Clinical Decision Support (eBook)

Front Cover 1
Clinical Decision Support 4
Copyright Page 5
Table of Contents 6
Contributors 10
Preface 12
PART I COMPUTER-BASED CLINICAL DECISION SUPPORT: CONCEPTS AND ORIGINS 18
Chapter 1 DEFINITION, SCOPE, AND CHALLENGES 20
1.1 INTRODUCTION 20
1.2 DEFINITION OF COMPUTER-BASED CLINICAL DECISION SUPPORT 23
1.3 FEATURES OF CDS 23
1.4 THE TALE OF A RELATIONSHIP 24
1.5 SCOPE AND PLAN OF THIS BOOK 39
REFERENCES 43
Chapter 2 A BRIEF HISTORY OF CLINICAL DECISION SUPPORT: TECHNICAL, SOCIAL, CULTURAL, ECONOMIC, AND GOVERNMENTAL PERSPECTIVES 48
2.1 PRIMARY RESEARCH METHODOLOGIES THAT HAVE BEEN PURSUED AND EXTENDED 48
2.2 DRIVING FORCES FOR CDS 75
2.3 CONCLUSION 86
REFERENCES 86
Chapter 3 FEATURES OF COMPUTER-BASED CLINICAL DECISION SUPPORT 96
3.1 CDS AND THE HUMAN 97
3.2 DESIGN AND STRUCTURE OF CDS 103
3.3 OTHER CONSIDERATIONS 121
REFERENCES 122
PART II CASE STUDIES AND CURRENT STATUS 126
Chapter 4 REGENSTRIEF MEDICAL INFORMATICS: EXPERIENCES WITH CLINICAL DECISION SUPPORT SYSTEMS 128
4.1 INTRODUCTION 128
4.2 HISTORY 129
4.3 CONCLUSION 140
REFERENCES 142
Chapter 5 PATIENTS, DOCTORS, AND INFORMATION TECHNOLOGY: CLINICAL DECISION SUPPORT AT BRIGHAM AND WOMEN’S HOSPITAL AND PARTNERS 144
5.1 HISTORY 144
5.2 CLINICAL DECISION SUPPORT AND INPATIENT CPOE AT BWH 146
5.3 DECISION SUPPORT DELIVERED USING THE OUTPATIENT ELECTRONIC HEALTH RECORD 151
5.4 OVERARCHING STUDIES 154
5.5 OVERARCHING LESSONS 155
5.6 FUTURE DIRECTIONS 156
REFERENCES 157
Chapter 6 CASE STUDIES IN CLINICAL DECISION SUPPORT: LDS HOSPITAL EXPERIENCE 160
6.1 INTRODUCTION 160
6.2 TOOLS FOR INFORMATION MANAGEMENT 163
6.3 TOOLS FOR FOCUSING ATTENTION 167
6.4 TOOLS FOR PATIENT-SPECIFIC CONSULTATION 175
6.5 CONCLUSION 180
REFERENCES 182
Chapter 7 PENETRATION AND AVAILABILITY OF CLINICAL DECISION SUPPORT IN COMMERCIAL SYSTEMS 186
7.1 INTRODUCTION 186
7.2 CDS PENETRATION AND AVAILABILITY IN COMMERCIAL SYSTEMS 187
7.3 CLINICAL ALERTING IN 2002 189
7.4 OBSTACLES TO CDS IN 2002 191
7.5 WHAT CHANGED SINCE EARLY 2002? 193
7.6 HOW FAR ALONG ARE CDS VENDORS IN 2005? 201
7.7 SELF-REPORTED VENDOR DATA AS OF FEBRUARY 2005 201
7.8 CONCLUSION 209
REFERENCES 210
VENDOR WEB SITE REFERENCES 211
Chapter 8 LESSONS LEARNED 212
8.1 ACADEMIC PROTOTYPES 213
8.2 STANDARDS AND SHARING OF INTEROPERABLE CONTENT AND TOOLS 217
8.3 USERS 218
8.4 OTHER CONSIDERATIONS 219
REFERENCES 220
PART III GENERATION AND FORMULATION OF KNOWLEDGE 222
Chapter 9 HUMAN-INTENSIVE TECHNIQUES 224
9.1 INTRODUCTION 224
9.2 THEORETICAL BASIS FOR KNOWLEDGE ACQUISITION 227
9.3 COGNITIVE TASK ANALYSIS 229
9.4 COMPUTER-BASED KNOWLEDGE ACQUISITION 237
9.5 CONCLUSION 239
REFERENCES 240
Chapter 10 GENERATION OF KNOWLEDGE FOR CLINICAL DECISION SUPPORT: STATISTICAL AND MACHINE LEARNING TECHNIQUES 244
10.1 INTRODUCTION 244
10.2 LEARNING FROM DATA 246
10.3 OVERVIEW OF LOGISTIC REGRESSION 247
10.4 OVERVIEW OF SOME MACHINE LEARNING MODELS 250
10.5 PREDICTION MODELS IN MEDICINE 253
10.6 CONCLUSION 258
REFERENCES 259
Chapter 11 EVIDENCE-BASED MEDICINE AND META-ANALYSIS: GETTING MORE OUT OF THE LITERATURE 266
11.1 SYSTEMATIC REVIEWS AND META-ANALYSES 267
11.2 METHODOLOGIES OF SYSTEMATIC REVIEW AND META-ANALYSIS 268
11.3 DEVELOPING A SYSTEMATIC REVIEW PROTOCOL 268
11.4 FORMULATING THE RESEARCH QUESTION 269
11.5 LITERATURE SEARCH 270
11.6 DATA EXTRACTION 271
11.7 ASSESSING THE QUALITY OF STUDIES 271
11.8 COMBINING DATA IN A META-ANALYSIS 272
11.9 EXPLORING HETEROGENEITY WITH SUBGROUP AND META-REGRESSION ANALYSES 272
11.10 ISSUES IN CONDUCTING META-ANALYSES 273
11.11 USES OF SYSTEMATIC REVIEWS AND META-ANALYSES 276
11.12 ACCESSING SYSTEMATIC REVIEWS AND META-ANALYSES AND RELATED PRODUCTS 277
11.13 CONCLUSION 278
REFERENCES 279
PART IV REPRESENTING THE KNOWLEDGE: STANDARDIZATION EFFORTS 282
Chapter 12 DECISION RULES AND EXPRESSIONS 284
12.1 INTRODUCTION 284
12.2 PROCEDURAL KNOWLEDGE 285
12.3 KNOWLEDGE AS PRODUCTION RULES 286
12.4 THE HYBRID APPROACH: ARDEN SYNTAX 290
12.5 EXPRESSION LANGUAGES 294
12.6 FUTURE WORK 295
12.7 CONCLUSION 296
REFERENCES 296
Chapter 13 GUIDELINES AND WORKFLOW MODELS 298
13.1 INTRODUCTION: CLINICAL GUIDELINES AND ALGORITHMS 298
13.2 THE KNOWLEDGE CONTAINED IN CLINICAL GUIDELINES 300
13.3 FORMAL METHODS FOR SPECIFYING CIGS 302
13.4 FROM NARRATIVE TO FORMAL REPRESENTATIONS OF GUIDELINES 311
13.5 INTEGRATION OF GUIDELINES WITH WORKFLOW 312
13.6 METHODS FOR SHARING OF CIG CONTENT 314
13.7 CONCLUSION 317
13.8 RECOMMENDED RESOURCES 320
ACKNOWLEDGMENTS 321
REFERENCES 321
Chapter 14 ONTOLOGIES, VOCABULARIES, AND DATA MODELS 324
14.1 INTRODUCTION 324
14.2 THE NEED FOR CODED DATA 324
14.3 REFERENCING DATA IN DECISION LOGIC 325
14.4 ISSUES OF PRE- AND POSTCOORDINATION 328
14.5 DATA REPRESENTATION USING NAME-VALUE PAIRS 330
14.6 TERMINOLOGY IN THE LIFE CYCLE OF DECISION SUPPORT PROGRAMS 333
14.7 CONTEXTUAL RESTRICTIONS WITHIN THE TERMINOLOGY 336
14.8 WHAT NEEDS TO BE DONE 339
REFERENCES 340
Chapter 15 GROUPED KNOWLEDGE ELEMENTS 342
15.1 INTRODUCTION 342
15.2 CLINICAL DOCUMENTATION 344
15.3 CURRENT APPROACHES TO CLINICAL DOCUMENTATION 348
15.4 GROUPED KNOWLEDGE ELEMENTS (KEGs) 352
15.5 CONCLUSION 358
REFERENCES 359
Chapter 16 INFOBUTTONS AND POINT OF CARE ACCESS TO KNOWLEDGE 362
16.1 INTRODUCTION 362
16.2 UNDERSTANDING AND ADDRESSING CLINICIAN INFORMATION NEEDS 363
16.3 LINKING CLINICAL INFORMATION SYSTEMS TO ONLINE RESOURCES 366
16.4 INFOBUTTONS 367
16.5 MANAGING INFOBUTTONS 373
16.6 INFOBUTTON STANDARDIZATION 380
16.7 STANDARDS FOR INFORMATION RESOURCES 383
16.8 CONCLUSION 384
RECOMMENDED RESOURCES 384
ACKNOWLEDGMENTS 385
REFERENCES 385
Chapter 17 THE ROLE OF STANDARDS: WHAT WE CAN EXPECT AND WHEN 390
17.1 KEY STANDARDS AND THEIR BENEFITS 390
17.2 HOW IMPORTANT ARE STANDARDS? 396
REFERENCES 398
PART V ORGANIZATIONAL, BUSINESS, AND SOCIAL CHALLENGES 400
Chapter 18 ORGANIZATIONAL AND CULTURAL CHANGE CONSIDERATIONS 402
18.1 INTRODUCTION 402
18.2 ORGANIZATIONAL ISSUES RELATED TO CLINICAL DECISION SUPPORT 405
18.3 PLANNING WITH THESE ISSUES IN MIND 411
18.4 DEVELOPMENT, IMPLEMENTATION, AND MODIFICATION 413
18.5 EVALUATION AND MAINTENANCE 416
18.6 CONCLUSION 417
RESOURCES 418
ACKNOWLEDGMENTS 418
REFERENCES 418
Chapter 19 MANAGING THE INVESTMENT IN CLINICAL DECISION SUPPORT 420
19.1 INTRODUCTION 420
19.2 KNOWLEDGE MANAGEMENT 421
19.3 ORGANIZATION OF THE EFFORT 424
19.4 KEY IT STRATEGIES AND CONSIDERATIONS 431
19.5 EVALUATION OF THE IMPACT AND VALUE OF KNOWLEDGE MANAGEMENT 435
19.6 CONCLUSION 438
REFERENCES 439
Chapter 20 LEGAL AND REGULATORY ISSUES RELATED TO THE USE OF CLINICAL SOFTWARE IN HEALTH CARE DELIVERY 440
20.1 INTRODUCTION 440
20.2 LEGAL ISSUES RELATED TO USING EMBEDDED AND FREE-STANDING DECISION SUPPORT SOFTWARE IN CLINICAL SETTINGS 440
20.3 RESPONSIBILITY FOR CDS SOFTWARE AT THE INSTITUTIONAL LEVEL AND POTENTIAL GOVERNMENTAL REGULATION 454
20.4 CONCLUSION 459
ACKNOWLEDGMENTS 459
REFERENCES 460
PART VI KNOWLEDGE MANAGEMENT APPROACHES 462
Chapter 21 KNOWLEDGE MANAGEMENT INFRASTRUCTURE: EVOLUTION AT PARTNERS HEALTHCARE SYSTEM 464
21.1 INTRODUCTION 464
21.2 RAPID INNOVATION DISCOVERY AND ADOPTION: KEY INFRASTRUCTURE REQUIREMENTS 465
21.3 KNOWLEDGE ASSET MANAGEMENT INFRASTRUCTURE 468
21.4 CONCLUSION 482
REFERENCES 483
Chapter 22 THE CLINICAL KNOWLEDGE MANAGEMENT INFRASTRUCTURE OF INTERMOUNTAIN HEALTHCARE 486
22.1 CLINICAL KNOWLEDGE MANAGEMENT AT INTERMOUNTAIN HEALTHCARE 486
22.2 KNOWLEDGE ASSETS 489
22.3 SOFTWARE INFRASTRUCTURE 503
ACKNOWLEDGMENTS 517
REFERENCES 517
Chapter 23 INTEGRATION OF KNOWLEDGE RESOURCES INTO APPLICATIONS TO ENABLE CLINICAL DECISION SUPPORT: ARCHITECTURAL CONSIDERATIONS 520
23.1 INTRODUCTION 521
23.2 TERM DEFINITIONS 521
23.3 KNOWLEDGE INTEGRATION TASKS 522
23.4 ARCHITECTURAL CONSIDERATIONS 525
23.5 CASE STUDIES 533
23.6 LESSONS LEARNED FROM MARKET ADOPTION PATTERNS 542
23.7 PROPOSAL FOR A SOA APPROACH TO CLINICAL DECISION SUPPORT 545
23.8 CONCLUSION 553
RECOMMENDED RESOURCES 553
ACKNOWLEDGMENTS 554
REFERENCES 554
PART VII THE ROAD AHEAD 556
Chapter 24 A PROPOSED STRATEGY FOR OVERCOMING INERTIA 558
24.1 EXISTING APPROACHES NOT WORKING 558
24.2 NEED FOR NEW MECHANISMS 559
24.3 RATIONALE FOR COMMUNAL INFRASTRUCTURE, RESOURCES, AND TOOLS 561
24.4 ORGANIZATION OF PROCESS 564
24.5 OVERVIEW OF STRATEGY 565
24.6 IDENTIFYING KEY SOCIETAL DRIVERS AND SETTING PRIORITIES 566
24.7 FORMALIZING THE THREE LIFE CYCLE PROCESSES 571
24.8 GETTING SPECIFIC: END-TO-END IMPLEMENTATION STARTING WITH HIGH-PRIORITY FOCUS AREA(s) 580
24.9 LOOKING AHEAD: EPILOGUE AS PROLOGUE 584
REFERENCES 585
INDEX 588