1. Supporting Medical Decision Making with Electronic Medical Records James J. Cimino Departments of Medicine and Medical Informatics Columbia University

2. Decision Making for Patients and Providers Access to (electronic) health records generates information needs Information needs go unmet “Best evidence”, educational material, training programs can address these needs

3. One-Stop Information Shopping? World Wide Web (The Hyperdocument) Information Resources Biblio- graphic Database Textbook Expert System Health Practitioner

4. One-Touch Information Shopping Information Resources World Wide Web (The Facilitator) Biblio- graphic Database Textbook Expert System Health Practitioner

5. ? MRSA Information for Decision-Making

6. Query MRSA Intelligent Decision Support ? Result !

7. Infobutton: Automating the Process Questions can be anticipated Match information source to question Automate the retrieval Query can use patient information

8. New York Presbyterian Hospital Information Architecture Central repository Data Access Modules Medical Entities Dictionary MedLEE CIS WebCIS PatCIS

9. Central Controlled Terminology

10. MED Semantic Network Medical Entity Plasma Glucose Test Laboratory Specimen Plasma Specimen Anatomic Substance Plasma Substance Sampled Part of Has Specimen Substance Measured Laboratory Procedure CHEM-7 Laboratory Test Event Diagnostic Procedure Substance Bioactive Substance Glucose Chemical Carbo- hydrate

11. Automated Decision Support Get Information From EMR Resource Selection Resource Terminology Querying Presentation Understand Information Needs Automated Translation 1 254 6 3 7 MRSA

12. Translations with the MED Gentamicin Etiology Measures Sensitivity Substance Measured Injectable Gentamicin Gentamicn Sensitivity Test Serum Gentamicin Level is-a Intravascular Gentamicin Tests Gentamicin Toxicity Has ingredient Summary Reports Decision Rule Expert System Drug Information

13. The Medline Button EMR and Decision Support - understand conditions Pharmacy Infobutton - review and teach

19. The Medline Button - understand conditions Pharmacy Infobutton EMR and Decision Support - review and teach Cholesterol Guideline - dietary planning

25. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline EMR and Decision Support - dietary planning DXplain Button - understand findings

26. From Test Result to Finding 1600 44 L 1600 Gluc32703 Serum Glucose Tests 32308 Intravascular Glucose Tests 42485 Elevated Abnormal Finding in Body Substance 42486 Decreased Abnormal Finding in Body Substance 42541 Hyperglycemia 3286 Hypoglycemia 32412 Intravascular Specimen 31987 Glucose 42527 Abnormal Level of Blood Glucose 3286 Hypoglycemia

31. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button EMR and Decision Support - understand findings QingCIS - problem-oriented views

32. Smarter Retrievals from the Record Repository stores events and results Clinical problems at a different level of granularity Re-use knowledge to map from problems to clinical data Produce problem-specific views of the medical record

33. Chest X ray Congestive Heart Failure Intravascular CK Test Creatine Kinase Chest X ray 2 View Cardiac Enzyme Angina Lab :1/1/99 Cardiac Enzyme Test Radiology :2/23/99 Chest X Ray Radiology :2/28/96 Head CT Lab :12/28/96 Sickle Cell Test Admission :3/14/96 Stroke Admission :2/14/98 Angina Lab :1/1/99 Blood Type Test Radiology :2/1/97 Knee X Ray Concept-oriented (Heart) Heart Disease Chest Discharge :1/15/99 CHF CHF Discharge :1/15/99 CHF CHF Admission :2/14/98 Angina Lab :1/1/99 Cardiac Enzyme Test Radiology :2/23/99 Chest X Ray

48. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings QingCIS EMR and Decision Support - problem-oriented views PatCIS - patient education

55. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings QingCIS - problem-oriented views PatCIS EMR and Decision Support - patient education Lab Infobutton - patient information

58. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings QingCIS - problem-oriented views PatCIS - patient education Lab Infobutton EMR and Decision Support - patient information Microbiology Infobuttons - infection control

65. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings QingCIS - problem-oriented views PatCIS - patient education Lab Infobutton - patient information Microbiology Infobuttons EMR and Decision Support - infection control Mammography Guideline - screening

68. The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings QingCIS - problem-oriented views PatCIS - patient education Lab Infobutton - patient information Microbiology Infobuttons - infection control Mammography Guideline EMR and Decision Support - screening Pap Smear Infobutton - screening

76. Summary Decision making requires high-quality, up-to-date, timely information The EMR generates information needs The EMR can help satisfy information needs The Web makes the rest easy Further study needed: –When do users need information? –What information do they need? –What terminology is needed? –What are the right resources? –How can retrievals be facilitated? –How do we present results?