©2010, Kensaku Kawamoto SEBASTIAN, Related Initiatives, and Lessons Learned AMIA 2010 Fall Symposium November 17, 2010 Kensaku Kawamoto, MD, PhD Assistant Professor Duke Center for Health Informatics

©2010, Kensaku Kawamoto Presentation Overview  SEBASTIAN  Duke Chronic Disease Management System  Key Standards for Scalable CDS Services  OpenCDS  Discussion

©2010, Kensaku Kawamoto Presentation Overview  SEBASTIAN  Duke Chronic Disease Management System  Key Standards for Scalable CDS Services  OpenCDS  Discussion

©2010, Kensaku Kawamoto SEBASTIAN CDS Web Service – Overview  System for Evidence-Based Advice through Simultaneous Transaction with an Intelligent Agent across a Network  Designed and developed by presenter to efficiently meet needs of multiple CDS efforts  Core SEBASTIAN features: Uses a patient information model based on HL7 Reference Information Model Terminology support provided using NLM’s UMLS Encapsulates medical knowledge in XML documents known as Executable Knowledge Modules (EKMs) Uses the EKMs to act as a CDS service Ref: Kawamoto K et al. Proc / AMIA Annual Symp,  System for Evidence-Based Advice through Simultaneous Transaction with an Intelligent Agent across a Network  Designed and developed by presenter to efficiently meet needs of multiple CDS efforts  Core SEBASTIAN features: Uses a patient information model based on HL7 Reference Information Model Terminology support provided using NLM’s UMLS Encapsulates medical knowledge in XML documents known as Executable Knowledge Modules (EKMs) Uses the EKMs to act as a CDS service Ref: Kawamoto K et al. Proc / AMIA Annual Symp, 2005.

©2010, Kensaku Kawamoto SEBASTIAN – Architectural Overview SEBASTIAN CDS Service Knowledge Modules Institution A Client Decision Support Apps Patient Data Sources Queries for required pt data Queries for required pt data Institution B Client Decision Support Apps Patient Data Sources Queries for required pt data Queries for required pt data Conclusions about patient Patient data, knowledge modules to use Patient data, knowledge modules to use Trigger

©2010, Kensaku Kawamoto EKM Authoring – Metadata Entry

©2010, Kensaku Kawamoto EKM Authoring – Input Data Specification

©2010, Kensaku Kawamoto EKM Authoring – Output Specification

©2010, Kensaku Kawamoto EKM Authoring – Logic Section (InfoPath)

©2010, Kensaku Kawamoto EKM Authoring – Logic Section (Java IDE)

©2010, Kensaku Kawamoto EKM Testing – Single Test Case Evaluation

©2010, Kensaku Kawamoto EKM Testing – Batch Evaluation

©2010, Kensaku Kawamoto SEBASTIAN Status  In operational use across multiple institutions Duke point-of-care disease management system Duke enterprise care quality reporting system NC Medicaid care manager alerting system NC Medicaid patient reminder letter system NC Medicaid medication management system NC Medicaid provider portal Hospital Italiano breast cancer management system Dana-Farber Cancer Institute cancer symptom management system

©2010, Kensaku Kawamoto Duke Dz. Mgmt. System – Architecture SEBASTIAN CDS Service Knowledge Modules Institution A Duke Clinical Information Viewer Patient Data Sources Queries for required pt data Queries for required pt data Dz. mgmt. conclusions about patient Patient data, dz.mgmt. modules to use Patient data, dz.mgmt. modules to use Dz. mgmt. invocation

©2010, Kensaku Kawamoto Example Disease Management Reminders Source: Duke University Health System. Lobach DF, Kawamoto K, et al. Medinfo. 2007;861-5.

©2010, Kensaku Kawamoto Usage

©2010, Kensaku Kawamoto Example Care Quality Reporting Source: Duke University Health System.

©2010, Kensaku Kawamoto Presentation Overview  SEBASTIAN  Duke Chronic Disease Management System  Key Standards for Scalable CDS Services  OpenCDS  Discussion

©2010, Kensaku Kawamoto HL7/OMG Decision Support Service standard  Specifies standard service interface for CDS services  Part of larger HL7-OMG Healthcare Services Specification Project (Kawamoto, JAMIA, 2009)  Effort led by presenter since 2005; based largely on SEBASTIAN service interface  Adopted as HL7 draft standard in 2006  Adopted as OMG draft standard in 2009; normative status expected December 2010  Available from

©2010, Kensaku Kawamoto HL7 Virtual Medical Record Standard  Problem addressed For scalable CDS and knowledge sharing, need standard information models for CDS inputs (e.g., patient data) and CDS outputs (e.g., recommended orders)  Provides: Standard “payloads” for CDS services Standard computational model for knowledge authoring  Status Initial ballot May 2010; active ongoing work  Wiki org/index.php?title=Virtual_Medical_ Record_(vMR)  Problem addressed For scalable CDS and knowledge sharing, need standard information models for CDS inputs (e.g., patient data) and CDS outputs (e.g., recommended orders)  Provides: Standard “payloads” for CDS services Standard computational model for knowledge authoring  Status Initial ballot May 2010; active ongoing work  Wiki org/index.php?title=Virtual_Medical_ Record_(vMR)

©2010, Kensaku Kawamoto Presentation Overview  SEBASTIAN  Duke Chronic Disease Management System  Key Standards for Scalable CDS Services  OpenCDS  Discussion

©2010, Kensaku Kawamoto OpenCDS  Goal Facilitate widespread availability of advanced CDS capabilities through open-source, collaborative development of standards-based DSS infrastructure, tooling, and high-value services  Methods Contribute through Open Health Tools Leverage open-source JBoss Drools rules engine Use modular architecture, enable iterative refinement, support multiple knowledge represent. approaches Develop all components required to author, test, and operationally support standards-compliant DSSs  Goal Facilitate widespread availability of advanced CDS capabilities through open-source, collaborative development of standards-based DSS infrastructure, tooling, and high-value services  Methods Contribute through Open Health Tools Leverage open-source JBoss Drools rules engine Use modular architecture, enable iterative refinement, support multiple knowledge represent. approaches Develop all components required to author, test, and operationally support standards-compliant DSSs

©2010, Kensaku Kawamoto Key Components  Standard interfaces and data models Reference implementation of HL7/OMG DSS interface vMR data model Data mappers (e.g., for CCD  vMR)  Reference DSS knowledge management framework JBoss Drools and associated authoring/knowledge management tools Full-featured terminology support A “domain specific language” for intuitive knowledge authoring  DSS “wrappers” for other CDS engines  Standard interfaces and data models Reference implementation of HL7/OMG DSS interface vMR data model Data mappers (e.g., for CCD  vMR)  Reference DSS knowledge management framework JBoss Drools and associated authoring/knowledge management tools Full-featured terminology support A “domain specific language” for intuitive knowledge authoring  DSS “wrappers” for other CDS engines

©2010, Kensaku Kawamoto OpenCDS – Sample Topologies DSS Client OpenCDS DSS Interface OpenCDSA dapter X OpenCDS Drools Adapter OpenCDS Drools Adapter OpenCDS Drools Engine CDS Engine/Service X (e.g., SEBASTIAN) CDS Engine/Service X (e.g., SEBASTIAN) OpenCDS Drools Knowledge Authoring Platform

©2010, Kensaku Kawamoto Current OpenCDS Collaborators  Duke Center for Health Informatics Ken Kawamoto (PI), David Shields, Guilherme Del Fiol  Veterans Health Administration  Intermountain Healthcare  University of North Carolina at Chapel Hill  Massachusetts General Hospital  EBSCO  Apelon, Inc.  Clinica Software, Inc.  IsoDynamic, Inc.  Keona Health  Visumpoint, LLC  Duke Center for Health Informatics Ken Kawamoto (PI), David Shields, Guilherme Del Fiol  Veterans Health Administration  Intermountain Healthcare  University of North Carolina at Chapel Hill  Massachusetts General Hospital  EBSCO  Apelon, Inc.  Clinica Software, Inc.  IsoDynamic, Inc.  Keona Health  Visumpoint, LLC

©2010, Kensaku Kawamoto OpenCDS – Terminology Mgmt. with Apelon

©2010, Kensaku Kawamoto OpenCDS – Terminology Mgmt. with Apelon

©2010, Kensaku Kawamoto OpenCDS – Demo

©2010, Kensaku Kawamoto Presentation Overview  SEBASTIAN  Duke Chronic Disease Management System  Key Standards for Scalable CDS Services  OpenCDS  Discussion

©2010, Kensaku Kawamoto Key Benefits and Challenges  Detailed analysis available from: Kawamoto et al. System-agnostic CDS services: benefits and challenges. Open Medical Informatics Journal, 2010 [in press].  Key benefits: Facilitates centralized knowledge management and knowledge sharing Enables agile CDS system development through loose coupling with other software components and services Facilitates implementation of CDS across applications and care settings

©2010, Kensaku Kawamoto Key Challenges and Potential Solutions ChallengePotential solutions Increased effort required to develop and support knowledge resources for use in multiple contexts  Balance generalizability with resource realities  Spread knowledge development cost over multiple deployment settings  Bottom line assessment: benefits >> challenges Need for service interface to be standardized  Facilitate widespread use of HL7/OMG DSS standard and emerging HL7 vMR standard (e.g., via OpenCDS)

©2010, Kensaku Kawamoto Acknowledgements  Research support  SEBASTIAN: NLM F37-LM (PI: K. Kawamoto)  OpenCDS: NHGRI K01 HG (PI: K. Kawamoto)  OpenCDS collaborators  Guilherme Del Fiol  Sandi Geary  Peter Haug  Kevin Hughes  Keith Larsen  Kevin Meldrum  Research support  SEBASTIAN: NLM F37-LM (PI: K. Kawamoto)  OpenCDS: NHGRI K01 HG (PI: K. Kawamoto)  OpenCDS collaborators  Guilherme Del Fiol  Sandi Geary  Peter Haug  Kevin Hughes  Keith Larsen  Kevin Meldrum  Javed Mostafa  Jonathan Nebeker  Oakkar Oakkar  Kraig Robson  David Shields  Jason Skowronski  Javed Mostafa  Jonathan Nebeker  Oakkar Oakkar  Kraig Robson  David Shields  Jason Skowronski

©2010, Kensaku Kawamoto