Just-in-time knowledge management and patient care.

In the last decade considerable attention has been given to making clinical knowledge available ‘just-in-time’1,2,3,4,5 to the primary care physician. It has been estimated that two questions are identified for every three patient encounters, and of these questions, only about 30% are immediately answered. Unmet information needs may result in delayed and uninformed decisions and are one of the causes of medical errors. The magnitude of the task is continually increasing due to the avalanche of information published about new drugs, new clinical procedures, new or revised management for a given disease, and even new diseases. At present, access to just-in-time knowledge is through web-based textbooks, PubMed, drug alerts in automated medication ordering systems, web-based CME, and web-based guidelines that offer evidence-based views of best practice. We will consider three different forms of just-in-time access to medical knowledge. In the first, knowledge access is "pulled" when a provider seeks information about a topic from an educational resource, within a context that the provider identifies manually. A second class of knowledge access occurs when knowledge is "pushed" to a provider. This can occur in the context of a provider performing tasks; e.g., as a provider enters a drug order, drug-drug interaction information is pushed to the provider for review. Knowledge can also be "pushed" to a provider with a context independent of any provider's action -- a context created outside the provider using information or events in the clinical record; e.g., an email about a patient with hyperlipidemia that combines recent labs, medications, and knowledge about recommended actions. Despite the enormous advances which have been made and the abundant amount of knowledge available in a wide variety of resources, there is an Achilles’ heel in the process of medical knowledge access – the information is often not readily accessible and even when available, the material is usually general and not focused on the specific clinical issue. Furthermore, accessing this information usually requires significant time and effort on the part of busy clinical practitioners. As a result, much appropriate information is not used by the health care professional in routine practice. Despite the increasingly robust information technology infrastructure of electronic medical records, there has been little success in integrating knowledge management capabilities with the information recording and retrieval aspects of the EMR. The object of this presentation will be to discuss the different factors that limit clinical knowledge access including a consideration of a knowledge management project at MGH that has successfully integrated in a single portal: knowledge management, workflow support, and a web-based ambulatory medical record system. Specific discussion items will be: How the correct and appropriate knowledge is selected, authenticated, maintained current, and indexed How the knowledge is represented and translated into recommended clinical actions for specific patient problems and specific decision needs How the clinical knowledge is made relevant to the specifics and patterns of care and the available resources of a given medical environment How the clinical knowledge can be integrated with the requirements for medical retrieval and recording How the clinical knowledge access can be integrated with workflow needs and administrative requirements To what extent the clinical knowledge can be codified and represented in a format that can be understood and processed by the computer What are the requirements for a knowledge management infrastructure both to manage the clinical knowledge and to support it with appropriate technology?