1. Allen Pavilion Medicine Grand Rounds James J. Cimino, MD, FACP, FACMI Professor of Medicine and Biomedical Informatics Columbia University May 13, 2004 “Medical Informatics”

2. Allen Pavilion Medicine Grand Rounds James J. Cimino, MD, FACP, FACMI Professor of Medicine and Biomedical Informatics Columbia University May 13, 2004 “Recognizing and Resolving Information Needs of WebCIS Users”

3. Studying Information Needs Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med. 1985 Oct;103(4):596-9.

4. Results of Observational Study 47 physicians Observed during a half day of typical practice Estimated 2-3 questions per physician per day 269 questions raised about patient management Only 30% were answered during the patient visit Usual resource was another physician

5. Other Observational Studies The information needs of practicing physicians in northeastern New York State. Assessment of physicians' information needs in five Texas counties Information needs of rural health care practitioners in Hawaii. Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians Information needs and information-seeking behaviors of on-call radiology residents Expanding the concept of medical information: an observational study of physicians' information needs Curbside consultation practices and attitudes among primary care physicians and medical subspecialists Information needs of health care professionals in an AIDS outpatient clinic as determined by chart review Methods for assessing information needs of clinicians in ambulatory care. Real-time information-seeking behavior of residency physicians Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered Physicians' use of computer software in answering clinical questions. Residents' medical information needs in clinic: are they being met?

6. Findings Information needs occur often They are often unresolved Computer-based resources are underused: –Lack of knowledge of existence –Lack of access –Lack of navigational skills –Perceived lack of time

7. Information Needs of CIS Users Stereotypical tasks suggest recurrent needs System knows: –Who the user is –Who the patient is –What the user is doing –What information the user is looking at User is sitting at a computer!

8. One-Stop Information Shopping? World Wide Web (The Hyperdocument) Information Resources Biblio- graphic Database Textbook Expert System Health Practitioner

9. One-Touch Information Shopping Information Resources World Wide Web (The Facilitator) Biblio- graphic Database Textbook Expert System Health Practitioner

10. Information for Decision-Making

12. ? MRSA Information for Decision-Making

13. Intelligent Decision Support

15. Query MRSA Intelligent Decision Support ? Result !

16. Automated Decision Support MRSA

17. Automated Decision Support Understand Information Needs 1 MRSA

18. Automated Decision Support Get Information From EMR Understand Information Needs 1 2 MRSA

19. Automated Decision Support Get Information From EMR Resource Selection Understand Information Needs 1 2 3 MRSA

20. Automated Decision Support Get Information From EMR Resource Selection Resource Terminology Understand Information Needs 1 24 3 MRSA

21. Automated Decision Support Get Information From EMR Resource Selection Resource Terminology Understand Information Needs Automated Translation 1 254 3 MRSA

22. Automated Decision Support Get Information From EMR Resource Selection Resource Terminology Querying Understand Information Needs Automated Translation 1 254 6 3 MRSA

23. Automated Decision Support Get Information From EMR Resource Selection Resource Terminology Querying Presentation Understand Information Needs Automated Translation 1 254 6 3 7 MRSA

24. First Attempt: The Medline Button CIS (WebCIS’s predecessor) on mainframe BRS/Colleague (Medline) on same mainframe Get them to talk to each other Search using patient diagnoses and procedures Kludge required Technical success Practical failure

25. Research Issues What are the information needs?

26. Portable Usability Lab User’s Workstation Microphone Video Converter 75 foot cable Converter Controller Cassette Recorder VCR Headphones Video Monitor

28. Research Issues Which context information is important? What are the information needs?

29. Context-Dependent Information Needs AgeSex TrainingRole DataTask Context ? ! Institution

30. Research Issues What resources can satisfy needs? How can retrieval be automated? –What context data are used? –How are the data translated? What are the information needs? Which context information is important?

31. The Medical Entities Dictionary (MED)

32. Research Issues –How are the data transmitted? What are the information needs? Which context information is important? What resources can satisfy needs? How can retrieval be automated? –What context data are used? –How are the data translated?

40. Under the Hood Infobutton links in WebCIS pass context to Infobutton Manager (IM) IM matches context to questions IM uses MED to translate concepts IM constructs English questions and Web links

41. Translation for Decision Support Gentamicin Injectable Gentamicin Gentamicn Sensitivity Test Serum Gentamicin Level Gentamicin Toxicity Etiology Measures Sensitivity Substance Measured Has ingredient Decision Rule Expert System Drug Information Clinical Data

42. Infobutton Manager Manager Maintains list of generic questions and links Maintains list of criteria for matching questions Placeholders are “fill in the blanks” (Madlibs)

43. The Coumadin Story Joe Tennenbaum wants link to Coumadin protocol First, I have to find the guidelines

45. The Coumadin Story Joe Tennenbaum wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table

47. The Coumadin Story Joe Tennenbaum wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table Finally, I link the question to the context

49. The Coumadin Story Joe Tennenbaum wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table Finally, I link the question to the context Voilá!

53. Next Steps Repeat the observational study Look at system logs to see if: –Infobutton use is rising –Use of other resources is falling Order entry Infobuttons Collaboration with Regenstrief and LDS Infobutton Manager to be an ANSI standard

54. Conclusions Information needs arise while using CIS Infobuttons are easy to build Are they the right buttons? Will information needs be satisfied? Will care improve?

55. Acknowledgments National Library of Medicine The team: –Jianhua Li –Sue Bakken –Vimla Patel –Mureen Allen –Leanne Currie –Mark Graham www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html Any users out there?