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

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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
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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 Oct103(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
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Clinical Decision Support Systems
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Infobuttons
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
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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
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First Attempt The Medline Button

• CIS (WebCISs 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 (WebCISs 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
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1984 1986 1988 1990 1992
1994 1996 1998 2000
2002 2004
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1984 1986 1988 1990 1992
1994 1996 1998 2000
2002 2004
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Just in Time Education
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Just in Time Education
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MRSA
Understand Information Needs
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Just in Time Education
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Get Information From EMR
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MRSA
Understand Information Needs
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Just in Time Education
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Get Information From EMR
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MRSA
Understand Information Needs
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Resource Selection
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Just in Time Education
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Get Information From EMR
Resource Terminology
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MRSA
Understand Information Needs
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Resource Selection
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Just in Time Education
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Get Information From EMR
Automated Translation
Resource Terminology
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MRSA
Understand Information Needs
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Resource Selection
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Just in Time Education
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5
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Get Information From EMR
Automated Translation
Resource Terminology
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1
MRSA
Querying
Understand Information Needs
3
Resource Selection
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Just in Time Education
2
5
4
Get Information From EMR
Automated Translation
Resource Terminology
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1
MRSA
Querying
Understand Information Needs
3
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Resource Selection
Presentation
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Research Issues

• What are the information needs?

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Portable Usability Lab
Users Workstation
75 foot cable
Video Monitor
Converter Controller
Microphone
Video Converter
Headphones
VCR
Cassette Recorder
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Research Issues

• What are the information needs?

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Information Resource Use According to Log Files
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Research Issues

• What are the information needs?

• Which context information is important?

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Context-Specific Resource Use
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Context-Dependent Information Needs
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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
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Infobuttons vs. Infobutton Manager
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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
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Infobutton Managers have been Deployed

• New York Presbyterian Hospitals WebCIS
• New York Presbyterian Hospitals Eclipsys
• New York State Psychiatric Institutes PSYCKES
• Regenstrief Medical Record System
• LDS Hospitals HELP system
• Partners Healthcare Systems Knowledgeliink
• Vanderbilt Universitys PC-POETS

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Evaluation of the Columbia Universitys
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
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Pop-up Survey Responses
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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)
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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?