1. Speed Saves Lives
Leveraging a Massively Parallel Expert System for Patient Surveillance
1

2. Pharmacy OneSource
•9 SAAS healthcare applications
•1 in 3 hospitals in the U.S. utilize our applications
•Active community of > 44,000 of pharmacy professionals.
2

3. Sentri7 Clinical Workflows
Surveillance
Intervention
Documentation
Reporting
3

4. What do we mean by…
Surveillance: Actively monitoring patients to identify
opportunities for intervention
Intervention: changing patient care to improve outcomes
Outcomes:
Quality & Safety
Efficacy
Efficiency
Cost effectiveness
4

5. Electronic Medical Records
EMR
Medications
Surgeries
Visit Diagnoses
Observations
Vitals
Patient Clinician
Lab technician
5

6. Enhancing the EMR
•Activating data Clinician
EMR •Intelligent Decisions
6

7. Reasoning in real time
On Demand
Event Driven
7

8. Event Stream Processing
Rule Rule Rule Rule
Rule T-1 Rule U-1 Rule CE-1 Rule S-1
T-2 U-2 CE-2 S-2
Rule Rule Rule Rule
T-N U-N CE-N S-N
8

9. Extract meaning with rules
HL7 standard open to interpretation
•Discrete and non-discrete data elements
•Variance between vendors & systems
•IDNs, Sites, and departments
Understanding the clinical meaning of a message
•Patient admission & discharge
•Active/visible medications
•Estimated creatinine clearance
•MDRO classification
9

10. What does it mean?
MSH|^~&|EPIC|EPICADT|SMS|SMSADT|199912271408|CHARRIS|ADT^A04|1817457|D|2.5|
PID||0493575^^^2^ID 1|454721||DOE^JOHN^^^^|DOE^JOHN^^^^|19480203|M||B|254 MYSTREET
Data AVE^^MYTOWN^OH^44123^USA||(216)123-4567|||M|NON|400003403~1129086|
NK1||ROE^MARIE^^^^|SPO||(216)123-4567||EC|||||||||||||||||||||||||||
PV1||O|168 ~219~C~PMA^^^^^^^^^||||277^ALLEN MYLASTNAME^BONNIE^^^^||||||||||
||2688684|||||||||||||||||||||||||199912271408||||||002376853
Facts
10

11. Determine relevance with rules
•Clinical outcomes & risk define time windows
•Active alerting
•Daily/weekly routines
•Criteria may exclude portions of the patient model or
patient populations
•Admission/discharge
•Location, patient status.
11

12. Event Lifespan
Reported Analyzed
Observed Received Archived
Event Relevance Window
12

13. Patient surveillance with rules
Active drug order
for "Piperacillin"
Estimated Last
Creatinine Estimated
Clearance < 40 Creatinine
ml/min in the Clearance > 40
last 10 days ml/min
13

14. Sentri7 surveillance rule builder
14

15. Iterative refinement in computer systems
Any automated system has this cycle
Agile attempts to reduce cycle time
15

16. Rule engine performance
FxR=P
Facts X Rules = Evaluations
1 Patient 550 X 57 = 31,428
1 Hospital 605,000 X 57 = 34,571,428
350 Hospitals 211,750,000 X 20,000 = 4,235,000,000,000
16

17. How does reasoning time affect patient care?
•Perception of
responsiveness
•Time sensitivity
of outcomes
17

18. Perception of responsiveness
1. Speed is everything—this is what information
system users value most.
2. Anticipate needs and deliver in real time—deliver
information when needed.
-“Ten Commandments for Effective Clinical Decision Support” American Medical Informatics
Association, 2003
18

19. Time sensitivity of outcomes
Simple, low risk. Therapeutic substitution.
“Nexium IV substituted to protonix”
Show all patients that have an active drug order where the drug
name contains the phrase "Pantoprazole Sodium" and route is IV
Complex, high risk. Sepsis.
“At Very high risk for Severe Sepsis with shock”.
19

20. At very high risk for severe sepsis with shock
Show all patients that have at Group C
least one match from each of the -Lactic Acid >= 3.5 mmol/L
following groups in the last 24 -Serum Creatinine > 2 mg/dL
hours. -Estimated Creatinine Clearance < 50 ml/min
-Platelet count < 80 thou/uL
Group A -Active Drug Order where Drug Name is not in
the list ("WARFARIN SODIUM", "ENOXAPARIN
-Pulse > 90 SODIUM", "HEPARIN SODIUM, PORCINE")
AND has one of the following:
-Resp < 20 -PT (INR) > 1.5
-aPTT > 60 sec
-PaCO2 < 32 mmHg
-BILIRUBIN TOTAL > 2 mg/dL AND ALT (SGPT)
>114 U/L
-Temp not in the range
-VENOUS O2 SATURATION (VO2HB) < 70%
96.8 F to 100.4 F
-pH < 7.30
-PaO2 < 80 mmHg
Group B
-pH < 7.35 AND PaCO2 < 50 mmHg
-WBC Count not in the
Group D
range 4 thou/uL to 12 thou/uL
-SYSTOLIC BP < 90
-Band > 10 % -SYSTOLIC BP has decreased 28%
20

21. Impact of Sepsis on Patient Health
• > 200,000 deaths per year in the US
Patient
Lives • Mortality from severe sepsis is
between 28-50% (with standard care)
• $16.7 billion in total annual U.S.
Hospital costs
Costs • Average cost = $22,100 - $29,900
• Average LOS = 19.6 - 23.3 days
Angus DC et al. Crit Care Med 2001;29(7):1303-1310.
21

22. Space-Based Architecture
22

23. GigaSpaces XAP – Elastic Application Platform
DATA PROCESSING EVENTS & MESSAGING WEB APPLICATION
SUPPORT
MANAGEMENT & HIGH AVAILABILITY ELASTICITY CLOUD
MONITORING READINESS
23

24. GigaSpaces + Drools
Performance
 Collocate rules with the data allowing extreme low latency rules execution
Rules Management
 Dynamically load/unload rules leveraging GigaSpaces & Drools APIs
Ultra Scalable
 Parallel rules execution across the different data-grid partitions
Elasticity
 Scale- up/down, in/out system and leverage extra resources on-demand
within private cloud or public cloud.
High-Availability
 Continuous availability running rules 24X7 without any downtime
24

25. Scaling our decision support system
25

26. Massively Parallel Expert System
Surveillance
Results
GigaSpaces Grid + Drools
26

27. Lessons Learned
•Accelerate through partners
•Procedural vs Declarative
•Open Source
27