Collaborative Authoring of Decision
Support Knowledge: A Demonstration
Tonya Hongsermeier, MD, MBA
Corporate Manager, Clinical Informatics R&D, Partners HealthCare System
Vipul Kashyap, PhD
Senior Medical Informatician, Clinical Informatics R&D, Partners HealthCare System
Robert Masson
EMC/Documentum
With assistance from:
Judith Colecchi, RN, MS
Corporate Team Lead I
Cathyann Harris
Project Manager
Paul Rapoza
Application Developer
Muffie Martin, RN, MSN
Senior Project Specialist
Eileen Yoshida, MS Pharm, MBA
Pharmacy Knowledge Engineering Team Lead 2
Blackford Middleton, MD, MPH, MSc
Director
Clinical Informatics Research and Development
Outline
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Knowledge Management: Strategic Goals
Steps for a Knowledge Management Solution
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KM Portal
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Implement Collaboration and Content
Management Tools from Documentum
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Integrate New and Legacy Content Editors with
Document Content Management Services
Case Example: Maintenance of a Geriatric
Dosing Database
Conclusions
Knowledge Management: Strategic Goals
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Reduce the cost and increase the speed of knowledge
acquisition and maintenance for decision support
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Speed translation of clinical innovation and evidence into
clinical practice
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Proactive, anticipatory decision support architecture to set
foundation for personalized medicine – avoid “interruptive”
decision support
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Improve Partners’ organizational effectiveness as a learning
organization through organizational alignment and data-driven
performance improvement
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Align knowledge assets with business, regulatory, safety and
quality requirements
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Only build what we cannot buy
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Partners has created some of the best decision support in
production in the world, the goal here is to keep the knowledge
up to date
Content Examples maintained at Partners
Healthcare System
• Medication Data Dictionary with default doses, weight-based doses,
dose strings, and drug-drug interaction checking (multiple applications and
populations via Common Medication Services)
• Gerios and Nephros for proactive dosing for elderly and/or renal
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insufficient
Drug-lab monitoring, duplicate drug checking, drug-group checking,
drug-disease checking, drug-pregnancy checking
Primary and secondary preventive health reminders
Results Manager
Inpatient and outpatient order sets
Inpatient interactive rules (application specific, hard-coded)
Concept dictionary and problem list
Patient monographs
Radiology ordering decision support
Outpatient documentation templates
Content Life-Cycle Challenges:
Committee, Department,
Researcher, or Other
Proposes to Implement Content
Guideline is Defined and Validated
Functional Knowledge Specification
For Encoding is
Designed and Validated
Specification is
Engineered into Production Generating
a Technical Specification
Ongoing Revisions or
Eventual Sunset
Of Encoded Guideline
•Prioritization mechanism not always clear
•Stewardship processes not always clear
•Lack of coordination
•Unclear mechanism for subject matter expert participation…
Who says so? Friend of Researcher?
•No budgetary model to reimburse experts…
•No tools to support efficient collaboration – 3000 row tables
•Little or no audit trail of decisions made
•Project competition with other engineering projects,
prioritization processes unclear
•Knowledge editors typically do not enable content auditing,
knowledge editors siloized, no support of inheritance or
propagation
•Little or no documentation about content in production
•MS Office doesn’t help maintain data about content
•Little analytic data available on decision support content or
impact on clinical outcomes impact to direct updating
•Tendency to rely on query of transaction systems
•No content management tools to support process and ensure timeliness
Clinical Content Committee:
Prioritizes and Sponsors Operational Stewardship of Content
Safety
SME
Groups
Quality
Disease Management
Primary Care
Disease Areas
Adult, Geriatrics,
Pediatrics,
Women’s Health
CAD/CHF, Diabetes,
Heme-Onc, Asthma,
ID/HIV, Nephrology,
Psych
Trend Management
Pharmacotherapy
Medication
Knowledge
Committee
Knowledge Analysts facilitate
Knowledge Editors update
Production Knowledge Repositories
PCHI
P&T
Imaging Studies
MGH
ROE
BWH
Precipio
How we are evolving our
knowledge management infrastructure:
Knowledge Management Generation 1 (2004):
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Build and deploy a document library to provide enterprise wide
access to specifications of decision support knowledge
Inventory all structured knowledge in production at Partners
Create and develop a knowledge repository
Knowledge Management Generation 2 (2005):
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Implement tools to support collaborative content consensus,
iterative drafting of guidelines and conversion to functional
knowledge specifications
Knowledge repository expanded to support browsing of preproduction and “in-production” knowledge
Implement tools to support content management processes using
lifecycles and workflows (knowledge maintenance)
Knowledge Management Generation 3 (2006):
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Integrate legacy and new content authoring tools with content
management infrastructure (knowledge editing)
Knowledge Management
Generation 1 Functionality
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A Partners-wide repository of documentation on clinical decision support
knowledge
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Knowledge organized based on:
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Search and lookup by:
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Well defined metadata and filters
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E.g., entity, content type, clinical descipline, application
Well defined taxonomic categories
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E.g., disease management, patient safety, signature initiative
areas
Free text, key word based search
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E.g., Get me all order sets that contain the word “cardiovascular”
Metadata and filter based search
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E.g., Get me all order sets that were created at BWH for
cardiology in the BICS system
Taxonomy based browsing
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E.g., I want to explore and iteratively all knowledge associated
with Patient Safety
Content upload tool (internally developed) enabled
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Mapping of clinical knowledge to filters and taxonomic concepts
Creation and management of taxonomies and metadata filters
DEMO of
Knowledge Management Portal
KM Portal: Taxonomy based Navigation
KM Portal: Filter-based Search
Documentum Content Management System (CMS):
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Provides order to unstructured and structured information by managing
processes for:
creation
processing
delivery
archival of any content according to user-defined business rules.
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Establishes relationships between pieces of content, allowing the same content to
be used in different contexts and renditions and supporting propagation of key content
relationships and dependency management.
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Natively supports XML content creation and authoring
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Adds intelligence, creating categorization schema and metadata that make search
and retrieval faster and more efficient.
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Automates the processing of content through its life cycle.
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Facilitates publication of content through multiple channels
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Promotes integration between departments and systems that previously worked
within silos.
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Enables access control security so that permissions for who can view, edit and
manage content are controlled at the user and role level
Knowledge Management
Generation 2 Functionality
Tools for content management
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Creation and management of different types of clinical content
metadata and (with configuration and/or customization) the content for
transaction systems
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E.g., Order Sets, Clinical Rules, Documentation Templates
Definition and Enforcement of Content Lifecycles
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Support for Content Dependency and Propagation
Definition and Enforcement of Content Workflows
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Support for different roles, e.g., Knowledge Engineer,
Administrator, etc.
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Support for Content Auditing processes
Metadata and Taxonomy Management
Tools for collaboration
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Enable vetting and refinement of clinical knowledge
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Support for different roles, e.g., Subject Matter Expert, Coordinator,
etc.
Expertise Location Functionality
Search and Retrieval of Content
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Keyword and filter-based search
Taxonomy-based browsing
KM Generation 2: Architecture
Internet
Explorer
Internet
Explorer
Content
Switch
Documentum Infrastructure
IIS 6.0
IIS 6.0
Collaboration
Server
Content
Server
Content
Intelligence
Server
IIS 6.0
Published
ASP Scripts
Content
(Production)
ASP Scripts
Verity
Search Server
KM Portal
Content Repository
Content Management
Collaboration
Shared RDBS
Metadata
Transformation
and Publication
Problem of Lost Knowledge and Lack of Collaboration Support:
Setting aside the challenge of “who decides on content”, this screenshot
shows a common way for clinical guideline spec management:
MS office folders, documents related by title and common location only,
Difficult to know what changed from one version to next or why,
people move on to new jobs and folders get lost…..
Solution: Structured tools for content collaboration lifecycle management
Gerios: Case Example Collaborative
Content Development using E-Room
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New Business Incentive for Geriatric Prescribing at
Partners
Gerios in production in BICS for several years, already
planned for move into LMR
Content reviewed for current categories, however, not
complete coverage of relevant drugs for elderly, many gaps
With added drugs, became a 160+ Row Decision Table
Geriatric expert panel chartered to work with our
Medication Services Knowledge Engineering team to
update the Geriatric Content and create a new version
called Gerios- Version 2 with a plan to standardize for all
CPOE utilizing common services
Partners maintains a geriatric dosing database that supports either default dosing
more appropriate for geriatric population or substitution recommendations
E-ROOM DEMONSTRATION:
Geriatric Subject Matter Expert Review
of Enterprise Geriatric Dosing Module
Votes
Other poll approaches
E-room report illustrating aggregation of expert input,
dramatically improves efficiency for subject matter experts
and medication services design teams
Vioxx alert shared, removed from
database
Knowledge Engineer updates the content in the Gerios editor……
A new cut of Gerios is posted to the portal….
Now, we move the Content Management interface to upload the new cut of Gerios to the Portal
And apply appropriate metadata filters and taxonomy tags…
Example LifeCycle of Functional
Knowledge Spec.
Edited State
Review State
Start
Publish State
Archive State
Roadmap: Proposed Sequence of Rearchitecting
Editors with Documentum:
A Knowledge Event Management Architecture
Transaction
Systems and
Services
Medication Services
Editors
New Order Entry
Editors
New Documentation
Editors
2007
Medication Svs
Repositories
Propagation
& Inheritance
Documentum
Order Entry
Repositories
Documentation
Repositories
Legacy Editors
Ilog Rule Editor
Legacy
Repositories
Ilog Rule
Repositories
2006
Complex Definition Editors
2007
Knowledge
Management
eRoom and Portal
Portal
Repositories (metaknowledge
Complex Definitions Repository
Health Language Inc Terminology Editors
about the knowledge)
2006
Terminology Repository
Conclusions
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Now that two groups have used it on Documentum’s hosted site,
we have a lot of pent up demand, rollout begins in December on
hosted environment
These are volunteer Subject Matter Experts, incentives are being
developed to reward contribution, however, current participants
describe it as fun and intellectually rewarding
The rollout of the rooms must be carefully designed, every room
needs a dedicated administrator who tees up the content for
review, shepards the content through the lifecycle
Leadership well recognizes that we can’t achieve enterprise-wide
clinical standards in our clinical decision support content without
such tools