Transcript Use, Usability, Usefulness and Impact of an Infobutton Manager

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
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)
Options: Computer-based Decision Support
• Electronic patient records
• Passive on-line knowledge resources
• Calculators
• Stand-alone expert systems
• Alerting and reminders systems (“push”)
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
“Just in Time” Education
“Just in Time” Education
1
Understand
Information
Needs
“Just in Time” Education
2
Get Information
From EMR
1
Understand
Information
Needs
“Just in Time” Education
2
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection
“Just in Time” Education
4
Resource
Terminology
2
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection
“Just in Time” Education
4
Resource
Terminology
5
2
Automated
Translation
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection
“Just in Time” Education
4
Resource
Terminology
6
5
2
Automated
Translation
Get Information
From EMR
1
Querying
Understand
Information
Needs
3
Resource
Selection
“Just in Time” Education
4
Resource
Terminology
5
2
Automated
Translation
Get Information
From EMR
6
1
Querying
Understand
Information
Needs
3
Resource
Selection
7
Presentation
“Just in Time” Education
4
Resource
Terminology
5
2
Automated
Translation
Get Information
From EMR
6
1
Querying
Understand
Information
Needs
3
Resource
Selection
7
Presentation
User’s
Workstation
75 foot cable
Video Monitor
Converter Controller
Microphone
Video Converter
Cassette Recorder
Headphones
VCR
Initial Lessons: Observational Data
• Log file analysis
– Resource use varies with user type and task
Context-Specific Resource Use
100%
Sensitivity IB
Culture IB
80%
Pharmacy IB
Medlineplus
60%
ICD9-CM
Journals
PubMed
40%
Harrison's
Formulary
20%
Ovid Medline
Micromedex
Ph
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S
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Vi
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ho
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Pa
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C
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R
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La
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or
y
0%
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%)
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”)
Evaluation
• Popup questionnaires (195)
• E-mail survey (73)
• Log file analysis (2 years)
Results: Pop-Up and E-Mail Surveys
Easy to use
Question on list >50% of time
Answered question
Useful
Helpful >50% of time
Positive effect on care
Specific cases of improved care
Pop-Up
83%
E-Mail
92%
89%
69%
77%
90%
74%
14
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
Resource Use by Context
3000
Laboratory Results Review
Inpatient Drug Order Review
600
2000
400
1000
200
0
0
Microbiology Sensitivity Results
Diagnosis List
60
200
40
150
100
20
50
0
0
60
40
20
0
Inpatient Lab Order Entry
200
150
100
50
0
Inpatient Drug Order Entry
Resource Use by Context - September
2500
2000
1500
Infobuttons
1000
Health
Resources
500
0
Lab
Results
Inpatient Outpatient
Drugs
Drugs
Order
Entry
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
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
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
Discussion
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