A study of diverse clinical decision support rule authoring environments and requirements for integration

Abstract

Background: Efficient rule authoring tools are critical to allow clinical Knowledge Engineers (KEs), Software Engineers (SEs), and Subject Matter Experts (SMEs) to convert medical knowledge into machine executable clinical decision support rules. The goal of this analysis was to identify the critical success factors and challenges of a fully functioning Rule Authoring Environment (RAE) in order to define requirements for a scalable, comprehensive tool to manage enterprise level rules.

Methods: The authors evaluated RAEs in active use across Partners Healthcare, including enterprise wide, ambulatory only, and system specific tools, with a focus on rule editors for reminder and medication rules. We conducted meetings with users of these RAEs to discuss their general experience and perceived advantages and limitations of these tools.

Results: While the overall rule authoring process is similar across the 10 separate RAEs, the system capabilities and architecture vary widely. Most current RAEs limit the ability of the clinical decision support (CDS) interventions to be standardized, sharable, interoperable, and extensible. No existing system meets all requirements defined by knowledge management users.

Conclusions: A successful, scalable, integrated rule authoring environment will need to support a number of key requirements and functions in the areas of knowledge representation, metadata, terminology, authoring collaboration, user interface, integration with electronic health record (EHR) systems, testing, and reporting.

Figure 1

Major processes for rule authoring. This diagram outlines six key processes for authoring CDS rules, key artifacts in each process and some associated dependencies. It was developed to assist in defining the requirements for a successful integrated RAE.

Figure 2

Reminder Editor. The Reminder Editor allows users to add a new rule or view/edit existing rules. It has six tabs and this figure includes screen shots of three of the six tabs of the Editor. 1) Reminder Maintenance (Figure 2a) records the metadata and a description of a rule. 2) The Risk Group tab defines specific risk group primitives (such as age, allergy, and disease). 3) Overdue Condition evaluates the most recent data of a test (e.g., Hemoglobin A1c) performed on the patient and determines if the test is due or overdue. 4) Coded Reponses (Figure 2b) are predefined clinician recommendations or actions to be linked to the reminder. Each coded response may have a snooze period associated with it. Snooze periods allow the clinician to defer the follow-up actions for a period of time. 5) Actions (Figure 2c) are commands that will automatically open other system modules or places within LMR. This will allow the clinician to easily implement a coded response reminder recommendation for orders, medications, radiology tests, and so on. 6) Physician Display defines the exact reminder message to be displayed in the patient’s electronic medical records and also defines references (e.g., guidelines) for this reminder.

Figure 3

DDI Editor (interaction between Warfarin and Sulfamethoxazole). On the right pane, a user can search for existing DDIs or add a new DDI by entering a drug name (e.g., Warfarin) in the Medicine search field. The search returns existing DDI records organized by Warfarin concepts coded by the First Data Bank Hierarchical Ingredient Code Sequence Number (HIC-SEQN). For example, H2084 is the HIC-SEQN for Warfarin. In the top right panel, the Editor provides some links to HIC_SEQN and Partners local drug dictionary. 395:2 represents a DDI record for Warfarin, where 395 is a system-generated DDI identifier and 2 is the level of the intervention (i.e., interruptive). The other two levels of intervention are 1- dead stop and 3 - non-interruptive. A text box appears when the user hovers over 395:2 and shows more information about the DDI. To view the details of a DDI, a user can click on one of the DDI records or type the DDI identifier in the Record # box in the top left panel of the DDI Editor. On the left panel, the Editor displays the details of a DDI, including message, locally defined category, intervention level, drugs in Partners drug dictionary that are mapped to the HIC-SEQN, conditions and action. The user can modify existing DDI or define a new DDI using the user interface on the left panel.

Figure 4

Medication Rule Editor in an ambulatory EHR. Rule editor used in ambulatory EHR to author drug-disease, drug-pregnancy, drug lab, drug-group, group-group interactions.