Clinical Decision Support Consortium (Massachusetts)

Project Details - Ended

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Summary:

In order to realize the quality and safety benefits of electronic health records (EHRs), they must be paired with clinical decision support (CDS) systems. CDS systems use a variety of techniques to facilitate and guide clinical decisionmaking toward evidence-based practice. Although benefits of CDS are clear, there have been a number of barriers to its widespread adoption, including the complexity of the CDS; difficulty translating medical knowledge and guidelines into a form that can be used by EHRs; a lack of understanding of how to create the initial building blocks of CDS; identifying actual costs; and identifying a process for maintaining and keeping existing CDS current.

This 5-year project, the Clinical Decision Support Consortium (CDSC), worked on assessing, defining, demonstrating, and evaluating best practices for knowledge management (KM) and CDS in health information technology (IT) across multiple ambulatory care settings and EHR technology platforms. Members of the CDSC included academic and community provider institutions, leading health IT organizations, EHR companies, and knowledge vendors.

The main objectives of the project were to:

  • Assess and define best practices for knowledge management and CDS in ambulatory care.
  • Define a novel, practical knowledge representation scheme that allows users to access knowledge in a manner that facilitates the translation of knowledge into CDS within EHRs.
  • Build a prototype national knowledge repository to support access and use of knowledge artifacts and collaborative knowledge engineering.
  • Build publicly available cloud-based Web services to provide remote CDS.
  • Build end-user CDS dashboards that would depict user's compliance with CDS and provide feedback to knowledge engineers on the efficacy of the CDS.
  • Coordinate overall CDS Consortium evaluation activities.
  • Demonstrate the feasibility of a service oriented architecture-based approach through multi-site, multivendor demonstration projects.
  • Disseminate results through a variety of traditional channels.

The accomplishments of the CDSC are detailed on the CDSC Web site: http://www.partners.org/cird/cdsc/. The CDSC solved critical technical challenges for sharing CDS and developing social and legal frameworks that facilitate such sharing. The project selected a service-oriented approach to providing clinical decision support. Web services were developed at Brigham and Women’s Hospital, the lead CDSC site, and made available to consumers across the US. In addition, the consortium designed, developed, and implemented cloud-based CDS services, as well as both human and human-readable artifacts, subsequently made available through a publicly accessible knowledge portal. CDSC contributed to the development of the Health eDecisions standards for CDS, and provided important feedback about the Continuity of Care Document standard.

The project was able to demonstrate that CDS developed at one site can be used at a variety of sites, including those that have different EHRs. This approach should be able to surmount current challenges in scalability and sharing for CDS. With the CDSC model, a small number of academic or commercial providers could develop high-quality decision support content that could be deployed across a wide range of clinical settings, resulting in a dramatic reduction in the cost of KM and development of CDS, allowing smaller organizations to deploy more and higher-quality CDS.

Clinical Decision Support Consortium - 2012

Summary Highlights

Summary: Electronic health records (EHRs), when used effectively, can improve the safety and quality of medical care. However, EHRs must be paired with clinical decision support (CDS) systems to infl uence physician behavior effectively. CDS includes a variety of techniques designed to facilitate and guide doctors’ decisionmaking toward evidence-based practice. Despite evidence that CDS is effective, only a small number of academic medical centers and integrated delivery networks account for the majority of CDS research and development. Wider CDS adoption has been limited by a variety of issues including: 1) a lack of widely adopted standards for representing and sharing clinical knowledge in a computable form; 2) difficulty developing clinical practice guidelines that can be readily and unambiguously translated into a computable form; 3) absence of a central repository or knowledge resource where computable guidelines can be stored and shared; 4) challenges integrating CDS into clinical workflow; and 5) limited understanding of organizational and social issues relating to CDS.

As demonstrated at sites where CDS is pervasive, these barriers are surmountable. The biggest challenges to widespread CDS adoption include the complexity of the CDS; a lack of understanding of how to create the initial building blocks; identifying costs; and identifying the process for maintaining an up-to-date CDS. To address these challenges, investigators from Brigham and Women’s Hospital, Harvard Medical School, and Partners HealthCare Systems (PHS) formed the CDS Consortium (CDSC) in collaboration with 31 organizations, including vendors, health care organizations, and academic institutions, from across the United States.

The goal of the CDSC has been to assess, define, demonstrate, and evaluate best practices for knowledge management and CDS in health information technology (IT) across multiple ambulatory care settings and EHR technology platforms in pursuit of widespread CDS adoption. The CDSC is developing a series of service-oriented CDS interventions focused on diabetes, coronary artery disease, and hypertension screening. Over the first 4 years, the CDSC has: conducted an ethnographic study of CDS that has led to a better understanding of technical and sociological issues related to decision support critical to the Consortium as it develops CDS content and demonstrations at a variety of member sites; developed a practical four-layer knowledge representation stack and knowledge authoring tool for translating clinical guidelines from human-readable into machine-executable form for a variety of CDS modalities; developed and launched a publicly accessible, Web-based Knowledge Management (KM) Portal for collating and browsing knowledge artifacts used in CDS; constructed and tested novel Web-based CDS services and integrated them into two EHRs – the PHS Longitudinal Medical Record (LMR) and the Regenstrief Institute CareWeb; devised a novel measurement model for CDS that takes into account the myriad of ways that CDS can influence practice, as well as accounting for both the decision support process and clinical quality; developed legal agreements to support CDSC knowledge-sharing and use of CDS services; built a robust clinical content governance process and tackled difficult issues relating to provenance, standardization, localization, and versioning; and disseminated findings through more than a dozen presentations at national and international meetings and published papers at conferences and in peer-reviewed journals.

Project Objectives:

  • Assess and define best practices for knowledge management and CDS in ambulatory care. (Ongoing)
  • Define a novel, practical knowledge representation scheme that allows users to access knowledgein a manner that facilitates the translation of knowledge into CDS within EHRs. (Achieved)
  • Build a prototype national knowledge repository to support access and use of knowledge artifactsand collaborative knowledge engineering. (Achieved)
  • Build publicly available cloud-based Web services to provide remote CDS. (Achieved)
  • Build end-user CDS dashboards that would depict user’s compliance with CDS and providefeedback to knowledge engineers on the efficacy of the CDS. (Achieved)
  • Coordinate overall CDS Consortium evaluation activities. (Ongoing)
  • Demonstrate the feasibility of a service oriented architecture-based approach through multi-site,multivendor demonstration projects. (Ongoing)
  • Disseminate results through a variety of traditional channels. (Ongoing)

2012 Activities: The CDSC continued to pursue research and development, completing a series of deliverables including but not limited to: 1) a CDSC knowledge authoring tool for creating knowledge artifacts at level 2 and level 3; 2) a new set of clinical rules that were implemented in the CDS service and KM Portal; and 3) Phase 2 demonstrations at the Regenstrief Institute. In addition, the CDS Consortium increased the number of collaborators to include Accenture, Applied Pathways, Evinance, Geisinger, Illinois Gastroenterology Group, InterSystems, Main Line Health, Mayo Clinic, MITRE, Mount Sinai Medical Center, newMentor, TruvenHealth, and the University of Utah.

Dissemination activities in 2012 included a presentation of CDSC progress in a series of demonstration meetings with EHR and clinical content vendors at the annual Healthcare Information and Management Systems Society Meeting in February as well as presentations at IntelliFest in October and at the 2012 American Medical Informatics Association annual symposium in November. The CDSC also published three journal articles and one conference paper in 2012. These included a paper published in the February volume of the BMC Medical Informatics and Decision Making journal, describing the results of the ethnographic field studies to identify recommended practices for CDS development and implementation and knowledge management processes: Recommended practices for computerized clinical decision support and knowledge management in community settings: a qualitative study. In addition, a paper describing the practices related to CDS in U.S. community hospitals with mature computerized provider order entry systems was published in the November-December volume of the Journal of the American Medical Informatics Association: Standard practices for computerized clinical decision support in community hospitals: a national survey. The full list of publications is available on the project profile.

Preliminary Impact and Findings: The CDSC has solved critical technical challenges for sharing CDS, developed social and legal frameworks and model contracts to facilitate such sharing, and most critically, built a trusting community of CDS researchers, developers, and clinical information system vendors who are ready to share their knowledge and expertise.

Target Population: Adults, Chronic Care*, Coronary Artery Disease, Diabetes, Hypertension

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

*This target population is one of AHRQ’s priority populations.

Clinical Decision Support Consortium - 2011

Summary Highlights

Summary: Despite evidence of the effectiveness of clinical decision support (CDS), only a small number of academic medical centers and integrated delivery networks account for the majority of CDS research and development. Wider CDS adoption has been limited by a variety of social, political, psychological, economic, and technical issues. These include: 1) a lack of widely adopted standards for representing and sharing clinical knowledge in a computable form; 2) difficulty developing clinical practice guidelines that can be readily and unambiguously translated into a computable form; 3) absence of a central repository or knowledge resource where computable guidelines can be stored and shared; 4) challenges integrating CDS into clinical workflow; and 5) limited understanding of organizational and social issues relating to CDS.

As demonstrated at sites where CDS is pervasive, these barriers are surmountable. The biggest challenges to widespread CDS adoption include the complexity of the CDS; a lack of understanding of how to create the initial building blocks; identifying costs; and identifying the process for maintaining an up-to-date CDS. To address these challenges, investigators from Brigham and Women's Hospital, Harvard Medical School, and Partners HealthCare Systems (PHS) formed the CDS Consortium in collaboration with 24 organizations across the United States, including vendors, health care organizations, and academic institutions.

The goal of the CDS Consortium is to assess, define, demonstrate, and evaluate best practices for knowledge management (KM) and CDS in health information technology (IT) across multiple ambulatory care settings and electronic health record (EHR) technology platforms in pursuit of widespread CDS adoption. The CDS Consortium is developing a series of service-oriented CDS interventions focused on diabetes, coronary artery disease, and hypertension screening. In the first 2 years of the project, the team developed the service-oriented CDS interventions and piloted them in four ambulatory sites in Massachusetts. Currently, the team is expanding the interventions and continues to gather data and develop best practices.

Project Objectives:

  • Assess and define best practices for knowledge management and CDS in ambulatory care. (Ongoing)
  • Define a novel, practical knowledge representation scheme that allows users to access knowledge in a manner that facilitates the translation of knowledge into CDS within EHRs. (Ongoing)
  • Build a prototype national knowledge repository to support access and use of knowledge artifacts and collaborative knowledge engineering. (Achieved)
  • Build publicly-available cloud-based Web services to provide remote CDS. (Achieved)
  • Build end-user CDS dashboards that would depict user's compliance with CDS and provide feedback to knowledge engineers on the efficacy of the CDS. (Achieved)
  • Coordinate overall CDS Consortium evaluation activities. (Ongoing)
  • Demonstrate the feasibility of a service oriented architecture-based approach through multi-site, multivendor demonstration projects. (Ongoing)
  • Disseminate results through a variety of traditional channels. (Ongoing)

2011 Activities: The CDS Consortium continued to pursue research and development, completing a series of deliverables including but not limited to: 1) a 6-month trial of Enterprise Clinical Rules Service with Regenstrief Instritute's CareWeb and PHS's Longitudinal Medical Record; 2) the initiation of the development of the dashboard prototypes using one of the OpenSource Dashboard programs; 3) publication of Structured Care Recommendations content on the CDS Consortium KM Portal; and 4) publication of the Advancing CDS project content. In addition, the CDS Consortium continued work with Next Gen and GE to implement cloud-based CDS into their EHR products.

Other work in 2011 included: 1) the development of a novel method for CDS performance assessment; 2) the development of a robust clinical content governance and editorial process; 3) the development of a legal framework to support the CDS Consortium activities; and 4) the development of the first prototype of the Knowledge Authoring Tool (CDSC-KAT) for creating knowledge artifacts at Level 3.

Dissemination activities in 2011 included a presentation of CDS progress and participation in a series of demonstration meetings with EHR and clinical content vendors at the American Medical Informatics Association (AMIA) annual symposium in October, and the annual Healthcare Information and Management Systems Society Meeting in February. The CDS Consortium also published six journal articles and three conference papers in 2011. These include a paper, published in the December 2011 volume of the Journal of the American Medical Informatics Association, describing a multi-layered knowledge representation framework for structuring guideline recommendations for implementation in a variety of CDS contexts. In addition, a paper describing a legal framework for developing agreements in support of sharing, accessing, and publishing content via the KM Portal, was presented at the 2011 AMIA symposium and received a Distinguished Paper nomination. The full list of publications is available on the project profile.

Preliminary Impact and Findings: The CDS Consortium has solved critical technical challenges for sharing CDS, developed social and legal frameworks and model contracts to facilitate such sharing and, most critically, built a trusting community of CDS researchers, developers, and clinical information system vendors who are willing and ready to share their knowledge and expertise. This work has brought the CDS Consortium and the United States CDS community much closer to the Consortium's ultimate goal to assess, define, demonstrate, and evaluate best practices for KM and CDS in health care information technology at scale across multiple ambulatory care settings and EHR technology platforms.

In its 3 1/2 years, the CDS Consortium matured significantly, as demonstrated by increasing collaboration with outside parties, such as EHR and content vendors, that initially were reluctant to join. The CDS Consortium also showed, for the first time, that their services could work external to PHS. This index case sets the stage for a much broader and more rapid rollout of CDS services across multiple ambulatory care settings and EHR technology platforms. The research also indicated that a sound legal foundation was required for knowledge sharing and CDS services in order to address data sharing, intellectual property, accountability, and liability concerns. Therefore, the team developed a set of clinical content editorial and governance procedures, and a legal framework with component legal agreements to make the CDS resource useful.

Target Population: Adults, Coronary Artery Disease, Diabetes, Hypertension

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Clinical Decision Support Consortium - 2010

Summary Highlights



Target Population: Coronary Artery Disease, Diabetes, Hypertension

Summary: Despite overwhelming evidence of clinical decision support’s (CDS’s) effectiveness, only a small number of academic medical centers and integrated delivery networks account for the bulk of CDS research and development. Wider CDS adoption has been limited by a variety of social, economic, and technical issues, including: a lack of widely adopted standards for representing and sharing clinical knowledge in a computable form; difficulty developing clinical practice guidelines that can be readily and unambiguously translated into a computable form; absence of a central repository or knowledge resource where computable guidelines can be stored and shared; challenges integrating CDS into the clinical workflow; and limited understanding of organizational and social issues relating to CDS.

As evidenced by sites where CDS is pervasive, these barriers are surmountable. The biggest challenge to fostering widespread CDS adoption is documenting, generalizing, and translating the experience from these advanced sites to broader community settings. To address this challenge, investigators from Brigham and Women's Hospital, Harvard Medical School, and Partners HealthCare Systems (PHS) formed the Clinical Decision Support (CDS) Consortium in collaboration with the Regenstrief Institute, the Veterans Health Administration, Kaiser Permanente Northwest Research Group, General Electric Healthcare, Siemens Medical Solutions, Mayo Clinic, NextGen, University of Texas School of Biomedical Informatics, Oregon Health and Science University, Mid-Valley Independent Physicians Association, and University of Medicine and Dentistry of New Jersey.

The goal of the CDS Consortium is to assess, define, demonstrate, and evaluate best practices for knowledge management (KM) and CDS in health information technology (IT) across multiple ambulatory care settings and electronic health record (EHR) technology platforms in pursuit of widespread CDS adoption. The CDS Consortium is developing a series of service-oriented CDS interventions focused on diabetes, coronary artery disease, and hypertension screening. In the first two years of the project, the team developed the service-oriented CDS interventions and piloted them in four ambulatory sites in Massachusetts. In the next few years, the team will expand the interventions and continue to gather data and develop best practices.

Project Objectives:
  • Assess and define best practices for knowledge management and CDS in ambulatory care. (Ongoing)
  • Define a novel, practical knowledge representation scheme that allows users to access knowledge in a manner that facilitates the translation of knowledge into CDS within EHRs. (Ongoing)
  • Build a prototype national knowledge repository to support access and use of knowledge artifacts and collaborative knowledge engineering. (Achieved)
  • Build publicly-available Web services to provide remote CDS. (Achieved)
  • Build end-user CDS dashboards depicting user compliance with CDS and provide feedback to knowledge engineers building the CDS knowledge artifacts and Web services on the efficacy of the CDS. (Achieved)
  • Coordinate overall CDSC evaluation activities. (Ongoing)
  • Demonstrate the feasibility of a service oriented architecture-based approach through multisite, multivendor demonstration projects. (Ongoing)
  • Disseminate results through a variety of traditional channels. (Ongoing)

2010 Activities: The CDS Consortium team continued to pursue research and development through the following project teams from institutions across the U.S: the Knowledge Management Lifecycle Assessment Team (KMLA); the Knowledge Translation and Specification (KTS) Team; the Knowledge Management (KM) Portal Team; the Recommendations Team; the Service Team; the Demonstration Team; the Dashboard Team; the Evaluation Team; and the Content Governancy Committee team. Each team made extensive progress on their goals completing a series of deliverables, including the completion of the beta version of the KTS stand-alone browser-based knowledge authoring tool; the go-live of the eRoom and KM portal; the development of the KM portal user assessment tool; the finalization of recommendations for Healthcare Information Technology Standards Panel, Certification Commission for Health Information Technology, and clinical content developers; the start of a trial of the CDS service in the production environment; the release of the enterprise clinical rules service to production; finalized data specifications for the project evaluation; a “lessons learned” document from the implementation in PHS’s Longitudinal Medical Record; and the go-live of the two PHS CDS dashboards.

Dissemination activities in 2010 included a presentation of results at a technical expert panel meeting in Washington, DC, and at the Guidelines International Network meeting in Chicago, IL. A paper on themes in CDS was submitted to the Journal of the American Medical Informatics Association (JAMIA); the KTS team also submitted their work on the multi-layered knowledge representation framework and evaluation study to JAMIA. Additionally, a paper describing KMLA’s rapid assessment process was submitted to Methods of Information in Medicine.

Preliminary Impact and Findings: Lessons learned from the teams and projects are outlined below.

KM Team: The team discovered that each external CDSC member must do a significant amount of preparation work before integrating the CDSC content. It is critical that KM be included in the discussions with the CDSC members from the beginning. In addition, the Centers for Medicare and Medicaid Service’s meaningful use standards are causing many delays as PHS rapidly transitions from existing systems to new systems that are certified for meaningful use.

KTS Team: The team’s assumptions about building a Web-based editing tool were invalidated by legal concerns. This suggests that a wider review of requirements and specifications is necessary early in the development process.

KMLA Team: The team found that the modified rapid assessment process works for clinical knowledge vendors. Clinical knowledge vendors are, in terms of informatics skills and knowledge, better prepared than anticipated.

Demonstration Team: The team found that despite similar standards and terms, differences in how terms are mapped and used persist, making the process of mapping burdensome. Integration of CDS into the workflow has to be customized by site due to the differences in the interfaces. Communication across health IT project silos is necessary to ensure that interdependencies are managed and all projects are successful.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

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