CDS in Regenstrief's New Gopher CPOE
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The Regenstrief Institute's Gopher is a next-generation clinical decision support system that evolved over 25 years to enhance functionality and efficiency in healthcare. Key advancements include dynamic alerting, real-time natural language processing, chart search capabilities, and customizable recipe authoring for decision support logic. The system focuses on improving patient safety, quality of care, and user satisfaction while minimizing the training required for both novice and expert users.
CDS in Regenstrief's New Gopher CPOE
- 1. Regenstrief Institute’s Next-Generation Clinical Decision Support System Jon D. Duke, MD, MS Burke Mamlin, MD Doug Martin MD
- 3. Gopher • Gopher grew from a single clinic to over 1000 workstations, inpatient and outpatient • 25+ years of iterations has resulted in robust functionality and efficiency • Served as the research platform for many of the seminal studies in healthcare computing
- 4. 1984 2010
- 5. Developing the new Gopher • In 2009 Regenstrief Institute began rebuilding its core clinical information system platform • In 2010, we began work on a new web-based version of the venerable Gopher • This system was designed using the knowledge gained from the past 25 years of Gopher as well as from the evolving literature on CPOE system design
- 6. What’s in the new Gopher?
- 7. Major Functions • Order entry • Documentation / note writing • Medication / problem / allergy management • Results viewing • Research • Clinical decision support
- 8. Major Functions • Order entry • Documentation / note writing • Medication / problem / allergy management • Results viewing • Research • Clinical decision support
- 9. Started with a Blank Slate
- 10. Guiding Principles Support Patient Safety Improve Quality of Care Improve User Satisfaction Promote Provider Efficiency
- 11. Usability Goals Minimal Training Necessary Novice & Expert Friendly Keyboard & Mouse Friendly Stay Out of User’s Way
- 13. Architecture Order Order User User SMART SMART Plug-in Plug-in Flowsheet Flowsheet Chart Search Chart Search Entry Entry Preferences Preferences Plug-in Plug-in Widgets Widgets Electronic Electronic Patient Patient User User Plug-in Plug-in SMART Adaptor SMART Adaptor Signature Signature Selection Selection Authentication Authentication Services Services Layout Layout Layout Layout Framework Framework Manager Manager Designer Designer Services Services Electronic Electronic Patient Patient User User SMART SMART Plug-in Plug-in Signature Signature Context Context Context Context API Registry API Registry Services Services Context Context Event Event Component Component Help Help Theme Theme Framework Framework Management Management Management Management Registration Registration Subsystem Subsystem Support Support Services Services Data Data Security Security Messaging Messaging Web Web Solr Search Solr Search Core Core Access Access Services Services Services Services Services Services Engine Engine Services Services
- 14. CDS Advancements in Gopher • Dynamic Alerting • Real-time Natural Language Processing • Chart Search • InfoPanel • Recipe Authoring
- 15. Advancement #1: Alerting • Context-driven dynamic alerts • Alerts that learn • Alert aggregation • Multimedia content
- 16. Dynamic Alerts • Embedded mechanics to dynamically change the alert display based on context – Patient – Physician – Institutional
- 17. Alerting Zones
- 18. Relevance Adjustment Module • Every alert has a baseline relevance level which determines its display location • For example, for DDI alerts, about 40% are interruptive and 60% non-interruptive • The RAM can adjust this default level
- 19. Lisinopril Order Original Alert Final Alert TRIAMTERENE Interacts with LISINOPRIL TRIAMTERENE Interacts with LISINOPRIL Risk of Hyperkalemia DDI DDI Risk of Hyperkalemia Severity: Moderate Alert Service Alert Service K 5.3*, Cr 1.3, GFR 55 Relevance: 5 (Average) Relevance: 7 (High) Relevance Adjustment Module Relevance Adjustment Module Related Related Data Data Concepts Concepts K, Cr, GFR Repository Repository Hyperkalemia Has Relevant Labs: Patient has lab values: K, Cr, GFR K 5.3*, Cr 1.3, GFR 55
- 21. Lisinopril Order Original Alert Final Alert TRIAMTERENE Interacts with LISINOPRIL TRIAMTERENE Interacts with LISINOPRIL Risk of Hyperkalemia DDI DDI Risk of Hyperkalemia Severity: Moderate Alert Service Alert Service K 3.3, Cr 0.8, GFR 114 Relevance: 5 (Average) Relevance: 3 (Low) Relevance Adjustment Module Relevance Adjustment Module Related Related Data Data Concepts Concepts K, Cr, GFR Repository Repository Hyperkalemia Has Relevant Labs: Patient has lab values: K, Cr, GFR K 3.3, Cr 0.8, GFR 55
- 23. Relevance Adjustment Module • RAM can also make changes based on provider characteristics • For example, can make particular alerts non- interruptive for certain specialties • Conversely, for medical students all alerts can be made interruptive
- 24. Learning Mastery TM Nintendo
- 25. Gopher is a Learning System • Gopher can track user actions and activity such as – Number of logins – Frequently selected orders – Responses to previous alerts • Can customize system behavior based on individual user history
- 28. Alert Aggregation • Can receive multiple alerts for the same order simultaneously • Sought to centralize the alerting and also provide quick overview of the safety concerns
- 31. Multimedia Alerts • Gopher alerts can embed pictures, video, hyperlinks
- 32. Advancement #2: Natural Language Processing • Can analyze notes in real-time • Can determine section (e.g., FHx, PMH) to give context to the concepts retrieved • Multiple services may be run simultaneously (e.g.,CDS, quality metrics, study recruitment) • Results may be displayed as alert or used for background data capture Section header detection thanks to SecTag from Vanderbilt University: http://knowledgemap.mc.vanderbilt.edu/research/content/sectag-tagging-clinical-note-section-headers
- 33. Order Detection
- 34. Study Reminders
- 35. Natural Language Processing • Can be used as a CDS trigger • Can be used to enhance structured documentation for meaningful use • Can be used for clinical research • Just beginning to explore the possibilities
- 36. Advancement #3: Chart Search • Google-like search within patient chart • Rapid retrieval of specific events, studies, physician notes • See lab trends, medication histories
- 39. Chart Search Patient Patient User Query User Query User User Selected Selected Patient Record Patient Record Medical Record Medical Record Indexing Indexing Index Builder Index Builder Index Index Query Engine Query Engine Solr/Lucene Solr/Lucene Request Queue Request Queue External External Appointment Appointment ADT Trigger ADT Trigger Batch Processor Batch Processor
- 40. Advancement #4: InfoPanel • The InfoPanel houses a ‘stream’ of information from different sources – Non-interruptive alerts – Clinical calculators – Study reminders – Situational awareness of chart access – Instant messaging
- 41. Non-interruptive Alerts • Adherence study • ADEWS study
- 42. Adverse Drug Event Early Warning System • Adherence study • ADEWS study
- 46. Situational Awareness of Chart Access • Locking of chart by original Gopher system was not popular with users • Must balance multi-user access with need to ensure awareness of current activity on patient
- 47. Situational Awareness of Chart Access
- 48. Situational Awareness of Chart Access
- 49. Situational Awareness of Chart Access
- 50. Advancement #5: Recipe Authoring • Rule authoring – Creating rules to drive decision support logic – Necessary for knowing what alerts should be shown when
- 52. Advancement #5: Recipe Authoring • In Gopher, we are broadening the concept of rule authoring • Introducing the notion of Recipe Authoring
- 53. Good artists copy. Great artists steal. - Pablo Picasso
- 72. User Patient Order Trigger Rosiglitazone Warning
- 73. “Rosiglitazone Warning” has been saved and compiled! Rosiglitazone Warning
- 74. Recipe Authoring = Customization • Design your own alerts • Design your own NLP triggers • Design your own studies
- 75. Gopher Demo
- 76. 5 Advancements in CDS • Dynamic Alerting • Real-Time Natural Language Processing • Chart Search • InfoPanel • Recipe Authoring
- 78. Acknowledgements • Chris Beesley • Allen Logan • Chris Bonham • Ernesto Maldonado • Mike Brehm • Burke Mamlin • Jason Cadwallader • Andrew Martin • Joshua Castagno • Doug Martin • Vidhya Chari • Jim Meeks-Johnson • Parishkar Chauhan • Pat Milligan • Ling Cheng • Justin Morea • Sireesha Chilukuri • Chris Power • Cyril Colvard • Linas Simonaitis • Jonathan Cummins • Kenneth Spry • Alex Franken • Jeff Stroup • Cindi Hart • Blaine Takesue • Charity Hilton • David Taylor • Joshua Jones • Jeff Warvel • Warren Killian • Jennifer Weatherspoon • Jeremy Leventhal • Chen Wen
Editor's Notes
- #49: ? Leave this out?