Scenario

"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 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 system detects that with each XXX administration, the patient experiences a transient, but clinically significant (suboptimal) drop in systemic blood pressure.  These dips, however, are still within the Philips Monitor's configured parameters and so no alarm is triggered. Typically, these transient events would be managed by a dose and/or interval adjustment.  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 patient waveform monitor data is analyzed by a 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 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 participants 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 base that augment its own analytic capabilities. The system publishes its 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 Mayo's 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 system then retrieves the corresponding orderable from Mayo's HeD compliant Order Catalog  and the provider completes and signs the order.

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. The provider accepts the recommendation and the corresponding Motive HeD Risk Assessment form is displayed. Upon completing the survey, the system evaluates the data and promptly 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.