Just In Time Education: Linking Clinical and Educational Systems James J. Cimino, MD Professor of Medicine and Biomedical Informatics Columbia University May 19, 2004

G.O. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covell et al. Information Needs G.O. Barnett DXplain 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

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.

Results of Observational Study 47 physicians Observed during a half day of typical practice Estimated 2-3 questions per physician per day 269 questions raised about patient management Only 30% were answered during the patient visit Usual resource was another physician

Other Observational Studies The information needs of practicing physicians in northeastern New York State. Assessment of physicians' information needs in five Texas counties Information needs of rural health care practitioners in Hawaii. Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians Information needs and information-seeking behaviors of on-call radiology residents Expanding the concept of medical information: an observational study of physicians' information needs Curbside consultation practices and attitudes among primary care physicians and medical subspecialists Information needs of health care professionals in an AIDS outpatient clinic as determined by chart review Methods for assessing information needs of clinicians in ambulatory care. Real-time information-seeking behavior of residency physicians Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered Physicians' use of computer software in answering clinical questions. Residents' medical information needs in clinic: are they being met?

Findings 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

Information Needs of CIS Users Stereotypical tasks suggest recurrent needs System knows: Who the user is Who the patient is What the user is doing What information the user is looking at User is sitting at a computer!

Information for Decision-Making Let’s start with a patient care scenario in which a physician is evaluating a patient with apparent new-onset myocardial infarction

Information for Decision-Making As part of the information gathering process, the physician turns to the medical record - in this case, an electronic one

Information for Decision-Making ? MRSA On-line resources are much more likely to have the available information, in a bibliographic database, an electronic text book, etc

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

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

Covel et al. Information Needs Don Lindberg UMLS G.O. Barnett DXplain 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

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

Covel et al. First Version Information Needs of UMLS Don Lindberg UMLS G.O. Barnett DXplain ICD9 MeSH Medline Button 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

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 Kludge required

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 Kludge required Technical success Practical failure

Covel et al. First Version Information Needs of UMLS PubMED Mosaic Don Lindberg UMLS Mosaic G.O. Barnett DXplain ICD9 MeSH Medline Button WebCIS Web-based Generic Queries 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covel et al. First Version Information Needs of UMLS PubMED Mosaic Don Lindberg UMLS Mosaic G.O. Barnett DXplain Web DXplain ICD9 MeSH Medline Button WebCIS Web-based Generic Queries DXplain Button 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

From Data to Findings Serum Cholesterol Test Serum Specimen Abnormalities of Serum Cholesterol Hypercholesterolemia

Covel et al. First Version Information Needs of UMLS PubMED Mosaic Don Lindberg UMLS Mosaic G.O. Barnett DXplain Web DXplain ICD9 MeSH Medline Button WebCIS Web-based Generic Queries DXplain Button Infobuttons 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Education at the Moment of Need MRSA Suffice it to say, that in each of these linkages, there are certain obstacles we need to overcome.

Education at the Moment of Need MRSA 1 Understand Information Needs The first is understanding the information need that arises in a particular context. It may not be enough to just search for LAC - the user may have a very specific question in mind. Also, other information about the patient and even the user may shape the kind of information needed. Without understanding the information needs, we cannot ask the right questions.

Education at the Moment of Need 2 Get Information From EMR MRSA 1 Understand Information Needs Next, we need to pull information from the EMR for use in the process. This can be difficult when the information exists in nonstandard forms and especially when it exists inside narrative text reports.

Education at the Moment of Need 2 Get Information From EMR MRSA 1 Understand Information Needs Based on the information from the EMR, and knowing what we know about information needs, the next step is to decide which resource will best meet the information need. 3 Resource Selection

Education at the Moment of Need 4 2 Resource Terminology Get Information From EMR MRSA 1 Understand Information Needs If we are going to query the selected resource automatically, we have to be able to speak its language. For example, if we are going to search Medline, we will want to be able to speak MeSH. 3 Resource Selection

Education at the Moment of Need 4 5 2 Resource Terminology Automated Translation Get Information From EMR MRSA 1 Understand Information Needs Since it is unlikely that our EMR data will be in this language, we need to perform a translation. 3 Resource Selection

Education at the Moment of Need 4 5 2 Resource Terminology Automated Translation Get Information From EMR 6 MRSA 1 Querying Understand Information Needs The next step is to perform the actual query, but there are few standards for this and each resource often has its own query format and commands. 3 Resource Selection

Education at the Moment of Need 4 5 2 Resource Terminology Automated Translation Get Information From EMR 6 MRSA 1 Querying Understand Information Needs Finally, we must consider how we will present the information to the user. A list of 400 medline citations, sorted by year is unlikely to be the best method for giving a speedy answer. 3 7 Resource Selection Presentation

Research Issues What are the information needs?

Portable Usability Lab User’s Workstation 75 foot cable Video Monitor Converter Controller Microphone Video Converter Headphones VCR Cassette Recorder

Research Issues What are the information needs? Which context information is important?

Context-Dependent Information Needs ? ! Institution Data Task Age Sex Training Role Context

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?

The Medical Entities Dictionary (MED)

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?

Covel et al. Information Needs First Version of UMLS PubMED Don Lindberg UMLS Mosaic G.O. Barnett DXplain Web DXplain ICD9 MeSH Medline Button WebCIS Web-based Generic Queries DXplain Button Infobuttons Infobutton Manager 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

The Coumadin Story Chair of Medicine wants link to Coumadin protocol First, I have to find the guidelines

The Coumadin Story Chair of Medicine wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table

The Coumadin Story Chair of Medicine wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table Finally, I link the question to the context

The Coumadin Story Chair of Medicine wants link to Coumadin protocol First, I have to find the guidelines Then I have to add the question to the IM table Finally, I link the question to the context Voilá!

Next Steps Repeat the observational study Look at system logs to see if: Infobutton use is rising (7000 in first 10 weeks) Use of other resources is falling (not yet) Order entry Infobuttons Collaboration with Regenstrief and LDS Infobutton Manager to be an ANSI standard

Covel et al. Information Needs First Version of UMLS PubMED Infobutton Manager Standard Don Lindberg UMLS Mosaic G.O. Barnett DXplain Web DXplain ICD9 MeSH Medline Button WebCIS Web-based Generic Queries DXplain Button Infobuttons Infobutton Manager 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Conclusions Information needs arise while using CIS Infobuttons are easy to build Are they the right buttons? Can retrievals be standardized? Will information needs be satisfied? Will care improve?

Acknowledgments National Library of Medicine The team: Jianhua Li Sue Bakken Vimla Patel Mureen Allen Leanne Currie Mark Graham www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html