1. Resolving Clinicians’ On-Line Information Needs: A Brief History of Buttons James J. Cimino, M.D. Biomedical Informatics and Medicine Columbia University June 24, 2005

2. Objectives Studying clinician information needs Evolution of infobuttons Research issues The Coumadin Story

3. 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

4. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Covell et al. Information Needs

5. 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.

6. 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

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. Information for Decision-Making

10. ? MRSA Information for Decision-Making

11. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 Covel et al. Information Needs UMLS Project

12. 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

13. 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

14. 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

20. 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

21. 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

24. 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

25. Cholesterol Hypercholesterolemia Serum Cholesterol Test Serum Specimen Serum From Data to Findings Abnormalities of Serum Cholesterol

29. 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

35. Information Resource Usage 12% IBs

36. Context-Specific Resource Use

37. “Just in Time” Education MRSA

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

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

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

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

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

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

44. “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

45. Research Issues What are the information needs?

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

48. What are the Information Needs? Observations: –Four days, three sites, 159 minutes of videotape –154 information needs 1/3 information about the patient –Abdominal CT was abnormal, what are LFTs? 1/3 institutional information –What specimen do I collect for this test? 1/3 health information –What does this pill look like? –What are the patient instructions? Computers used 50% of the time 81/154 needs not satisfied

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

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

51. 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?

52. The Medical Entities Dictionary (MED)

53. 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?

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 s

65. The Coumadin Story Chair of Medicine wants link to Coumadin protocol First, I have to find the guidelines

67. The Coumadin Story Chair of Medicine wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table

69. The Coumadin Story Chair of Medicine 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…

71. The Coumadin Story Chair of Medicine 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… … and I’m done - about 15 minutes.

75. Discussion Resources are available Simple interactions are usually possible Interaction method (format) issues: –“Give me a page” vs. “Give me the answer” –Standards needed for asking questions –Standards needed for passing parameters Representation (terminology) issues: –Clinical systems use homegrown “standards” –Resources (except PubMed) don’t use any standards (i.e., they are indexed by text word)

76. 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

78. Next Steps Evaluation

80. Next Steps Evaluation Order entry Infobuttons Collaborations: LDS/IHC, Regenstrief and NYSPI Infobutton Manager to be an ANSI standard

81. Conclusions Information needs arise while using CIS Infobuttons are easy to build Build it and they may not come Can retrievals be standardized? Will information needs be satisfied? Will care improve? Resources exist Creative solutions required Need to engage resource providers Infobutton manager provides a platform for exploration

82. Button. - Jimmy Cimino, 1956

83. Acknowledgments The Columbia team: –Jianhua Li –Sue Bakken –Vimla Patel –Mureen Allen –Leanne Currie –Mark Graham LDS/IHC: Guilherme del Fiol, Stan Huff Regenstrief: Marc Overhage NYSPI: Tom White National Library of Medicine research grant National Library of Medicine training grant National Institute of Nursing Research www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html