1. An Integrated Approach to Computer-Based Decision Support at the Point of Care James J. Cimino, M.D., FACMI, FACP Professor of Biomedical Informatics and Medicine Columbia University College of Physicians and Surgeons New York, New NY

2. Motivation: Errors and Information Needs Information needs are frequent and often unmet Unmet needs  delayed/wrong decisions  errors Barriers to information access: –Ignorance of the existence of a resource –Lack of familiarity with using a resource –Effort required (actual or perceived)

3. Options: Computer-based Decision Support Electronic patient records Passive on-line knowledge resources Calculators Stand-alone expert systems Alerting and reminders systems (“push”)

4. Solution: Integrated Decision Support Information needs often occur while using a computer The computer has access to resources The computer can use context to suggest resources The computer can assist retrieval (“pull”) But, build it and they may not come

5. “Just in Time” Education

6. Understand Information Needs 1

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

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

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

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

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

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

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

14. User’s Workstation Microphone Video Converter 75 foot cable Converter Controller Cassette Recorder VCR Headphones Video Monitor

17. Initial Lessons: Observational Data Log file analysis –Resource use varies with user type and task

18. Context-Specific Resource Use

19. Initial Lessons: Observational Data Log file analysis –Resource use varies with user type and task Direct observations –Information needs are frequent (1/5.5min) –Questions are fall into small number of patterns –Resources are available to answer questions –Resources are used infrequently (<50%) –Needs are frequently unmet (51%)

20. Technical Solutions: Infobuttons Infobuttons –Links as “i” icons in clinical information system –Capture context parameters Patient age and gender User Task Concept of interest –Pass information to Infobutton Manager Infobutton Manager –Can be called from any system with Web access –Matches context to questions –Creates links to answer context-specific questions –Passes links back to user (“pull”)

28. Evaluation Popup questionnaires (195) E-mail survey (73) Log file analysis (2 years)

29. Results: Pop-Up and E-Mail Surveys Pop-UpE-Mail Easy to use 83% 92% Question on list >50% of time 89% Answered question 69% Useful 77% Helpful >50% of time 90% Positive effect on care 74% Specific cases of improved care 14

30. Results: Log Files Questions chosen 48.7% (10.5%-78.7%) 3/04 – 9/06: 2,160 users, 28,553 accesses Monthly: >300 users, 1,200 access

31. Resource Use by Context Laboratory Results Review Inpatient Drug Order Review Microbiology Sensitivity Results Diagnosis List Inpatient Lab Order Entry Inpatient Drug Order Entry

32. Resource Use by Context - September

33. Lessons Learned Good: –Easy to use –Anticipates users’ questions –Fast –Useful –Positive impact on patient care Room for improvement –Navigation of Infobutton Manager page –Additional questions needed –Adoption has been slow

36. Conclusions 1.Context-specific access to health knowledge resources has been successfully accomplished 2.Impact on patient care decisions has been positive 3.Increased information resource use should result in clinicians making better informed patient care decisions

37. Acknowledgments This work is supported by NLM grant R01LM07593 Evlauation plan: –Vimla Patel –Sue Bakken –Leanne Currie –Beth Friedman Programming: Jianhua Li Log files: Rick Gallagher

38. Discussion ?