1. Tonya Hongsermeier, MD, MBA Corporate Manager, Clinical Informatics R&D, Partners HealthCare System Vipul Kashyap, PhD Senior Medical Informatician, Clinical Informatics R&D, Partners HealthCare System Robert Masson EMC/Documentum With assistance from: Judith Colecchi, RN, MS Corporate Team Lead I Cathyann Harris Project Manager Paul Rapoza Application Developer Muffie Martin, RN, MSN Senior Project Specialist Eileen Yoshida, MS Pharm, MBA Pharmacy Knowledge Engineering Team Lead 2 Blackford Middleton, MD, MPH, MSc Director Clinical Informatics Research and Development Collaborative Authoring of Decision Support Knowledge: A Demonstration

2. Outline Knowledge Management: Strategic Goals Steps for a Knowledge Management Solution  KM Portal  Implement Collaboration and Content Management Tools from Documentum  Integrate New and Legacy Content Editors with Document Content Management Services Case Example: Maintenance of a Geriatric Dosing Database Conclusions

3. Knowledge Management: Strategic Goals Reduce the cost and increase the speed of knowledge acquisition and maintenance for decision support Speed translation of clinical innovation and evidence into clinical practice Proactive, anticipatory decision support architecture to set foundation for personalized medicine – avoid “interruptive” decision support Improve Partners’ organizational effectiveness as a learning organization through organizational alignment and data-driven performance improvement Align knowledge assets with business, regulatory, safety and quality requirements Only build what we cannot buy Partners has created some of the best decision support in production in the world, the goal here is to keep the knowledge up to date

4. Content Examples maintained at Partners Healthcare System Medication Data Dictionary with default doses, weight-based doses, dose strings, and drug-drug interaction checking (multiple applications and populations via Common Medication Services) Gerios and Nephros for proactive dosing for elderly and/or renal insufficient Drug-lab monitoring, duplicate drug checking, drug-group checking, drug-disease checking, drug-pregnancy checking Primary and secondary preventive health reminders Results Manager Inpatient and outpatient order sets Inpatient interactive rules (application specific, hard-coded) Concept dictionary and problem list Patient monographs Radiology ordering decision support Outpatient documentation templates

5. Content Life-Cycle Challenges: Committee, Department, Researcher, or Other Proposes to Implement Content Guideline is Defined and Validated Functional Knowledge Specification For Encoding is Designed and Validated Ongoing Revisions or Eventual Sunset Of Encoded Guideline Prioritization mechanism not always clear Stewardship processes not always clear Lack of coordination Unclear mechanism for subject matter expert participation… Who says so? Friend of Researcher? No budgetary model to reimburse experts… No tools to support efficient collaboration – 3000 row tables Little or no audit trail of decisions made Project competition with other engineering projects, prioritization processes unclear Knowledge editors typically do not enable content auditing, knowledge editors siloized, no support of inheritance or propagation Little or no documentation about content in production MS Office doesn’t help maintain data about content Little analytic data available on decision support content or impact on clinical outcomes impact to direct updating Tendency to rely on query of transaction systems No content management tools to support process and ensure timeliness Specification is Engineered into Production Generating a Technical Specification

6. Clinical Content Committee: Prioritizes and Sponsors Operational Stewardship of Content Safety CAD/CHF, Diabetes, Heme-Onc, Asthma, ID/HIV, Nephrology, Psych Disease Areas Adult, Geriatrics, Pediatrics, Women’s Health Primary Care PCHI P&T Pharmacotherapy QualityDisease ManagementTrend Management SME Groups Medication Knowledge Committee BWH Precipio Imaging Studies MGH ROE Production Knowledge Repositories Knowledge Analysts facilitate Knowledge Editors update

7. How we are evolving our knowledge management infrastructure: Knowledge Management Generation 1 (2004): Build and deploy a document library to provide enterprise wide access to specifications of decision support knowledge Inventory all structured knowledge in production at Partners Create and develop a knowledge repository Knowledge Management Generation 2 (2005): Implement tools to support collaborative content consensus, iterative drafting of guidelines and conversion to functional knowledge specifications Knowledge repository expanded to support browsing of pre- production and “in-production” knowledge Implement tools to support content management processes using lifecycles and workflows (knowledge maintenance) Knowledge Management Generation 3 (2006): Integrate legacy and new content authoring tools with content management infrastructure (knowledge editing)

8. Knowledge Management Generation 1 Functionality A Partners-wide repository of documentation on clinical decision support knowledge Knowledge organized based on: — Well defined metadata and filters E.g., entity, content type, clinical descipline, application — Well defined taxonomic categories E.g., disease management, patient safety, signature initiative areas Search and lookup by: — Free text, key word based search E.g., Get me all order sets that contain the word “cardiovascular” — Metadata and filter based search E.g., Get me all order sets that were created at BWH for cardiology in the BICS system — Taxonomy based browsing E.g., I want to explore and iteratively all knowledge associated with Patient Safety Content upload tool (internally developed) enabled — Mapping of clinical knowledge to filters and taxonomic concepts — Creation and management of taxonomies and metadata filters

9. DEMO of Knowledge Management Portal

10. KM Portal: Taxonomy based Navigation

11. KM Portal: Filter-based Search

12. Documentum Content Management System (CMS): Provides order to unstructured and structured information by managing processes for: creation processing delivery archival of any content according to user-defined business rules. Establishes relationships between pieces of content, allowing the same content to be used in different contexts and renditions and supporting propagation of key content relationships and dependency management. Natively supports XML content creation and authoring Adds intelligence, creating categorization schema and metadata that make search and retrieval faster and more efficient. Automates the processing of content through its life cycle. Facilitates publication of content through multiple channels Promotes integration between departments and systems that previously worked within silos. Enables access control security so that permissions for who can view, edit and manage content are controlled at the user and role level

13. Knowledge Management Generation 2 Functionality Tools for content management Creation and management of different types of clinical content metadata and (with configuration and/or customization) the content for transaction systems E.g., Order Sets, Clinical Rules, Documentation Templates Definition and Enforcement of Content Lifecycles Support for Content Dependency and Propagation Definition and Enforcement of Content Workflows Support for different roles, e.g., Knowledge Engineer, Administrator, etc. Support for Content Auditing processes Metadata and Taxonomy Management Tools for collaboration Enable vetting and refinement of clinical knowledge Support for different roles, e.g., Subject Matter Expert, Coordinator, etc. Expertise Location Functionality Search and Retrieval of Content Keyword and filter-based search Taxonomy-based browsing

14. KM Generation 1: Architecture Internet Explorer Content Switch IIS Web Server 1 IIS Web Server 2 KM Portal/ Win 2003 Shared SQL Server Database keyword based search filter based search taxonomy based browsing stored procedures SQL queries Verity Web Server IIS Web Server 3 KM Portal/ Win 2003 Upload Control synchronized copy KM Portal Internet Explorer Goes Away

15. KM Generation 2: Architecture Internet Explorer IIS 6.0 Collaboration Server Content Repository Internet Explorer Content Switch IIS 6.0 ASP Scripts Verity Search Server Published Content (Production) KM Portal Collaboration Content Management Content Server Content Intelligence Server Shared RDBS Metadata Transformation and Publication Documentum Infrastructure

16. Problem of Lost Knowledge and Lack of Collaboration Support: Setting aside the challenge of “who decides on content”, this screenshot shows a common way for clinical guideline spec management: MS office folders, documents related by title and common location only, Difficult to know what changed from one version to next or why, people move on to new jobs and folders get lost….. Solution: Structured tools for content collaboration lifecycle management

17. Gerios: Case Example Collaborative Content Development using E-Room New Business Incentive for Geriatric Prescribing at Partners Gerios in production in BICS for several years, already planned for move into LMR Content reviewed for current categories, however, not complete coverage of relevant drugs for elderly, many gaps With added drugs, became a 160+ Row Decision Table Geriatric expert panel chartered to work with our Medication Services Knowledge Engineering team to update the Geriatric Content and create a new version called Gerios- Version 2 with a plan to standardize for all CPOE utilizing common services

18. Partners maintains a geriatric dosing database that supports either default dosing more appropriate for geriatric population or substitution recommendations

19. E-ROOM DEMONSTRATION: Geriatric Subject Matter Expert Review of Enterprise Geriatric Dosing Module

23. Votes

26. Other poll approaches

28. E-room report illustrating aggregation of expert input, dramatically improves efficiency for subject matter experts and medication services design teams Vioxx alert shared, removed from database

29. Knowledge Engineer updates the content in the Gerios editor…… A new cut of Gerios is posted to the portal….

31. Now, we move the Content Management interface to upload the new cut of Gerios to the Portal And apply appropriate metadata filters and taxonomy tags…

38. Example LifeCycle of Functional Knowledge Spec. Start Edited State Review State Publish State Archive State

39. Roadmap: Proposed Sequence of Rearchitecting Editors with Documentum: A Knowledge Event Management Architecture Documentum eRoom and Portal Repositories (metaknowledge about the knowledge) Knowledge Management Portal Health Language Inc Terminology Editors Terminology Repository Legacy Editors Legacy Repositories Medication Services Editors Medication Svs Repositories New Order Entry Editors Order Entry Repositories New Documentation Editors Documentation Repositories Transaction Systems and Services Ilog Rule Editor Ilog Rule Repositories 2007 2006 Complex Definition Editors Complex Definitions Repository 2007 Propagation & Inheritance

40. Conclusions Now that two groups have used it on Documentum’s hosted site, we have a lot of pent up demand, rollout begins in December on hosted environment These are volunteer Subject Matter Experts, incentives are being developed to reward contribution, however, current participants describe it as fun and intellectually rewarding The rollout of the rooms must be carefully designed, every room needs a dedicated administrator who tees up the content for review, shepards the content through the lifecycle Leadership well recognizes that we can’t achieve enterprise-wide clinical standards in our clinical decision support content without such tools