The Morningside Initiative A Public-Private Partnership for Collaborative Development of a Knowledge Repository for Clinical Decision Support (CDS)

Problems that have limited the dissemination & adoption of CDS  Reluctance of organizations to share knowledge content for “implementable” CDS  Content not formalized, or is encoded in proprietary formats  Knowledge management mechanisms not available

RE: proprietary concerns, it can be argued that:  Core medical knowledge shouldn’t be proprietary  The expected “tsunami” of new knowledge will require sharing  Optimization by enterprises should be at level of their business practices/workflow processes

Decision Rule Example Enterprise alerting rule IF Med1 = Captopril AND Med2 = Dyazide AND serum K+ > 5.0 THEN page MD Core Medical knowledge Classes of drugs (ACE inhibitor, thiazide/triamterene) Hyperkalemia as a definition Alerting condition Adaptable for different modes of interaction and use in CPOE, pharmacy order management, lab alert, ADE monitoring, … various alerting approaches, workflows, triggering rules, notification processes, …

History of efforts to share CDS knowledge  AHCPR, other consensus panels  Yet difficulty operationalizing, not sufficiently patient-specific  EPCs, Cochrane Collaboration  Knowledge but not executable  Guidelines.gov  Not highly curated, most not executable  Arden Syntax  HL7/ANSII standard, widely used, but highly proprietary implementations  Requires host-specific customization of all rules  CPMC site lists ~240 rules, but not updated since 1997  GELLO  New HL7/ ANSII standard expression language, but implementations just emerging, no content libraries  IMKI  Effort to form consortium of vendors, professional societies, and academic medical centers ~ 2001  Failed due to lack of willingness to contribute content

Can we prime the process of sharing?  This is the challenge the Morningside Initiative seeks to address  Formed in August 2007

The Morningside Initiative A joint project of:  American Medical Informatics Association  Arizona State University  DoD Tri-Care Management Activity, Military Health System  Henry Ford Health System  Intermountain Health  Kaiser Permanente  Partners Healthcare  Veterans Healthcare Administration

Goal to stimulate sharing by  Starting with a small group of committed organizations  Public-private partnership  Focusing on “executable” knowledge for CDS  Already implemented, evaluated, effective  Concentrating on organizational, technical, and content issues that have impeded sharing in the past  Demonstrating effectiveness  In terms of content and knowledge resources and secondary adoption  Aim of scaling up to broader national (perhaps international) ongoing process

CDS focus  Emphasis on high-impact CDS needs  Develop high quality knowledge resources  Adopt formal representations  Develop tools for managing the knowledge  Develop tools and services for adapting knowledge to local settings

Enterprise Knowledge Base Alerts Order sets Guidelines Reminders Shared Knowledge Base Enterprise Knowledge Base … Collaborative Knowledge Management External Knowledge Sources External Knowledge Sources

Multiple rules have similar intent Differences relate to how triggered, how delivered, process/workflow integration Challenge is to identify core medical knowledge and to develop a taxonomy to capture types of implementation differences

Morningside Initiative Structure  Steering Committee  Representatives of each organization  Processes and procedures for collaboration, pursuit of funding, growth of initiative, approach to long-term sustainability  Content Committee  Use-case driven focus on kinds of application needs, sources of knowledge, editing and approval process, application of knowledge  Technical Committee  Tools and resources to share, manage, represent, update knowledge

Functional requirements  Driving use cases: Interoperable delivery of CDS at point of care through SOA interface  DoD AHLTA and NHIN interoperability node as first case  Goal of establishing a Knowledge Management Repository (KMR) and Guideline Workbench  To deliver CDS into AHLTA environment via SOA  Show interoperability on the NHIN DoD Federal Adapter

Functional requirements overall model RequirementDiscussion The shareable knowledge repository will be a multi-component model The decision support capabilities are divided into separate components for analysis and design. Repository featuresContains essential CDS components: Medical logic Metadata Workflow descriptors Documentation Conformance testing data Management ToolsIncludes tools for managing/maintaining knowledge resources: Knowledge authoring tools Metadata editors Focused and batch testing tools Sharability FeaturesContains features that support exchange of medical knowledge among dissimilar systems: Knowledge Interchange Format (KIF) Converters to and from KIF Conformance data exchange tools Execution EnvironmentWhile not an official part of Morningside, a basic runtime environment will ultimately be needed to support knowledge testing within the knowledge repository.

1. Knowledge Repository – the content  Maintain stages of analysis, provenance of content  Target of standard representation with annotations enabling localization and adaptation to particular settings

2. Tools - the technology  Knowledge acquisition  Markup  Management  Localization

3. Methods, ontologies, and schemas for sharability  Meta data tags, standards, templates, and vocabularies for representation and markup  Taxonomy of process/workflow/implementation contexts

Delivery – the execution environment  Not the focus of Morningside but provide the driving use cases  Will also need a test environment for validating execution performance  SOA as a particular example  requiring precise specification of information model, terminology, and method for inserting into process/workflow

Progress to date and plans  Initial organization  Founding members  Work out collaboration and governance issues  To expand to include other developers and adopters  To be housed under AMIA umbrella initially  Initial funding from TATRC, now with funds from a Congressional redirection  Content development  Initial focus on diabetes  Collect, organize, synthesize from different sources  Identify representation, browsing, editing, query, and application needs  To expand to other areas  Technical approach  Based on open tools and data formats, non-proprietary  Currently building first prototypes  Adoption of standards where possible, intent to contribute to standards efforts

Timeline  Anticipated 5-year effort  Year 1: inventory, planning, prototyping, organizing, gathering, working out details  Year 2: initial implementation and experience  Year 3-4: refinement and testing, planning for scale up  Year 5: expansion and transition to self- sustaining model

Why This Approach Is Unique  Establishes a public-private partnership to collaboratively develop and disseminate CDS knowledge broadly  Leverages time, expertise and cost investments across entities  Provides a multi-organizational framework for decision making about content inclusion

Acknowledgments  Organizational support from American Medical Informatics Association (AMIA)  Organizational and funding support from Telemedicine & Advanced Technology Research Center (TATRC)  Funding support from Geneva Foundation: Congressionally Directed Medical Research Program