Knowledge Management Challenges

in the Healthcare Delivery Market

Tonya Hongsermeier, MD, MBA

Corporate Manager, Clinical Decision Support and Knowledge Management,
Clinical Informatics Research & Development
Partners HeatlhCare System, Inc.

Agenda

About Partners Healthcare

Knowledge Management and Informatics
Knowledge

Application
Knowledge Discovery
Knowledge Asset Management

Challenges in Healthcare Delivery

Weak

Organizational Alignment
Weak Investment in Asset Management
Implications for Clinical R&D
Implications for Personalized Medicine

Partners HealthCare

Massachusetts General Hospital, Brigham and

Womens Hospital and several other hospitals in the
network
Licensed Beds 3196
Births
18,478
Admissions
134,991
Patient Days 871,321
Average LOS 5.31
Total Outpatient Visits
2,324,073

Partners Information Systems

Much published on innovative use of informatics in

healthcare (Bates, Teich, Glaser, Kuperman, Barnett,
Chueh, and many others)
800 applications
520 active projects
680 employees based in 19 locations
FY02 operating budget of $92.3M
FY02 capital budget of $47M
These are relatively generous numbers as a percentage
of operating expenses

Some Current Clinical Knowledge

Assets Developed at Partners

Medication Data Dictionary and DDIs

Inpatient alerts and interactive order rules
Gerios and Nephros for proactive filtering of drug doses
for elderly and/or renal insufficient
Radiology Ordering decision support
Preventive health reminders
Outpatient lab result decision support
Outpatient documentation templates
Piloting outpatient drug-lab, drug-disease interactive
reminders

Current State Challenges Typical of Many

Academic Healthcare Delivery Organizations

7 homegrown and 2 commercial CPOE systems, plan

to evolve to next generation CPOE in next 5 years
Limited implementation of structured (encoded) clinical
documentation
Proprietary approaches to knowledge encoding
Not re-usable or sharable
Much updating/maintenance is bottlenecked by
resource constraints
Research datawarehouse in place, but struggle to
expand in face of fragmented clinical systems
environment

Typical Committee and Project Structures

Related to Medication Safety Illustrate
Organizational Alignment Problem
Information Technology Projects

Physician Order Entry

Team
Clinical Data
Repository Team
Pharmacy System
Team
Clinical Documentation
Team
Electronic Medication
Adminstration Team

Committees and Departments

Pharmacy and
Therapeutics
Patient Safety
Quality or Performance
Improvement
Policies and
Procedures
Formulary
Infection Control

Medication Use Process Organization

Medication Safety Steering Committee
Chief Medical Officer, Chief Nursing Officer, Chief Information Officer, Chief Quality Officer

Interdisciplinary Medication Use Process Advisory Team

Physicians, Nurses, Pharmacists, Clinical Systems Architects

Information Technology Projects

Physician Order Entry

Team
Clinical Data Repository
Team
Pharmacy System Team
Clinical Documentation
Team
Electronic Medication
Administration Team

Committees and Departments

Pharmacy and
Therapeutics
Patient Safety
Quality or Performance
Improvement
Policies and Procedures
Formulary
Infection Control

Knowledge Management: The Core Processes

Knowledge
Application

Knowledge
Asset Management

Knowledge
Discovery

A Continuum of Clinical Decision Support

and Knowledge Discovery*
Surveillance Interactive
Reference
Reference
Knowledge
Knowledge
Linking
Linking

Event
Event
Monitoring
Monitoring

Monitoring
patient
data with
passive
decision
support

Proactive

Safety
SafetyNet
Net Anticipation
Anticipation

Intercepting Making the

right
incorrect
decisions
clinical
the easiest
decisions
decisions

*modified from the First Consulting Group Model of Clinical Decision Support

Learning
Understanding
Understanding
and
andPredicting
Predicting
Performance
Performance

Predictive
Modeling
Casebased
Reasoning
Learning
Knowledge
Repository

Medication Decision Support Categories at Partners

REFERENCE INFORMATION

Drug-information knowledge linking via info

button adjacent to drug name

Partners handbook provides access to

numerous drug information databases

Planned drug-information knowledge linking

via info button in electronic medication
administration record in FY 04
SURVEILLANCE AND MONITORING

Drug-induced abnormal lab result notification

of physician

Drug-induced abnormal lab result notification

of pharmacist

Renal function decline in patient on renally

excreted drug notification of physician and
pharmacist
INTERACTIVE DECISION SUPPORT FOR
PHYSICIAN AND PHARMACIST:

Drug-allergy checking

Drug-drug interaction checking

Drug-food interaction checking

Drug-herb interaction checking

Drug-disease interaction checking

INTERACTIVE DECISION SUPPORT FOR PHYSICIAN

ORDER ENTRY ONLY:

Drug-lab interaction checking

Consequent order recommendations

Relevant lab display

Indication-required orders

Height, weight, allergy update required

notification

Dose calculation tools

Intravenous to oral conversion recommendation

on renewal of intravenous order when patient
receiving other oral medications

Formulary substitution alerts

Antibiotic restriction alerts

PROACTIVE DECISION SUPPORT

Gerios for elderly patient medication dosing

Nephros for dosing in renal insufficiency

Preventive health reminders

Problem-linked order sets

Laboratory Notification with consequent

order recommendations

Alternate Procedures, Redirects, DrugAllergy, Drug-Drug, Drug-Lab etc.

Gerios: Dose-filters for age

Nephros: Dose-filters for renal function

Inappropriately sedated elderly inpatients on average incur $5600 excess

costs over expected for severity of illness

Preventive Reminders

Problem-level anticipatory
decision support

Today, order sets and documentation templates are static

which means that clinician must change them to personalize
them to patient
We plan to use inferencing to dynamically generate problemdriven order sets and documentation templates that account for
multiple co-morbidities
Must be able to incorporate future onslaught of gene diagnostic
and prognostic data

Knowledge Application must anticipate

these dimensions of the clinical encounter
Clinical Standardization
Standards of Practice,
Role/Venue Requirements
Billing/Regulatory Requirements

Improvisation
Patient Preferences

User Personalization
End-user workflow preferences
Learning and User-defined

Poly-hierarchical inferencing with

actionable advice surveillance,

This is an example from clinical decision support company called Theradoc

A Continuum of Clinical Decision Support

and Knowledge Discovery
Surveillance Interactive
Reference
Reference
Knowledge
Knowledge
Linking
Linking

Event
Event
Monitoring
Monitoring

Monitoring
patient
data with
passive
decision
support

Proactive

Safety
SafetyNet
Net Anticipation
Anticipation

Intercepting Making the

right
incorrect
decisions
clinical
the easiest
decisions
decisions

*modified from the First Consulting Group Model of Clinical Decision Support

Learning
Understanding
Understanding
and
andPredicting
Predicting
Performance
Performance

Predictive
Modeling
Casebased
Reasoning
Learning
Knowledge
Repository

Current Initiatives

Quality data warehouse with Clinician

Dashboards
Early identification of patients at risk for case
management
Longer term knowledge discovery goals to use
performance data to enhance knowledge
repository
Need to evolve towards non-human dependent
modes of knowledge acquisition

Knowledge Asset Management Infrastructure:

Analysis of clinical performance data to understand where

knowledge deficits are to support performance goals
Authoring and support of virtual, asynchronous collaborative
authoring by knowledge editors and leaders of research, safety
and quality improvement initiatives (reference knowledge
specs for encoding
Knowledge acquisition from commercial/etc knowledge bases
Validation and audit trail maintenance (meta-knowledge)
Inventory (knowledge librarian)
Publishing and Sharing
Reference information and knowledge model

What are the challenges today:

Healthcare delivery organizations purchase

systems but dont invest in knowledge asset
management, they install plumbing
Vendors sell knowledge editors, not knowledge
management support infrastructure
There is no repository of best clinical IT
practices at a national level, few among the
vendors
No knowledge encoding and representation
standards to facilitate knowledge sharing

Partners-Wide Knowledge Management Model

KNOWLEDGE ASSET MANAGEMENT
Signature Initiatives and
Sub-Committees set
Enterprise-wide Strategy,
Clinical Standards and
Performance Measures

Decision Support Design Teams

direct the design of crossfunctional knowledge to be
encoded

Performance Feedback to Leaders,

SMEs, Committees, and End-users

Subject Matter Expert (SME) Panels

Advise on Entity, Venue, Role, Specialty,
Primary Care, Disease Management, and
Safety related requirements for
application function and knowledge bases

Partners Genetics
Computing Platform
Applications for Virtual Collaborative
Knowledge Authoring and Maintenance
Knowledge
Repository
Knowledge
Building Blocks
Common Services
Knowledge Editors

Information
Model

Clinical Workflow
Applications and
Services
DECISION SUPPORT
(APPLIED KNOWLEDGE)

Data Warehouse
PERFORMANCE
and OUTCOMES
(KNOWLEDGE
DISCOVERY)

Knowledge Asset Management:

Translating Goals into a Knowledge Repository Taxonomy
Goal Framework: Safety, Quality, Efficiency, Research

Data/Knowledge
Seeking

Assessment

Dx/Rx
Decision Making

Billing
Reporting
Transfer/
Tasks/Proc/Mar,Messaging,Handoff
CDS,

Order Fulfillment,
Communication and
Applications
Coordination

Care
(Results, Observations, Orders,
Measurement)
CORE CARE PROCESS
AUTOMATION TAXONOMY
and Knowledge Bases
Medical Management, Research, and Reporting
Care Applications
(Results, Observations, Orders, Tasks/Proc/Mar,Messaging, CDS,
Clinical Knowledge forMeasurement)
Personalized Medicine Taxonomy
and Knowledge Bases
Role and Venue Domain Taxonomy

Requirements
Care Applications
and Knowledge Bases

Reference Information Model

MEDICATION USE PROCESS: Acetaminophen in a 2.5 Kg Premature Infant

Sample High-level Example Taxonomy for Knowledge Assets

Center for Clinical Knowledge Engineering

Welcome to the National Knowledge Engineering Repository
Go

Content search HEDIS

Advanced Search Filters (press Ctrl to select more than one):

Clinical Discipline: Surgical

Cardiothoracic Surgery
Interventional Cardiology
Orthopedics
Etc.
Clinical Discipline: Non-Surgical

Cardiovascular
Endocrinology
Gastroenterology
Etc.
Clinical Discipline: Safety

Nosocomial Infection Control

Medication Safety
Decubitus Ulcer Prevention
Etc.
Clinical Discipline: Disease Management

Diabetes Mellitus
Congestive Heart Failure
Multiple Sclerosis
Etc.

Informatics Mode

Interactive Rules
Surveillance and Notifications
Documentation Templates
Etc.
Age

Adult
Pediatrics
Neonate
Etc.
Role

Nurse
Physician
Case Manager
Etc.
Venue

CCU
Ambulatory Care
Emergency Department
Etc.

Search File Hierarchy

Knowledge Asset Management Toolkit
Link to references, survey instruments, diagrams,
descriptions, process flow diagrams, etc on
Partners and VA approaches to asset management

Submit Content to Editor

About Us

Knowledge Specifications
For Encoded Knowledge
Vs
Meta-knowledge about
The knowledge

Future State KM Model

Collaborative
Knowledge
Authoring
Tools

Portal

Meta-Knowledge
Repository

Workflow Applications

Knowledge-based Services
Knowledge Repositories

Information Model

Barriers to Success at the Intersection

of Clinical Informatics and KM

Leadership inadequately committed

Products inadequate to support
processes
Business case intangible
Fear of exposure (technology increases
transparency)
Few roadmaps to success are proven in
the healthcare arena

Market Drivers will Propel Progress

Aging population: computer literate and population

growth will outstrip service capacity, informatics must
support self-management
Business community will aid transition from commodity
to value based purchasing by employers and
consumers, they know that the current inflation rate of
the commodity is untenable
Leapfrog and Government are beginning to purchase
quality
Genomics: personalized medicine will require
technologies for personalization, these same
technologies will enable more user-friendly safety
solutions

Where are we?