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Knowledge Management Challenges in the Healthcare Delivery Market Tonya Hongsermeier, MD, MBA Corporate Manager, Clinical Decision Support and Knowledge.

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Presentation on theme: "Knowledge Management Challenges in the Healthcare Delivery Market Tonya Hongsermeier, MD, MBA Corporate Manager, Clinical Decision Support and Knowledge."— Presentation transcript:

1 Knowledge Management Challenges in the Healthcare Delivery Market Tonya Hongsermeier, MD, MBA Corporate Manager, Clinical Decision Support and Knowledge Management, Clinical Informatics Research & Development Partners HeatlhCare System, Inc.

2 Agenda About Partners Healthcare Knowledge Management and Informatics Knowledge Application Knowledge Discovery Knowledge Asset Management Challenges in Healthcare Delivery Weak Organizational Alignment Weak Investment in Asset Management Implications for Clinical R&D Implications for Personalized Medicine

3 Partners HealthCare Massachusetts General Hospital, Brigham and Womens Hospital and several other hospitals in the network Licensed Beds3196 Births18,478 Admissions134,991 Patient Days871,321 Average LOS5.31 Total Outpatient Visits2,324,073

4 Partners Information Systems Much published on innovative use of informatics in healthcare (Bates, Teich, Glaser, Kuperman, Barnett, Chueh, and many others) 800 applications 520 active projects 680 employees based in 19 locations FY02 operating budget of $92.3M FY02 capital budget of $47M These are relatively generous numbers as a percentage of operating expenses

5 Some Current Clinical Knowledge Assets Developed at Partners Medication Data Dictionary and DDIs Inpatient alerts and interactive order rules Gerios and Nephros for proactive filtering of drug doses for elderly and/or renal insufficient Radiology Ordering decision support Preventive health reminders Outpatient lab result decision support Outpatient documentation templates Piloting outpatient drug-lab, drug-disease interactive reminders

6 Current State Challenges Typical of Many Academic Healthcare Delivery Organizations 7 homegrown and 2 commercial CPOE systems, plan to evolve to next generation CPOE in next 5 years Limited implementation of structured (encoded) clinical documentation Proprietary approaches to knowledge encoding Not re-usable or sharable Much updating/maintenance is bottlenecked by resource constraints Research datawarehouse in place, but struggle to expand in face of fragmented clinical systems environment

7 Typical Committee and Project Structures Related to Medication Safety Illustrate Organizational Alignment Problem Physician Order Entry Team Clinical Data Repository Team Pharmacy System Team Clinical Documentation Team Electronic Medication Adminstration Team Information Technology Projects Pharmacy and Therapeutics Patient Safety Quality or Performance Improvement Policies and Procedures Formulary Infection Control Committees and Departments

8 Medication Use Process Organization Physician Order Entry Team Clinical Data Repository Team Pharmacy System Team Clinical Documentation Team Electronic Medication Administration Team Information Technology Projects Pharmacy and Therapeutics Patient Safety Quality or Performance Improvement Policies and Procedures Formulary Infection Control Committees and Departments Interdisciplinary Medication Use Process Advisory Team Physicians, Nurses, Pharmacists, Clinical Systems Architects Medication Safety Steering Committee Chief Medical Officer, Chief Nursing Officer, Chief Information Officer, Chief Quality Officer

9 Knowledge Application Knowledge Discovery Knowledge Asset Management Knowledge Management: The Core Processes

10 A Continuum of Clinical Decision Support and Knowledge Discovery* Monitoring patient data with passive decision support Intercepting incorrect clinical decisions Making the right decisions the easiest decisions Predictive Modeling Case- based Reasoning Learning Knowledge Repository Reference Knowledge Linking Reference Knowledge Linking Event Monitori ng Safety Net Anticipati on Understan ding and Predicting Performan ce Understan ding and Predicting Performan ce Surveillance Interactive Proactive Learning *modified from the First Consulting Group Model of Clinical Decision Support

11 Medication Decision Support Categories at Partners REFERENCE INFORMATION Drug-information knowledge linking via info button adjacent to drug name Partners handbook provides access to numerous drug information databases Planned drug-information knowledge linking via info button in electronic medication administration record in FY 04 SURVEILLANCE AND MONITORING Drug-induced abnormal lab result notification of physician Drug-induced abnormal lab result notification of pharmacist Renal function decline in patient on renally excreted drug notification of physician and pharmacist INTERACTIVE DECISION SUPPORT FOR PHYSICIAN AND PHARMACIST: Drug-allergy checking Drug-drug interaction checking Drug-food interaction checking Drug-herb interaction checking Drug-disease interaction checking INTERACTIVE DECISION SUPPORT FOR PHYSICIAN ORDER ENTRY ONLY: Drug-lab interaction checking Consequent order recommendations Relevant lab display Indication-required orders Height, weight, allergy update required notification Dose calculation tools Intravenous to oral conversion recommendation on renewal of intravenous order when patient receiving other oral medications Formulary substitution alerts Antibiotic restriction alerts PROACTIVE DECISION SUPPORT Gerios for elderly patient medication dosing Nephros for dosing in renal insufficiency Preventive health reminders Problem-linked order sets

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13 Laboratory Notification with consequent order recommendations

14 Alternate Procedures, Redirects, Drug- Allergy, Drug-Drug, Drug-Lab etc.

15 Gerios: Dose-filters for age Nephros: Dose-filters for renal function Inappropriately sedated elderly inpatients on average incur $5600 excess costs over expected for severity of illness

16 Preventive Reminders

17 Problem-level anticipatory decision support Today, order sets and documentation templates are static which means that clinician must change them to personalize them to patient We plan to use inferencing to dynamically generate problem-driven order sets and documentation templates that account for multiple co-morbidities Must be able to incorporate future onslaught of gene diagnostic and prognostic data

18 Knowledge Application must anticipate these dimensions of the clinical encounter Improvisation Patient Preferences User Personalization End-user workflow preferences Learning and User-defined Clinical Standardization Standards of Practice, Role/Venue Requirements Billing/Regulatory Requirements

19 Poly-hierarchical inferencing with actionable advice – surveillance, interactive, or proactive mode

20 This is an example from clinical decision support company called Theradoc

21 A Continuum of Clinical Decision Support and Knowledge Discovery Monitoring patient data with passive decision support Intercepting incorrect clinical decisions Making the right decisions the easiest decisions Predictive Modeling Case- based Reasoning Learning Knowledge Repository Reference Knowledge Linking Reference Knowledge Linking Event Monitori ng Safety Net Anticipati on Understan ding and Predicting Performan ce Understan ding and Predicting Performan ce Surveillance Interactive Proactive Learning *modified from the First Consulting Group Model of Clinical Decision Support

22 Current Initiatives Quality data warehouse with Clinician Dashboards Early identification of patients at risk for case management Longer term knowledge discovery goals to use performance data to enhance knowledge repository Need to evolve towards non-human dependent modes of knowledge acquisition

23 Knowledge Asset Management Infrastructure: Analysis of clinical performance data to understand where knowledge deficits are to support performance goals Authoring and support of virtual, asynchronous collaborative authoring by knowledge editors and leaders of research, safety and quality improvement initiatives (reference knowledge specs for encoding Knowledge acquisition from commercial/etc knowledge bases Validation and audit trail maintenance (meta- knowledge) Inventory (knowledge librarian) Publishing and Sharing Reference information and knowledge model

24 What are the challenges today: Healthcare delivery organizations purchase systems but dont invest in knowledge asset management, they install plumbing Vendors sell knowledge editors, not knowledge management support infrastructure There is no repository of best clinical IT practices at a national level, few among the vendors No knowledge encoding and representation standards to facilitate knowledge sharing

25 Partners-Wide Knowledge Management Model Knowledge Repository Data Warehouse KNOWLEDGE ASSET MANAGEMENT DECISION SUPPORT (APPLIED KNOWLEDGE) PERFORMANCE and OUTCOMES (KNOWLEDGE DISCOVERY) Applications for Virtual Collaborative Knowledge Authoring and Maintenance Decision Support Design Teams direct the design of cross- functional knowledge to be encoded Clinical Workflow Applications and Services Signature Initiatives and Sub-Committees set Enterprise-wide Strategy, Clinical Standards and Performance Measures Knowledge Building Blocks Information Model Common Services Knowledge Editors Subject Matter Expert (SME) Panels Advise on Entity, Venue, Role, Specialty, Primary Care, Disease Management, and Safety related requirements for application function and knowledge bases Partners Genetics Computing Platform Performance Feedback to Leaders, SMEs, Committees, and End-users

26 Care Applications (Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS, Measurement) and Knowledge Bases Care Applications (Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS, Measurement) and Knowledge Bases Dx/Rx Decision Making Order Fulfillment, Communication and Coordination Reference Information Model Knowledge Asset Management: Translating Goals into a Knowledge Repository Taxonomy Goal Framework: Safety, Quality, Efficiency, Research Data/Knowledge Seeking Requirements Assessment Billing Reporting Medical Management, Research, and Reporting Care Applications and Knowledge Bases CORE CARE PROCESS AUTOMATION TAXONOMY Transfer/ Handoff Clinical Knowledge for Personalized Medicine Taxonomy Role and Venue Domain Taxonomy

27 MEDICATION USE PROCESS: Acetaminophen in a 2.5 Kg Premature Infant

28 Sample High-level Example Taxonomy for Knowledge Assets

29 Center for Clinical Knowledge Engineering HEDIS Content search Welcome to the National Knowledge Engineering Repository Go Advanced Search Filters (press Ctrl to select more than one): Cardiothoracic Surgery Interventional Cardiology Orthopedics Etc. Clinical Discipline: Surgical Cardiovascular Endocrinology Gastroenterology Etc. Clinical Discipline: Non-Surgical Nosocomial Infection Control Medication Safety Decubitus Ulcer Prevention Etc. Clinical Discipline: Safety Congestive Heart Failure Multiple Sclerosis Etc. Clinical Discipline: Disease Management Diabetes Mellitus Interactive Rules Surveillance and Notifications Documentation Templates Etc. Informatics Mode Adult Pediatrics Neonate Etc. Age Nurse Physician Case Manager Etc. Role Ambulatory Care Emergency Department Etc. Venue CCU Search File Hierarchy Knowledge Asset Management Toolkit Link to references, survey instruments, diagrams, descriptions, process flow diagrams, etc on Partners and VA approaches to asset management Submit Content to Editor About Us

30 Knowledge Specifications For Encoded Knowledge Vs Meta-knowledge about The knowledge

31 Future State KM Model Workflow Applications Knowledge Repositories Information Model Meta-Knowledge Repository Collaborative Knowledge Authoring Tools Portal Knowledge-based Services

32 Barriers to Success at the Intersection of Clinical Informatics and KM Leadership inadequately committed Products inadequate to support processes Business case intangible Fear of exposure (technology increases transparency) Few roadmaps to success are proven in the healthcare arena

33 Market Drivers will Propel Progress Aging population: computer literate and population growth will outstrip service capacity, informatics must support self-management Business community will aid transition from commodity to value based purchasing by employers and consumers, they know that the current inflation rate of the commodity is untenable Leapfrog and Government are beginning to purchase quality Genomics: personalized medicine will require technologies for personalization, these same technologies will enable more user-friendly safety solutions

34 Where are we?


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