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[Hongsermeier] clinical decision support services amdis final
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[Hongsermeier] clinical decision support services amdis final

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  • 1. Clinical Decision Support Services Tonya Hongsermeier, MD, MBA CMIO
  • 2. Agenda • About Clinical Decision Support Services • Experience of the Clinical Decision Support Consortium • Standards Efforts Underway to Make Them Widely Available • Opportunities and Challenges
  • 3. About Clinical Decision Support Services (CDSS) Outside the Cloud Inside the Cloud CDSS Firewall Data Normalization and Classification Services Cloud-based Clinical Decision Support Services CDSS EHR Consumer PATIENT DATA ASSESSMENTS and RECOMMENDATIONS 1) Externalizes application of CDS Logic that can provide assessments and guidance 2) Externalizes curation of clinical knowledge to a CDSS provider or their respective content supplier 3) EHR vendor is responsible for making it possible to send data in the appropriate workflow context and receive assessments and recommendations from CDSS 4) EHR vendor is responsible for making it possible to insert CDSS guidance into the appropriate EHR workflow context 5) Implementing consumer still needs to determine insertion, support ongoing semantic harmonization
  • 4. Clinical Decision Support Consortium (CDSC) 1. Knowledge Management Life Cycle 2. Knowledge Specification 3. Knowledge Portal and Repository 4. CDS Public Services and Dashboard 5. Evaluation Process for each CDS Assessment and Research Area 6. Dissemination Process for each Assessment and Research Area • Knowledge management lifecycle • Knowledge specification • Knowledge Portal and Repository • CDS Knowledge Content and Public Web Services • Evaluation • Dissemination Led by Dr. Blackford Middleton AHRQ funded from 2008-2013
  • 5. CDSC Conceptual Approach CDSC Evidence-based Guidelines (e.g., DM, HTN, CAD) Level 1 Translation Dissemination Level 2 and Level 3 Specifications CDS Services Provider Dashboard Developer Dashboard KM Portal and Repository EMR End user access Refinement Performance Measures Collaboration Collaboration NextGen Centricity Regenstrief Partners LMR
  • 6. Reminders Partners HealthCare EHR Regenstrief Medical Record System® Two Examples of CDSC Implementation of CDS services ©CDS Consortium
  • 7. Legal Agreements Developed to Address Liability Points of Failure • CDS manufacturing defect – Software does not perform as designed – i.e. alerts fail to notify due to gap in software or service  Device – CDS supplier must be able to audit/trace all guidance provided • CDS implementation defect – Customer implementation of software results in defective functioning – i.e. alerts fail to fire because customer has incorrectly implemented services insertion or failed to notify CDS supplier that their dictionary changed • CDS user error – Software performs as designed, customer has implemented correctly, however user does not utilize correctly – i.e. user ignores alert, turns off alerts, fails to notice alert – Blurred distinctions here because users typically blame CDS manufacturer or implementation team for creating unusable CDS. – Legal precedent to date still renders the Provider accountable for determining if the CDS guidance is appropriate because the Provider has the richer context of the patient to interpret the relevance of the guidance
  • 8. CDSC Services Rule Building Blocks Problem Classes Drug Classes Classes of Observations And Test Results Indication State Inferences Goal State Inferences Contraindication State Inferences Infobutton Knowledge Access Diagnostic Testing Care Management Observation Dictionaries LOINC or SNOMED Order Classes Drug Dictionaries RX Norm Order Catalogues Patient Assessment Problem Dictionaries SNOMED Risk State Inferences Recommendations Guideline Context Family History Patient Preference Phenotypic State Genotypic State Classes Of Raw Data Inferred Patient Context (Clinical State Rules) Patient Education
  • 9. Qualifying for ACEI ARB Drug Class ACEi Drug Class Contra Indication To ACEi/ARB Allergy to ACEi/ARB Clinical State Rule Pregnant Clinical State Rule Pregnant Prob Class Subset Preg. Complications Prob Class Subset Low BP Clinical State Rule Low BP Prob Class Subset Hyperkalemia Disease State Rule Hyperkalemia Prob Class Subset NOTNOT NOT Non-Gest DM Disease State Rule DM Disease State Rule DM Prob Class Subset DM Complications Prob Class Subset Gest DM Disease State Rule Gest DM Prob Class Subset NOT Simple Rules are NOT Simple: IF in non-gestational DM pt with non-ESRD qualifying for ACEi Key: ___ AND . . . OR Non-ESRD CRF Disease State Rule CRF Prob Class Subset Creat >2 w/in 12 mo Calc Rule GFR<50 Calc Rule Proteinuria Disease State Rule Malb/cre>30 Calc Rule Proteinuria Prob Class Subset ESRD Disease State Rule ESRD Prob Class Subset Dialysis Comp Prob Class Subset &NOTO R
  • 10. CDSC, ACDS, HL7 and Other Standards ONC S&I Health eDecisions Use Case 1 – Data Model for CDS Artifact Authoring – Knowledge Representation for CDS Artifacts – Artifacts can be value sets (groupers), rules, order sets, documentation templates, etc – Enable interoperable knowledge sharing CDS Artifact Sharing Use Case FR & Data Elements VMR GEM eRECS CDSC L3 HL7 Order Set Model SHARP ARDEN Inputs Use Case 1: CDS Artifact Sharing HeD Artifact Sharing Standard Harmonization and Modeling for 3 Artifact Types CREF
  • 11. CDSC, Open CDS, HL7 ONC S&I Health eDecisions Use Case 2 • Use Case 2: CDS Guidance Services – CDS Services Insertion – Patient Data Output by EHR/PHR system to CDS Guidance Service CDS Guidance Services Use Case FR & Data Elements HL7 Consolidated CDA Other Standards HL7 DSS Services Inputs HeD CDS Guidance Services Standards Harmonization and Modeling HL7 Context Aware Information Retrieval
  • 12. Opportunities and Challenges • EHR vendors can’t expect their customers to curate all this knowledge inside their EHR walls  Immunizations, Genetics, Genomics, Personalized Medicine • Few EHR CDS systems can actually execute the kind of inferencing required for personalized medicine • Hence, Memorial Sloan Kettering is training IBM Watson  Personalized Cancer Rx service • We need to advocate for EHR vendors to move beyond “walled gardens of simple CDS”