anticipating and satisfying clinician information needs: the infobutton manager project james j....

Anticipating and Satisfying Clinician Information Needs:

The Infobutton Manager Project

James J. Cimino, M.D.

Department of (Bio)Medical Informatics

Weekly Seminar

March 6, 2003

Studying Clinician Information

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

• Other studies: Osheroff, Forsythe, Gorman, Ely…• Types of needs

– Patient-specific– General knowledge– Institutional

• Resources– Medical record– Colleagues– Journals– Books

Do Clinicians Satisfy their Needs?

• Needs are underestimated• Information needs may not be recognized• Resources are outdated or unavailable• Computers not used• Resolution may be deferred• Unsatisfied information needs are a potential

source for errors

Needs Related to CIS Use?

• Very small part of the clinician’s day• Very important part of the day

– New information stimulates needs– Decision-making moments

• Opportunity to resolve needs (using a computer)• Context might predict needs• Context might help resolve needs• Needs in this setting have not been studied

Context-Dependent Information Needs

Age Sex TrainingRole DataTask

Context

? !

Institution

Hypothesis:

• Information needs are stereotypical

• Information needs can be predicted based on context

• Appropriate resource can be identified (automatically or in advance)

• Resource can be queried automatically

• Information from context can be used for query

• “Infobuttons”

A Brief History of Infobuttons

• 1991: “Medline Button” translated ICD9 to MeSH and performed Medline searches

• 1994: World Wide Web

• 1994: First CPMC Web-based CIS

• 1996: WebCIS

• 1996: Infobuttons link microbiology and medication data to PubMed and Micromedex

• 1997: Infobuttons for patients (PatCIS)

• 2002: Handheld, wireless infobuttons (PalmCIS)

Infobutton Manager Project

• Study information needs of CIS users• Characterize needs based on context• Develop way to anticipate needs• Develop ways to resolve needs• Deploy anticipation/solution• Evaluate

Infobutton Manager Team Members

• Jim Cimino• Jianhua Li• Sue Bakken• Vimla Patel• Mark Graham• Leanne Currie• Mureen Allen• Anne-Marie Ramierez• Your name here?

Methods

• Determine information needs– WebCIS log files– WebCIS user questionnaires– Observational studies

• Characterize information needs• Build Infobutton Manager (IM)• Build infobuttons• Populate IM database• Integrate IM with WebCIS• Evaluation

Insert WebCIS Demo Here

https://webcis.cpmc.columbia.edu/

WebCIS Log File Methods

• Health Resources page in WebCIS• Infobuttons in WebCIS• Problems:

– Which user selected which resource?– What was the user was doing?

• Solution: look at previous activity at same IP address

WebCIS Log File Records

Mar 2 16:16:46 webcis3-i syslog: |WebCIS|ciminoj|156.111.145.61|3131313 |lab^2003-03-02-05.19.00.819650|view

Mar 2 16:18:55 webcis3-i syslog: |WebCIS|ciminoj|156.111.145.61|3131313 |healthresource|view

Mar 2 16:18:58 webcis3-i syslog: |Resources|(nobody)|156.111.145.61|| |url^http://salk.cpmc.columbia.edu:70/mdxdocs

WebCIS Log Files Results

• Six months of log files• 2,607 users (1,034 per month) used a resource• 2931 IPs (2008 “156.x.x.x”)• User types:

Housestaff: 51%

Attendings: 34%

Nurses: 5%

Other: 10%


38,763 uses of resources

14,036 outside WebCIS (2339/month)

24,727 within WebCIS (4,104/month; 4/user)

19,913 uses of 24 resources (3,319/month)

4,814 uses of 3 infobuttons (802/month)

WebCIS Log Files ResultsPopular resources: Inside Outside

Micromedex: 56.5% 51.7%Ovid: 7.4% 8.2%NYP Formulary 7.2% 7.1%Harrison’s 5.1% 5.1%PubMed 5.1% 5.1%Health Journals 5.0% 8.2%Medline Plus 3.3% 3.6%ICD9-CM 3.3% 2.9%

InfobuttonsPharmacy/Micromedex 92.9% -Microbiology/PubMed 6.1% -Pharmacy/PubMed 1.0% -

80.4%

Health Resources: 19,913 times in 105 contexts:

Lab results: 52.1%

Radiology results: 9.0%

Clinical notes: 7.4%

Pathology results: 2.8%

Visit list: 2.1%

Pharmacy: 2.0%

Discharge summary: 1.9%


100%

Infobuttons: 4,814 times in 2 contexts:

Pharmacy: 93.9%

Lab results (Micro): 6.1%

WebCIS Log Files ResultsContext: Lab Rad Note Card Path Vis Phar DSum

MDX 53% 9% 3% 3% 3% 2% 2% 2%Ovid 49% 9% 6% 2% 3% 1% 1% 1%Formul. 52% 8% 6% 3% 3% 1% 3% 2%Harrison 49% 10% 5% 3% 4% 1% 1% 3%PubMed 48% 10% 7% 3% 5% 1% 3% 1%Journals 43% 8% 7% 6% 5% 2% 2% 1%Med+ 50% 8% 6% 3% 2% 4% 2% 1%ICD9 37% 12% 10% 2% 3% 2% 1% 2%

InfobuttonsMDX - - - - - - 100% -PubMed 86% - - - - - 14% -

WebCIS Log Files ResultsContext: Lab Rad Note Card Path Vis Phar DSum

MDX 56% 57% 61% 59% 49% 42% 9% 62%Ovid 7% 7% 8% 5% 8% 4% 1% 6%Formulary 7% 6% 6% 6% 7% 3% 1% 7%Harrisons 5% 6% 4% 5% 6% 3% 1% 7%PubMed 5% 5% 5% 4% 8% 2% 1% 3%Journals 4% 4% 5% 9% 8% 3% 1% 3%Med+ 3% 3% 2% 3% 3% 32% 1% 2%ICD9 1% 4% 4% 2% 3% 2% .2% 3%

InfobuttonsMDX - - - - - - 84% -PubMed 3% - - - - - 2% -

WebCIS Log Files ResultsUser: Housestaff Attending Nurse Other

MDX 62% 61% 42% 27%Ovid 6% 7% >1% 1%Formulary 6% 5% 3% 5%Harrison 4% 3% 4% 3%PubMed 4% 5% 1% 1%Journals 3% 0% 3% 1%Med+ 2% 2% 3% 2%ICD9 3% 5% 1% 1%Statref 1% 1% 1% 3%PIER 0% 2% 3% 1%

InfobuttonsMDX 5% 6% 42% 53%PubMed 2% 1% 2% 1%

WebCIS Usage Logs Results• Take home messages:

– Micromedex is a popular resource– Ovid edges out PubMed– Lab tests are a popular context for resources– No correlation between context and resource– Nurses and pharmacists like the Micromeex infobutton

for microbiology• Still needed:

– Context/resource/user type interactions– Concept-oriented contexts

• Questions:– How much is based on knowledge of resources?– What are the questions in each context?

WebCIS User Questionnaires

• Health resources page outside vs. inside WebCIS• Resources used, how often, how useful, anecdotes• Infobuttons used, how often, how useful, anecdotes• Other resources used

WebCIS User Questionnaire Results

1055 users in January300 randomly selected250 with valid e-mail addresses surveyed 42 responded

21 attendings 19 housestaff 1 nurse 1 pharmacist


How often do you access: Never <Month Monthly Weekly Daily

Attend 2 1 3 5 9House 3 11 5Nurse 1Pharm 1

Attend 11 8 2House 14 3 1 1Nurse 1 Pharm 1

Resource

Infobut


Why do you access: Patient Qs Genl Know Other

Attend 20 12 3 House 18 10 1 Nurse 1Pharm 1 1

Attend 10 House 4 Nurse Pharm 1

Resource

Infobut


How do you access: None WC-Login WC-Menu Both

OtherAttend 2 4 7 8 12House 0 8 8 3 17Nurse 1 Pharm 1 1

Resource

WebCIS User Questionnaire ResultsWhat resources and how useful: Very Somewhat Not _ A H A H A HMMDX 17 17 0 2 1 0Ovid 10 11 1 2 0 0PubMed 12 7 2 3 0 0Medline+ 4 4 0 1 1 0FullText 8 7 2 2 0 0Harrisons 7 4 3 9 1 0PIER 2 4 3 1 1 0Formulary 2 3 2 1 1 0Health J 6 9 0 1 0 1Science J 3 4 0 1 1 0STATref 1 2 6 0 1 1ICD9 1 2 5 0 0 1

WebCIS User Questionnaire ResultsHow useful are infobuttons: Very Somewhat Not _ A H A H A HMicro Org 3 3 5 1 2 0Micro Sens 7 3 2 3 0 0Pharmacy 6 1 0 2 0 0


A

A

A

A

A

A

A

A

A

AA

A

A

AA

A

A

AA

PN

H

H

H

HH

H

HH

HH

H

H

H

HH

HHH

H

A

Never <Monthly Monthly Weekly DailyHealth Resources

100

80

60

40

20

0

How does self-reporting correlate with log files?


HHH

HHH

HH

HH H

HH

HH

H

H

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A AAA

AA

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N

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Never <Monthly Monthly Weekly DailyInfobuttons

25

20

15

10

5

0

How does self-reporting correlate with log files?


• Anecdotes:– Avoid errors (drug interactions)– Identify correct doses– Identify pills– Prepare publications– Teaching– Understand abbreviations (sensitivity tests)

• Other desired resources:– Up To Date– NEJM– MDConsult– Books


• Resources are used and liked• Resources are used within WebCIS• Resources are used to answer patient-specific

questions• Use of resources may be overestimated (can’t tell

for sure)• Infobuttons are used and liked• Additional resources requested• Questions:

– How knowledgeable are users about resources?– What are the context-specific questions

Observational Studies

• Connect portable usability lab to clinical workstation• Ask users to think aloud about information needs• Videotape screen and audiotape users• Transcribe tapes• Code transcripts, using tapes• Analysis of coding

Portable Usability LabUser’s Workstation

Microphone

Video Converter

75 foot cable

Converter Controller

Cassette RecorderVCR

Headphones

Video Monitor

Observational Results

• Sites: – Medical /Surgical – CCU– Ambulatory Care

• Number of Days: – 7 different days – Varying days of the week – Varying times of day

• Total hours of tape: 15 hrs 29 minutes• Total Number of events: 154


Total Number of events: 154

Medical/Surgical 71 (46%)

CCU 35 (23%)

Ambulatory Care 48 (31%)


Total Number by User Type

Nurse 17 (11%)

House Officer 103 (67%)

Attending/Fellow 18 (12%)

Student 7 (5%)

Event Coding

• Types of Events:– Foreground/Background– Implicit/Explicit– Patient/Institution/Administrative/Domain

• Types of Resources– Human/Computer/Paper

• Types of Outcomes– Success/Deferred/Failed

Coding Event Type

• Foreground– Specific information about patient management – Problem, Intervention, Comparison, Outcome

• Background – Root question: who, what, where,when, why, how?

– Related to health disorder or aspect of a disorder

Coding Event Type

Coding Event Type

• Explicit: Subject expresses an information need • Implicit: Subject uses a resource other than WebCIS

Coding Event Type

Coding Event Type• Patient

– A patient related need • Institution

– An information need that is related to the infrastructure of the institution

• Administrative– An institutional information need that is

related to a specific patient • Domain

– A domain related information need that is related to a specific patient

Coding Event Type

Coding Resources Used

• Human– The subject sought information from a human

interaction in person or via telephone • Computer

– The subject sought information from a computer interaction either webCIS or other internet resource

• Paper– The subject sought information from a paper

resource – patient chart or text book

Coding Event Type

Coding Outcomes

• Success– The subject sought and found the desired

information • Deferred

– The subject did not seek an answer • Failed

– The subject sought, but did not find desired information

Coding Outcomes

Coding Events• Need to correlate across event types• Especially need to look at types of needs that

were deferred or that failed• Good news:

– Information needs exist and can be identified– Needed resources are computer-based

• Bad news (good news for us):– Many needs failed or deferred– Solutions will require integration of patient

data with information resources• Questions:

– What are the triggers?– What resources can help?

Classification of Information Needs Classification Definition

Navigation A question about anything in WebCIS (either currently present or could be added at a later date to WebCIS) that the user is unable to access or use. The IB link would take the user to a resource that tells him how to access the needed information.

Functionality A response or question which alludes to the need to add an item to WebCIS or give the user access to another resource which answers the need. The IB would access the resource that would solve the problem and present the solution to the user.

Laboratory Information needs that are institution or patient specific related to the laboratory. The IB would provide specific information about a laboratory finding.

Pharmacy Information needs that are institution or patient specific related to the pharmacy. The IB would provide information about specific medications.

Differential Diagnosis

Questions related to alternate causes of a symptom or laboratory or radiology finding. IB would provide context-specific differential diagnoses

Definition/ Information

Questions related to the meaning of words. In addition, general information on a topic. IB would provide a definition or general information about a topic/word.

Miscellany Those needs that do not readily translate into patient/institution needs.

Methods: Classification Scheme

General question: What is the normal value for this calcium result?

Generic question: What is the normal value of this laboratory test?

Classification: Navigation: because normal laboratory values are available in WebCIS, this IB link would take the user to another page informing the users on how to access the information needed.

Methods: Classification Scheme

General question: Since the CT scan of the liver is abnormal what are his liver function test results?

Generic question: What laboratory tests are associated with this radiology report?

Classification: Functionality group since it will require designing an IB that would bring information to the user from another area in WebCIS (or some other resource) while he is at a particular site.

Classification Code

48 31.227 17.519 12.331 20.1

9 5.8

15 9.75 3.2

154 100.0

Navigation

Functionality

Laboratory

Pharmacy

DifferentialDiag.

Definition/info.

Miscellany

Total

Count Percent

Observational Studies Results

Observational Studies Results

• Wide variety of information needs• Many needs are stereotypical• Many can be answered with simple resources• Some complex solutions will be needed• Next steps:

– Finish the characterizations of needs– Propose ways to solve each need– Build infobuttons (project opportunities!)

The Infobutton Manager

• CGI script using “get” or “post”• Context parameters as input• Uses context table and infobutton table• Returns a list of questions that are links• Log files for calls to IM and selecting links• Infobutton Manager Manager for maintenance

Matching Context to Need

Context

ContextMatching

QuestionSelection

Instantiation

Infobuttons

Infobutton Manager

Context Table

Question Table

Context Parameters

• Patient: age, gender

• User: physician, nurse, student, patient, …

• Setting: lab reports, medications, …

• Concept of interest: lab test, drug, …

Infobutton Parameters

• Question type: fixed, fill-in-the-blank• Source type: simple query, additional data• URL:

http://www.guideline.gov/SEARCH/search_results.asp? sSearch_string=<>&bSort_by_date=&query_id=& bDebug=&results=10&view=search_results

• Question:

What are guidelines for evaluation of <>?

Infobutton Manager Manager Demo

Insert Infobutton Manager Demo Here

Insert Infobutton Manager Manager Demo Here

https://flux.cpmc.columbia.edu/webcisdev13/start.cgi

https://flux.cpmc.columbia.edu/webcisdev13/webcis_manage.cgi

Evaluation Plan

• Baseline observation– Creation of Infobutton Manager tables– Resources used– Unmet information needs

• Log of access to online resources• Introduction of infobuttons

– Usability studies• Log of access to online resources (infobuttons)• Post-intervention observation

– Use of infobuttons and other resources– Unmet information needs

Discussion

• Information needs occur and are detectable• Information needs are unmet• Information needs are predictable based on context• Solutions are at hand• Solutions are institution independent• Integration into clinical systems is easy• Will infobuttons reduce unmet information needs?• Next project: show that this reduces errors!

Acknowledgments

• National Library of Medicine grant R01-LM07593

• Rick Gallagher

• The team: Jianhua Li, Sue Bakken, Vimla Patel, Mark Graham, Leanne Currie, Mureen Allen, Anne-Marie Ramierez

<a href="Javascript:get_info('35702')"><img src="info.gif"></a>

function get_info(mc){ var infowin = window.open("","INFO"); infowin.focus(); document.INFO.info_med.value=mc; document.INFO.submit(); }

<form method="POST" name=“INFO” action="wc_infomanage.cgi"><input type="HIDDEN" name="info_med" value=""><input type="HIDDEN" name="info_context" value="LabDetail"><input type="HIDDEN" name="info_institute" value="CPMC"><input type="HIDDEN" name="DOB" value="1951-05-26"><input type="HIDDEN" name="SEX" value="F"><input type="HIDDEN" name="USER" value="ciminoj"></form>

Context Parameters

• Patient: age, gender

• User: physician, nurse, student, patient, …

• Setting: lab reports, medications, …

• Concept of interest: lab test, drug, …

• Institution: CPMC, RMRS, LDS, …

anticipating and satisfying clinician information needs: the infobutton manager project james j....

Documents

needs needs

needs context

unsatisfied information

webcis infobuttons

webcis evaluation slide

mdxdocs slide

query infobuttons slide

webcis demo