1. Infobuttons: Anticipatory Passive Decision Support ACMI Senior Member Presentation James J. Cimino, MD, FACMI Laboratory for Informatics Development NIH Clinical Center and Lister Hill National Center for Biomedical Communications National Library of Medicine Bethesda, Maryland

2. Infobutton (noun): in'·fō·but'·tən – a link from one on-line information system to another that uses contextual information from the former to facilitate the retrieval of relevant information from the latter. Example: links in clinical information systems that provide patient-data-specific links to health knowledge resources. Decision Support. Passive. Anticipatory.

3. Topics The Why, When, and How of infobuttons? Research issues Infobutton and infobutton-like systems The HL7 standard AMIA 2007 demonstration Current status of commercial efforts Librarian Infobutton Tailoring Environment (LITE)

4. Why Infobuttons?

5. Everybody is worried about losing their job to automation. They’re afraid they’ll be replaced by a button. But I’m smart. I’m going to get a job in the factory where they make the buttons. - Jackie Gleason, The Jackie Gleason Show, circa 1968

6. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 G.O. Barnett DXplain Covel et al. Information Needs UMLS Project First Version of UMLS ICD9  MeSH Medline Button Mosaic Infobuttons Web-based Generic Queries Infobutton Manager Infobutton Manager Standard PubMEDWeb DXplain DXplain Button WebCIS Micromedex Infobutton Access Librarian Infobutton Tailoring Environment (LITE) The When of Infobuttons

7. Infobuttons in the Medical Literature Beverly Collins, et al. Attaching Context Sensitive Infobuttons to an EHR Options and Issues. SJ Darmoni, et al. French Infobutton: an academic and… business perspective. Per H Gesteland, et al. Clinician Use and Acceptance of Population-Based Data about Respiratory Pathogens: Implications for Enhancing Population-Based Clinical Practice Sookyung Hyun, et al. Nurses’ Use and Perceptions of Usefulness of National Cancer Institute’s Tobacco-related Cancer Information Service (CIS) Resources. Robert A. Jenders, et al. Standards in Clinical Decision Support: Activities in Health Level Seven.

8. The How of Infobuttons Common tasks may have common needs System knows: –Who the user is –Who the patient is –What the user is doing –What information the user is looking at We may be able to predict the specific need User is sitting at a computer! We may be able to automate retrieval

9. Research Issues MRSA

10. Research Issues Understand Information Needs 1 MRSA

11. Research Issues Get Information From EMR Understand Information Needs 1 2 MRSA

12. Research Issues Get Information From EMR Resource Selection Understand Information Needs 1 2 3 MRSA

13. Research Issues Get Information From EMR Resource Selection Resource Terminology Understand Information Needs 1 24 3 MRSA

14. Research Issues Get Information From EMR Resource Selection Resource Terminology Understand Information Needs Automated Translation 1 254 3 MRSA

15. Research Issues Get Information From EMR Resource Selection Resource Terminology Querying Understand Information Needs Automated Translation 1 254 6 3 MRSA

16. Research Issues Get Information From EMR Resource Selection Resource Terminology Querying Presentation Understand Information Needs Automated Translation 1 254 6 3 7 MRSA

17. Infobutton and Infobutton-like Systems Columbia University’s Infobutton Manager Vanderbilt University’s PC-POETS LDS Hospital’s HELP system Partners Healthcare System’s Knowledgeliink

28. Deployment of Columbia’s Infobutton Manager Columbia University’s Infobutton Manager New York Presbyterian Hospital’s WebCIS New York Presbyterian Hospital’s Eclipsys New York State Psychiatric Institute’s PSYCKES Regenstrief Medical Record System Crystal Run Healthcare’s (Monroe, NY) (NextGen)

30. NY Office of Mental Health (Psykes)

32. Regenstrief Medical Record System

33. Crystal Run Healthcare (NextGen)

34. Infobuttons vs. Infobutton Manager Page of Hyperlinks Infobutton Clinical System Resource Infobutton Manager Context Query Knowledge Base s

35. The HL7 Standard Approved as Draft Standard for Trial Use (DSTU) http://www.hl7.org/v3ballot2008MAY/html/ domains/uvds/uvds_Context- awareInformationRetrieval(Infobutton).htm

39. Example 1: In this example the user is looking at a coded problem list of a male, 77 years-old patient with Bacterial Pneumonia. The user clicks on an infobutton that presents a series of questions. The user selects “How do I treat Bacterial Pneumonia?” The following message payload represents the communication between the Decission Support System and the Information Resource.

40. Pneumonia

41. http://www.e-resource.com/api? infobuttonEventNotification.effectiveTime.v=20060706001023& assignedEntity.name.r=Organization- Username&assignedEntity.certificateText.r=organization-password& patientPerson.administrativeGenderCode.c=F&patientPerson.administrati veGenderCode.dn=Female age.v.v=77&age.v.unit=a ageGroup.v.c=D000368&ageGroup.v.cs=2.16.840.1.113883.6.177&ageGrou p.v.dn=Aged taskContext.c.c=PROBLISTREV&taskContext.c.dn=Problem+list+review& subTopic.c.c=Q000628&subTopic.c.cs=2.16.840.1.113883.6.177&subTopic. c.dn=therapy mainSearchCriteria.c.c=D018410&mainSearchCriteria.c.cs=2.16.840.1.1138 83.6.177& mainSearchCriteria.c.dn=Bacterial+Pneumonia& mainSearchCriteria.c.ot=Pneumonia

42. AMIA 2007 Demo Participants Health care & academic institutions –Intermountain Healthcare, Columbia University, Partners Healthcare Content providers –Wolters Kluwer Health, ACP, EBSCO, Thomson/Micromedex, UpToDate, Lexicomp

49. Current Status of Clinical Systems Epic – InfoButton with direct connection to specific resources Eclipsys – Infobutton tab using HL7 standard

50. Current Status of Infobutton Managers University of Utah –Applications: HELP2 Clinical Desktop, narrative practice guidelines –HL7 compliant, but using original API –Resources: Micromedex, Clineguide, MDConsult, PubMed, Medline Plus, Genetics Home Reference, Gene Tests, Uptodate, Ebsco (Cochrane and CINAHL), ARUP Consult, ICD9 search web site, Intermountain Care Process modules, Intermountain geriatric drug monographs –Context parameters: task context, main search criteria, age, gender, subtopic, observation interpretation (for labs), content recipient, and authentication parameters

51. Current Status of Infobutton Managers Columbia University –Applications: WebCIS, Eclipsys, Regenstrief Medical Record System, generic –HL7 compliant, but using original API –Resources: Anion Gap Calculator, ARUP Reference Manual, Beers Criteria, CancerWEB, CPMC Lab Manual, DrugConsult, FirstConsult, Dxplain, ECG Interpreter, Eclipsys Training, Harrisons Principles of Internal Medicine, Lab Tests Online, LexiComp, MCW Pregnancy Calculator, Medicine on the Net, Micromedex, Miriam-Webster, National Guidelines Clearinghouse, NYPH Antibiotics Guidelines, OneLook, Proquest, PubMed, Rhuematology.org, RxList, UpToDate –Context parameters: task context, main search criteria, age, gender, user type, user ID, medical record number, authentication parameters, “other available data”

52. Current Status of Knowledge Sources Thomson/Reuters –Applications: Mediware Worx, Ex Libris, Crown, "Ask Mayo“ –Limited HL7 compliance –Resources: (Micromedex) Clinical Drug, Clinical Disease, Clinical Lab, Consumer Drug, Consumer Disease, Consumer Lab, Clinical Checkpoints –Context parameters: Application, Care Setting, Institution, Content Target, Language, Subtopics EBSCO –Resources: Medline, Dynamed, CINAHL –HL7 InfoButton Manager; working to extend functionality –Translator

53. Current Status of Knowledge Sources Wolters Kluwer –Resources: Clin-eguide –HL7: Clin-eguide –Parameters: Provider Information, ICD9-CM, SNOMED CT, LOINC, RxNorm, result high/low, age, age group, subtopic, such as diagnosis or treatment Elsevier –Resources: DrugConsult, FirstConsult PIER – currently in hibernation

54. Infobutton Manager Maintenance Tool Functions: Browse Add Update Delete Clinician Infobutton Manager Translation Table Term Translation Context Table Context Matching Infobutton Table Query Construction Page of Links System Maintainer Institution Customization Tasks

55. Librarian Infobutton Tailoring Environment (LITE) Librarian Infobutton Tailoring Environment (LITE) Infobutton Manager Log File LITE Log File LITE Auditing LITE Monitoring Infobutton Manager Monitoring Institution Librarian Context Definition Resource Utilization Terminology Specification Question Construction Resource Selection Clinician Infobutton Manager Translation Table Term Translation Context Table Context Matching Infobutton Table Query Construction Page of Links

56. LITE Research Plan 1)Establish librarian user community 2)Refine LITE features 3)Collect feedback from librarians 4)Develop documentation 5)Collect feedback from librarians 6)Go to (2)

78. Conclusions Infobuttons and infobutton-like applications have a long history of development in the informatics community Context-specific links improve patient care The World Wide Web made resources available and made integration feasible The HL7 standard is driving adoption by clinical system vendors and knowledge vendors Tools are needed to enable institution-specific customization Join LITE and help out

79. Acknowledgments Jianhua Li Many student contributors Steve Johnson Sue Bakken Leanne Currie Guilherme Del Fiol Saverio Maviglia Noemie Elhadad National Library of Medicine

80. www.infobuttons.com

81. www.infobuttons.org

82. lite.dbmi.columbia.edu

83. Buttons. - Jimmy Cimino, 1956