Use Case Table of Contents
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Bilirubin Chart Writes a Transcutaneous Bilirubin Observations
To assess the risk of hyperbilirubinemia in new borns, a clinician uses a transcutaneous bilirubinometer to read the serum bilirubin levels. The clinician then documents the reading to be stored as part of the patients longitudinal record inside the EHR using the Bilirubin Chart Application.
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Proposed: Comprehensive scenario demonstrating a multitude of different CDS use cases.
This scenario and its constituent uses cases are being developed by the CDS Collaboratory, a "joint venture" between the OpenCDS, Socratic Grid that will soon include other open source HSPC participants.
"A San Diego VA patient with essential hypertension is traveling in the Phoenix area and is involved in a severe car accident that leaves him severely injured and comatose. He is admitted to a local intensive care unit and is being treated, among other things, with drug XY XXX for hypertension. His vital signs and arterial blood pressure are displayed on a bedside Phillips CR Monitor. A Clinical Decision Support System (CDSS) monitors the patient's care and advises the clinical staff as they treat the patient for his injuries.
Use Case #1: The Several days into the hospitalization, the system detects that with each XY administration, the patient experiences is experiencing a transient, but clinically significant (suboptimal) drop in systemic blood pressure. These dips, however, are still within the Philips Monitorpatient monitor's configured parameters and so no alarm is triggered. The system checks with a third party sepsis screening system to evaluate the possibility that these dips are infection related. If there is evidence of sepsis, the system responds accordingly. If not, the system evaluates further and determines that the dips are correlated with with each XXX administration, Typically, these transient events would be managed by a dose and/or interval adjustment if there is no risk of infection. However, the hospital is a NwHN participant and has access to the patient's VA medical history and genome profile. It determines that the patient is genetically predisposed to unpredictable responses to his XXX medication. After determining alternative therapies, the system checks a drug-allergy knowledge base, evaluates the possibilities in light of the patient's VA allergies, recommends a suitable substitute and generates the corresponding provider recommendation.
Use Case #2: When the provider fails to acknowledge the alert within a mandated period of time, the system escalates the message to the provider's cell phone. Upon receiving an appropriate HIPAA compliant text, the provider logins in, opens the alert, reviews several InfoButton provided references, and ultimately accepts the recommendation. The system then retrieves the corresponding orderable from an Order Catalog and the provider completes and signs the order.
Use Case #3: Later, as the patient is preparing to be discharged, the system prompts the provider to complete a suicide risk assessment as recommended for all former combat veterans. Upon completing the survey, the system passes the information to a Suicide Risk predictive model that determines that the patient is a high risk. The corresponding mental health follow-up appointment is made and the VA provider is notified to ensure appropriate transition of care."
Architecture
The CDSS system has components for processing different event types. The waveform monitor data is analyzed by an Event Manager and a Complex Event Processor component that extracts a variety of features from the event stream and publishes those features (facts) to an HL7 compliant Event Publication and Subscription Service.
The CDSS system is a subscriber to the Medical Device topic in the EPS topic tree. The system also subscribes to many other topics that publish clinical data being recorded in the EMR. One of these topics is Medication Administration.
The CDSS system can make requests to remote organizations for pertinent patient information and can parse any returned documents containing valuable past medical history and/or genome profile.
The CDSS system can make requests to non-self knowledge bases that augment its own analytic capabilities. These systems also publish their return advice to a corresponding EPS Advice topic.
An HL7 compliant Unified Communication Services is a subscriber to the EPS Advice topic. It is responsible for communicating advice to recipients and managing any required re-routing or escalation.
The EMR manages provider visualization of advice in part by using a Smart-On-FHIR CDS "Inbox". The Inbox is a Smart On FHIR component that plugs in to a CareWeb bedside GUI. When the provider fails to acknowledge the alert within a mandated period of time, the system escalates the message to the provider's cell phone. Upon receiving an appropriate HIPAA compliant text, the provider logins in, opens the alert, reviews several InfoButton provided references, and ultimately accepts the recommendation.
The CDSS system then retrieves the corresponding orderable from an HeD compliant Order Catalog and the provider completes and signs the order.
The CDSS system can process and display HL7 HeD compliant structured documents, order sets and simple rules. It can evaluate captured data using CDS including predictive models that determines that the patient is a high risk.
