Infobuttons: Linking Clinical Information Systems to On-Line Information Resources to Resolve...

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

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covell et al.Information Needs

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.

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

Information Needs in Clinical Care

?

Clinical Information for Decision Support

Health Knowledge for Decision Support

Automated Clinical Decision Support

Alerting and Reminder System

Clinical Decision Support Systems

Infobuttons

Anticipate Need and Provide Queries

i

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

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covel et al.Information Needs

UMLSProject

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

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

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

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

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


UMLSProject


ICD9MeSH

MedlineButton

Mosaic

Web-basedGeneric Queries

PubMED

WebCIS

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain


UMLSProject


ICD9MeSH

MedlineButton

Mosaic


PubMED

Web DXplain

DXplainButton

WebCIS

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain


UMLSProject


ICD9MeSH

MedlineButton

Mosaic

Infobuttons


PubMED

Web DXplain

DXplainButton

WebCIS

“Just in Time” Education

MRSA


UnderstandInformation

Needs

1MRSA


Get InformationFrom EMR


Needs

1

2

MRSA



ResourceSelection


Needs

1

2

3

MRSA



ResourceSelection

ResourceTerminology


Needs

1

24

3

MRSA



ResourceSelection

ResourceTerminology


Needs

AutomatedTranslation

1

254

3

MRSA



ResourceSelection

ResourceTerminology

QueryingUnderstandInformation

Needs


1

254

6

3

MRSA



ResourceSelection

ResourceTerminology

Querying

Presentation


Needs


1

254

6

3

7

MRSA

Research Issues

• What are the information needs?

Portable Usability LabUser’s Workstation

Microphone

Video Converter

75 foot cable

Converter Controller

Cassette RecorderVCR

Headphones

Video Monitor

Research Issues


Information Resource Use According to Log Files

6%

4%

4%

4%

51%

3%3%7%

6%

1% 1%10% MicromedexPharmacy IB

Sensitivity IBCulture IB

Ovid MedlineOnline FormularyHarrison's

PubMedJournals

MedlinePlusICD9-CM

Other Resources

12% IBs

Research Issues

• Which context information is important?


Context-Specific Resource Use

0%

20%

40%

60%

80%

100%

Sensitivity IB

Culture IB

Pharmacy IB

Medlineplus

ICD9-CM

Journals

PubMed

Harrison's

Formulary

Ovid Medline

Micromedex

Context-Dependent Information Needs

Age Sex TrainingRole DataTask

Context

? !

Institution

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?

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain


UMLSProject


ICD9MeSH

MedlineButton

Mosaic

Infobuttons


InfobuttonManager

PubMED

Web DXplain

DXplainButton

WebCIS

Infobuttons vs. Infobutton Manager

Pageof

Hyperlinks

InfobuttonClinical System Resourc

e

InfobuttonManager

ContextQuery

KnowledgeBase

s

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

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

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain


UMLSProject


ICD9MeSH

MedlineButton

Mosaic

Infobuttons


InfobuttonManager

InfobuttonManagerStandard

PubMED

Web DXplain

DXplainButton

WebCIS

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

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?

Evaluation Modalities

• System log files

• Pop-up surveys

• On-line feedback

• E-mail surveys

How much did the IM increase access to health resources?

• Over two years: 20,249 accesses

• Currently: 1,226 per month

Resource and Question Selection from HR and IM Pages

0

1000

2000

3000Laboratory Results Review

0

200

400

600Inpatient Drug Order Review

0

20

40

60Microbiology Sensitivity Results

0

100

200Diagnosis List

0

20

40

60Inpatient Lab Order Entry

0

50

100

150

200Inpatient Drug Order Entry

Pop-up Survey Responses

Q1: Easy to useQ2: Got answerQ3: Helpful

E-mail Survey Responses

0%

20%

40%

60%

80%

100%A

tte

nd

ing

Ho

use

sta

ffN

urs

eS

tud

en

tO

the

r

Atte

nd

ing

Ho

use

sta

ffN

urs

eS

tud

en

tO

the

r

Atte

nd

ing

Ho

use

sta

ffN

urs

eS

tud

en

tO

the

r

Atte

nd

ing

Ho

use

sta

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Q2 Q3 Q4 Q5 Q6

5

4

3

2

1

Q2: Infobuttons are easy to useQ3: Presence of question on the listQ4: Speed of answerQ5: Helpful answerQ6: Positive effect on patient care decisions1 (strongly positive) to 5 (strongly negative)

Usabilty

• Pop-ups and e-mail surveys correlated

• Easy to use (83-92%)

• Faster than usual method (62%)

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

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

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

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

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

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

Questions?

Infobuttons: Linking Clinical Information Systems to On-Line Information Resources to Resolve...

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