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

2. G.O.

3. Covell et al. Information Needs G.O. Barnett DXplain

4. Studying Information Needs
Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med Oct;103(4):596-9.

5. 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

6. 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?

7. 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

8. 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!

9. 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

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

11. 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

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

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

14. Covel et al. Information Needs Don Lindberg UMLS G.O. Barnett DXplain

15. 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

16. Covel et al. First Version Information Needs of UMLS Don Lindberg UMLS
G.O. Barnett
DXplain
ICD9
MeSH
Medline
Button

17. 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

23. 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

24. 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

27. 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

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

32. 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

38. 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.

39. 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.

40. Education at the Moment of Need2
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.

41. Education at the Moment of Need2
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

42. Education at the Moment of Need4 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

43. Education at the Moment of Need4 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

44. Education at the Moment of Need4 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

45. Education at the Moment of Need4 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

46. Research Issues
What are the information needs?

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

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

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

51. 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?

52. The Medical Entities Dictionary (MED)

53. 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?

54. 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

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

64. 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

66. 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

68. 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!

72. 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

73. 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

74. 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?

75. Acknowledgments National Library of Medicine The team: Jianhua Li
Sue Bakken
Vimla Patel
Mureen Allen
Leanne Currie
Mark Graham