Collaborative Knowledge Management Tools

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					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
•    Knowledge Management: Strategic Goals
•    Steps for a Knowledge Management Solution
       KM Portal
       Implement Collaboration and Content
        Management Tools from Documentum
       Integrate New and Legacy Content Editors with
        Document Content Management Services
•    Case Example: Maintenance of a Geriatric
     Dosing Database
•    Conclusions
Knowledge Management: Strategic Goals
  •   Reduce the cost and increase the speed of knowledge
      acquisition and maintenance for decision support

  •   Speed translation of clinical innovation and evidence into
      clinical practice

  •   Proactive, anticipatory decision support architecture to set
      foundation for personalized medicine – avoid ―interruptive‖
      decision support

  •   Improve Partners’ organizational effectiveness as a learning
      organization through organizational alignment and data-driven
      performance improvement

  •   Align knowledge assets with business, regulatory, safety and
      quality requirements

  •   Only build what we cannot buy

  •   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
    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,            •Prioritization mechanism not always clear
         Researcher, or Other             •Stewardship processes not always clear
     Proposes to Implement Content        •Lack of coordination


                                          •Unclear mechanism for subject matter expert participation…
    Guideline is Defined and Validated                                 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

   Functional Knowledge Specification
            For Encoding is                •Project competition with other engineering projects,
         Designed and Validated            prioritization processes unclear
                                           •Knowledge editors typically do not enable content auditing,
                                           knowledge editors siloized, no support of inheritance or
                                           propagation
             Specification is
                                           •Little or no documentation about content in production
  Engineered into Production Generating
                                           •MS Office doesn’t help maintain data about content
        a Technical Specification

                                            •Little analytic data available on decision support content or
          Ongoing Revisions or              impact on clinical outcomes impact to direct updating
             Eventual Sunset                •Tendency to rely on query of transaction systems
          Of Encoded Guideline              •No content management tools to support process and ensure timeliness
                                 Clinical Content Committee:
                         Prioritizes and Sponsors Operational Stewardship of Content


   Safety             Quality             Disease Management                     Trend Management




            Primary Care              Disease Areas          Pharmacotherapy           Imaging Studies
                                    CAD/CHF, Diabetes,
SME         Adult, Geriatrics,                              Medication
                                    Heme-Onc, Asthma,                     PCHI          MGH      BWH
Groups        Pediatrics,                                   Knowledge
                                    ID/HIV, Nephrology,                   P&T           ROE     Precipio
            Women’s Health                                  Committee
                                           Psych




                                     Knowledge Analysts facilitate



                                        Knowledge Editors update


                                  Production Knowledge Repositories
How we are evolving our
knowledge management infrastructure:

 Knowledge Management Generation 1 (2004):
     •    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):
     •    Implement tools to support collaborative content consensus,
          iterative drafting of guidelines and conversion to functional
          knowledge specifications
     •    Knowledge repository expanded to support browsing of pre-
          production and ―in-production‖ knowledge
     •    Implement tools to support content management processes using
          lifecycles and workflows (knowledge maintenance)
 Knowledge Management Generation 3 (2006):
     •    Integrate legacy and new content authoring tools with content
          management infrastructure (knowledge editing)
Knowledge Management
Generation 1 Functionality

•    A Partners-wide repository of documentation on clinical decision support
     knowledge

•    Knowledge organized based on:
    —     Well defined metadata and filters
         •    E.g., entity, content type, clinical descipline, application
    —     Well defined taxonomic categories
         •    E.g., disease management, patient safety, signature initiative
              areas

•    Search and lookup by:
    —     Free text, key word based search
         •    E.g., Get me all order sets that contain the word ―cardiovascular‖
    —     Metadata and filter based search
         •    E.g., Get me all order sets that were created at BWH for
              cardiology in the BICS system
    —     Taxonomy based browsing
         •    E.g., I want to explore and iteratively all knowledge associated
              with Patient Safety

•    Content upload tool (internally developed) enabled
    —     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):

•    Provides order to unstructured and structured information by managing
     processes for:
         creation
         processing
         delivery
         archival of any content according to user-defined business rules.

•    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.

•    Natively supports XML content creation and authoring

•    Adds intelligence, creating categorization schema and metadata that make search
     and retrieval faster and more efficient.
•
     Automates the processing of content through its life cycle.

•    Facilitates publication of content through multiple channels

•    Promotes integration between departments and systems that previously worked
     within silos.

•    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
       •     Creation and management of different types of clinical content
             metadata and (with configuration and/or customization) the content for
             transaction systems
            •    E.g., Order Sets, Clinical Rules, Documentation Templates
       •     Definition and Enforcement of Content Lifecycles
            •    Support for Content Dependency and Propagation
       •     Definition and Enforcement of Content Workflows
            •    Support for different roles, e.g., Knowledge Engineer,
                 Administrator, etc.
            •    Support for Content Auditing processes
       •     Metadata and Taxonomy Management

  Tools for collaboration
       •     Enable vetting and refinement of clinical knowledge
            •   Support for different roles, e.g., Subject Matter Expert, Coordinator,
                etc.
       •     Expertise Location Functionality

  Search and Retrieval of Content
       •     Keyword and filter-based search
       •     Taxonomy-based browsing
KM Generation 2: Architecture



                                                                                             Internet
                 Internet                                                                    Explorer
                 Explorer
                                                                                             Content
                                                                                             Switch
        Documentum Infrastructure


                                                                     IIS 6.0                    IIS 6.0
       IIS 6.0                      Content        Published
                                    Server         Content      ASP Scripts                  ASP Scripts
   Collaboration                     Content       (Production)
      Server                       Intelligence
                                      Server

                                                                                       Verity
                                                                                   Search Server


                                                      KM Portal
                        Content Repository                                 Metadata
                                                  Content Management
                                                                           Transformation
                                                     Collaboration         and Publication
                                                    Shared RDBS
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
 •   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
                                               Medication Services          New Order Entry         New Documentation
             Services
                                                     Editors                    Editors                  Editors
                                                                                                                        2007
                                                  Medication Svs              Order Entry               Documentation
                                                   Repositories               Repositories               Repositories



                               Propagation                 Legacy Editors                    Ilog Rule Editor
                               & Inheritance                                                                            2006
                                                               Legacy                           Ilog Rule
                                                             Repositories                      Repositories




                   Documentum                                        Complex Definition Editors
                                                                                                                        2007
Knowledge                                                          Complex Definitions Repository
Management     eRoom and Portal
Portal     Repositories (metaknowledge                      Health Language Inc Terminology Editors
                about the knowledge)                                                                                    2006
                                                                      Terminology Repository
Conclusions

•   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

				
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