Papers by Howard Goldberg
Pediatrics, Jan 24, 2017
We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN)... more We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma. Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend. We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P < .05) but modestly (2.3%-3.7...
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, Jan 6, 2008
As Electronic Healthcare Records become more prevalent, there is an increasing need to ensure una... more As Electronic Healthcare Records become more prevalent, there is an increasing need to ensure unambiguous data capture, interpretation, and exchange within and across heterogeneous applications. To address this need, a common, uniform, and comprehensive approach for representing clinical information is essential. At Partners HealthCare System, we are investigating the development and implementation of enterprise-wide information models to specify the representation of clinical information to support semantic interoperability. This paper summarizes our early experiences in: (1) defining a process for information model development, (2) reviewing and comparing existing healthcare information models, (3) identifying requirements for representation of laboratory and clinical observations, and (4) exploring linkages to existing terminology and data standards. These initial findings provide insight to the various challenges ahead and guidance on next steps for adoption of information model...
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, Jan 14, 2009
A systematic and standard process for capturing information within free-text clinical documents c... more A systematic and standard process for capturing information within free-text clinical documents could facilitate opportunities for improving quality and safety of patient care, enhancing decision support, and advancing data warehousing across an enterprise setting. At Partners HealthCare System, the Medical Language Processing (MLP) services project was initiated to establish a component-based architectural model and processes to facilitate putting MLP functionality into production for enterprise consumption, promote sharing of components, and encourage reuse. Key objectives included exploring the use of an open-source framework called the Unstructured Information Management Architecture (UIMA) and leveraging existing MLP-related efforts, terminology, and document standards. This paper describes early experiences in defining the infrastructure and standards for extracting, encoding, and structuring clinical observations from a variety of clinical documents to serve enterprise-wide n...
Applied Clinical Informatics, 2016
SummaryFor children who present to emergency departments (EDs) due to blunt head trauma, ED clini... more SummaryFor children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial.Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic® EHR. All sites implementing EHR-based CDS built the rules by using the vendor’s CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider e...
Journal of the American Medical Informatics Association : JAMIA, Jan 13, 2015
Develop and test web services to retrieve and identify the most precise ICD-10-CM code(s) for a g... more Develop and test web services to retrieve and identify the most precise ICD-10-CM code(s) for a given clinical encounter. Facilitate creation of user interfaces that 1) provide an initial shortlist of candidate codes, ideally visible on a single screen; and 2) enable code refinement. To satisfy our high-level use cases, the analysis and design process involved reviewing available maps and crosswalks, designing the rule adjudication framework, determining necessary metadata, retrieving related codes, and iteratively improving the code refinement algorithm. The Partners ICD-10-CM Search and Mapping Services (PI-10 Services) are SOAP web services written using Microsoft's.NET 4.0 Framework, Windows Communications Framework, and SQL Server 2012. The services cover 96% of the Partners problem list subset of SNOMED CT codes that map to ICD-10-CM codes and can return up to 76% of the 69 823 billable ICD-10-CM codes prior to creation of custom mapping rules. We consider ways to increase...
Terminology modeling for an enterprise laboratory orders catalog
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, Jan 14, 2009
Laboratory test orders are used in a variety of clinical information systems at Partners HealthCa... more Laboratory test orders are used in a variety of clinical information systems at Partners HealthCare. At present, each site at Partners manages its own set of laboratory orders with locally defined codes. Our current plan is to implement an enterprise catalog, where laboratory test orders are mapped to reference terminologies and codes from different sites are mapped to each other. This paper describes the terminology modeling effort that preceded the implementation of the enterprise laboratory orders catalog. In particular, we present our experience in adapting HL7's "Common Terminology Services 2 - Upper Level Class Model" as a terminology metamodel for guiding the development of fully specified laboratory orders and related services.
Creating shareable decision support services: an interdisciplinary challenge
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, Jan 13, 2010
Creating shareable decision support services is a complex task requiring effort from multiple int... more Creating shareable decision support services is a complex task requiring effort from multiple interdisciplinary role players with a wide variety of experience and expertise. The CDS Consortium research project has developed such a service, defining a multi-layer representation of knowledge and building upon an architectural service design created at Partners Health Care, and is demonstrating its use in both a local and an external institutional setting. The process was iterative, and we encountered unexpected requirements based on decisions made at various points. We report in this paper on challenges we faced while pursuing this research: knowledge representation and modeling, data interchange and standards adoption, the process of getting agreement on content, logistics of integrating into a system that already has multiple CDS interventions, legal issues around privacy and access, inter-team communication and organization.
Journal of the American Medical Informatics Association : JAMIA, Jan 28, 2014
Clinical data warehouses have accelerated clinical research, but even with available open source ... more Clinical data warehouses have accelerated clinical research, but even with available open source tools, there is a high barrier to entry due to the complexity of normalizing and importing data. The Office of the National Coordinator for Health Information Technology's Meaningful Use Incentive Program now requires that electronic health record systems produce standardized consolidated clinical document architecture (C-CDA) documents. Here, we leverage this data source to create a low volume standards based import pipeline for the Informatics for Integrating Biology and the Bedside (i2b2) clinical research platform. We validate this approach by creating a small repository at Partners Healthcare automatically from C-CDA documents. We designed an i2b2 extension to import C-CDAs into i2b2. It is extensible to other sites with variances in C-CDA format without requiring custom code. We also designed new ontology structures for querying the imported data. We implemented our methodology...
Studies in health technology and informatics
Journal of the American Medical Informatics Association, 2014
Objective To create a clinical decision support (CDS) system that is shareable across healthcare ... more Objective To create a clinical decision support (CDS) system that is shareable across healthcare delivery systems and settings over large geographic regions. The enterprise clinical rules service (ECRS) realizes nine design principles through a series of enterprise java beans and leverages off-theshelf rules management systems in order to provide consistent, maintainable, and scalable decision support in a variety of settings. Results The ECRS is deployed at Partners HealthCare System (PHS) and is in use for a series of trials by members of the CDS consortium, including internally developed systems at PHS, the Regenstrief Institute, and vendor-based systems deployed at locations in Oregon and New Jersey. Performance measures indicate that the ECRS provides sub-second response time when measured apart from services required to retrieve data and assemble the continuity of care document used as input. Discussion We consider related work, design decisions, comparisons with emerging national standards, and discuss uses and limitations of the ECRS. Conclusions ECRS design, implementation, and use in CDS consortium trials indicate that it provides the flexibility and modularity needed for broad use and performs adequately. Future work will investigate additional CDS patterns, alternative methods of data passing, and further optimizations in ECRS performance.
Challenges Implementing Pharmacogenomic Decision Support in the Enterprise Clinical Rules Service
Substitutable apps that run across diverse HIT platforms are feasible, as the experience of the f... more Substitutable apps that run across diverse HIT platforms are feasible, as the experience of the first two years of the SMART Platforms project has shown. Several platforms have become SMART-enabled and several SMART apps that run across HIT platforms have been developed and are now in use. The challenge at this time is to scale this concept and broaden adoption. This will create a market and will unleash the creativity of innovative app developers. One key step is building an easy-to-use API, which has been done. Improvements are underway to add write capabilities. Another important step is to explore forming a SMART consortium which would maintain the SMART API standard, which will underpin an app store (or stores) for health. Context On September 10 and 11, many of the leading thinkers in the world of health information technology came together to review the role and importance of substitutable apps, to discuss a standard that will underpin an "app store" for health, and to determine what actions are required to create an ecosystem for such apps. A few of the key themes are summarized below, and summaries of each session follow.
Applied clinical informatics, Jan 8, 2017
The Centers for Medicare & Medicaid Services' Stage 2 final rule requires that eligible hospi... more The Centers for Medicare & Medicaid Services' Stage 2 final rule requires that eligible hospitals provide a visit summary electronically at transitions of care in order to qualify for "meaningful use" incentive payments. However, Massachusetts state law and Federal law prohibit the transmission of documents containing "sensitive" data unless there is a new patient consent for each transmission. To describe the implementation and evaluation of a rule-based decision support system used to screen transition of care documents for sensitive data. We implemented a rule-based document screening system to identify transition of care documents that might contain sensitive data. The transmission of detected documents is withheld until a new patient consent is obtained. The documents that were flagged as containing sensitive data were reviewed in two different time periods to verify that the decision support system was not missing documents or withholding more documents...
AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium, 2012
The Clinical Decision Support Consortium has completed two demonstration trials involving a web s... more The Clinical Decision Support Consortium has completed two demonstration trials involving a web service for the execution of clinical decision support (CDS) rules in one or more electronic health record (EHR) systems. The initial trial ran in a local EHR at Partners HealthCare. A second EHR site, associated with Wishard Memorial Hospital, Indianapolis, IN, was added in the second trial. Data were gathered during each 6 month period and analyzed to assess performance, reliability, and response time in the form of means and standard deviations for all technical components of the service, including assembling and preparation of input data. The mean service call time for each period was just over 2 seconds. In this paper we report on the findings and analysis to date while describing the areas for further analysis and optimization as we continue to expand our use of a Services Oriented Architecture approach for CDS across multiple institutions.
Workshop on Evaluation of Ontology-based Tools, 2003
CST's Baby CareLink provides a 'collaborative healthware' environment for parents of ... more CST's Baby CareLink provides a 'collaborative healthware' environment for parents of premature infants that incorporates just-in-time learning as one means of knowledge exploration and patient empowerment (1), (2), (3). As the Baby CareLink content base has continued to grow, it has become increasingly difficult for content prescribers to identify all relevant resources for parents at a given point in time
Journal of Biomedical Informatics, 2013
Integration of clinical decision support services (CDSS) into electronic health records (EHRs) ma... more Integration of clinical decision support services (CDSS) into electronic health records (EHRs) may be integral to widespread dissemination and use of clinical prediction rules in the emergency department (ED). However, the best way to design such services to maximize their usefulness in such a complex setting is poorly understood. We conducted a multi-site cross-sectional qualitative study whose aim was to describe the sociotechnical environment in the ED to inform the design of a CDSS intervention to implement the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules for children with minor blunt head trauma. Informed by a sociotechnical model consisting of eight dimensions, we conducted focus groups, individual interviews and workflow observations in 11 EDs, of which 5 were located in academic medical centers and 6 were in community hospitals. A total of 126 ED clinicians, information technology specialists, and administrators participated. We clustered data into 19 categories of sociotechnical factors through a process of thematic analysis and subsequently organized the categories into a sociotechnical matrix consisting of three high-level sociotechnical dimensions (workflow and communication, organizational factors, human factors) and three themes (interdisciplinary assessment processes, clinical practices related to prediction rules, EHR as a decision support tool). Design challenges that emerged from the analysis included the need to use structured data fields to support data capture and re-use while maintaining efficient care processes, supporting interdisciplinary communication, and facilitating family-clinician interaction for decision-making.
Journal of the American Medical Informatics Association : JAMIA
This study sought to develop a functional taxonomy of rule-based clinical decision support.
We seek to leverage enhanced expressivity in OWL 1.1 via property chain axioms with right identit... more We seek to leverage enhanced expressivity in OWL 1.1 via property chain axioms with right identities in order to organize and constrain anatomic concepts for use in clinical descriptions. Anatomic knowledge represented in SNOMED CT uses SEP triplets; we anticipate that property chains will allow a more parsimonious organization of anatomic concepts. However, these constructs may lead to unanticipated inference, especially when scaling to large numbers of concepts [1]. We used a bottom-up approach based on targeted use case questions to iteratively develop a "micro theory" that both identifies the sensible locations of fractures in long bones and also supports logic-based classification of fractures. Alternative representations of the statement "fractures occur in bone" were explored with the aim of creating rich clinical descriptors that support classification for inference and data mining. The process of creating this micro theory is discussed, where pragmatic decisions were made with an intention of both constraining data entry and enabling inferences within the scope of the use cases.
Capturing Clinical Data, Encoding Clinical Knowledge���Implementing a Dual Perspective in Formal Clinical Ontologies
Several efforts have been undertaken to create very large, formal ontologies for health care appl... more Several efforts have been undertaken to create very large, formal ontologies for health care applications."2 Such ontologies are envisioned as the cornerstone of future generations of the electronic medical record in order to 1) guide the representation of clinical events for clinical documentation; 2) represent clinical knowledge necessary for decision support and "intelligent" applications. Because ontologies developed using formalisms such as description logic create concepts by describing definitions, relationships, and constraints, it appears that such ontologies are well-suited to serve as clinical terminologies that can capture clinical data while encoding clinical knowledge. Whether this dual perspective can be adequately incorporated into a single very large clinical ontology remains to be demonstrated.
An enterprise ���Problem Picker��� for capturing clinical problem data
... Proc AMIA Symp. 1998: 1006. PMCID: PMC2232148. Copyright notice. An Enterprise Problem Picke... more ... Proc AMIA Symp. 1998: 1006. PMCID: PMC2232148. Copyright notice. An Enterprise Problem Picker for Capturing Clinical Problem Data. Howard S Goldberg, Vincent Law, Peter C Jones, Kevin D Keck, Mark S Tuttle, and Charles Safran. ...
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Papers by Howard Goldberg