infobuttons: linking clinical information systems to on-line information resources to resolve...
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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
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Covell et al.Information Needs
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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.
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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
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Information Needs in Clinical Care
?
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Clinical Information for Decision Support
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Health Knowledge for Decision Support
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Automated Clinical Decision Support
Alerting and Reminder System
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Clinical Decision Support Systems
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Infobuttons
Anticipate Need and Provide Queries
i
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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
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Covel et al.Information Needs
UMLSProject
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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
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Covel et al.Information Needs
UMLSProject
First Versionof UMLS
ICD9MeSH
MedlineButton
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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
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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
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
Covel et al.Information Needs
UMLSProject
First Versionof UMLS
ICD9MeSH
MedlineButton
Mosaic
Web-basedGeneric Queries
PubMED
WebCIS
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
G.O. BarnettDXplain
Covel et al.Information Needs
UMLSProject
First Versionof UMLS
ICD9MeSH
MedlineButton
Mosaic
Web-basedGeneric Queries
PubMED
Web DXplain
DXplainButton
WebCIS
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
G.O. BarnettDXplain
Covel et al.Information Needs
UMLSProject
First Versionof UMLS
ICD9MeSH
MedlineButton
Mosaic
Infobuttons
Web-basedGeneric Queries
PubMED
Web DXplain
DXplainButton
WebCIS
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“Just in Time” Education
MRSA
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“Just in Time” Education
UnderstandInformation
Needs
1MRSA
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“Just in Time” Education
Get InformationFrom EMR
UnderstandInformation
Needs
1
2
MRSA
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“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
UnderstandInformation
Needs
1
2
3
MRSA
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“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
UnderstandInformation
Needs
1
24
3
MRSA
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“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
UnderstandInformation
Needs
AutomatedTranslation
1
254
3
MRSA
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“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
QueryingUnderstandInformation
Needs
AutomatedTranslation
1
254
6
3
MRSA
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“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
Querying
Presentation
UnderstandInformation
Needs
AutomatedTranslation
1
254
6
3
7
MRSA
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Research Issues
• What are the information needs?
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Portable Usability LabUser’s Workstation
Microphone
Video Converter
75 foot cable
Converter Controller
Cassette RecorderVCR
Headphones
Video Monitor
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Research Issues
• What are the information needs?
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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
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Research Issues
• Which context information is important?
• What are the information needs?
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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
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Context-Dependent Information Needs
Age Sex TrainingRole DataTask
Context
? !
Institution
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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?
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
G.O. BarnettDXplain
Covel et al.Information Needs
UMLSProject
First Versionof UMLS
ICD9MeSH
MedlineButton
Mosaic
Infobuttons
Web-basedGeneric Queries
InfobuttonManager
PubMED
Web DXplain
DXplainButton
WebCIS
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Infobuttons vs. Infobutton Manager
Pageof
Hyperlinks
InfobuttonClinical System Resourc
e
InfobuttonManager
ContextQuery
KnowledgeBase
s
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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
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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
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1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
G.O. BarnettDXplain
Covel et al.Information Needs
UMLSProject
First Versionof UMLS
ICD9MeSH
MedlineButton
Mosaic
Infobuttons
Web-basedGeneric Queries
InfobuttonManager
InfobuttonManagerStandard
PubMED
Web DXplain
DXplainButton
WebCIS
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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
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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?
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Evaluation Modalities
• System log files
• Pop-up surveys
• On-line feedback
• E-mail surveys
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How much did the IM increase access to health resources?
• Over two years: 20,249 accesses
• Currently: 1,226 per month
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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
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Pop-up Survey Responses
Q1: Easy to useQ2: Got answerQ3: Helpful
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E-mail Survey Responses
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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)
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Usabilty
• Pop-ups and e-mail surveys correlated
• Easy to use (83-92%)
• Faster than usual method (62%)
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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
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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
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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
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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
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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
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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
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Questions?