1. The InterMed TM Collaboratory –the early years (1994-1996)  Biomedical informatics researchers & systems developers at 5 sites: Harvard/Brigham and Women’s Hospital Harvard/Massachusetts General Hospital Columbia Presbyterian Medical Center University of Utah School of Medicine Stanford University School of Medicine

2. The initial InterMed concept  Biomedical application development too slow  Silos, limited reuse  Internet could provide common resources (middleware) Domain-specific Seven-tiered model Built on infrastructure “service” layer

3. Infrastructure Classes & Services Vocabulary / Taxonomy Data Bases & Knowledge Bases Component Tools Composition Methods Applications Policies & Procedures InterMed’s Seven-Tiered Model

4. SNOMED MED (Columbia) LOINC IVORY (WARP) InterMed Vocabulary Model UMLS...... InterMed Vocabulary Server Populated with sample domain-specific content Map into local vocabularies for existing applications Local vocabs for new applications Implemented using convenient representation language Input/Output Specifications and Protocols Browsing & Maintenance Requirements Define meta-terminology Keep implementation-independent Provide generic solution TheNetSys Collaborative Model Development

5. Intended applications  Linking DXplain to a clinical information system  Internet-based clinical guidelines  Internet-based clinical research queries

6. Component development work  DXplain access (MGH) - tiers 3,4  Guideline tools (MGH, BWH versions) - tiers 3,4  Semantic net tool: TheNetSys - tier 2,4  Semantic model for CXR reports - tier 3  Form tool (a la HTML 3) using semantic model - tiers 3,4  Development of import/export (TheNetSys/Ontolingua)  Image tool (with pan, zoom, grayscale adjust) - tier 4  Tree walker for state maps & protocols - tier 4  WWW access modules - tier 4

7. Application construction tools (Tier 5)  Interface builder Use of visual embedding/ compound document architectures (Open Doc, OLE-2) Script-based communication among components  Work-flow-management-oriented framework An approach to integration based on clinical guidelines: the GEODE-CM project

8. Early findings ~ 1995  Activities weren’t converging  Progress in the different labs was not aligned Each was working on what interested it  Vision was too abstract Hard to identify measures of success  We decided to select a single application focus to drive the project Needed to be something all of the labs cared about

9. Common guideline representation as a second year focus  Multiple purposes of guidelines education (reference) training (how to do something) problem-solving responding to events (alerts) protocolized care/data capture care plans/critical paths -- UR and QA consultation workflow management (GEODE)

10. Multiple representation approaches  Flow charts  Narratives  Decision tables  Rule-base  MLM procedures  State model database

11. Collaborative Model Development InterMed Guidelines Model...... InterMed Guidelines Server Populated with sample domain-specific content Map into local representation for existing applications Local versions for new applications Implemented using convenient representation language Input/Output Specifications and Protocols Browsing & Maintenance Requirements AHCPR Guidelines T-Helper Protocols CPMC Clinical Pathways & Guidelines UTI and Other Guidelines at MGH Define meta-terminology Keep implementation-independent Provide generic solution BWH GEODE Clin. Mgt. Pathways

12. Goals to explore:  Whether a common representation could be devised that maintains all of the information needed to support all of the applications  How the guideline knowledge should interact with vocabulary knowledge  What components and tools would be needed

13. Work was then able to be partitioned  Requirements analysis  Model development  Tool building  Testing and refinement  Application exploration  Cognitive studies  SDO participation, conference planning, community development

14. Difficulties still occurred when:  Groups disagreed about emphasis or approach  No one signed up for a needed task  Need for continuing work on maintaining a shared vision

15. Collaboratory issues  Ideal C’y needs shared vision and buy-in strong business case intellectual and practical appeal  Tight project management funding dependent on performance  Can peer-based C’y be productive?  Can research-based C’y (vs. product- focused) be successful?