Active Clinical Decision Support

in a RHIO

Introduction

The Clinical Document Architecture has emerged as a means of making systems interoperable. Clinical data can cross barriers. We are approaching an era of Computable Semantic Interoperability.

Decision Support works when complex information is available. It works for a community when that data is available across systems so that patients can be treated with quality wherever they are seen. Active decision support provides guidance and recommendations at the point of care.

In a RHIO, decision support will support evidence based care using standards to obtain and manipulate information.

What is Active Decision Support?

• Decision support: any means of helping get the right thing done

• Passive Decision Support: documents or systems that can be searched or browsed to get answers

• Active Decision Support: can reason with its knowledge and likely can communicate or act on its recommendations

CDA Enables Active Decision Support

1. Active Decision Support depends on access to clinical and administrative data about patients.

2. CDA documents carry information that can be understood across systems.

3. So, Decision Support is enabled by CDA. Knowledge systems can operate in RHIOs, and as services in cooperation with clinical data systems.

Computable Semantic Interoperability

- Charlie Mead, ‘06

“A collaborative project to develop a universal framework for sharing health knowledge in the form of computable clinical practice guidelines”

An R&D consortium to develop the technology infrastructure to enable computable clinical guidelines, that will be shareable and interoperable across multiple clinical information system platforms.• A 5-year, industry-academic research collaboration

• Led by IDX Systems, now GE Healthcare

• In partnership with:

– Apelon, Inc.

– Intermountain Healthcare

– Mayo Clinic

– Stanford Medical Informatics

– University of Nebraska Medical Center

The SAGE Project

Guidelines are Active

What If . . . . • Guideline content became

active, offering targeted, relevant guidance at the point of care?

• Patients were evaluated against proven guidelines -- automatically?

• Key data, care rationale and guidance were presented at critical decision points -- automatically?

• A technology infrastructure that supports sharable, computable clinical practice guidelines -- augmenting clinical knowledge processing at the point of care.

• With SAGE − Health experts can author and encode evidence-based clinical guidelines in a standard computable format.− Organizations throughout the world can easily deploy those guidelines using any conforming clinical information system.

The SAGE Project Vision

Type 2 Diabetes

Evaluation If

Needed

Needs Stabilization?

yes

no

Recommend self-management program:Nutrition therapyPhysical ActivityEducation for self-managementFoot care

Set individualized treatment goals:Glycemic control: HbA1c < 7%Lipid levels: LDL " 130 mg/dlBP control: BP " 130/85 mm HgASA unless contraindicatedTobacco cessation if indicated

no

Treatment goals notmet:• Modify treatmentbased on appro-priate guidelineand/or• See GlycemicControl Algorithmand/or• Consider referralto diabetes healthteam or specialists

Are Treatment Goals Met?

yes

See Ongoing Management

Algorithmfor maintaining treatment goals

and complication prevention

AD

AD

AD

AD

AD

AD

Initial stabilization

for outpatients requiring

immediate insulin

treatment

SAGE in a RHIO Environment

• Guidelines could execute at the “RHIO” level.

• Guideline execution could obtain patient EMR data from a central or distributed repository.

• Real-time, patient-specific recommendations could be provided via functions of the local CIS.

• CDA documents are the basis for exchanging information.

Central Repository Model

EMR

EMR EMR

EMR EMR

Guideline

File(s)

SAGEGuidelin

e Engine

Think of SAGE as guidelines

good idea!

tapping busyclinicians on the shoulder

at just the right time.

Active Guideline Environment

Gentle SAGE Recommendations

Guideline recommendations integrated into a nurse care flowsheet

• View suggested orders• Process suggested orders

Real time access to reference information

Shows history, and future plans

Order Sets as SAGE Recommendations

HL7 Standard Order Set

Open Here SAGE adds patient specific comments to orders,and chooses preferred orders.

How Classic SAGE Technology Works• SAGE reads and executes an encoded

guideline using standard terminology.

• It communicates with CIS via a Virtual Medical Record standard interfaces.

• SAGE detects events in the clinical workflow.

• Queries patient data from the electronic medical record.

• SAGE executes guideline logic based on patient specific data.

• Real-time, patient-specific recommendations are expressed by the local CIS.

Your Clinical Information System

Guideline

File(s)

SAGEGuidelin

e Engine

PAS

Orders

More…Labs

Events

EMR Data

Queries

Actions

RHIOs: Where is the patient record?

EMR EMR

Central EMR(with distributed access)

(cf. PeaceHealth)

Central Repository(“copy” of local EMRs)

(cf. INPC, UK Spine)

Distributed EMR(no central EMR)

(cf. Santa Barbara)

EMR EMR

EMR EMR

EMR EMR

EMR EMR

• SAGE reads and executes an encoded guidelines using standard terminology.

• It communicates with users and stores via CDA interfaces.

• SAGE responds to events or requests from clinical systems.

• Queries patient data from the RHIO or requester. The data are returned in CDA documents.

• SAGE executes guideline logic based on patient specific data.

• Patient-specific recommendations are expressed through CDA.

How CDA SAGE Technology Works

SAGEGuidelin

e Engine

Guideline

File(s)

CDA

RHIOstore

CDA CDA

CDA

Clinical Document Architecture

• CDA defines a document structure that contains medical information.

• CDA docs (XML) cross the wire.

• In CDA v2, coded admin and clinical data may be present for use by decision support systems.

XML Body: two types of content

• Human readable (usually HTML)- required

• Machine readable which can drive automated processes including decision support- optionalexcept when doing decision support

Major Components

Thanksto Bob Dolin, MDKaiser Permanente

Major Comp-

onents of a CDA

Document

Major Comp-

onents of a CDA

Document

<ClinicalDocument> ... <structuredBody> <section> <text>...</text> <observation>...</observation> <substanceAdministration> <supply>...</supply> </substanceAdministration> <observation> <externalObservation> ... </externalObservation> </observation> </section> <section> <section>...</section> </section> </structuredBody></ClinicalDocument>

DOCUMENT

BODY

Header

SECTIONS

Narrative Block

ENTRIES

ExternalReferences

<section> <code code="101155-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC"/> <title>Allergies and Adverse Reactions</title> <text> <list> <item><content ID="A1">Penicillin - Hives</content></item> <item>Aspirin - Wheezing</item> <item>Codeine - Itching and nausea</item> </list> </text> <entry> <observation classCode="OBS" moodCode="EVN"> <code code="247472004" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Hives"> <originalText><reference value="#A1"/></originalText> </code> <entryRelationship typeCode="MFST"> <observation classCode="OBS" moodCode="EVN"> <code code="91936005" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Allergy to penicillin"/> </observation> </entryRelationship> </observation> </entry></section>

Example CDA v2 for an Allergy ListExample CDA v2 for an Allergy List

CDA, Release Two

Thanksto Bob Dolin, MDKaiser Permanente

1st Scenario: Consultation on Request

• Small medical office, part of RHIO network

• Patient goes to the office. Patient has some previous history of hypertension.

• MD requests a consultation on medications for hypertension management.

Office

VERY SIMPLE!

Small Practice in a RHIO

40 y.o. seen in clinic:

BP checked,Hypertension

already known

SAGE Installed Centrally

MD requestsSAGE advice

SAGEGuideline

Engine

CentralEMREMR

EMR

CDA document containsVital Signs, Hx, Labs, Allergies, Current Meds, …

CDA

Office

SAGE Onlin

e

SAGE reasons

Sources

SAGEGuideline

Engine

CentralEMR

CDA

SAGE analyzes data

Central DB containsseveral visit historiesfrom multiple institutions

1. Is ACE Inhibitor at max dose?

2. Any contraindications to Ca Channel Blocker?

3. Is Average Systolic BP over last 5 measurements> 150 mmHg

4. etc.

Sources

CDA

Office

CDA

Recommendations Delivered

BP Not under Control. Consider one of the following:

1) increase dose of lisinopril to 20mg qd2) add felodipine3) add thiazide diuretic, monitor K+4) add atenolol

RecommendsSAGE replies:

Why is SAGE not just an Expert System?

Recommends

• Context (a series of events)• State (enrollment)• Sharable (across institutions)• Active (influence on care)

Where are the data?

• SAGE uses – CDA data submitted with consultation request,

AND

– Stored centrally in RHIO for this patient

• Central store is CDA XML documents– Past history, Problem list, Allergies, Current Meds,

History of Meds, Vital Signs, Laboratory work, etc.

For Example, Current Medications include

<section> <text>Digoxin 0.125mg, 1 PO qDay, #30, 5 refills.</text> <entry> <substanceAdministration classCode="SBADM" moodCode="RQO"> <effectiveTime xsi:type="PIVL_TS"> <period value="24" unit="h"/> </effectiveTime> <routeCode code="PO" codeSystem="2.16.840.1.113883.5.112"/> <doseQuantity value="1"/> <consumable> <manufacturedProduct><manufacturedLabeledDrug> <code code="317896006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Digoxin 125micrograms tablet"/> </manufacturedLabeledDrug></manufacturedProduct> </consumable> <entryRelationship typeCode="COMP"> <supply classCode="SPLY" moodCode="RQO"> <repeatNumber> <low value="0"/><high value="5"/> </repeatNumber> <independentInd value="false"/> <quantity value="30"/> </supply> </entryRelationship> </substanceAdministration> </entry></section>

This SNOMED-CT Coded entryis thus available forfor SAGE to use inreasoning to make recommendations.

<manufacturedProduct><manufacturedLabeledDrug> <code code="317896006" codeSystem="2.16.840.1.113883.6.96" codeSystemName="SNOMED CT" displayName="Digoxin 125micrograms tablet"/> </manufacturedLabeledDrug></manufacturedProduct>

2nd Scenario: SAGE helps out at the Cancer Clinic

• RHIO/SAGE is sent a patient list before the clinic opens on Friday morning.

• List is actually 47 CDA docs with up to date labs and findings for those patients who will appear in clinic that day.

05:30Patient list

sent to SAGE SAGEGuideline

Engine

CDACDACDACDACDACDACentral

EMR

Other Systems

SAGE assesses each patient against protocol

• Decision logic possibly requires additional historical, or missing patient data

• SAGE can look for trends, specific alert levels, recent posted warnings, …

0531-0546SAGE

executesdecision logic

SAGEGuideline

Engine

CentralRHIO EMR

Other Systems

SAGE Guideline Provides Advice for Each Patient

• When each patient is first seen by a clinician, that person is notified of any recommendations.

• The clinician may act on some of those recommendations directly.

• Each recommendation comeswith literature and logic references.

SAGE publishes recommendations

SAGEGuideline

Engine

John Abelson, #76789576F5, DOB: 03-04-1945 has a very low platelet count (5240).

Other Labs:Na 134K 14WBC 10,100

Recommend1. D/C Heparin2. Reduce Met to 3.4g

qd3. Repeat count in 24 hr

Recommendations may be comprehensive

• SAGE may suggest – new diagnoses– new interventions– changes in schedules– adjustments in current

treatments– additional studies– all with explanations

and literature references.

MRN: 60946T3 NAME: Frederick T. Withers

Recent BP: 06-07-05 152/86Enter Today’s BP:

Goal: SBP < 135, DBP < 95 [diabetes, chf, renal insuffiency]

Stage 1 Hypertension.BP out of control. Systolic trend upwards.

Patient may benefit from 1 or more additional medication(s).

Recommendations:

Consider one of:ACE lisinopril 10mg qdARB spironolactone 25mg qdBB atenolol 25mg qd

www.sageproject.com