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
UnderstandInformation
Needs
1
“Just in Time” Education
Get InformationFrom EMR
UnderstandInformation
Needs
1
2
“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
UnderstandInformation
Needs
1
2
3
“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
UnderstandInformation
Needs
1
24
3
“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
UnderstandInformation
Needs
AutomatedTranslation
1
254
3
“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
QueryingUnderstandInformation
Needs
AutomatedTranslation
1
254
6
3
“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
Querying
Presentation
UnderstandInformation
Needs
AutomatedTranslation
1
254
6
3
7
“Just in Time” Education
Get InformationFrom EMR
ResourceSelection
ResourceTerminology
Querying
Presentation
UnderstandInformation
Needs
AutomatedTranslation
1
254
6
3
7
User’s Workstation
Microphone
Video Converter
75 foot cable
Converter Controller
Cassette RecorderVCR
Headphones
Video Monitor
Initial Lessons: Observational Data
• Log file analysis– Resource use varies with user type and task
Context-Specific Resource Use
0%
20%
40%
60%
80%
100%
Sensitivity IB
Culture IB
Pharmacy IB
Medlineplus
ICD9-CM
Journals
PubMed
Harrison's
Formulary
Ovid Medline
Micromedex
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
Pop-Up E-Mail
Easy to use 83% 92%
Question on list >50% of time 89%
Answered question 69%
Useful 77%
Helpful >50% of time 90%
Positive effect on care 74%
Specific cases of improved care 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
0
1000
2000
3000 Laboratory Results Review
0
200
400
600 Inpatient Drug Order Review
0
20
40
60Microbiology Sensitivity Results
0
50
100
150
200Diagnosis List
0
20
40
60Inpatient Lab Order Entry
0
50
100
150
200Inpatient Drug Order Entry
Resource Use by Context - September
0
500
1000
1500
2000
2500
LabResults
InpatientDrugs
OutpatientDrugs
OrderEntry
Infobuttons
HealthResources
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?
