B3 Group


B3 Group Moves the VA and Healthcare Community Towards Standardization with KNARTS project

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The Veterans Health Administration’s (VHA) Office of Knowledge Based Systems (KBS) Clinical Decision Support (CDS) Content and Health Level-7 (HL7)-compliant Knowledge Artifacts (KNARTS) project aligns with the Office’s mission to improve the ability of clinicians to provide patientcare while increasing quality, safety, and efficiency.

The project is designed to support the Department of Veterans Affairs’ (VA) healthcare community in achieving standardization of clinical content by organizing clinical knowledge and logic in a way that is universally shareable via any CDS tool, any Electronic Health Record (EHR), or any IT platform. These updates will thereby improve the ability of clinicians to deliver patient care by increasing quality, safety, and efficiency while also aiming to improve the referral process.

The KNARTS project will enable the VA to take the first step toward widespread sharing of CDS by creating the content for, and the conceptualization and extensible markup language XML-based representations of, Event Condition Action (ECA) rules, order sets, documentation templates, and consult requests which comply with the HL7 CDS Knowledge Artifact Specification (KAS).

To achieve this, B3 Group developed the first set of KNARTS (104 across 10 clinical domains) for future implementation. This included developing the necessary processes and templates to produce the KNARTS. B3 Group collaborated with VA and Department of Defense (DoD) subject matter experts (SMEs) to combine and leverage current agency best practices with commercial best practices and guidance to develop the strongest clinical content aligned with the VA’s respective clinical and patient communities.

The VA anticipates that the KNARTS created as a result of this effort may be made available in central knowledge repositories. The VA anticipates using CDS engines and clinical information systems to search and download KNARTS, such as those that shall be created via this project, for implementation and execution in the future.


Evolving Project Management
This project encompasses new work, is fast-paced and includes a large volume of delivery in a short time span. The team is responsible for 300+ deliverables and has leveraged lessons learned through discussions, weekly status meetings, and collaborative sessions with members of the client management team to work through issues and plan for continued progress.

SME Coordination
The SMEs’ input was extremely valuable for developing the clinical content for the KNARTS, but coordinating schedules and asking for dedicated time/input/reviews for already-busy clinicians was a huge challenge. This challenge did impact the schedule. However, the way B3 Group was able to communicate and work with the team, structure meetings, and create templates for information population/etc., as well as staggering/sequencing the clinical domains’ respective meetings over a few months, had an overall resoundingly positive response. Upon completion of this stage of the project, the best approach identified was to have a limited number of SMEs per clinical domain, each including a Primary Care Clinician.

Deliverable Lifetime After Project Completion
One example of this is that clinical guidance, policies, requirements, etc. will mature over time, and the KNARTS will have to be maintained to reflect the updated information as it aligns with the KNARTS’ CDS. The clinical content white papers, which capture the clinical intent and content for the KNARTS, have been developed to include clear, concise, and complete information, thus acting as the heart for future KNART maintenance.

Nonexistent Platform
All work completed under this project will not be usable until a platform exists that the VA can employ to ingest and process these XML files for end users’ day-to-day work. To better examine the overall production process, there are two recommended options:

1) Run through the entire KNARTS development cycle for a smaller number of KNARTS and then apply the process to all remaining KNARTS.

2) Utilize a prototype innovation effort to cover the entire lifecycle, from development to implementation, in a test environment to help identify all potential issues, lessons learned, etc.


For ECA rules, order sets, and documentation template KNARTS, the team:

  • Researched and identified (in collaboration with VA/DoD SMEs) the specific clinical content, supported by CDS, to be included based on the specific domain and use case.
  • Extracted and represented the clinical information in an HL7 CDS KAS-compliant XML format, including producing an accompanying conceptual structure.
  • Validated the KNARTS for appropriate clinical flow, calculations, and other behaviors and functionality consistent with the clinical content and context of the KNARTS and the HL7 CDS KAS.
  • Recognized that consult request KNARTS required integrating documentation template(s) with one or more order sets to eliminate redundancy and support the correct clinical workflow.

Overall, the open source-based assembly package dynamically generates documents which are situationally aware, contextually appropriate given patient history, and provide evidence-based guidance to clinicians. Together, these attributes ensure Veterans receive not only health services supported by the latest technology but also the latest medical studies.


The program is ongoing through 2018. B3 Group’s results will include providing the VA for the first time with an initial set of KNARTS that can be considered for future implementation, in addition to the templates, processes, and lessons learned.  The deliverables of this program are intended to be leveraged by the VA and set the foundational stage for follow-on work, specifically in creating KNARTS for an expanded set of clinical issues that participating SMEs have identified as high-priority items for the next phase of the Office’s program.

Through B3 Group’s efforts, the program will help move the VA and the entire healthcare community towards standardization of clinical content and interoperable systems, thereby reducing costs for payers and increasing healthcare outcomes for patients.