Healthcare Knowledge Management:

The Art of the Possible

Syed Sibte Raza Abidi
NICHE Research Group, Faculty of Computer Science, Dalhousie University Halifax,
B3H1W5, Canada

Kevin Lai, Lim Kai Wen, Jacquelyn Wang

 Why - Healthcare Knowledge Management (HKM)

• Recent research & statistics shows

– Suboptimal care occurs due to physicians inability to
access and apply current and relevant healthcare
knowledge
– US Institute of Medicine estimates ~98,000 of patient
death are due to preventable errors
– UK hospitals found that 11% of admitted patience
experienced adverse events of which 48% are likely
preventable if the right knowledge was applied
Why - Healthcare Knowledge Management (HKM)
Clinical "We treat it. If she [he] gets better we know that we're right." `
decisions
Interpretation of
Patient Data

Monitoring Symptoms

Diagnosis
Knowledge of Knowledge
Unique Patient
Patient Response
& Intervention

Treatment Hypothesis

Knowledge of
Treatment
Why - Healthcare Knowledge Management (HKM)

Preventable Errors Medical

(Death & Adverse Breakthroughs
reactions)

New Diagnostic
Communication
Technology
needs (due to
current care
infrastructure) Dynamic Environment

Evolving Best
Practices

Practitioner implicit
knowledge updates
Cost Care Balance
The case for HKM
• Success factors for a clinical decision depends on:
– Availability of correct and relevant knowledge
– In a timely manner
– With respect to the clinical context
• Timely utilization of HKM can transform healthcare practices to
achieve
– high levels of patient safety
– care quality
– team-care
– patient centeredness
– cost-effectiveness
What is HKM
• HKM can be characterized as the
– systematic creation of HKM (evidence based medicine)
– Modelling (care path , care plans)
– Sharing (knowledge sharing and organization learning)
– operationalization and translation of healthcare knowledge to improve the
quality of patient care (put in use)
• In practice, HKM is pursuing this goal through the advancement
of innovative knowledge-mediated solutions and their integration
in institutional workflows, to improve the quality, efficiency and
efficacy of healthcare delivery system.
• Eg. NHG = Faster, Better, Cheaper and Safer
Real world strategy alignments?
• Our Philosophy – Patients First
• We put our patients first. This means we design and provide care and
services around our patients’ needs, not the other way round.
• A key strategy of our patient-centric care is “right sitting” - the right type of
care provided by the right person, at the right place and right time, with
the benefit of quality care and cost savings for patients, and better use of
healthcare resources.
• As far as possible, from the continuum of care available – from home care to
primary care by general practitioners and polyclinics to hospitals and specialist
centres – a patient should be cared for at the most appropriate and affordable
level in this continuum.
• Another of NHG’s key patient-centric strategies is proactive disease
management.
• With the growing incidence of chronic diseases, brought on in part by an
ageing population and changing lifestyles, it is imperative for us to help our
patients detect illnesses early and manage these illnesses well to preserve
their quality of life, with all its attendant benefits.
What is demanded of HKM
• Healthcare professionals are demanding
– Integration and incorporation of current knowledge in clinical workflows to
support decision making.
• Similarly patients demands that each of their care is personalized
and seek to understand their own care continuum and options.
(HKM for patients- correct and accurate information for patients)
• Healthcare Knowledge as a service (Vs Resource)
• To be valuable, these knowledge has to be in active participation
with the healthcare setting & environment rather than a
“repository” / resource
How HKM addresses knowledge gaps (HKM Portfolio)

Knowledge Gaps
(Addressed by)
Technical Infra-structure Operational Info-structure
- KM strategies - Operational issues and strategies
- knowledge representation
- Organizational approaches
(Purpose)
(Purpose)
Develop and deploy Incorporate KM solutions
a knowledge centric solution into the clinical workflow

What does the HKM portfolio do? Why is this important?

Captures, represents, models, organizes and To realize comprehensive, validated and

synthesizes the different modalities of accessible healthcare knowledge resources.
healthcare knowledge
Allows access, sharing and dissemination of Usable format for healthcare stakeholders
current and case-specific knowledge

Operationalizes and utilizes healthcare To provide pragmatic patient care services, such
knowledge within clinical workflows as decision-support and care planning, at the
point-of-care and point-of-need
Healthcare Knowledge (HK)
• Knowledge rich BUT under-utilized
• HK needed to support clinical decision making
– Interplay between the different types of HK
HKM as an Approach
• A systematic approach to design, deploy knowledge-centric
services
• Addresses many issues. 7 examples are:-
of heterogeneous healthcare knowledge resources and modalities
Integration (Evidence-based publications, Problem-based discussions, Experience-based
insights, Observation-based health data)
of healthcare processes and workflows in general
Modeling Using the model to represent heterogeneous healthcare operational environments

Specific needs of range of healthcare knowledge stakeholders.

Understanding Each group has different capabilities, orientations, terminology, expectations
(physicians, nurses, therapists, policy makers, patients, support groups etc)
Dispersion and integration of knowledge across different
Handling 1) Individuals, 2) Departments, 3) Institutions

Unique clinical situations that demand a contextualized manipulation of available

Operating healthcare knowledge to provide patient specific interventions. (Each patient has
unique set of problems)
of the same healthcare knowledge in an inter-changeable and re-usable manner to
Applying different healthcare delivery contexts to achieve improved outcomes.

Practical and meaningful outcome measurement metrics relating the utilization of

Specifying healthcare knowledge to the quality of service.
HKM as a Change Agent
HKM Initiatives

Intention Function

CHANGE AGENTS Change the way healthcare

What are they? knowledge is valued by
stakeholder
Innovative applications

What do they offer? Design and deployment

High-quality knowledge-centric services impacts?
• changes potential for utilization
Examples? • changes pattern of healthcare
• Point-of-care decision support knowledge during care delivery
• Access to evidence based clinical guidelines & lit
• Optimal clinical workflows/pathways
• Sharing and reusing knowledge from experience
HKM as a Strategy
• Ensure successful uptake of HKM applications
allowing them to serve as change agents
Design
Map and identify
Educate institution-
opportunities
Stakeholders specific
and barriers
applications

Design HKM Identify resources

Involve
applications/ and their
Stakeholders
frameworks accessibility

• Translate knowledge into policy and practices

• Address “Know-do” gaps in technical and strategic
dimensions to ensure HKM success
HKM Knowledge Types
8 types: - Orientation and domain of knowledge
- Interplay between types of HK is important for decision making
Patient Health status of the patient. Medical relationships between the various observations of the patient and the inferences
drawn by physicians Provide a complete picture of the patient.
Practice-related tacit knowledge.Withheld by a practitioner and exercised whilst discharging patient care.
Practitioner Acquired from active learning, internship, observations and experiences.

Medical The core domain knowledge describing the theories about health and healthcare, healthcare delivery models and
processes.
The quantification of the care delivery resources and infrastructure available within a healthcare setting.
Resource Up-to-date resource knowledge so that users are aware of what resources are available when they are making
decisions about diagnostic and treatment interventions.
Concerns institution-specific care pathways (or workflows).
Process Standardized way to treat a patient, whilst addressing pragmatic considerations such as the resources needed to treat
the patient as per the care pathway.
Represents the organizational structure and policies exercised by a healthcare institution. It entails the information and
knowledge flows within the organization.
Organizational
Iimportant when deploying HKM solutions because their successful deployment needs to be congruent with the
organizational and process knowledge.
Reflects the social capital withheld
Relationship 1) understanding of how knowledge seeking and sharing can be effectuated. Asking the right question to the right
people
2) communication mechanisms and contacts for the purposes of patient information sharing.
Details the metrics, criterion and standards to measure success of a healthcare delivery process/system and the
associated health outcomes.
Measurement 1)set meaningful performance, efficiency and safety benchmarks,
2)to measure things that really matter as opposed to superfluous parameters,
3)to ask the right research questions,
4)to understand the results with respect to different healthcare contexts,
5)to intelligently analyze the data (Achieving the desired results? What is the knowledge uptake via the deployed HKM
solution?)
HKM Knowledge Modalities
9 types: - Representation medium in which the knowledge exists
- each modality captures ≥1 HK types as HK artifact

Tacit Manifested in terms of practitioners’ problem-solving skills, judgement and

intuition.

Explicit Evidence-based medical literature, reviews, case studies, clinical practice

guidelines and so on.

Clinical (both recorded and observed)

Lessons learnt.
experiences
Collaborative problem-solving discussions between practitioners.

Operational policies eliciting clinical protocols and care pathways.

Educational Medical education content for practitioners

Health education content for patients.

Decision (symbolic) rules obtained from domain experts and/or decision models induced
from data, and stored in knowledge-bases.
support
Social Community of practice (CoP) and their communication patterns, interests and
expertise of individual community members.
knowledge
Data-induced Derived from clinical observations, diagnostic tests and therapeutic treatments
recorded in medical records.
observations
Types VS Modalities
Knowledge Types Knowledge
Modalities
What is it? Orientation and domain of Representation medium in
knowledge which the knowledge exists

No. of types? 8 9

Other Info Each modality can capture one

or more knowledge types as a
healthcare knowledge artifact

Quick note:
Distinction is important for:-
HK Artifact
1) Understanding source and pragmatics
of knowledge type
What are they? Types?
2) Modeling of knowledge using the right Objects that allow Structured
formalism, so that it can be operationalized knowledge to be Semi-structured
for HKM services captured and Unstructured
communicated
independently of
its holder
Spectrum of HKM Services
• HKM
– Provides methodologies and methods to develop task-
oriented services
– Targets specific needs of different healthcare stakeholders

• HKM Service
– Provides functionality to achieve a specified task/function
– Addresses knowledge gaps within the healthcare delivery
process
– Comprises of a wide spectrum of services
– Complements data-driven activities
semantic and
pragmatic viability to a healthcare solution
Spectrum of HKM Services

A hierarchical organization of a spectrum of HKM services

Enabling Services

• To target identification, collection, organization and

modeling of knowledge together with mechanisms to
access the knowledge
• HKM services = knowledge platforms for development
of high level services
Care Services

• Provide operationalization and utilization of healthcare

knowledge
• Used by stakeholders during diagnostic-therapeutic
cycle
• Support for context-specific healthcare delivery needs
• Builds on knowledge capital from the enabling service
• Success relies on transformation services
Transformational Services

• Change agents
• Stipulate and promote culture of knowledge-centric
healthcare practices
• Enhance knowledge uptake through Care services
• Impact on clinical processes, policies, research,
outcome measurements
Transformational Services

• Output = Feedback:-
– Important for the design and functionality of the Enabling
services
– Streamline resources with
• Stakeholder needs and demands
• Operational barriers and opportunities
Scenario

Chronic Clinical and Care is not

disease with operational fully integrated
co-morbidities challenges faced

Operational gaps Information gaps

cause duplication in patient’s
of resources health
Economic burden in
treating chronic Results in sub-
diseases optimal patient care
(Unsafe for the patient!)
HKM Services To The Rescue
HKM Service
Types
Knowledge
Translation

Patient
Management

Knowledge
Sharing

Knowledge
Creation
4 Dimensions of HKM
Must be comprehensive and
pragmatically sound

Aligned with
institutional clinical State-of-the-art
workflows

Specifications
Determines functional
- Service needs
sophistication of HKM
- Usage preferences
service
Research Frontiers in HKM

Available at
point-of-care and
point-of-need

Next-generation of HKM-based patient management

services will be:
• Knowledge centric
• Pervasive
• Pro-active
• Customized to stakeholder needs
• Scientific evidence based
• Inter-operable between different knowledge source and operating
environments
• Embedded within clinical workflows
• Interconnected with patient information systems
• Compliant to standards
• Sensitive to socio-ethical values
Research Frontiers in HKM
Healthcare professionals want to provide optimal, safe and
high quality patient care.

Challenging

It involves a complex, multi-faceted and dynamic interplay

between
• Continuously evolving patient parameters
• Up-to-date medical knowledge, existing in different modalities, that need to
be accurately applied during the discourse of the care process
• Pre-defined medical pathways that need to be adjusted to meet the
patient’s conditions
• Operational constrains defining the healthcare setting
• Health outcome measurements
Semantic Web Framework
Semantic Web
What is it? Features?
Technology used to 1) Semantic modeling of procedural and declarative
develop Next-Gen HKM HK as ontologies
services. - rich, executable knowledge representation formalism
2) Annotation of HK artifacts
Technical framework to - ie. Resource Description Framework
achieve: 3) Representation of different patient data sources
-Interpretation - est. semantic similarity between data elements
-Abstraction 4) Determines semantic interoperability between
-Axiomatization multiple ontologies
-Annotation - use multiple knowledge resources to address all
aspects of a healthcare problem
5) Specifying decision-making logic in terms of
symbolic rules
- infer semantically sound recommendations or
actions
6) Provide justification of inferred recommendations
- help users understand rationale for interventions
Outcomes of research
• Develop a lifelong patient management framework
• Generate adaptive patient-specific care plans
• Guide caregiver’s interventions within specific
healthcare settings
CarePlan framework
• Information layer
• Profile of patient
– Patient documents
– Health records
CarePlan framework
• CarePlan episodes
– Patient’s current health
profile and conditions
– Allows for healthcare
professional to obtain
clinical decision and
care planning in the
form of a CarePlan
query
– A sequence of episodes
is patient’s longitudinal
health record
CarePlan framework
• Knowledge layer
– Knowledge-centric
services
– Verified against clinical
practice guidelines
– Aligned with healthcare
institute’s clinical
pathway
– Knowledge of patient
generated
CarePlan framework
• Knowledge morphing
– Fusion of all relevant
knowledge
• Tacit knowledge of expert
• Problem specific
discussions
• Population health data
• Past evidence
• Clinical decision support
• Guidelines and protocols
CarePlan framework
• Planning layer
• Use of workflow and
proof engine
– Design and validate a
CarePlan
– Based on morphed
knowledge
– Customised to patient’s
needs
– Compliant to current
healthcare setting
• Validated by healthcare
professional
CarePlan framework
• Interface of CarePlan
allows healthcare
professional to interact
• CarePlan is stored in
database as part of
patient’s longitudinal
medical record
• Historical records can
affect future CarePlan
recommended actions
– Eg. Old injuries
sustained, previous
treatments
CarePlan features
• A combination of different patient management
services (eg. Clinical decision support, patient
education, alerts & reminders)
• Creates a personalised healthcare pathway
– a roadmap of clinical care activities
– a recorder of the temporal sequence of medical events,
actions and outcomes as they occur in the longitudinal
continuum of care
– a care-team collaboration medium
– a gateway to access case-specific healthcare knowledge to
justify the patient’s diagnosis and to formulate the patient’s
treatment plan
– patient-specific educational interventions
CarePlan features
• Handles patients with co-morbidities
• Suggests actions and recommendations that are
derived after satisfying the clinical pragmatics
constraints for the patient’s co-morbid conditions
Conclusion
• Increasing demand by healthcare stakeholders for
pragmatic, proactive, multi-faceted and comprehensive
healthcare knowledge to be available at the point of
care
• Need to make use of HKM principles and practices to
allow healthcare professionals to manage medical
knowledge with effectively and with ease
Obstacles and future
• Lack of understanding about the potential of HKM
• Existence of operational barriers towards the flow and
use of knowledge within the healthcare system
• Advancements in HKM applications to remove the
barriers
• Achieve high levels of patient safety, care quality, team-
care, patient centeredness, and cost-effectiveness
• Important to address the scalability, variability and
validity issues concerning both healthcare knowledge
and knowledge-centric services
 Where are we today

http://www.himssanalytics.org/stagesGraph.asp
 Where are we today

http://www.himssanalytics.org/stagesGraph.asp
 Where are we today?
• Full integration of healthcare knowledge management is far
from ideal and unlikely to happen in the near future. This
can be attributed to the various field of specialty. A CDSS
solution is likely to be field specific.
• In practice there are various standardization. Some of the
toughest challenges today is integration and data exchange
and these are primarily driven by standards. Eg. HL7,
DICOM, etc It’s wild wild west out in the industry. Even
when there are standards not all vendors can integrate.
• Basic data dictionary (Diagnosis Codes) can sometimes be
a thorn and not be decided upon and mapped upwards and
downwards (ICD10-SNOMED)
Parting Thoughts

“Everybody lies.“