1. Use, Usability, Usefulness and Impact of an Infobutton Manager James J. Cimino, M.D. Department of Biomedical Informatics Columbia University College of Physicians and Surgeons 2006 AMIA Fall Symposium

2. Evaluating the Infobutton Manager What are Infobuttons? What is the Infobutton Manager? How do we study it (modalities)? What did we learn? –How is it used? –How usable is it? –How useful is it? –What is its impact?

7. Infobuttons vs. Infobutton Manager Page of Hyperlinks Infobutton Clinical System Resource Infobutton Manager Context s

16. CPMC Infobutton Managers Deployed: New York Presbyterian Hospital’s WebCIS New York Presbyterian Hospital’s Eclipsys New York State Psychiatric Institute’s PSYCKES Regenstrief Medical Record System Crystal Run Healthcare’s NextGen

17. Evaluation of Infobuttons Rosenbloom ST, Geissbuhler AJ, Dupont WD, et al. Effect of CPOE user interface design on user-initiated access to educational and patient information during clinical care. JAMIA. 2005;12(4):458-73. 105 house officers studied over 11 months 278 uses Findings: 15-fold increased use of resources Maviglia SM, Yoon CS, Bates DW, Kuperman G. KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs. JAMIA. 2006;13(1):67-73. 359 users over 12 months 7,972 uses Findings: 84% found answers to their question, positive impact on patient care 15% of the time

18. Evaluation Modalities System log files

19. Mar 5 06:46:03|xxx9017|156.145.18.47|lab^524732|view Mar 5 06:46:33|xxx9017|156.145.18.47|healthresource|view Mar 5 06:46:35|xxx9017|156.145.18.47|url^http://www.crlonline.com Mar 5 06:47:21|xxx9017|156.111.245.19|LabDetail|ibutt^35776 Mar 5 06:47:24|xxx9017|156.111.245.19|LabDetail|Infomgr^70^35776 What does the CPMC Lab Manual say about the Serum Ferritin test?

20. Evaluation Modalities System log files Pop-up surveys

22. Evaluation Modalities System log files Pop-up surveys On-line feedback

24. Evaluation Modalities System log files Pop-up surveys On-line feedback E-mail surveys

25. 1) How often do you use Infobuttons __ Once a month or less __ A few times a month __ A few times a week __ A few times a day ----------------------------------------------------------- 2) Infobuttons are easy to use: __ Strongly Agree __ Agree Somewhat __ Neither Agree nor Disagree __ Disagree Somewhat __ Strongly Disagree ------------------------------------------------------------ 3) When I click on an Infobutton in WebCIS, the question I am interested in is: __ Almost never on the list __ Usually not on the list __ Is only on the list about half the time __ Usually on the list __ Almost always on the list ------------------------------------------------------------ 4) Compared to the way I usually get answers to my questions, the Infobuttons are: __ Much slower __ Somewhat slower __ About the same speed __ Somewhat faster __ Much faster ------------------------------------------------------------ 5) When I click on a question on the question list __ I almost always get a helpful answer __ I usually get a helpful answer __ I get a helpful answer about half the time __ I usually do not get a helpful answer __ I almost never get a helpful answer ------------------------------------------------------------ 6) Which statement most accurately describes your experience with Infobuttons? __ Infobuttons almost always have a negative effect on my patient care decisions __ Infobuttons sometimes have a negative effect on patient care __ Infobuttons have no effect (positive or negative) on my patient care decisions __ Infobuttons sometimes have a positive effect on my patient care decisions __ Infobuttons almost always have a positive effect on my patient care decisions ------------------------------------------------------------ 7) Please tell us about a time that Infobuttons improved a patient care decision (please do not include any information that would identify a patient) ------------------------------------------------------------ 8) Please tell us about a time that Infobuttons hindered a patient care decision (please do not include any information that would identify a patient)

26. Evaluation Log file analysis On-line survey Popup questionnaires E-mail survey Log file analysis: 32 months of data

27. Results: System Log Files March 2004-October 2006: –IM: 3,009 users, 29,541 times

28. Infobutton Manager (IM) Usage

29. Resource Use by Context Laboratory Results Review Inpatient Drug Order Review Microbiology Sensitivity Results Diagnosis List Inpatient Lab Order Entry Inpatient Drug Order Entry Health Resources Infobutton Manager

30. Results: System Log Files March 2004 - October 2006: –IM: 3,009 users, 29,541 times October 2006: – IM: 281 users, 1,022 times (33/day) – HR: 708 users, 5,744 times (185/day) –HR: 3,609 users, 155,718 times

31. Resource Use by Context - October

32. Finding a Resource or Question Users chose questions 48.7% of the time Diagnosis list: 10.5-24.3% Outpatient drug order review:23.0-63.3% Inpatient drug order review: 63.3-78.7% Users chose at least one resource from HR page 92.4% of the time (82.6-93.7%, depending on user type and context)

33. Evaluation Log file analysis On-line survey Popup questionnaires E-mail survey Log file analysis: 32 months of data On-line survey: 108 comments

34. Results: On-line Feedback 108 questions or topics submitted by users –54 (50%) in Laboratory Results Review context 30 were about test interpretation –22 (20%) in Inpatient Drug Order Review 15 were about side effects, dosage, cost, trade names, and interactions

35. Evaluation Log file analysis: 32 months of data On-line survey: 108 comments Popup questionnaires: E-mail survey Popup questionnaires: 195/~3,642 (5.4%)

36. Pop-up Survey Responses Q1: Easy to use Q2: Got answer Q3: Helpful

37. Evaluation Log file analysis: 32 months of data On-line survey: 108 comments Popup questionnaires: E-mail survey Popup questionnaires: 195/~3,642 (5.4%) E-mail survey: 73/1,228 (5.8%)

38. 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)

39. 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 (40% of negative responses due to Lab Manual) (Students were the least positive)

40. Summary of Impact Over 29,000 additional accesses to resources (19%) Positive impact at least half the time: 74% 14 respondents identified one or more specific situations in which patient care improved

41. Lessons Learned Use of the IM has been more gradual than desired User fails to select a question half the time –Is the IM failing to anticipate the information need? –Example - questions sugested during lab review: Housestaff did not select a question 57.8% of time Online survey: 4/11 dealt with reference ranges IM almost always provides a link to lab manual –Is the user unable to find questions on the IM page? Solutions: –Education –Add questions –User interface

43. Conclusions 1.Context-specific access to health knowledge resources has been successfully accomplished 2.Impact on patient care decisions has been positive 3.Need to improve user interface for navigation 4.Increased resource use should result in clinicians making better informed patient care decisions

44. 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

45. Questions? www.dbmi.columbia.edu/cimino/amia06-app.pdf