Resolving Clinicians’ On-Line Information Needs:

A Brief History of Buttons

James J. Cimino, M.D.Biomedical Informatics and Medicine

Columbia UniversityJune 24, 2005

Objectives

• Studying clinician information needs

• Evolution of infobuttons

• Research issues

• The Coumadin Story

Everybody is worried about losing their job to automation. They’re afraid they’ll be replaced by a button. But I’m smart. I’m going to get a job in the factory where they make the buttons.

- Jackie Gleason, The Jackie Gleason Show, circa 1968

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covell et al.Information Needs

Studying Information Needs

Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med. 1985 Oct;103(4):596-9.

Findings of Observational Studies

• 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

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!

Information for Decision-Making

Information for Decision-Making

?MRSA

Information for Decision-Making

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covel et al.Information Needs

UMLSProject

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 1986/1993

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

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

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• Technical success• Practical failure

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

Mosaic

Web-basedGeneric Queries

PubMED

WebCIS

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

Mosaic

Web-basedGeneric Queries

PubMED

Web DXplain

DXplainButton

WebCIS

Cholesterol

Hypercholesterolemia

Serum Cholesterol Test

Serum Specimen

Serum

From Data to Findings

Abnormalities ofSerum Cholesterol

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

Mosaic

Infobuttons

Web-basedGeneric Queries

PubMED

Web DXplain

DXplainButton

WebCIS

Information Resource Usage

6%

4%

4%

4%

51%

3%3%7%

6%

1% 1%10% MicromedexPharmacy IBSensitivity IBCulture IBOvid MedlineOnline FormularyHarrison'sPubMedJournalsMedlinePlusICD9-CMOther Resources

12% IBs

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

“Just in Time” Education

MRSA

“Just in Time” Education

UnderstandInformation

Needs

1MRSA

“Just in Time” Education

Get InformationFrom EMR

UnderstandInformation

Needs

1

2

MRSA

“Just in Time” Education

Get InformationFrom EMR

ResourceSelection

UnderstandInformation

Needs

1

2

3

MRSA

“Just in Time” Education

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

UnderstandInformation

Needs

1

24

3

MRSA

“Just in Time” Education

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

UnderstandInformation

Needs

AutomatedTranslation

1

254

3

MRSA

“Just in Time” Education

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

QueryingUnderstandInformation

Needs

AutomatedTranslation

1

254

6

3

MRSA

“Just in Time” Education

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

Querying

Presentation

UnderstandInformation

Needs

AutomatedTranslation

1

254

6

37

MRSA

Research Issues

• What are the information needs?

Portable Usability LabUser’s Workstation

Microphone

Video Converter

75 foot cable

Converter Controller

Cassette Recorder VCRHeadphones

Video Monitor

What are the Information Needs?• Observations:

– Four days, three sites, 159 minutes of videotape

– 154 information needs• 1/3 information about the patient

– Abdominal CT was abnormal, what are LFTs?

• 1/3 institutional information– What specimen do I collect for this test?

• 1/3 health information– What does this pill look like?– What are the patient instructions?

• Computers used 50% of the time• 81/154 needs not satisfied

Research Issues

• Which context information is important?

• What are the information needs?

Context-Dependent Information Needs

Age Sex TrainingRole DataTask

Context

? !

Institution

Research Issues

• What resources can satisfy needs?• How can retrieval be automated?

– What context data are used?– How are the data translated?

• What are the information needs?• Which context information is important?

The Medical Entities Dictionary (MED)

Research Issues

– How are the data transmitted?

• 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?

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

Mosaic

Infobuttons

Web-basedGeneric Queries

InfobuttonManager

PubMED

Web DXplain

DXplainButton

WebCIS

Infobuttons vs. Infobutton Manager

Pageof

Hyperlinks

InfobuttonClinical System Resourc

e

InfobuttonManager

Context

s

The Coumadin Story

• Chair of Medicine wants link to Coumadin protocol• First, I have to find the guidelines

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

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…

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…• … and I’m done - about 15 minutes.

Discussion• Resources are available• Simple interactions are usually possible• Interaction method (format) issues:

– “Give me a page” vs. “Give me the answer”– Standards needed for asking questions– Standards needed for passing parameters

• Representation (terminology) issues:– Clinical systems use homegrown “standards”– Resources (except PubMed) don’t use any

standards (i.e., they are indexed by text word)

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

G.O. BarnettDXplain

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

Mosaic

Infobuttons

Web-basedGeneric Queries

InfobuttonManager

InfobuttonManagerStandard

PubMED

Web DXplain

DXplainButton

WebCIS

Next Steps

• Evaluation

Next Steps

• Evaluation• Order entry Infobuttons• Collaborations: LDS/IHC, Regenstrief and NYSPI• Infobutton Manager to be an ANSI standard

Conclusions• Information needs arise while using CIS• Infobuttons are easy to build• Build it and they may not come• Can retrievals be standardized?• Will information needs be satisfied?• Will care improve?• Resources exist• Creative solutions required• Need to engage resource providers• Infobutton manager provides a platform for

exploration

Button.- Jimmy Cimino, 1956

Acknowledgments• The Columbia team:

– Jianhua Li– Sue Bakken– Vimla Patel– Mureen Allen– Leanne Currie– Mark Graham

• LDS/IHC: Guilherme del Fiol, Stan Huff• Regenstrief: Marc Overhage• NYSPI: Tom White• National Library of Medicine research grant• National Library of Medicine training grant• National Institute of Nursing Research

www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html