ACTS COVID-19 Collaborative Learning Community

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  • This page is a resource to help stakeholders working along the COVID-19 evidence-to guidance- to action - to data - to evidence cycle improve their work processes and results (see diagram at the top of this page). The ultimately goal is to a soon as possible, improve COVID-19 care delivery and outcomes.
  • The tables below are designed to aggregate Collaborative participant recommendations for addressing steps in this COVID-19 knowledge ecosystem. The recommended tools and approaches are being gathered and will evolve over time as stakeholder input is received and community consensus around best practices - and the pandemic itself - evolve.

Recommendation

...

     Table List

Table Listing

  • Identify Studies
  • Synthesize Evidence
  • Produce Guidance
  • Make Guidance Computable
  • Implement Guidance
  • Analyze Care Results
  • Leverage Results Analysis (e.g., for Quality Improvement, Reporting, Evidence Generation)

Identify Studies

...

...

...

  • For steroids systematic meta-review, 8 sources have been identified these are (Prospero, ...) 

...

  • Librarian Reserve Corps
    • COVID-Evidence Project - building a database to gather all the evidence around a drug (University of Basil - currently focused on hydroxychloroquine, but model could be adaptable to other targets)
    • Identification of sources to identify primary studies - validation study of specialized COVID-19 databases (systematic reviewers are going to different sources - this effort is to identify best practices)
    • Advocate for librarian representation in searches and reviews - leverage skillsets/best practices in this work
      [SLMC]: close gaps between needs that clinicians are seeing on the front line and topics covered in reviews guidelines
  • COKA Evidence/ Tools WG [Project Google Drive](work in process)

...

Synthesize Evidence

...

...

...

...

...

...

...

...

  • COVID-NMA has initiated communication with all trialists to try to ensure consistent approaches e.g. selection of outcomes, reduction of risk of bias, and to invite them to contribute missing data. 
  • Framework slides: Applying Standards to the Evidence Domain (from the COKA Evidence Ecosystem Liaison WG)

Produce Guidance

...

  • See Output Repositories from Synthesize Evidence table

...

...

...

...

...

Make Guidance Computable

...

  • See output repositories under Produce Guidance

...

...

...

...

...

From C19HCC Digital Guideline WG:

  • Using CPG-on-FHIR standard for representing/ expressing the full intent of the Guidance in computer-interpretable artifacts (part of HL7 CPG-IG)
  • Using the Agile Approach to CPG Development (inclusive of Integrated Process) to concurrently Produce Guidance and Make Guidance Computable (part of HL7 CPG-IG)
  • Use Agile Knowledge Engineering methods, principles, and tools
    • Cross-functional Integrated team (Agile CPG Team)
    • Leverage composite nature of CPGs (e.g. can develop logic for inferences on patient information- CPG_CaseFeatures) to build incrementally and iteratively with rapid feedback
    • Pull knowledge engineers into Content design/reviews; pull domain SMEs into knowledge representation design/reviews
  • Leverage CPG-on-FHIR as a faithful expression of Guidance and its ability to create computationally derived CDS and Cognitive Support, patient-specific, practice-level digital Quality Measures/Metrics, eCaseReports, etc. to create computable artifacts used downstream in the Learning Health System and to provide closed-loop feedback/feedforward.
  • Leverage established tools and capabilities (e.g. BPM+ process and tooling, Clinical Ontology) to author computable Guidance and Open Source tooling to translated into HL7 CPG-on-FHIR to leverage derivative and native compute
  • tips:
    • Use established standards and work with standards community (to understand and evolve as needed)
    • Engage consumers/ users early and often
    • Engage downstream vendors (e.g Terminology vendor USED in the EHRs) early
    • Just because everyone everyone is using the same terminology systems doesn't mean they're agreeing how to use the actual terms- this needs to be considered and addressed to make ecosystem/supply chain work properly (feedforward from Evidence, but also feedback of data semantics back into evidence)
    • Learn from related communities of practice (e.g. Agile Software Engineering)

Implement Guidance (e.g., as CDS, eCQMs)

...

  • See output repositories for Make Guidance Computable

...

  • C19 Digital Guidelines WG developing and implementation guide for COVID-19 interventions

...

Analyze Care Results

...

...

...

Leverage Results Analysis (e.g., for Quality Improvement, Reporting, and Evidence Generation)

...

Process for Populating Recommendation Tables

  • Identify 'leads' for each table who are currently doing extensive, collaborative work around the ecosystem step.
  • Leads provide pointers to what their collaborative communities to be high value resources for table cells
  • Other Collaborative participants likewise add comments and suggestions about this emerging information
  • Formal processes/criteria will be developed by the Collaborative for adding/vetting information in the tables to optimize their value and use (including defining explicit criteria for what belongs in each row), e.g., 
    • Input Sources: 
    • Search Strategies: 
    • Output Repositories: 
    • Standards: 
    • Initiatives: 
    • Tools/Platforms: 
    • Other Best Practices: 

Recommendation Tables for Knowledge Ecosystem Steps

Identify Studies



General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks



What to know/do (and why) Overview

('nouns and verbs' - what goes in rows below in each table are the 'lists' associated with this the bullets in this row)

include: what tools to use under what circumstance. Information about the item so people can match it to their need.


--------------------

Regarding Terminologies: HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.




Input Sources

COVID specific systematic and rapid reviews

COVID specific mixed (reviews and trials)

COVID specific Trials



  • For steroids systematic meta-review, 8 sources have been identified these are (MEDLINE, CORD-19, L-OVE/Episteminokos, NIH iSearch COVID-19, EuropePMC, WHO COVID-19 Database, EMBASE + Prospero) 
Search Strategies



Output Repositories



Standards



Initiatives
  • Librarian Reserve Corps
    • COVID-Evidence Project - building a database to gather all the evidence around a drug (University of Basil - currently focused on hydroxychloroquine, but model could be adaptable to other targets)
    • Identification of sources to identify primary studies - validation study of specialized COVID-19 databases (systematic reviewers are going to different sources - this effort is to identify best practices)
    • Advocate for librarian representation in searches and reviews - leverage skillsets/best practices in this work
      [SLMC]: close gaps between needs that clinicians are seeing on the front line and topics covered in reviews guidelines
  • COKA Evidence/ Tools WG [Project Google Drive](work in process)



Tools/ Platforms

  • Indico’s SaaS approach allows an efficient asynchronous, distributed volunteer workflow for traditional Title/Abstract and Full-Text screening based on PICO inclusion/exclusion criteria with client-defined conflict resolution.




Other Best Practices



Synthesize Evidence


General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks
  • includes evaluation of quality of evidence 
  • also needs to address processing of real world evidence
  • [weave in ICER - search ISER opioids]



What to know/do (and why) Overview


  • For organizations consuming evidence syntheses
    • For selecting/using synthesized evidence: Is there a GRADE evidence profile? Do they make quality assessments? How comprehensive are they? Search date


--------------------


Regarding Terminologies:HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.




Input Sources
Output Repositories


Standards


Initiatives


Tools/ Platforms


Other Best Practices
  • COVID-NMA has initiated communication with all trialists to try to ensure consistent approaches e.g. selection of outcomes, reduction of risk of bias, and to invite them to contribute missing data. 
  • Framework slides: Applying Standards to the Evidence Domain (from the COKA Evidence Ecosystem Liaison WG)
  • ACCP/CHEST notes that given the need for rapid guideline development in COVID (1-2 month timeframe), they do not have the resources needed to produce full GRADE guidelines in these topic areas. They have adopted a heavily modified approach to limit some of the steps of GRADE – given this, they typically issue “ungraded” recommendations related to COVID.

    Modification of the Rapid Guideline Development approach from GIN-McMaster: https://health-policy-systems.biomedcentral.com/articles/10.1186/s12961-018-0330-0





Produce Guidance


General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks



What to know/do (and why) Overview

For people producing guidance:

  • make sure that recommendations include the most specific information possible on who/what/when/where/how (and why); bring guideline consumer stakeholders to the table very early in the process of developing guidelines to ensure that the recommendations will be helpful in meeting clinical needs - and be consumable in a computable fashion. (e.g., - have a knowledge engineer in the loop - see 'make guidance computable section below for details.)
  • Coding is important to support downstream computability efforts - (Need to lay out exactly what guidance producers need to know and do to make this - integrate guidance development with efforts to make computable)
  • For maintenance, i.e., 'living guidance' -
    • Monitor literature (studies and systematic reviews) that relate to the focus of the guideline. Grade material is it becomes available. Don't start from scratch- leverage other efforts to process the upstream evidence. (include links in this guidance section back to pertinent tools in the 'upstream' supply chain tables above)
    • Modify the guideline according.
  • GIN Library to register guidelines in process
  • PICO(TTS) paradigm
  • GRADEpro GDT
  • WHO-INTEGRATE evidence to decision framework
  • EtD Framework
  • mDelphi surveys to achieve consensus
  • GRADE for grading recs
  • GIN-McMaster Guideline Development Checklist
  • WHO Handbook for Guideline Development
  • Indico platform to assist in guideline development and dissemination. Unbundled database of guideline representation that allows precise version control, recommendation-specific database elements including appropriate use, field-level keyword/coding, and consensus management via rec voting/Delphi, form/general/text-specific external feedback. "Living" is achieved by selectively applying updates to the consensus management flow and into deliverable pathways which could include publication, mobile apps, integrated web pages, and any API integrated platform.
  • Many medical professional societies develop guidelines and each has its own manual, available on the society’s website and/or published in their journal

--------------------

Regarding Terminologies: HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.


ACEP/EvidenceCare ED Severity Classification/Testing/Triage Tool
Input Sources
  • See Output Repositories from Synthesize Evidence table
  • BMJ/Remote Triage in Ambulatory Care

  • INESSS has not published any reports on testing/triage but scientific teams at INESSS have provided information to the Ministry of Health for the provincial management of the pandemic. The Institut national de santé publique du Québec (INSPQ – Quebec National Institute of Public Health) is also involved in this regard.


Output Repositories

Standards

IOM Standards: Clinical Practice Guidelines We Can Trust




Initiatives



Tools/ Platforms


Other Best Practices
  • The patient's voice should always be part of guideline and HTA development. Alternatively, include parents of children or other advocates and/or healthcare consumers.
  • COVID-END Recommending WG guidance on producing COVID-19 Guidelines [to be released soon]
  • 2011 NAM (IOM) Standards for Guidelines
  • Guideline development resources: GIN/McMaster Checklist, Australia Guidelines for Guidelines Handbook
  • Methodologies for the Development of CHEST Guidelines and Expert Panel Reports 
  • “Developing an institutional health technology assessment framework: the example of principles for stakeholder participation”, presents some recent developments in INESSS methods;
  • “HTA Ultra-rapid responses to inform decision-making during the COVID-19 pandemic: methodological development”, summarizes the methods developed at INESSS since March to rapidly answer COVID-19 related questions for the Ministry of Health and clinicians in the health network in Quebec.
  • ACCP/CHEST reports that it has been helpful having a preset document format for COVID-related documents so guidelines have a similar structure and format across topic areas. This also allows for more rapid production and development.




Make Guidance Computable


General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks
  • [CPG on FHIR and BPM+ IGs do this separately - need to be combined and simplified (e.g., with helpful graphics); e.g., leverage L1-L4]
  • [Approach section from CPG on FHIR IG might be helpful in framing scope]



What to know/do (and why) Overview

For people looking for guidance repositories:

There are threads of work in HL7 and BPM+ community. Results of this work should be available in the coming weeks/months.

By end of Nov HL7 should publish details of how the DGWG got the ED use case guidance to L3.

Draft slide overview of VA considerations in making guidelines computable

Tips from DGWG, based on CPG on FHIR Implementation Guide:

  • Knowledge Elicitation: This goes through types of input that are needed, what needs to be made explicit and computable. Interactions with people developing the guideline. Getting information from guidance developer tools/artifacts into a DGWG tool (based on McMaster work) for making guidance computable. The DGWG template will be made available as part of this tool.
  • Terminology Management: reach out to terminology vendors for mappings about how terms are expressed in working systems (e.g., EHRs) and connect this to how guidance developers described terms. Narrative guidelines have clinicians as an audience (e.g., understand what terms like 'patients with diabetes' mean); for guidelines to be computerized, these terms must be expressed based on computable code sets. Fleshing out these terms/definitions is the lion's share of the work in making guidelines computable.
  • Execution Model: describes target representation that models the execution semantics that are necessary for any specific implementation (Sivaram/Matt to provide example). Has 'pragmatics' that consistently conveys guidance intent. Translates what SMEs, knowledge engineers, etc. know into system behavior. There are tools to facilitate this work (e.g., OMG BPM+ tools, OWL). 'Case' describes patient details, 'Plan' describes what is (or should be) done for specific patients.

The approach above is intended as a paradigm shift in the approach to developing guidance. Historically it has started with developing a text representation for the guidance that is directly applied by clinicians to enhance decisions and actions. The shift here is developing a computable representation of the guidance that serves as the 'source of truth' for subsequent implementation and modifications. When changes to the guidance model are made, these changes can then flow more seamlessly to CDS interventions, quality measures, eCase Reports, etc. This is more efficient than having a non-computable, text-based representation of the guidance as the 'source of truth,' since the former requires extensive adaptation (which introduces error, ambiguity, time delays, etc.) for implementation and modification.

(Sivaram/Matt to flesh this out) Use shared ontologies to ensure consistent guidelines, reduce rework. These get pulled into authoring tools...


--------------------

Regarding Terminologies: HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.

(VA has library of 100 knowledge artifacts - used HL7 KNART spec to make XML rendering. Using clinical content from these to represent as FHIR questionnaires. This other HL7 work outlined above resonates, and potentially could be leveraged to support VA efforts. There are only a handful of guidelines that VA pushes out from national - other CDS interventions are developed more locally by VA facilities using tools available in the HIT infrastructure. Question: How does the above process reconcile when there are competing recommendations on a particular topic. Answer: The HL7 CPG on FHIR IG addresses localization - can related to workflows, but can also reflect how organizations combine different external recommendations to make essentially a local guideline that differs from the external guidelines. There are 10 workflows and visio diagrams: Robert Lario and Linda Wedemeyer are expressing these in BPM+ as an experiment.)


------------------


[Evidence synthesis teams would like to have something that summarizes for a COVID resource database, where are they pulling information from, what are their inclusion/exclusion criteria, why you might use one source vs. another]

[CPG on FHIR team would like to incorporate insight we generate here - including BPM+ synergies, back into that resource. The 'Integrated Process' about how to develop narrative and computable guidelines in parallel - will be published in about a month.]

Robert Lario - co-chairs OMG BPM+ activities. 3 languages - process modeling (BPMN), decision modeling (DMN), case/event (CMMN) modeling. VA using these to express clinical practice guidelines - sometimes just instructive, other times executable. All have execution models. BPM+ has its own ecosystem. Gaps and hard to do some things with BPM +. Started working on 3 other modeling languages. Situational data - how do you represent structure of data, etc. Provenance who owns/controls and access. and Pedigree: what produces what. Knowledge Package: Many languages/constructs used in a guideline (sequencing). How do you bundle these up into a CPG. How do you surface models, discuss dependencies. Focusing on how do you express knowledge in a clear and unambiguous way, and how to you create artifacts? CPG on FHIR speaks more to methodology - complements BPM+ which doesn't get into deep detail on this. Also not looking at curation and management of models.

Blackford: DGWG ran through effort to implement guidance based on CPG on FHIR. Would like to use a resource like this table to know which tools to use to make guidance computable in different circumstances. How do you implement this at scale.

Address dissemination and marketplaces. (HL7 Marketplaces spec)


Computable version of ACEP/EvidenceCare ED Severity Classification/Triage tool 


Case Study within HL7 CPG on FHIR Implementation Guide for how the C19 Digital Guideline WG supported development of the ACEP/EvidenceCare tool above.


HL7 Care Management Implementation Guide COVID-19 Severity Classification and Disposition (using ACEP/EvidenceCare tool as a use case)


Input Sources
  • See output repositories under Produce Guidance



Output Repositories


Standards


Initiatives



Tools/ Platforms


Other Best Practices

From C19HCC Digital Guideline WG:

  • Using CPG-on-FHIR standard for representing/ expressing the full intent of the Guidance in computer-interpretable artifacts (part of HL7 CPG-IG)
  • Using the Agile Approach to CPG Development (inclusive of Integrated Process) to concurrently Produce Guidance and Make Guidance Computable (part of HL7 CPG-IG)
  • Use Agile Knowledge Engineering methods, principles, and tools
    • Cross-functional Integrated team (Agile CPG Team)
    • Leverage composite nature of CPGs (e.g. can develop logic for inferences on patient information- CPG_CaseFeatures) to build incrementally and iteratively with rapid feedback
    • Pull knowledge engineers into Content design/reviews; pull domain SMEs into knowledge representation design/reviews
  • Leverage CPG-on-FHIR as a faithful expression of Guidance and its ability to create computationally derived CDS and Cognitive Support, patient-specific, practice-level digital Quality Measures/Metrics, eCaseReports, etc. to create computable artifacts used downstream in the Learning Health System and to provide closed-loop feedback/feedforward.
  • Leverage established tools and capabilities (e.g. BPM+ process and tooling, Clinical Ontology) to author computable Guidance and Open Source tooling to translated into HL7 CPG-on-FHIR to leverage derivative and native compute
  • tips:
    • Use established standards and work with standards community (to understand and evolve as needed)
    • Engage consumers/ users early and often
    • Engage downstream vendors (e.g Terminology vendor USED in the EHRs) early
    • Just because everyone everyone is using the same terminology systems doesn't mean they're agreeing how to use the actual terms- this needs to be considered and addressed to make ecosystem/supply chain work properly (feedforward from Evidence, but also feedback of data semantics back into evidence)
    • Learn from related communities of practice (e.g. Agile Software Engineering)




Implement Guidance (e.g., as CDS, eCQMs)


General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks
  • Implement Guidance includes integrating the computable guidance into organizational information system infrastructure, and deploying the intervention to users, and maintaining the interventions over time. Includes looking at 'leading' indicators (e.g., process changes) regarding intervention use and results. (as opposed to the next "Analyze Care Results" table below that addresses 'lagging indicators' (e.g., clinical outcomes))
  • Informatics architecture required to make computable guidelines usable.

--------------------

Regarding Terminologies: HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.


Definition: Implementation is the process of integrating the computable guidance into the practice system, deploying the intervention to users, and maintaining the intervention over time. The process includes pre adoption of innovation (e.g. integration of innovation into EHR, creation of policies and procedures, training, etc.), actual adoption (daily use) and post adoption (maintenance/sustainability). (See Rabin et al. 2008)

Goal: “To assess the extent to which implementation is effective in a specific context to optimize intervention benefits, prolong sustainability of the intervention in that context, and promotes dissemination of findings into other contexts” (Damschroder, et al. 2009)

Framework: The Consolidated Framework for Implementation Research (CFIR), a comprehensive implmentation model that consolidates a broad range of constructs from many theories (theories related to “dissemination, innovation, organizational change, implementation, knowledge translation, and research uptake”)

Rabin BA, et al. A glossary for dissemination and implementation research in health. J Public Health Manag Pract. 2008 Mar-Apr;14(2):117-23.

Damschroder LJ, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50.




What to know/do (and why) Overview

For people looking for guidance repositories:



Regarding Terminologies: HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.




Input Sources
  • See output repositories for Make Guidance Computable

Sources for Computable guidance  

  • Here, please add sources from where organizations can find computable guidance

Implementation should follow selecting the appropriate computable guidance. If the  guidance is not available in a computable format, standards should be followed to translate the knowledge into computable format first. 

 

Process of translating the guideline text into a computable format

 

Criteria for selecting appropriate computable and un-computable guidance

Clinical Practice Guidelines We Can Trust (2011)




Standards

Successful integration of CDSs into the workflow

Standards for implementation success

King DK, et al. Planning for Implementation Success Using RE-AIM and CFIR Frameworks: A Qualitative Study. Front Public Health. 2020 Mar 3;8:59.  

Standards for Outputs

CPG on FHIR; BPM+; CDS Hooks; SMART on FHIR; COVID-19 Interoperability Alliance Value Sets; (Logica-led Care Management Implementation Guide [standards and guidance] to cultivate synergies between CPG on FHIR and BPM+ [in development])

Consolidated Framework for Implementation Research (CFIR)

Modeling guidelines for integration into clinical workflow. Tu SW, et al. Stud Health Technol Inform. 2004;107(Pt 1):174-8.

Standards for Inputs

Implementation should follow selecting the appropriate computable guidance. If the  guidance is not available in a computable format, standards should be followed to translate the knowledge into computable format first. 

Sources for Computable guidance  

CDS Connect Repository

Process of translating the guideline text into a computable format

 Criteria for selecting appropriate computable and un-computable guidance

Clinical Practice Guidelines We Can Trust (2011)




Initiatives
  • C19 Digital Guidelines WG developing and implementation guide for COVID-19 interventions



Tools/ Platforms


Other Best Practices



Analyze Care Results (Within and Across Care Delivery Organizations)


General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks
  • Includes gathering the data that will be analyzed within and across care delivery organizations. A common reference architecture (a template or blueprint from moving data from one system to another) will help ensure that the data can be combined in meaningful ways. The standards and data harmonization initiatives mentioned below should be used with this reference architecture.
  • 'Results' include 'lagging indicators' such as clinical outcomes. Analyzing/addressing 'leading indicators' (e.g., process changes) is addressed under "Implement Guidance"
  • (add something explaining what we mean by 'analyze' - e.g., leveraging machine learning/AI, etc.)



What to know/do (and why) Overview
  • CPG on FHIR: describes how computable guidelines can be used to get data out of EHRs for reporting to registries, health plans, CMS using FHIR (see especially Approach section)
  • MedMorph IG draft (see this page - workflows for how to extract/share data from EHRs to endpoints such as public health agencies and research organizations)
  • Use BPM+ as a standardized way to model workflow and processes; we know how to generate evidence in a standard way; we need to share this knowledge so it can be put into practice in LHS cycle, These processes can all be represented in standard way (BPM+). This will help us be more effective at deploying knowledge in practice. Easier for those in front line to understand and implement guidance. WHO looking at using BPM in developing their L2 artifacts that they use CQL to ultimately express.
  • There is a Tiger Team working to implement the best that BPM+ offers for workflow modeling with what CPG on FHIR offer for decision modeling. Create an 'uber standard'
  • DEQM FHIR IG does similar things to what MedMorph does but focuses on quality reporting. Focused initially on data exchange for quality reporting, but now looking at other use cases, e.g., med reconciliation. Parallel with MedMorph, which focuses more on public health perspectives - and is therefore more robust/expansive in scope. These initiatives are communicating to support how to get FHIR data from EHRs to various different consumers.
  • Pay attention to data quality (details to come); need think about harmonized data quality terminology framework; 3/3 guideline for secondary use of data from EHRs
    • pilot of MedMorph architecture planned for March 21. Will explore whether more specific criteria for sending and receiving data can help improve data quality.
  • ODHSI: data harmonization and the use of data from different systems in a commonly understandable an informative method. (have outstanding data quality dashboard)
  • ACEP/EvidenceCare ED Severity project used CPG on FHIR, so that is a good use case for addressing this part of the cycle. Likewise for UMN work on anticoagulation. (NACHC using CPG on FHIR and MedMorph as part of addressing the full ecosystem cycle for Hepatitis B/C and HIV).



  • Curate data into a structured, centralized resource - applying specific instructions about how to obtain and document the data (historically a manual process to locate information but becoming more automated)
    • Need semantic interoperability so that results can be aggregated/compared across CDOs; should be based on widely used, open data and standards
  • Put information into registry (institution-specific or cross-institution)
  • Generate report - to get feedback about effectiveness, safety, etc. of various interventions


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Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.




Input Sources



Search Strategies



Output Repositories
  • Registries, e.g., from specialty societies. (discuss with Frank Opelka, ACS)



Standards
  • [under development] MCBK Standards WG Metadata work
  • standards that do (or could) underpin registries



Initiatives


Tools/ Platforms


Other Best Practices




Leverage Results Analysis (e.g., for Quality Improvement, Reporting, and Evidence Generation)


General RecommendationsAnticoagulationTesting/TriageOther (Long COVID, Vaccine, Steroids)
Key Definitions and Frameworks



What to know/do (and why) Overview
  • Use reports (see analyze care results)
  • Review reports (see analyze care results) with key stakeholders



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Regarding Terminologies: HL7 Project "Guidelines for a Standardized Terminology Knowledge base"

Regarding Value Sets recommend the following process (applies to anticoagulation, testing/triage, vaccines, steroids, and any other topic):

  1. Take inventory of what value sets you’ll need (be specific)
  2. Check Alliance website or Value Set Authority Center (VSAC), we might have already published some of them among the 600+ value sets
  3. If certain value sets are not present or you are unsure, contact Victor Lee (Victor_Lee@ClinicalArchitecture.com) to inquire or to request development

Clinical Architecture and other Alliance collaborators are donating our efforts, and Clinical Architecture is leveraging its software tooling, hosting infrastructure, and manual labor to donate all of the COVID-19-related value set content to the public domain (i.e., completely free, no strings attached). That being said, we all have day jobs, so we appreciate having as much lead time as possible to fulfill requests. Happy to take questions.


MUSC - AI for risk assessment in virtual visits
Input Sources



Output Repositories



Current StandardsEmerging Standards



Initiatives


Tools/ Platforms



Other Best Practices



...