SEBASTIAN, Related Initiatives, and Lessons Learned

1. SEBASTIAN, Related Initiatives, and Lessons Learned AMIA 2010 Fall Symposium November 17, 2010 Kensaku Kawamoto, MD, PhD (kawam001@mc.duke.edu) Assistant Professor Duke Center for Health Informatics

2. Presentation Overview SEBASTIAN Duke Chronic Disease Management System Key Standards for Scalable CDS Services OpenCDS Discussion

3. Presentation Overview SEBASTIAN Duke Chronic Disease Management System Key Standards for Scalable CDS Services OpenCDS Discussion

4. SEBASTIAN CDS Web Service – Overview • SystemforEvidence-BasedAdvicethroughSimultaneousTransaction 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.

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

6. EKM Authoring – Metadata Entry

7. EKM Authoring – Input Data Specification

8. EKM Authoring – Output Specification

9. EKM Authoring – Logic Section (InfoPath)

10. EKM Authoring – Logic Section (Java IDE)

11. EKM Testing – Single Test Case Evaluation

12. EKM Testing – Batch Evaluation

13. 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

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

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

16. Usage

17. Example Care Quality Reporting Source: Duke University Health System.

18. Presentation Overview SEBASTIAN Duke Chronic Disease Management System Key Standards for Scalable CDS Services OpenCDS Discussion

19. 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 http://hssp-dss.wikispaces.com

20. 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 • http://wiki.hl7. org/index.php?title=Virtual_Medical_ Record_(vMR)

21. Presentation Overview SEBASTIAN Duke Chronic Disease Management System Key Standards for Scalable CDS Services OpenCDS Discussion

22. OpenCDS • Goal • Facilitate widespread availability of advanced CDS capabilities through open-source, collaborativedevelopment 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

23. 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

24. OpenCDS – Sample Topologies DSSClient OpenCDS DSS Interface OpenCDSAdapter X OpenCDS Drools Adapter OpenCDS Drools Engine CDS Engine/Service X (e.g., SEBASTIAN) OpenCDS Drools Knowledge Authoring Platform

25. 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

26. OpenCDS – Terminology Mgmt. with Apelon

27. OpenCDS – Terminology Mgmt. with Apelon

28. OpenCDS – Demo

29. Presentation Overview SEBASTIAN Duke Chronic Disease Management System Key Standards for Scalable CDS Services OpenCDS Discussion

30. 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

31. Key Challenges and Potential Solutions • Bottom line assessment: benefits >> challenges

32. Acknowledgements • Research support • SEBASTIAN: NLM F37-LM008161 (PI: K. Kawamoto) • OpenCDS: NHGRI K01 HG004645 (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

33. www.opencds.org