A Web Services Approach to Public Health Clinical Decision Support

Oct. 25, 2016
Could clinicians subscribe to real-time public health clinical decision support 'knowledge nuggets' from within their EHR workflow?

Although it is still early days, I am increasingly convinced that the movement to bring a web services approach to healthcare is real. Every week brings announcements of new efforts to create modules that do one thing well and that providers could subscribe to from within their EHR. This approach makes so much more sense than each provider working with its software vendor to recreate the wheel.

This is especially appealing in the realm of clinical decision support (CDS), in which knowledge management is so time-consuming and difficult for provider organizations. But could hospital physicians and ambulatory providers subscribe to real-time public health clinical decision support information from within their EHR workflow? That is the question that two clinical informatics fellows at the Children’s Hospital of Philadelphia (CHOP) are seeking to answer with the creation of PHRASE (Population Health Risk Assessment Support Engine). As I understood it, their prototype solution takes advantage of FHIR to match up public health recommendations to relevant patient encounters in real time.

PHRASE was chosen as the first place winner of the Practical Playbook and the de Beaumont Foundation's Closing the Data Divide Challenge and also one of four to take first place in ONC's Provider User Experience Challenge.

On Oct. 20, Mark Tobias, M.D., and Naveen Muthu, M.D., the two informatics fellows and practicing physicians, gave a presentation at CHOP about the problems they saw in getting relevant public health information at the point of care and how their solution might help.

Muthu said that as part of their work, they checked in with approximately 30 different healthcare organizations to get a sense of where they are with CDS governance and what their needs are. He gave an anecdotal example of the type of problem they are trying to solve: How a physician knows how to get knowledge or support when they are seeing a pregnant patient who traveled to the Miami area and now has a fever. The clinician can go to the CDC website or look for an e-mail from the local department of public health that summarizes what to do. The CDC has found that providers know they are supposed to do something, but often don’t order all the tests that CDC suggests for optimal care. CDS is critical, Muthu said, because the knowledge base is changing so fast. “Clinical decision support removes the need for providers to know what they don’t know and provides them with in-context information.”

 They spoke with 30 healthcare organizations about how they keep up with updates such as CDC Zika guidelines in terms of CDS.

“Many said they don’t know how to implement a change management process, he said, One community hospital with 500 providers and a chief medical information officer told them that although the hospital has had CDS capability for several years, it has only built six pieces of CDS since the EHR went live. “They haven’t cobbled together the expertise to go through a CDS lifecycle,” Muthu said.

He said hospitals that use Epic or Cerner have to customize CDS.  “What they offer is a bucket of tools. But you have to build and maintain the knowledge. The knowledge management phase is where things fall apart entirely,” he said. “Many organizations don't have a process for review to make sure it is up to date.”

In crafting a potential solution, Muthu and Tobias looked at how to break up the elements in the CDS support lifecycle to determine which aspect the public health organizations can do and which the provider can do. The public health groups can identify formal definitions and logic conditions, and the providers can identify workflow scenarios and convert that to their platform.

In this scenario, the public health institution authors and maintains CDS knowledge artifacts and the provider integrates it into work flow.

PHRASE works as a CDS integrator sitting between the public health agency and the provider organization’s EHR, Tobias said.

As their website notes, “PHRASE offers a vendor-agnostic method to provide guideline recommendations to and receive data from electronic health records. For a healthcare organization, PHRASE offers an up-to-date knowledge base for clinical decision support systems that can be incorporated into local practices and workflows with ease.” The prototype was created using CHOP’s customized CDS within its flavor of Epic and alerts from CDC and the City of Philadelphia Department of Public Health.

As the clinical encounter is going on, the PHRASE engine sits between the EHR and the public health data repository in the cloud. Using FHIR requests against the EHR data, it checks to see if any of the criteria that would spur a public health recommendation are met, and if so the CDS alert pops up in the EHR. Tobias demonstrated how a clinical encounter documented in Epic brings over the recommendation from the public health agency.

To avoid providers getting too many alerts, they can turn on and off public health CDS from CDC and other local and state agencies.

PHRASE also allows reporting from frontline clinicians back to the content creators via real-time feedback. So while clinicians consume these recommendations in the EHR, they can also utilize one-click reporting of disease cases back to the public health department.

Muthu and Tobias are starting to pilot PHRASE’s use in areas of emerging illness such as the Zika virus, local surveillance for problems like lead poisoning, and recognition of patterns like toxidromes based on recent poison control data. 

They are reaching out to other provider organizations to have them test PHRASE in their environments.

“We have to determine the cost in time and resources for scaling the system across institutions,” Tobias said.

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