Transcript Use of Online Resources While Using a Clinical Information

Integrating Health Information Resources
with Web-Based Clinical Information Systems
James J. Cimino, MD
Columbia University, New York, New York
Guilherme Del Fiol, MD, MS
Intermountain Health Care, Salt Lake City, Utah
William R. Hersh, MD
Oregon Health and Science University, Portland, Oregon
J. Marc Overhage, MD, PhD
Regenstrief Institute, Indianapolis, Indiana
Panel Outline
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Motivation
History
OHSU experience
IHC experience
Columbia experience
Regenstrief experience
Institution-independent solutions
Open discussion
Motivation for Linking Clinical
Systems and Resources
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Information needs arise with clinical systems
The user is using a computer
Questions can be anticipated based on context
Resource can be anticipated based on question
Retrieval can be automated using question,
resource and context
History: the Pre-Web Years
• Yale: Hepatopix and Psychtopix - preconstructed
topic-specific queries to Medline
• Duke: TMR-NLM link - acid-base nomogram to
Medline using graphical input
• MGH: Interactive Query Workstation - UMLS to map to
multiple resources - what can the resource answer?
• SUNY Buffalo: Medical Desktop - cut and paste into
UMLS-based Term Linker
• Pittsburgh: Chartline - used UMLS to match text in
reports to MeSH, then searched Medline
History: the Pre-Web Years (continued)
• Columbia: Medline Button - used ICD9 data, through
UMLS, to search Medline
• Yale: NetMenu and Meta-Front End: UMLS translation
to terminologies used by multiple resources
• Duke: Internet Gopher - hardwired links from Care
Maps to Internet-based resources
How the Web Changed Things
• Local resources became widely available
• Clinical systems became Web-based
• HTML and URLs made integration easier
Challenges
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Integration without distraction
Understand information needs
Finding appropriate resources
Capturing the clinical context for use in retrieval
Institution-independence to allow sharing
Patient confidentiality
Copyright and license restrictions
Maintenance
Linking Knowledge to Practice
William Hersh, M.D.
Department of Medical Informatics & Clinical Epidemiology
Oregon Health & Science University
[email protected]
www.billhersh.info
Overview
• SmartQuery – linking knowledge to
practice at OHSU
• Toward interoperability of knowledgebased resources
SmartQuery (Price & Hersh, 2002)
• Linkage provided on top of NetAccess, Webbased interface to Siemens Medical Systems
(SMS) Lifetime Clinical Record (LCR) repository
• Context of patient extracted from
– Laboratory results – translation from lab system not
simple, e.g., Meas ICA, Wh B → calcium,
hypocalcemia, hypercalcemia
– Diagnosis codes – ICD-9 codes translated to MeSH
– Portions of clinical narrative
Resources in SmartQuery
• Available for free or licensed by OHSU
– MEDLINE – via PubMed
– Best Evidence (American College of Physicians) –
collection of extended, structured abstracts of
important journal literature
– Harrison’s On-Line (McGraw-Hill) – electronic
version of an internal medicine textbook
– National Guidelines Clearinghouse (AHRQ) –
collection of clinical practice guidelines
– CliniWeb – collection of human-reviewed and
MeSH-indexed Web pages
SmartQuery selects concepts
and offers resources
Results offer linkages to resources
Current status
• Vendor acquired by another vendor;
project on indefinite hold in transition
• Hard-wired access is not ideal; what we
really need is interoperability of clinical
information resources…
Rationale: Consider this scenario
• A primary care clinician of an elderly patient
who has hypertension, congestive heart
failure, sleep apnea, and obesity
– Has charted pertinent information in electronic
health record
– Now wants recommendations from a guideline
with overview of supporting evidence
– Later wants to explore recommendations in more
detail, including reading systematic review and
some original clinical trials it has included
– May want basic review of topics seen infrequently
in practice
Some impediments for this clinician
• Cannot link directly from guideline to
supporting or background information
• Wants to access pertinent section of a
favorite textbook directly
– Does not want to go to each Web site, log on, and
use site search engine
• Would like to navigate across levels of
evidence from compendium to systematic
review to original clinical trial or other study
• May want to create personal digital library of
preferred content
Impediments for others
• Publishers
– Might desire to allow access to pieces of
content but need assurances of revenue
and intellectual property protection
• Content aggregators
– Want to “mix and match” content that is
“best of breed” but difficult to do across
content of different publishers
The current problem: most
information is in silos
Web site
Most
Search
Engine
Content
User
Metadata
Few
Content
Other App
(eg, EHR)
Overcoming the impediments:
Interoperability
• IEEE, 1990: “Ability of two or more
systems…to exchange information or use the
information that has been exchanged”
• Used in digital library community to describe
seamless access and integration
• Required to facilitate IR interoperability are
– Minimum set of metadata and interapplication
interfaces
– Cooperation among publishers, vendors, and
others to agree upon standards
From silos to interoperability
Metadata
Repository
Content
Metadata
Content
Metadata
Site
Search
Site
Search
Other
Application
Search
Interface
User
How might we achieve this?
• A starting point is Open Archives Initiative
(OAI, www.openarchives.org)
• OAI promotes the “exposure” of archives’
metadata such that systems can know what
content is available and how it can be
harvested (Lagoze, 2001)
• Each record in an OAI collection contains
metadata
– Protocol has “verbs” for metadata harvesting
– Example: http://www.purl.org/NET/oai_explorer
Is this possible?
• Yes, look to the genomics community, e.g.,
dtabases of National Center for
Biotechnology Information (NCBI)
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Literature
Nucleotide and protein sequences
Protein structures
Textbooks and other textual resources
Genomes and map
• Doing this in clinical medicine will take
agreement from publishers and others
The Columbia University Experience:
Infobuttons and the Infobutton Manager
James J. Cimino, M.D.
Department of Biomedical Informatics
Columbia University College of Physicians and Surgeons
[email protected]
Columbia Experience
• Medline Button
– Translated ICD9-CM to MeSH to search Medline
– Hard to build
– Did not satisfy users’ needs
• Infobuttons
– Web-based
– Easy to build
– Require custom programming
– Used preferentially in some settings
Columbia Experience
• Medline Button
– Translated ICD9-CM to MeSH to search Medline
– Hard to build
– Did not satisfy users’ needs
• Infobuttons
– Web-based
– Easy to build
– Used preferentially in some settings
– Require custom programming
• Infobutton Manager
– Standard set of context variables
– Matches context to frequently-asked questions
– Each question has corresponding solution
– Table-driven
<a href=“flux.cpmc.columbia.edu/webcisdev13/
wc_infomanage.cgi?9info_institute=NYPH&
info_age=5& info_sex=F&info_usertype=MD&
info_med=28743&info_context=InPatientDrugs”>
<img info.gif\"> </a>
Infobutton Manager
Context Table
Institute
Age
Sex
User
Task
Concept
Infobutton
NYPH
Adult
Any
Any
InPatient
Drugs
Drug
Level
33
NYPH
Child
Any
Any
InPatient
Drugs
Drug
Level
34
Infobutton Table
Infobutton
URL
Question
33
http://www.crlonline.com/crlsql
/leaflets-english/…
Give me patient
information for…
34
http://www.crlonline.com/crlsql
/pleaflets/…
Give me pediatric
information for…
Columbia Experience to Date
• Questions determined by empiric observation
• Resources found to answer questions
• Infobutton Manager links added to WebCIS
Columbia Experience – Next Steps
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Currently carrying out heuristic evaluation
Usability study is next
Roll-out to 4000 WebCIS users planned
Follow-up observational study to determine:
– Usefulness
– Impact
Institution-Independent Solutions
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Contexts are common across institutions
Information needs may be common
Infobutton Manager is institution-independent
“Institute” is a parameter
– Questions can be customized by institution
– Resources can differ by institution
• Questions and resources can be shared
• Terminology is the limiting factor
www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html
The Regenstrief Institute Experience
J. Marc Overhage, MD, PhD
Regenstrief Institute
Indianapolis, Indiana
[email protected]
Abstract
Many researchers are developing linkages between
their clinical information systems and on-line
information resources to provide context-sensitive
decision support for medical decisions. The
discussants of this panel, from the Regenstrief
Institute, Oregon Health and Science University,
Intermountain Health Car, and Columbia University
are all working independently on such solution. They
are identifying common problems and common
solutions that may lead to collaborative development
and resource sharing. The purpose of this panel is to
discuss areas of commonality and invite discussion
from attendees on their problems and solutions.
Folate
Gopher Example
Gopher
Gopher CPOE Integration
One Ring
Shared Memory
Messages
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2
3
Browser
DLL
4
DOS/Gopher
PC
1. Notify one
ring of the
query
2. Construct
and store
URL
3. Send URL
to browser
DLL
4. Browser
opens URL
Context
• Institution
• User
• Patient demographics
– Age
– Gender
• Parameter of interest
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Diagnosis (ICD-9)
Laboratory result (LOINC)
Radiology study (text name/local codes)
Question (text)
Logging/Tracking
• At source
Aug 1 10:25:21 flux syslog:
|Infomgr|jil7001^CPMC|vc5liu.cpmc.columbia.edu||med|ibutt1600
Aug 1 10:30:19 flux syslog:
|Infomgr|jil7001^RMRS|vc5liu.cpmc.columbia.edu||med|ibutt^glucose
Aug 1 10:31:33 flux syslog:
|Infomgr|jil7001^RMRS|vc5liu.cpmc.columbia.edu||med|ibutt12628-4
Other challenges
• Lots of links increases size of web
pages delivered
• Broken links due to changes in sites
• Access control
– IP – proxy server
– Password
• Fuzzy edges
– Clinical sometimes adjunct faculty?
– Fellows?
Electronic Health Information
Resources at Intermountain
Health Care
Guilherme Del Fiol, MD, MS
Jim Reichert, MD
Paul D. Clayton, PhD
Intermountain Health Care (IHC)
• 21 hospitals, >90 outpatient facilities
– 4 teaching facilities
• 500 employed physicians
• 1.6 million individuals with computerbased clinical data
• 16,000 clinical system users
Barriers to access health
information resources
• Lack of time
• Limited access to resources
• Difficulty learning and using multiple
resources
• Variable quality of information
What we’re doing to lower the
barriers
• Seamless access from the point-of-care
– E-resources page: transparent access from
clinical information systems
– Infobuttons
• Build clinical questions using patient data and
context
• Take user to the most relevant section within an
information resource with a minimum number of
mouse clicks
• In operation since September 2001
How does it work?
What are the clinical
manifestations of high
serum potassium?
Question
formulation
Resource
selection
What are the clinical
manifestations of high
serum potassium?
•65 years old
•female
•physician
•lab results
i
?
Answer
retrieval
Resource 1
Resource 2
Answer
Key factors:
• Structure
• Indexing
• Context
Resource 3
Infobutton request
http://www.InformationResource.com/search.cgi
applicationContext = labResults
searchString = “Serum potassium”
clinicalConcept = 2823-3
terminology = “LOINC”
labResult = “High”
patientAge = 65
modifier = “Clinical Manifestations”
<LabTest>
<LabTestIdentifier>2823-3</LabTestIdentifier>
<Section>
<AgeLowerLimit>18</ AgeLowerLimit >
<Content>
<Causes> ... </Causes>
<ClinicalManifestations>
Arrhythmias: sinus bradycardia, sinus arrest, first degree AV
block.
Progressive ECG changes: peaked T waves
Neuromuscular manifestations: depressed tendon reflexes
</ClinicalManifestations>
<FurtherStudies> ... </FurtherStudies>
</Content>
</Section>
</LabTest>
IHC Infobuttons
Resource
Terminologies
Lab results
Clineguide,
MDConsult
LOINC, free-text
Medications
Micromedex,
Clineguide
NDC,
free-text
Problem list
MDConsult,
Clineguide,
PubMed
ICD-9CM,
free text
p0
3
3
l- 0
2500
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-0
3
M
ay
-0
3
n03
M
ar
Ja
2
2
02
p0
l- 0
No
v-
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2
M
ay
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2
n02
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ar
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Infobutton
E-resources page
2,247 hits
2000
1500
1,218 hits
1000
500
0
Problems
5%
Patient Education
13%
Medications
51%
Lab tests
31%
Challenges
• Development / Maintenance
– Multiple clinical information systems in an
institution may need Infobuttons
– Adding new resources, changes on APIs
– Need for an independent component
• Selection of resources
• Structure of resources frequently not
driven to Infobuttons
Current status
• External content resources
– Collaborations to improve content structure
and Infobutton APIs
• Internal content resources
– Conversion of policies, guidelines, and
protocols to XML
– Make resources accessible to Infobutton
HL7 Proposal
Infobutton
Standard API calls
Non-standard APIs
i
POE system
API
Lab results review
Outpatient clinical
information system
i
Resource 1
API
Resource 2
Infobutton
Manager 1
i
API
API
Infobutton
Manager 2
API
Resource 3
Standard APIs
i
POE system
Resource 1
Infobutton
Manager 1
Lab results review
i
HL7
HL7
Infobutton
Manager 2
Outpatient clinical
information system
i
Resource 2
Resource 3
HL7 proposal
• Common syntax and terminology for
Infobutton managers and information
resources API calls
• Parameters
– Main search concept
– Application context
– Patient context
– Modifiers
What is the treatment for
pneumonia ?
•45 years
old
•problems
http://www. resource.com/search.cgi
searchString
= Pneumonia
terminology
= MeSH
conceptOfInterest
= D018410
applicationContext = problems
ageContext
= 45
modifier
= treatment
Current Status
• Draft proposal at HL7 web site
• Continue discussion
– Conference calls to be initiated
– Improved draft to be presented at next HL7
meeting – San Diego, Jan 2004
• Volunteers are welcome
Open Discussion
• Understanding how local solutions may be
transferable to other settings
• Identifying challenges to shared solutions
• Discussion of a standard for evoking resources in
context-specific ways
• Solutions to privacy and copyright issues
• Establishing mechanisms for collaboration
• Anything else…
www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html