Howard S. Goldberg

A Description and Functional Taxonomy of Rule-based Decision Support Content at a Large Integrated Delivery Network

OBJECTIVE This study sought to develop a functional taxonomy of rule-based clinical decision support. DESIGN The rule-based clinical decision support content of a large integrated delivery network with a long history of computer-based point-of-care decision support was reviewed and analyzed along four functional dimensions: trigger, input data elements, interventions, and offered choices. RESULTS A total of 181 rule types were reviewed, comprising 7,120 different instances of rule usage. A total of 42 taxa were identified across the four categories. Many rules fell into multiple taxa in a given category. Entered order and stored laboratory result were the most common triggers; laboratory result, drug list, and hospital unit were the most frequent data elements used. Notify and log were the most common interventions, and write order, defer warning, and override rule were the most common offered choices. CONCLUSION A relatively small number of taxa successfully described a large body of clinical knowledge. These taxa can be directly mapped to functions of clinical systems and decision support systems, providing feature guidance for developers, implementers, and certifiers of clinical information systems.

Electronic patient records and the impact of the Internet

The term electronic patient record (EPR) means the electronic collection of clinical narrative and diagnostic reports specific to an individual patient. A true EPR should allow physicians and nurses to practice in a paperless fashion. The wide adoption of Internet technologies should allow truly distributed sharing of patient data across traditional organizational barriers. Hence, the meaning of an EPR, as a representation of documents, should be transformed into a collaborative environment that supports workflow, enables new care models and allows secure access to distributed health data. This paper reviews the current realization of EPRs in the context of paper-based medical records. The Internet architecture that Boston-based medical informatics researchers refer to as W3-EMRS is described in the context of a successful implementation of CareWeb at the Beth Israel Deaconess Medical center. Finally, we describe how this Internet-based approach can be extended beyond the boundaries of traditional care settings to help evolve new collaborative models of eHealth.

A pilot study of distributed knowledge management and clinical decision support in the cloud

OBJECTIVE Implement and perform pilot testing of web-based clinical decision support services using a novel framework for creating and managing clinical knowledge in a distributed fashion using the cloud. The pilot sought to (1) develop and test connectivity to an external clinical decision support (CDS) service, (2) assess the exchange of data to and knowledge from the external CDS service, and (3) capture lessons to guide expansion to more practice sites and users. MATERIALS AND METHODS The Clinical Decision Support Consortium created a repository of shared CDS knowledge for managing hypertension, diabetes, and coronary artery disease in a community cloud hosted by Partners HealthCare. A limited data set for primary care patients at a separate health system was securely transmitted to a CDS rules engine hosted in the cloud. Preventive care reminders triggered by the limited data set were returned for display to clinician end users for review and display. During a pilot study, we (1) monitored connectivity and system performance, (2) studied the exchange of data and decision support reminders between the two health systems, and (3) captured lessons. RESULTS During the six month pilot study, there were 1339 patient encounters in which information was successfully exchanged. Preventive care reminders were displayed during 57% of patient visits, most often reminding physicians to monitor blood pressure for hypertensive patients (29%) and order eye exams for patients with diabetes (28%). Lessons learned were grouped into five themes: performance, governance, semantic interoperability, ongoing adjustments, and usability. DISCUSSION Remote, asynchronous cloud-based decision support performed reasonably well, although issues concerning governance, semantic interoperability, and usability remain key challenges for successful adoption and use of cloud-based CDS that will require collaboration between biomedical informatics and computer science disciplines. CONCLUSION Decision support in the cloud is feasible and may be a reasonable path toward achieving better support of clinical decision-making across the widest range of health care providers.

Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department

Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.

A highly scalable, interoperable clinical decision support service.

OBJECTIVE To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions. MATERIALS AND METHODS The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-the-shelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings. RESULTS The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey. Performance measures indicate that the ECRS provides sub-second response time when measured apart from services required to retrieve data and assemble the continuity of care document used as input. DISCUSSION We consider related work, design decisions, comparisons with emerging national standards, and discuss uses and limitations of the ECRS. CONCLUSIONS ECRS design, implementation, and use in CDS consortium trials indicate that it provides the flexibility and modularity needed for broad use and performs adequately. Future work will investigate additional CDS patterns, alternative methods of data passing, and further optimizations in ECRS performance.

Cytomegalovirus immune globulin after liver transplantation: a cost‐effectiveness analysis

Objective: Cytomegalovirus (CMV) immune globulin (CMVIG) has been shown to significantly reduce severe CMV‐associated disease complicating orthotopic liver transplant (OLT). We evaluated the economic impact of severe CMV‐associated disease and calculated the marginal cost‐effectiveness (C/E) of routine prophylaxis with CMVIG after OLT.Design: C/E analysis.Setting: Four teaching hospitals in Boston.Patients: Patients who underwent OLT from January 1988 through June 1990.Measurements: We gathered actual cost data of hospital care for patients enrolled in a clinical trial of CMVIG prophylaxis in OLT. We calculated average outpatient expenses from a separate group of patients undergoing OLT and developed a regression model to estimate costs during the first year post‐transplant (R2=0.77). Based on this model, we calculated variable costs (in 1999 US dollars) for all patients in the randomized trial. From the published literature we obtained the probability of CMV outcomes and of long‐term survival after OLT. We then developed a decision analytical model to determine an incremental C/E ratio, using a Markov simulation to estimate long‐term survival and long‐term costs. We discounted costs and life‐years at 3% and 5% per yr.Results: Based on the efficacy rate of 54% in the controlled trial, we estimate that CMVIG will increase life expectancy by 0.65 discounted years at an additional cost of

Taking advantage of continuity of care documents to populate a research repository

11 600, providing a marginal C/E ratio of

Underutilization of Anticoagulation for Stroke Prevention in Atrial Fibrillation.

17 900/yr life saved. Examining the confidence limits of efficacy, we estimate that CMVIG will have a marginal C/E ratio of

Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support

66 200 gained/yr at an efficacy of 11% and

Use of a remote clinical decision support service for a multicenter trial to implement prediction rules for children with minor blunt head trauma

14 000 gained/yr at an efficacy of 83%.Conclusion: After OLT, prophylactic CMVIG has an incremental C/E ratio comparable to that of other well‐accepted medical therapies and should be used routinely in these patients.