Transcript 2006-AMIA-Panel-Integration of Health Information Resources into

Integration of Health Information
Resources into Electronic Health Records
Guilherme Del Fiol, MD, MS
Intermountain Healthcare
University of Utah, Salt Lake City, UT
James J. Cimino, MD
Department of Biomedical Informatics, Columbia
University, New York, NY
Saverio Maviglia, MD, MSc
Partners Healthcare System, Boston, MA
Nick Ackerson
Thomson Micromedex, Greenwood Village, CO
Point-of-care information needs
Most answers can be
found on the Web
2 questions out of
every 3 patients seen
i
Barriers
Used less than
10% of the time
Most questions
left unanswered
Errors: 770,000 injuries and
deaths annually in the US
Topics of this Panel
What are the benefits?
Are people using
infobuttons?
Have content
providers
bought into
this?
Are there any
standards?
How can I have
infobuttons in my
institution?
Healthcare
organizations
EHR
developers
Content
providers
Integration of Health Information Resources
into Electronic Health Records
James J. Cimino, M.D.
Department of Biomedical Informatics
Columbia University College of Physicians and Surgeons
2006 AMIA Fall Symposium
The Columbia/NYPH Infobutton Manager
• Are people using infobuttons?
• What are the benefits?
• Are there any standards?
• Are content providers bought into this?
• How can I have Infobuttons in my institution?
Infobuttons at My Institution
• What is an Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager
Infobuttons at My Institution
• What is an Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Infobuttons vs. Infobutton Manager
Resource s
Clinical System
Infobutton
Context
Infobutton
Manager
Page
of
Hyperlinks
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
How Does the Infobutton Manager Work?
Clinical Application/User’s Browser
Integrate
Link
https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi?
MRN=<xxx>&info_institute=<xxx>&info_med=<xxx>&info_context
=<xxx>&info_usertype=<xxx>&info_age=<xxx>&info_sex=<xxx>
How Does the Infobutton Manager Work?
Clinical Application/User’s Browser
Integrate
Link
Fill in
Parameter
Values
https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi?
MRN=3131313&info_institute=GENERIC&info_med=sodium&
info_context=LabDetail&info_usertype=MD&info_age=22&
info_sex=F
How Does the Infobutton Manager Work?
Clinical Application/User’s Browser
Integrate
Link
User Clicks
On Link
Fill in
Parameter
Values
Institute=CPMC & Context=LabDetail
Concept=“sodium”
Terms=
Write to
Identify
CPMC Serum Sodium Test
Log File
Terminology
Sodium Ion
Hypernatremia
Translate to Terms of Interest
Hyponatremia
CU/NYPH Infobutton Manager
How Does the Infobutton Manager Work?
Clinical Application/User’s Browser
Integrate
Link
User Clicks
On Link
Write to
Log File
Fill in
Parameter
Values
Identify
Terminology
Translate to Terms of Interest
CU/NYPH Infobutton Manager
User Clicks
On Link
Call
Resource
Display Page
Of Links
Write to
Log File
Generate List of
Questions/Links
Match Parameters
to Contexts
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
How do I integrate the Infobutton Manager?
Contact me:
[email protected]
Agree on Domain
And Terminology
Identify
Questions
Identify
Resources
Identify
Contexts
Determine Method for
Automated Retrieval
Add Everything to the
Infobutton Manager Manager
Integrate with Clinical
System to Pass Parameters
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Use of the CU/NYPH Infobutton Manager
•
WebCIS (CU/NYPH)
•
Eclipsys (NYPH)
Use of the CU/NYPH Infobutton Manager
•
WebCIS (CU/NYPH)
•
Eclipsys (NYPH)
•
Psyckes (NYSPI)
Use of the CU/NYPH Infobutton Manager
•
WebCIS (CU/NYPH)
•
Eclipsys (NYPH)
•
Psyches (NYSPI)
•
RMRS (Regenstrief)
Use of the CU/NYPH Infobutton Manager
•
WebCIS (CU/NYPH)
•
Eclipsys (NYPH)
•
Psyches (NYSPI)
•
RMRS (Regenstrief)
•
NextGen (Crystal Run Healthcare)
Use of the CU/NYPH Infobutton Manager
•
WebCIS (CU/NYPH)
•
Eclipsys (NYPH)
•
Psyches (NYSPI)
•
RMRS (Regenstrief)
•
NextGen (Crystal Run Healthcare)
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Infobuttons at My Institution
• What is an CU/NYPH Infobutton Manager?
• How does the CU/NYPH Infobutton Manager work?
• How do I integrate the CU/NYPH Infobutton Manager
• Who is using the CU/NYPH Infobutton Manager?
• How can I use the CU/NYPH Infobutton Manager?
Do you want to use the Columbia IM?
• Contact me: [email protected]
• Help with terminology/context/questions
• Adoption of HL7
• Librarian Infobutton Tailoring Environment (LITE)
• Supported by NLM Grant R01LM07593
• For more information:
http://www.dbmi.columbia.edu/cimino/Infobuttons.html
KnowledgeLink
Saverio Maviglia, MD, MSc
Partners Healthcare System
Harvard Medical School
Boston, MA
S68: Integration of Health Information Resources into EHRs
KnowledgeLink v1
“digoxin”
HTML
Source Application
Target Reference
(LMR)
(Micromedex or
Skolar)
KL v1: Typical Use
• Infrequent
– 2.3x/mo average (0.5 median, range 0.1-100)
– 0.7% of patient encounters, varying by
• Provider role (0.8% primary care MDs, 0.3%
specialist MDs, 1.1% NPs, 0.3% other)
• Provider gender (females 1.0%, males 0.5%)
• Target resource (0.9% MDX, 0.3% Skolar)
• Site (range 0-18% of encounters)
• Quick
– 4 pages accessed per use (only 1 content page)
– 21 sec spent per content page
KnowledgeLink Hits by User Role
MD
51.8%
RN
29.0%
NP
25.9%
non-NP
3.1%
Not Specified
0.5%
Admin.
1.8%
Other clinical
16.9%
EFFECTIVENESS AND SATISFACTION
• 84% of all KnowledgeLink queries are
answered
• 17% of physician use results in a change
in management, 33% among specialists
• >=80% rated KnowledgeLink positively on
–
–
–
–
Ease of use
Relevance
Speed
Impact on patient care
Comments
• General Praise
– Knowledge link is fantastic. VERY useful.
– Great resource!!
– I love knowledge link
• Quality of Care
– …very helpful with patient-directed questions during the visit
– I was able to quickly answer the patient’s question …the patient
had been promptly served on his needs
– This info actually saved me from making a medical error…I rarely
use this feature of the LMR, but this time it really helped me
• Convenience
– Knowledge Link is a great time saver…handy and easy to use.
– I really like having the ability to look up drugs without having to
change screens
– I really like having the information available one click away from
the med list
– I was very happy to be able to click on the information link as I
was pulling up the prescription
– To have info on meds right at my fingertips is a great timesaver
– it is very helpful to have all the information right at my finger tips
instead of browsing through multiple book sources
User Requests for KL II
Assertion
%
agreeing
(n=59)
KL should be extended to problems and diseases.
79%
KL should be extended to lab results and reports.
67%
I would like to be able to specify more precise KL
queries.
65%
I would like to be able to specify to which resource
KL goes.
58%
KnowledgeLink v2
Micromedex
LMR
Skolar
eMAR
UpToDate
Results
KnowledgeLink Manager
BWH guidelines
Source Applications
Target References
• Links chosen and ordered according to
•Context (meds, labs, disease)
•Source app (LMR, eMAR, Results)
•Provider (MD, RN, Pharm, other)
•Clinic
• Easy to modify/change search, restrict
to patient information links, or print
KnowledgeLink Sessions
50,000
45,000
35,000
3/05: eMAR
30,000
25,000
20,000
15,000
1/03: KL I study
(18 clinics)
10,000
8/04: KL II
launched
2/04: KL I opened to
all clincs
8/06: MGHOE
5,000
Date
Ju
l-0
6
O
ct
-0
6
Ju
l-0
5
O
ct
-0
5
Ja
n06
Ap
r06
Ju
l-0
4
O
ct
-0
4
Ja
n05
Ap
r05
Ja
n04
Ap
r04
Ju
l-0
3
O
ct
-0
3
Ja
n03
Ap
r03
ct
-0
2
0
O
Sessions/month
40,000
KnowledgeLink Users
1000
3/05: Live in
eMAR
900
700
600
8/04: KL II
launched
500
400
300 1/03: KL I study (18
clinics)
200
2/04: KL I opened to
all clincs
Date
Ja
n06
Ap
r06
Ju
l-0
5
O
ct
-0
5
Ja
n05
Ap
r05
Ju
l-0
4
O
ct
-0
4
Ja
n04
Ap
r04
Ju
l-0
3
O
ct
-0
3
Ja
n03
Ap
r03
ct
-0
2
0
Ju
l-0
6
O
ct
-0
6
8/06: Live in
MGHOE
100
O
New users per month
800
4/06: Live
in PAML
Usage By Application
95% medications
3% lab results
LMR
20%
2% diseases
Results
2%
WEBMAR
63%
75% Micromedex
19% Partners
3% Skolar
1% eMedicine
Handbook
3%
AdultRx
9%
PAML
0%
MGHOE
3%
USAGE BY ROLE
NP
4%
MD
10%
1% of patient
encounters (LMR)
Other
2%
Ancillary
3%
Pharm
11%
40-75% of
patient
encounters
(WebMAR)
RN
70%
KL Session Characteristics
Num of links Time Spent
viewed
(median sec)
Medications
1.3
7
Labs
1.2
11
Diseases
1.2
12
-0
Ja 2
n0
M 3
ar
-0
M 3
ay
-0
3
Ju
l-0
Se 3
p0
N 3
ov
-0
Ja 3
n0
M 4
ar
-0
M 4
ay
-0
4
Ju
l-0
Se 4
p0
N 4
ov
-0
Ja 4
n0
M 5
ar
-0
M 5
ay
-0
5
Ju
l-0
Se 5
p0
N 5
ov
-0
Ja 5
n0
M 6
ar
-0
M 6
ay
-0
6
Ju
l-0
Se 6
p0
N 6
ov
-0
6
N
ov
Sessions per Month
80,000
70,000
60,000
50,000
40,000
Total MDX
MDX via KL
30,000
20,000
10,000
0
Date
Summary
• Infobuttons are utilized and valued by all
types of care providers, not just MDs
– Rapid adoption despite lack of training or
introduction
– Extremely positive feedback overall
• Infobuttons are effective (84% answer rate)
• Infobuttons can have significant impact on
patient care even when used infrequently, but
direct measurement of effect is difficult
• A minimal implementation can be both
technically simple and clinically effective
HL7 Standard for Infobutton
Integration
Guilherme Del Fiol, MD, MS
Intermountain Health Care
University of Utah
Salt Lake City, UT
Why do we need a standard?
• There is not a common integration
language
– Query parameter names
– Terminologies used for content
search retrieval
• Hundreds of resources available
– Not designed for infobutton
integration: suboptimal results
– Labor intensive integration: just a few
are actually used
Multiple ways of
“asking” the same question
What is the dose of
azithromycin ?
i
http://resource1.com/
search = “azithromycin AND dose”
http://resource2.com/
query = "azithromycin"[MeSH Terms]
AND dose[All Fields]
http://resource3.com/
searchConcept = 3333 ^ azithromycin
filter = 11 ^ dosage
No standard in place
API
http://resource1.com/search.cgi?
Resource 1
search = “azithromycin AND dose”
http://resource2.com/
Clinical
Information
System
i
API
Infobutton
Manager
query = "azithromycin"[MeSH Terms]
AND dose[All Fields]
API
Resource 2
http://www.resource3.com/search.cgi?
searchConcept = 3333 ^ azithromycin
filter = 11 ^ dosage
API
Resource 3
Standard-based integration
HTML
HL7
Clinical
Information
System
i
Infobutton
HL7 Manager
HL7
HL7
HTML
Resource 1
Resource 2
Resource 3
Participants
• HL7 Clinical Decision Support
Technical Committee
• Health care academic institutions
– IHC, Columbia University, Partners
Healthcare, Cedars-Sinai, Kaiser
Permanente
• Content providers
– ACP, Wolters Kluwer, Micromedex,
First Data Bank, Elsevier, Zynx
• EHR vendors
– GE, Epic, Eclipsys
Example 1
• The user is looking at a problem
list of a male, 77 years-old patient
with Bacterial Pneumonia. The
user clicks on an infobutton that
presents a series of questions. The
user selects “How do I treat
Bacterial Pneumonia?”
<patientContext>
<gender code="C10173"
displayName="Male"/>
<age value="77" unit="y"/>
<ageGroup code="D000368“
displayName="Aged"/>
•HL7 code for “Male”
•Age in years
•MeSH code for “65
and older”
•HL7 code for “Problem
list review”
<taskContext code="11"
•MeSH code for
displayName="Problem List Review"/>
“Pneumonia”
<mainSearchCriteria code="D018410"
codeSystem="2.16.840.1.113883.6.177"
displayName="Bacterial Pneumonia"/>
<subTopic code="Q000628"
•MeSH code for
“Therapy”
displayName="therapy"/>
http://www.e-resource.com/api?
patientContext.gender.c=C10173
patientContext.gender.dn=Female
age.v=77&age.u=y
ageGroup.c=D000368
ageGroup.dn=Aged
taskContext.c=11
taskContext.dn=Problem list review
mainSearchCriteria.c=D018410
mainSearchCriteria.dn=Bacterial Pneumonia
subTopic.c=Q000628
subTopic.dn=therapy
Example 2
• The user (an RN) is looking at a
medication list of a female,
Spanish speaker, 32 years-old
patient. The user clicks on the
infobutton next to “Azithromycin”
and is presented with a series of
links. The user selects the “patient
education" link.
<patientContext>
<age value="32" unit="y"/>
<gender code="C10174"
displayName=“Female"/>
<taskContext code=“5"/>
•HL7 code for “Female”
•“Medications list
review”
•User is “care provider”
•HL7 code for “RN”
<performer><healthCareProvider>
<discipline code="S13232" displayName="RN"/>
<language code="eng" displayName=“English"/>
•ISO 639-2 for “English”
•Content recipient
<informationRecipient><patient>
is “patient”
<language code=“spa" displayName=“Spanish"/>
•ISO code for “Spanish”
<mainSearchCriteria code="59762-3080-01"
displayName="Azithromycin"/>
http://www.hl7.org/v3ballot/html/
welcome/environment/index.htm
Current Status
• XML version
– Approved at committee level
– Membership level in January 2007
• URL version
– Implementation guide (not-normative)
– 1st ballot in January 2007
• Reference implementations
Commercial InfoButton Applications
Content Vendors Perspective
Nick Ackerson
Product Manger – Integrated
Solutions
Thomson Healthcare
InfoButton Snapshot
• Growing list of HCO’s adopting principle
of embedded CDS (InfoButtons)
• Growing list of HIS vendors realizing
benefits of CDS/customer pull
• Thought leading academia prevalent
and well known. Leading push
• InfoButton API’s now available with
commercial access, not just academics
• HCO’s striving for comprehensive,
unbiased standardization of access to
clinical content investments. (HL7)
Clinical Deployment Results
A Case Study: Wake Med
• 851 Bed Integrated Health Care System,
Research Triangle, Raleigh NC
• 444,360 Outpatient Visits
• 13,702 Inpatient Surgery & Endoscopy
• 25,954 Outpatient Surgery &
Endoscopy
• 24,908 Cardiovascular procedures
• Ranks #1 in volume among all North Carolina
Hospitals, highest volume Heart Center
• North Carolina’s first freestanding Children’s ED
~40,000
Wake Med’s Clinical Motivators
• Manual upkeep of drug policies and
procedures
• Regulation compliance
• Practice variation
• Medical errors
• Adverse events
Other Motivators
• The need to centralize and streamline
accessibility to clinical knowledge
• Assess impact of deploying evidencedbased drug content
• Analysis of staff time and productivity
• Improved decision making/Empower
clinicians
• Optimization of content workflow tools
to improve performance
Online Injectable Administration
Results of Deployment
• Over 55% of Wake Meds surveyed
respondents were using InfoButton
• Altered course of treatment 20%
of the time
• Overall satisfaction was excellent
• Integration time was 2 – 4 weeks
• Training was communicated in
newsletter.
Wake Med Usage
Benefits Realized by
Users/Institution
• Reduces time/effort to answer key
clinical questions - little/no training
required
• More care, less searching used frequently
• Needed knowledge more directly into
workflow - affects decisions
• Context/patient-specific information more responsive to needs
Benefits for Institution
• Enhanced care sooner:
– Quick/easy integration; hosted data
– less training
• Promotes best clinical practices:
– Reduce unanswered/un-pursued clinical ?s
and negative care impact
– Alters medical/treatment decision 15-20%
of the time*
• Leverages existing subscriptions
– Summary/infobutton -> drill down to richer
content
*Health Management Technology “Delivering Informed Care” Feb 2006, Maviglia
*Wake Medical Health and Hospitals Survey, 2006
Peer Groups Implementing IB
applications
• WakeMed
• Alverno/Central
Washington
• Ohio Health
• Cedars Sinai
• University of
North Carolina
Healthcare Chapel Hill
• Salem Hospital
(Epic)
• Metropolitan Hospital
• Miami Baptist
• Sentara Health (Epic)
• Marshfield Clinic
• Texas Health
Resources (Epic,
Baylor)
• University Medical
Center (Eclipsys)
• Froedtert Hospital
(Epic)
Lessons Learned
• Flexible, scaleable, HL7-compliant technology key to
meet realities of HIS vendors and HCOs (API’s)
• Granular content leveraging robust Content
Management System is key asset
• Testing protocols and implementation team is key to
successful deployment and usage
• Demonstrated value from dynamic delivery of
information relevant to the clinician’s task
• Academic research and ongoing market analysis are key
to continuous improvement
• InfoButtons are used by health care providers of all
disciplines
• InfoButtons are convenient, intuitive, effective, and
relatively simple to implement
• Standardized messaging should increase specificity and
utility over time, Build out technology
• Efficient, intuitive, productive and proven to improve
care and prevent ADE’s