1. Integration of Health Information Resources into Electronic Health Records Guilherme Del Fiol, MD, MS Intermountain Healthcare University of Utah, Salt Lake City, UT James J. Cimino, MD Department of Biomedical Informatics, Columbia University, New York, NY Saverio Maviglia, MD, MSc Partners Healthcare System, Boston, MA Nick Ackerson Thomson Micromedex, Greenwood Village, CO

2. Point-of-care information needs 2 questions out of every 3 patients seen Most questions left unanswered Most answers can be found on the Web Used less than 10% of the time Barriers Errors: 770,000 injuries and deaths annually in the US i

3. Content providers EHR developers Healthcare organizations Topics of this Panel What are the benefits? Are people using infobuttons? How can I have infobuttons in my institution? Are there any standards? Have content providers bought into this?

4. Integration of Health Information Resources into Electronic Health Records James J. Cimino, M.D. Department of Biomedical Informatics Columbia University College of Physicians and Surgeons 2006 AMIA Fall Symposium

5. The Columbia/NYPH Infobutton Manager Are people using infobuttons? What are the benefits? Are there any standards? Are content providers bought into this? How can I have Infobuttons in my institution?

6. Infobuttons at My Institution What is an Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager

7. Infobuttons at My Institution What is an Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

11. Infobuttons vs. Infobutton Manager Page of Hyperlinks Infobutton Clinical System Resource Infobutton Manager Context s

15. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

16. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

17. How Does the Infobutton Manager Work? Integrate Link Clinical Application/User’s Browser https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi? MRN= &info_institute= &info_med= &info_context = &info_usertype= &info_age= &info_sex=

18. How Does the Infobutton Manager Work? Integrate Link Clinical Application/User’s Browser Fill in Parameter Values https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi? MRN=3131313&info_institute=GENERIC&info_med=sodium& info_context=LabDetail&info_usertype=MD&info_age=22& info_sex=F

19. How Does the Infobutton Manager Work? Integrate Link Clinical Application/User’s Browser CU/NYPH Infobutton Manager User Clicks On Link Write to Log File Identify Terminology Translate to Terms of Interest Fill in Parameter Values Institute=CPMC & Context=LabDetail Concept=“sodium” Terms= CPMC Serum Sodium Test Sodium Ion Hypernatremia Hyponatremia

20. How Does the Infobutton Manager Work? Integrate Link Clinical Application/User’s Browser CU/NYPH Infobutton Manager User Clicks On Link Write to Log File Identify Terminology Translate to Terms of Interest Match Parameters to Contexts Generate List of Questions/Links Display Page Of Links User Clicks On Link Call Resource Write to Log File Fill in Parameter Values

21. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

22. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

23. How do I integrate the Infobutton Manager? Contact me: jjc7@columbia.edu Agree on Domain And Terminology Identify Resources Determine Method for Automated Retrieval Integrate with Clinical System to Pass Parameters Identify Questions Identify Contexts Add Everything to the Infobutton Manager Manager

24. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

25. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

26. Use of the CU/NYPH Infobutton Manager WebCIS (CU/NYPH) Eclipsys (NYPH)

28. Use of the CU/NYPH Infobutton Manager WebCIS (CU/NYPH) Eclipsys (NYPH) Psyckes (NYSPI)

31. Use of the CU/NYPH Infobutton Manager WebCIS (CU/NYPH) Eclipsys (NYPH) Psyches (NYSPI) RMRS (Regenstrief)

33. Use of the CU/NYPH Infobutton Manager WebCIS (CU/NYPH) Eclipsys (NYPH) Psyches (NYSPI) RMRS (Regenstrief) NextGen (Crystal Run Healthcare)

35. Use of the CU/NYPH Infobutton Manager WebCIS (CU/NYPH) Eclipsys (NYPH) Psyches (NYSPI) RMRS (Regenstrief) NextGen (Crystal Run Healthcare)

36. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

37. Infobuttons at My Institution What is an CU/NYPH Infobutton Manager? How does the CU/NYPH Infobutton Manager work? How do I integrate the CU/NYPH Infobutton Manager Who is using the CU/NYPH Infobutton Manager? How can I use the CU/NYPH Infobutton Manager?

38. Do you want to use the Columbia IM? Contact me: jjc7@columbia.edu Help with terminology/context/questions Adoption of HL7 Librarian Infobutton Tailoring Environment (LITE) Supported by NLM Grant R01LM07593 For more information: http://www.dbmi.columbia.edu/cimino/Infobuttons.html

39. KnowledgeLink S68: Integration of Health Information Resources into EHRs Saverio Maviglia, MD, MSc Partners Healthcare System Harvard Medical School Boston, MA

40. KnowledgeLink v1 Source Application (LMR) Target Reference (Micromedex or Skolar) “digoxin” HTML

42. KL v1: Typical Use Infrequent –2.3x/mo average (0.5 median, range 0.1-100) –0.7% of patient encounters, varying by Provider role (0.8% primary care MDs, 0.3% specialist MDs, 1.1% NPs, 0.3% other) Provider gender (females 1.0%, males 0.5%) Target resource (0.9% MDX, 0.3% Skolar) Site (range 0-18% of encounters) Quick –4 pages accessed per use (only 1 content page) –21 sec spent per content page

44. EFFECTIVENESS AND SATISFACTION 84% of all KnowledgeLink queries are answered 17% of physician use results in a change in management, 33% among specialists >=80% rated KnowledgeLink positively on –Ease of use –Relevance –Speed –Impact on patient care

45. Comments General Praise –Knowledge link is fantastic. VERY useful. –Great resource!! –I love knowledge link Quality of Care –…very helpful with patient-directed questions during the visit –I was able to quickly answer the patient’s question …the patient had been promptly served on his needs –This info actually saved me from making a medical error…I rarely use this feature of the LMR, but this time it really helped me Convenience –Knowledge Link is a great time saver…handy and easy to use. –I really like having the ability to look up drugs without having to change screens –I really like having the information available one click away from the med list –I was very happy to be able to click on the information link as I was pulling up the prescription –To have info on meds right at my fingertips is a great timesaver –it is very helpful to have all the information right at my finger tips instead of browsing through multiple book sources

46. Assertion % agreeing (n=59) KL should be extended to problems and diseases.79% KL should be extended to lab results and reports.67% I would like to be able to specify more precise KL queries. 65% I would like to be able to specify to which resource KL goes. 58% User Requests for KL II

47. KnowledgeLink v2 Target References Micromedex Skolar UpToDate KnowledgeLink Manager Source Applications LMR eMAR Results BWH guidelines

48. Links chosen and ordered according to Context (meds, labs, disease) Source app (LMR, eMAR, Results) Provider (MD, RN, Pharm, other) Clinic Easy to modify/change search, restrict to patient information links, or print

51. KnowledgeLink Sessions

52. KnowledgeLink Users

54. 95% medications 3% lab results 2% diseases 75% Micromedex 19% Partners 3% Skolar 1% eMedicine

55. USAGE BY ROLE 1% of patient encounters (LMR) 40-75% of patient encounters (WebMAR)

56. KL Session Characteristics Num of links viewed Time Spent (median sec) Medications1.37 Labs1.211 Diseases1.212

57. Top Resources (Oct 06) Medications (35529 sessions) 1.MDX (84%) 2.Partners resources (14%) Labs (999 sessions) 1.Skolar/Clineguide (78%) 2.MDX (11%) 3.Partners resource (4%) Diseases (573 sessions) 1.eMedicine (63%) 2.Partners resources (12%) 3.MDX (10%) …UTD was ranked 5 (3%)

59. Summary Infobuttons are utilized and valued by all types of care providers, not just MDs –Rapid adoption despite lack of training or introduction –Extremely positive feedback overall Infobuttons are effective (84% answer rate) Infobuttons can have significant impact on patient care even when used infrequently, but direct measurement of effect is difficult A minimal implementation can be both technically simple and clinically effective

60. Opportunities & Challenges KnowledgeLink is middleware –Easier to develop internally, independent of host applications –Limited influence over hosting applications Context information sent to KL for choosing and ordering links User interface (ex. MGHOE) –Limited (but improved) ability to influence target resources KnowledgeLink is not tied to any controlled vocabularies and terminologies (SNOMED, ATC, ICD-10, RxNorm, etc.) –Makes implementation in host apps a breeze –But query messages less precise and error-prone –Working on national level to establish common query messaging protocols (HL7) Measuring progress is difficult –What metrics to use? –Indirect access to end user Managing 3 rd party reference licenses can be tricky

61. MGH OE

63. HL7 Standard for Infobutton Integration Guilherme Del Fiol, MD, MS Intermountain Health Care University of Utah Salt Lake City, UT

64. Why do we need a standard? There is not a common integration language –Query parameter names –Terminologies used for content search retrieval Hundreds of resources available –Not designed for infobutton integration: suboptimal results –Labor intensive integration: just a few are actually used

65. http://resource1.com/ http://resource1.com/ search = “ azithromycin AND dose ” What is the dose of azithromycin ? i Multiple ways of “asking” the same question http://resource3.com/ searchConcept = 3333 ^ azithromycin filter = 11 ^ dosage http://resource2.com/ query = "azithromycin"[MeSH Terms] AND dose[All Fields]

66. Resource 3 Resource 1 Resource 2 Infobutton Manager API No standard in place Clinical Information System i http://resource1.com/search.cgi? http://resource1.com/search.cgi? search = “ azithromycin AND dose ” http://www.resource3.com/search.cgi? http://www.resource3.com/search.cgi? searchConcept = 3333 ^ azithromycin filter = 11 ^ dosage http://resource2.com/ query = "azithromycin"[MeSH Terms] AND dose[All Fields]

67. Clinical Information System i Resource 3 Resource 1 Resource 2 HL7 Infobutton Manager HL7 Standard-based integration HTML

68. Participants HL7 Clinical Decision Support Technical Committee Health care academic institutions –IHC, Columbia University, Partners Healthcare, Cedars-Sinai, Kaiser Permanente Content providers –ACP, Wolters Kluwer, Micromedex, First Data Bank, Elsevier, Zynx EHR vendors –GE, Epic, Eclipsys

71. Example 1 The user is looking at a 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?”

72. <taskContext code="11" displayName="Problem List Review"/> HL7 code for “Problem list review” HL7 code for “Male” Age in years MeSH code for “Therapy” MeSH code for “Pneumonia” MeSH code for “65 and older”

73. http://www.e-resource.com/api? patientContext.gender.c=C10173 patientContext.gender.dn=Female age.v=77&age.u=y ageGroup.c=D000368 ageGroup.dn=Aged taskContext.c=11 taskContext.dn=Problem list review mainSearchCriteria.c=D018410 mainSearchCriteria.dn=Bacterial Pneumonia subTopic.c=Q000628 subTopic.dn=therapy

74. Example 2 The user (an RN) is looking at a medication list of a female, Spanish speaker, 32 years-old patient. The user clicks on the infobutton next to “Azithromycin” and is presented with a series of links. The user selects the “patient education" link.

75. “Medications list review” User is “care provider” HL7 code for “RN” ISO 639-2 for “English” ISO code for “Spanish” HL7 code for “Female” Content recipient is “patient”

76. http://www.hl7.org/v3ballot/html/ welcome/environment/index.htm

77. Current Status XML version –Approved at committee level –Membership level in January 2007 URL version –Implementation guide (not-normative) –1 st ballot in January 2007 Reference implementations

78. Commercial InfoButton Applications Content Vendors Perspective Nick Ackerson Product Manger – Integrated Solutions Thomson Healthcare

79. InfoButton Snapshot Growing list of HCO’s adopting principle of embedded CDS (InfoButtons) Growing list of HIS vendors realizing benefits of CDS/customer pull Thought leading academia prevalent and well known. Leading push InfoButton API’s now available with commercial access, not just academics HCO’s striving for comprehensive, unbiased standardization of access to clinical content investments. (HL7)

80. Clinical Deployment Results A Case Study: Wake Med 851 Bed Integrated Health Care System, Research Triangle, Raleigh NC 444,360 Outpatient Visits 13,702 Inpatient Surgery & Endoscopy 25,954 Outpatient Surgery & Endoscopy 24,908 Cardiovascular procedures Ranks #1 in volume among all North Carolina Hospitals, highest volume Heart Center North Carolina’s first freestanding Children’s ED ~40,000

81. Wake Med’s Clinical Motivators Manual upkeep of drug policies and procedures Regulation compliance Practice variation Medical errors Adverse events

82. Other Motivators The need to centralize and streamline accessibility to clinical knowledge Assess impact of deploying evidenced- based drug content Analysis of staff time and productivity Improved decision making/Empower clinicians Optimization of content workflow tools to improve performance

83. Online Injectable Administration

86. Results of Deployment Over 55% of Wake Meds surveyed respondents were using InfoButton Altered course of treatment 20% of the time Overall satisfaction was excellent Integration time was 2 – 4 weeks Training was communicated in newsletter.

88. Wake Med Usage

89. Benefits Realized by Users/Institution Reduces time/effort to answer key clinical questions - little/no training required More care, less searching - used frequently Needed knowledge more directly into workflow - affects decisions Context/patient-specific information - more responsive to needs

90. Benefits for Institution Enhanced care sooner: –Quick/easy integration; hosted data –less training Promotes best clinical practices: –Reduce unanswered/un-pursued clinical ?s and negative care impact –Alters medical/treatment decision 15-20% of the time* Leverages existing subscriptions –Summary/infobutton -> drill down to richer content *Health Management Technology “Delivering Informed Care” Feb 2006, Maviglia *Wake Medical Health and Hospitals Survey, 2006

91. Peer Groups Implementing IB applications WakeMed Alverno/Central Washington Ohio Health Cedars Sinai University of North Carolina Healthcare - Chapel Hill Salem Hospital (Epic) Metropolitan Hospital Miami Baptist Sentara Health (Epic) Marshfield Clinic Texas Health Resources (Epic, Baylor) University Medical Center (Eclipsys) Froedtert Hospital (Epic)

92. Lessons Learned Flexible, scaleable, HL7-compliant technology key to meet realities of HIS vendors and HCOs (API’s) Granular content leveraging robust Content Management System is key asset Testing protocols and implementation team is key to successful deployment and usage Demonstrated value from dynamic delivery of information relevant to the clinician’s task Academic research and ongoing market analysis are key to continuous improvement InfoButtons are used by health care providers of all disciplines InfoButtons are convenient, intuitive, effective, and relatively simple to implement Standardized messaging should increase specificity and utility over time, Build out technology Efficient, intuitive, productive and proven to improve care and prevent ADE’s