;

action:

Write ‘Patient has not had a blood pressure screening in the last year’ at PCPemail;

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

Knowledge Document Structure (L3)

CDS Knowledge Document

CDS Knowledge Document

Knowledge Module: Reminder Rule

Knowledge Module: Reminder Rule

Knowledge Module: Order Set

Knowledge Module: Order Set

Knowledge Module: Documentation Template

Knowledge Module: Documentation Template

Knowledge Module: Info Button

Knowledge Module: Info Button

Knowledge Module Knowledge Module Action Action Behavior Behavior Presentation Presentation Metadata Metadata Data Data

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

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

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

Thanks

• CDSC team members

• Agency for Healthcare Research and

Quality

• Health eDecisions team members and

community

Wrapping up AHRQ Contract

CDSC Chapter 2

Lana Tsurikova, MSc, MA

AHRQ Asked Us

Evaluation

Evaluation _{DisseminationDissemination}

Demonstration

Demonstration

Implementation

8 clinical sites 5 EHR systems

Accomplishments

CDS Services

Children’’s Hospitals Hospital Colorado

Colorado Kaiser Roseville

UC Davis

Kaiser Sacramento Kaiser San Rafael Kaiser San Francisco California Wishard Hospital Wishard Hospital Indianapolis, IN Indianapolis, IN 1.7M CDS transactions 240 users

Accomplishments

Knowledge Management

375 immunization schedule rules

Accomplishments

Accomplishments

Dissemination

Dissemination

24 published papers

24 published papers

16 papers in progress

16 papers in progress

11 sets of recommendations

11 sets of recommendations

CDS Grand Challenges

Manage large clinical knowledge databases

Create an internet-accessible, clinical decision support repository

Create an architecture for sharing executable CDS modules Disseminate best practices

Prioritize CDS content development and implementation

Additional Challenges

• Lack or ambiguity of standards

• Terminology alignment

Additional Products

AMIA Annu Symp Proc. 2011

Turechek et al.,

What It Took

Clinical Outcomes

• CDS services perform well

• Sites aim to increase participation by

adding clinics or clinicians

• SOA-based approach to CDS is feasible

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

Wrapping up CDSC V1

Wrapping up CDSC V1

•

7/8/2013

•

Final report

•

•

Complete

Complete

existing and new

existing and new

demonstrations

demonstrations

•

•

Continue work

Continue work

on publications

Reflections

Reflections

•

Leadership

•

Pre-competitive R&D

CDSC Chapter 2 – What’s next

•

Clinical content

•

Standards

•

Integrations

•

Meaningful Use Stage 2

Future Members

1. Healthcare service providers

2. EHR and content vendors

3. Insurance companies

4. HIT community, guidelines developers,

specialty societies

CDSC Chapter 2 – How

• PHS CDS Lab

• Academic-Industrial Collaborative

• CDS Institute or CDS National Center for

Excellence

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

Thank you!

Lana Tsurikova, MSc, MA rtsurikova@partners.org

www.partners.org/cird/cdsc