1. Infobuttons: Linking Clinical Information Systems to On-Line Information Resources to Resolve Clinician Information Needs James J. Cimino, M.D. Biomedical Informatics and Medicine Columbia University

2. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Covell et al. Information Needs

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. Findings of Observational Studies 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

5. Information Needs in Clinical Care ?

6. Clinical Information for Decision Support

8. Health Knowledge for Decision Support

10. Automated Clinical Decision Support Alerting and Reminder System

11. Clinical Decision Support Systems

12. Infobuttons Anticipate Need and Provide Queries i

13. Information Needs of CIS Users 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 So: We may be able to predict the specific need User is sitting at a computer! So: We may be able to get an answer automatically

14. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Covel et al. Information Needs UMLS Project

15. Unified Medical Language System The purpose of the UMLS is to improve the ability of computer programs to “understand” the biomedical meaning in user inquiries and to use this understanding to retrieve and integrate relevant machine-readable information for users. - Donald A.B. Lindberg 1986/1993

16. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Covel et al. Information Needs UMLS Project First Version of UMLS ICD9  MeSH Medline Button

17. 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

22. 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 Technical success Practical failure

23. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Covel et al. Information Needs UMLS Project First Version of UMLS ICD9  MeSH Medline Button Mosaic Web-based Generic Queries PubMED WebCIS

26. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 G.O. Barnett DXplain Covel et al. Information Needs UMLS Project First Version of UMLS ICD9  MeSH Medline Button Mosaic Web-based Generic Queries PubMEDWeb DXplain DXplain Button WebCIS

30. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 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 PubMEDWeb DXplain DXplain Button WebCIS

36. “Just in Time” Education MRSA

37. “Just in Time” Education Understand Information Needs 1 MRSA

38. “Just in Time” Education Get Information From EMR Understand Information Needs 1 2 MRSA

39. “Just in Time” Education Get Information From EMR Resource Selection Understand Information Needs 1 2 3 MRSA

40. “Just in Time” Education Get Information From EMR Resource Selection Resource Terminology Understand Information Needs 1 24 3 MRSA

41. “Just in Time” Education Get Information From EMR Resource Selection Resource Terminology Understand Information Needs Automated Translation 1 254 3 MRSA

42. “Just in Time” Education Get Information From EMR Resource Selection Resource Terminology Querying Understand Information Needs Automated Translation 1 254 6 3 MRSA

43. “Just in Time” Education Get Information From EMR Resource Selection Resource Terminology Querying Presentation Understand Information Needs Automated Translation 1 254 6 3 7 MRSA

44. Research Issues What are the information needs?

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

48. Research Issues What are the information needs?

49. Information Resource Use According to Log Files 12% IBs

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

51. Context-Specific Resource Use

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

53. Research Issues 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? –How are the data transmitted?

54. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 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 PubMEDWeb DXplain DXplain Button WebCIS

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

57. Infobutton Manager Version 1  2 Heuristic evaluation: –Language –Match –Minimalist –Consistency –Memory Infobuttons placed too far from concept (scope) Questions repeat concept each time (too wordy) Resource not always clear (match) Result: questions simplified, resource identified

60. Infobutton Manager Version 2  3 Low selection rate Long perusal time Class project: improve the Infobutton Manager user interface Consistent appearance/layout Minimal text (topics, not questions) Lab evaluation of Version 2: perusal time - 11.13 sec Lab evaluation of Version 3: perusal time - 5.92 sec

71. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 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

72. Infobutton Managers have been Deployed New York Presbyterian Hospital’s WebCIS New York Presbyterian Hospital’s Eclipsys New York State Psychiatric Institute’s PSYCKES Regenstrief Medical Record System LDS Hospital’s HELP system Partners Healthcare System’s Knowledgeliink Vanderbilt University’s PC-POETS

76. Evaluation of the Columbia University’s Infobutton Manager at NYPH Use: who, what, when, where, and why? How usable is it? How useful is it? What impact is it having?

77. Evaluation Modalities System log files Pop-up surveys On-line feedback E-mail surveys

78. How much did the IM increase access to health resources? Over two years: 20,249 accesses Currently: 1,226 per month

79. Resource and Question Selection from HR and IM Pages Laboratory Results Review Inpatient Drug Order Review Microbiology Sensitivity Results Diagnosis List Inpatient Lab Order Entry Inpatient Drug Order Entry

80. Pop-up Survey Responses Q1: Easy to use Q2: Got answer Q3: Helpful

81. E-mail Survey Responses Q2: Infobuttons are easy to use Q3: Presence of question on the list Q4: Speed of answer Q5: Helpful answer Q6: Positive effect on patient care decisions 1 (strongly positive) to 5 (strongly negative)

82. Usabilty Pop-ups and e-mail surveys correlated Easy to use (83-92%) Faster than usual method (62%)

83. Usefulness Logs, pop-ups, and e-mail correlated Useful (69-77%) Question on the list at least half the time (89%) Questions often not on the list: –Test interpretation –Drug details (cost, interactions) 90% got helpful answer

84. Impact Over 20,000 accesses to resources (9%) Positive impact at least half the time: 74% 14 respondents identified one or more specific situations in which patient care improved

85. But Jim, How Can I Play Along at Home? Insert Web browser link into clinical system Set up Infobutton Manager tables: –Translation of concept of interest –Define questions to be answered –Figure out how to answer the questions What resource? How to automate the retrieval? –Define the contexts for the questions

90. Librarian Infobutton Tailoring Environment (LITE) Establish a community of users Develop prototype Iterative design with feedback Tutorial Training Help with integration Terminology issues G08 (resource) grant proposal to the NLM

91. Conclusions Infobuttons are easy to build and integrate Infobuttons increase access to health knowledge Infobuttons improve patient care Many possible questions in each context User interface needs to help user navigate questions Dissemination to other systems requires: –Integration into clinical systems –Finalization of HL7 standard –Standardized interfaces to knowledge resources –Solving the “terminology problem” –Building LITE

92. Acknowledgments The Columbia team: Jianhua Li, Sue Bakken, Vimla Patel, Leanne Currie, Sarah Collins The Students: Mureen Allen, Beth Friedmann, Kevin Jackson, Jenia Pevzner, Jesse Wrenn LDS/IHC: Guilherme del Fiol, Stan Huff Regenstrief: Marc Overhage, JT Finnell NYSPI: Tom White National Library of Medicine research grant National Library of Medicine training grant National Institute of Nursing Research National Library of Medicine Resource Grant? www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html

93. Questions?