Regenstrief Institute’s New
Medical Gopher:
A Next-Generation Open-Source
Physician Order Entry System
Jon D. Duke, MD, MS...
Gopher
• Gopher grew from a single clinic to over
1000 workstations, inpatient, outpatient, ED
• 25+ years of iterations h...
1984 2010
• In 2009 Regenstrief Institute began rebuilding
its core clinical information system platform
• In 2010, we began work on...
Started with a Blank Slate
Improve User Satisfaction
Support Patient Safety
Improve Quality of Care
Promote Provider Efficiency
Guiding Principles
Set Gravity in the Right Direction
Leverage Metaphors
Constrain Then Innovate
Design Strategies
Leverage
Metaphors
Leveraging Metaphors
Leveraging Metaphors
Leveraging Metaphors
E-Commerce
Workflow Wizards
Smart Autocompletion
Constrain
Then Innovate
140 characters
hashtags
retweets
url shorteners
brevity
Instagram
Vine
Yammer
Waze
Screen Real Estate
• At outset of development process, set aside
an untouchable area of screen real estate
• That area– th...
Set Gravity in the
Right Direction
Right Thing
Wrong Thing
UserUser
Formulary Recognition
Allergy Entry
Fitt’s Law
What’s inside the new Gopher?
Major Functions
• Order entry
• Documentation / note writing
• Medication / problem / allergy management
• Results viewing...
Advancements in New Gopher
• Context-Driven Dynamic Alerts
• Adaptive Learning
• Real-time Natural Language Processing
• M...
Advancement #1: Dynamic Alerts
• Gopher has embedded mechanics to
dynamically change alert display based on
context
– Pati...
Alerting Zones
Relevance Adjustment Module
• Every alert has a baseline relevance level
which determines its display location
• For examp...
DDI
Alert Service
DDI
Alert Service
TRIAMTERENE Interacts with LISINOPRIL
Risk of Hyperkalemia
Severity: Moderate
Relevanc...
DDI
Alert Service
DDI
Alert Service
TRIAMTERENE Interacts with LISINOPRIL
Risk of Hyperkalemia
Severity: Moderate
Relevanc...
Relevance Adjustment Module
• RAM can also make changes based on
provider characteristics
• For example, can make particul...
TM Nintendo
Advancement #2:
Gopher is a Learning System
Advancement #2:
Gopher is a Learning System
• Gopher can track user actions and activity
such as
– Number of logins
– Freq...
Alerts That Learn
• Picture of learning message, then another of
the small alert
Diazepam
Diazepam 5 MG
Alerts That Learn
Diazepam
Diazepam 5 MG
Advancement #3:
Natural Language Processing
• Gopher can analyze notes in real-time
• Can determine section (e.g., FHx, PM...
Order Detection
Study Reminders
Natural Language Processing
• Can be used as a CDS trigger
• Can be used to enhance structured
documentation for ‘meaningf...
Advancement #4:
Multimedia Alerts
Adherence Information
Research Study Eligibility
Advancement #5:
Advanced Rule Authoring
• The Rule Authoring and Validation
Environment (RAVE) is a rule authoring tool
wi...
Rule Authoring
• Rules are necessary to drive decision support
logic as well as other system actions
• Rule authoring is g...
Good artists copy.
Great artists steal.
- Pablo Picasso
ifttt.com
Great Artists Steal
RAVE = IFTTT for EMRs
• Built a variety of channels for EMR activities
• Channels may server as
– Triggers (If)
– Actions ...
Rule Authoring and Validation Environment
• Picture HERE
Rule Authoring and Validation Environment
• Picture HERE
Rule Authoring and Validation Environment
• Picture HERE
RAVE Channels
If Channels
• Orders
• Diagnoses
• Allergies
• Note NLP
• Chart Actions
• Observations
• ADT
• HL7
Then Chan...
FOR: Patient Channel
• Picture HERE
IF: Diagnosis Channel
• Picture HERE
THEN: Alert Channel
• Picture HERE
RAVE Output
• Picture HERE
RAVE Output
• Picture HERE
RAVE DROOLS Syntax
• Picture HERE
Rule Authoring and Validation Environment
RAVE = Customizability
• Can mix and match channels to create a
remarkable array of functionality without
need for program...
Gopher Demo
Gopher and Open Source
• Regenstrief is philosophically and
contractually committed to release of the new
Gopher platform ...
Acknowledgements
• Chris Beesley
• Chris Bonham
• Mike Brehm
• Jason Cadwallader
• Joshua Castagno
• Vidhya Chari
• Parish...
Questions?
jduke@regenstrief.org
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
Regenstrief New Gopher - Med Info 2013
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Regenstrief New Gopher - Med Info 2013

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Updated report on features of the Regenstrief New Gopher System

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  • The Regenstrief Institute, a pioneer in physician order entry and clinical decision support systems, is currently in the midst of deploying a new platform built on open-source technologies. The centerpiece of this effort is G3, a CPOE designed to support advanced research in clinical decision support, usability, physician workflow, and patient safety. We will be demonstrating this new system, with a focus on its interface design, CDS architecture, natural language processing capabilities, and provider communications. We will also be discussing our user-centered design process, opportunities for collaboration, and future development plans.
  • Lila camera story
  • In G3,
  • Is there a current visual map of all the plugins and functionalities of G3?
  • 67,360 recpies!
  • Demo Server: https://172.30.204.24/CareWebDemo/careWeb.zul App Dev: https://app-devel.regenstrief.org/CareWebWishard/zkau/web/org/regenstrief/framework/ui/security/impl/loginWindow.zul
  • Regenstrief New Gopher - Med Info 2013

    1. 1. Regenstrief Institute’s New Medical Gopher: A Next-Generation Open-Source Physician Order Entry System Jon D. Duke, MD, MS Burke Mamlin, MD Doug Martin MD MedInfo 2013
    2. 2. Gopher • Gopher grew from a single clinic to over 1000 workstations, inpatient, outpatient, ED • 25+ years of iterations has resulted in robust functionality and efficiency • Served as the research platform for many of the seminal studies in healthcare computing
    3. 3. 1984 2010
    4. 4. • In 2009 Regenstrief Institute began rebuilding its core clinical information system platform • In 2010, we began work on a new web-based version of the venerable Gopher • This system was designed using the knowledge gained from the past 25 years of Gopher as well as from the evolving literature on CPOE system design Developing the new Gopher
    5. 5. Started with a Blank Slate
    6. 6. Improve User Satisfaction Support Patient Safety Improve Quality of Care Promote Provider Efficiency Guiding Principles
    7. 7. Set Gravity in the Right Direction Leverage Metaphors Constrain Then Innovate Design Strategies
    8. 8. Leverage Metaphors
    9. 9. Leveraging Metaphors
    10. 10. Leveraging Metaphors
    11. 11. Leveraging Metaphors
    12. 12. E-Commerce
    13. 13. Workflow Wizards
    14. 14. Smart Autocompletion
    15. 15. Constrain Then Innovate
    16. 16. 140 characters hashtags retweets url shorteners brevity Instagram Vine Yammer Waze
    17. 17. Screen Real Estate • At outset of development process, set aside an untouchable area of screen real estate • That area– the InfoPanel– was not utilized for >1 year into development but has become a critical asset
    18. 18. Set Gravity in the Right Direction
    19. 19. Right Thing Wrong Thing UserUser
    20. 20. Formulary Recognition
    21. 21. Allergy Entry
    22. 22. Fitt’s Law
    23. 23. What’s inside the new Gopher?
    24. 24. Major Functions • Order entry • Documentation / note writing • Medication / problem / allergy management • Results viewing • Research • Clinical decision support
    25. 25. Advancements in New Gopher • Context-Driven Dynamic Alerts • Adaptive Learning • Real-time Natural Language Processing • Multimedia Alerts • Advanced Rule Authoring
    26. 26. Advancement #1: Dynamic Alerts • Gopher has embedded mechanics to dynamically change alert display based on context – Patient – Physician – Institutional
    27. 27. Alerting Zones
    28. 28. Relevance Adjustment Module • Every alert has a baseline relevance level which determines its display location • For example, for DDI alerts, about 40% are interruptive and 60% non-interruptive • The RAM can adjust this default level
    29. 29. DDI Alert Service DDI Alert Service TRIAMTERENE Interacts with LISINOPRIL Risk of Hyperkalemia Severity: Moderate Relevance: 5 (Average) TRIAMTERENE Interacts with LISINOPRIL Risk of Hyperkalemia K 5.3*, Cr 1.3, GFR 55 Relevance: 7 (High) Lisinopril Order Related Concepts Related Concepts Hyperkalemia Has Relevant Labs: K, Cr, GFR Data Repository Data RepositoryK, Cr, GFR Relevance Adjustment ModuleRelevance Adjustment Module Original Alert Final Alert Patient has lab values: K 5.3*, Cr 1.3, GFR 55
    30. 30. DDI Alert Service DDI Alert Service TRIAMTERENE Interacts with LISINOPRIL Risk of Hyperkalemia Severity: Moderate Relevance: 5 (Average) TRIAMTERENE Interacts with LISINOPRIL Risk of Hyperkalemia K 3.3, Cr 0.8, GFR 114 Relevance: 3 (Low) Lisinopril Order Related Concepts Related Concepts Hyperkalemia Has Relevant Labs: K, Cr, GFR Data Repository Data RepositoryK, Cr, GFR Relevance Adjustment ModuleRelevance Adjustment Module Original Alert Final Alert Patient has lab values: K 3.3, Cr 0.8, GFR 55
    31. 31. Relevance Adjustment Module • RAM can also make changes based on provider characteristics • For example, can make particular alerts non- interruptive for certain specialties • Conversely, for medical students all alerts can be made interruptive
    32. 32. TM Nintendo Advancement #2: Gopher is a Learning System
    33. 33. Advancement #2: Gopher is a Learning System • Gopher can track user actions and activity such as – Number of logins – Frequently selected orders – Responses to previous alerts • Can customize system behavior based on individual user history
    34. 34. Alerts That Learn • Picture of learning message, then another of the small alert Diazepam Diazepam 5 MG
    35. 35. Alerts That Learn Diazepam Diazepam 5 MG
    36. 36. Advancement #3: Natural Language Processing • Gopher can analyze notes in real-time • Can determine section (e.g., FHx, PMH) to give context to the concepts retrieved • Multiple services may be run simultaneously (e.g.,CDS, quality metrics, study recruitment) • Results may be displayed as alert or used for background data capture Section header detection thanks to SecTag from Vanderbilt University: http://knowledgemap.mc.vanderbilt.edu/research/content/sectag-tagging-clinical-note-section-headers
    37. 37. Order Detection
    38. 38. Study Reminders
    39. 39. Natural Language Processing • Can be used as a CDS trigger • Can be used to enhance structured documentation for ‘meaningful use’ • Can be used for clinical research • Integrated with our Advanced Rule Authoring environments
    40. 40. Advancement #4: Multimedia Alerts
    41. 41. Adherence Information
    42. 42. Research Study Eligibility
    43. 43. Advancement #5: Advanced Rule Authoring • The Rule Authoring and Validation Environment (RAVE) is a rule authoring tool within Gopher • The RAVE is designed to empower stakeholders to create complex, rule-based actions using a simple graphical interface
    44. 44. Rule Authoring • Rules are necessary to drive decision support logic as well as other system actions • Rule authoring is generally a complex task requiring code-like syntax
    45. 45. Good artists copy. Great artists steal. - Pablo Picasso
    46. 46. ifttt.com
    47. 47. Great Artists Steal
    48. 48. RAVE = IFTTT for EMRs • Built a variety of channels for EMR activities • Channels may server as – Triggers (If) – Actions (Then) – Both • Additionally, we added a ‘For’ component to specify when the rule should be run
    49. 49. Rule Authoring and Validation Environment • Picture HERE
    50. 50. Rule Authoring and Validation Environment • Picture HERE
    51. 51. Rule Authoring and Validation Environment • Picture HERE
    52. 52. RAVE Channels If Channels • Orders • Diagnoses • Allergies • Note NLP • Chart Actions • Observations • ADT • HL7 Then Channels • Alerts • Email / SMS • Logging • Observations For Channels • Patient • User
    53. 53. FOR: Patient Channel • Picture HERE
    54. 54. IF: Diagnosis Channel • Picture HERE
    55. 55. THEN: Alert Channel • Picture HERE
    56. 56. RAVE Output • Picture HERE
    57. 57. RAVE Output • Picture HERE
    58. 58. RAVE DROOLS Syntax • Picture HERE
    59. 59. Rule Authoring and Validation Environment
    60. 60. RAVE = Customizability • Can mix and match channels to create a remarkable array of functionality without need for programmer intervention • Can write rules just for yourself or (with permission) your clinic, specialty, or all users • Rule syntax is generated automatically in a standard rules syntax (Drools)
    61. 61. Gopher Demo
    62. 62. Gopher and Open Source • Regenstrief is philosophically and contractually committed to release of the new Gopher platform as open source software • We are looking for partners to take part in both software development and community building around this effort • Please let us know if this is something you would be willing to commit time and energy to pursuing
    63. 63. Acknowledgements • Chris Beesley • Chris Bonham • Mike Brehm • Jason Cadwallader • Joshua Castagno • Vidhya Chari • Parishkar Chauhan • Ling Cheng • Sireesha Chilukuri • Cyril Colvard • Jonathan Cummins • Alex Franken • Cindi Hart • Charity Hilton • Joshua Jones • Warren Killian • Jeremy Leventhal • Allen Logan • Ernesto Maldonado • Burke Mamlin • Andrew Martin • Doug Martin • Jim Meeks-Johnson • Pat Milligan • Justin Morea • Chris Power • Linas Simonaitis • Kenneth Spry • Jeff Stroup • Blaine Takesue • David Taylor • Jeff Warvel • Jennifer Weatherspoon • Chen Wen
    64. 64. Questions? jduke@regenstrief.org

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