Supporting Medical Decision Making with Electronic Medical Records

James J. CiminoDepartments of Medicine and Medical Informatics

Columbia University

Decision Making for Patients and Providers

• Access to (electronic) health records generates information needs

• Information needs go unmet

• “Best evidence”, educational material, training programs can address these needs

One-Stop Information Shopping?

World Wide Web(The Hyperdocument)

InformationResources

Biblio-graphic

Database

Textbook

ExpertSystem

HealthPractitioner

One-Touch Information Shopping

InformationResources

World Wide Web(The Facilitator)

Biblio-graphic

Database

Textbook

ExpertSystem

HealthPractitioner

?MRSA

Information for Decision-Making

Query

MRSA

Intelligent Decision Support

?

Result

!

Infobutton: Automating the Process

• Questions can be anticipated

• Match information source to question

• Automate the retrieval

• Query can use patient information

New York Presbyterian Hospital Information Architecture

• Central repository

• Data Access Modules

• Medical Entities Dictionary

• MedLEE

• CIS

• WebCIS

• PatCIS

Central Controlled Terminology

MED Semantic NetworkMedicalEntity

PlasmaGlucose

Test

LaboratorySpecimen

PlasmaSpecimen

AnatomicSubstance

Plasma Substance

Sampled

Part of

Has S

pecimen

Substance Measured

LaboratoryProcedure

CHEM-7

LaboratoryTest

Event

DiagnosticProcedure

Substance

BioactiveSubstance

Glucose

Chemical

Carbo-hydrate

Automated Decision Support

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

Querying

Presentation

UnderstandInformation

Needs

AutomatedTranslation

1

254

6

3

7

MRSA

Translations with the MED

Gentamicin

EtiologyMeasures

Sensitivity

Substance Measured

InjectableGentamicin

Gentamicn Sensitivity

Test

SerumGentamicin

Level

is-a

IntravascularGentamicin

Tests

GentamicinToxicity

Has ingredient

SummaryReports

DecisionRule

ExpertSystem

DrugInformation

• The Medline Button

EMR and Decision Support

- understand conditions• Pharmacy Infobutton - review and teach

• The Medline Button - understand conditions• Pharmacy Infobutton

EMR and Decision Support

- review and teach• Cholesterol Guideline - dietary planning

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline

EMR and Decision Support

- dietary planning• DXplain Button - understand findings

From Test Result to Finding

1600 44 L

1600 Gluc

32703 SerumGlucose Tests

32308 IntravascularGlucose Tests

42485 ElevatedAbnormal Findingin Body Substance

42486 DecreasedAbnormal Findingin Body Substance

42541 Hyperglycemia 3286 Hypoglycemia

32412 IntravascularSpecimen

31987 Glucose

42527 AbnormalLevel of Blood

Glucose

3286 Hypoglycemia

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline - dietary planning• Dxplain Button

EMR and Decision Support

- understand findings• QingCIS - problem-oriented views

Smarter Retrievals from the Record

• Repository stores events and results

• Clinical problems at a different level of granularity

• Re-use knowledge to map from problems to clinical data

• Produce problem-specific views of the medical record

Chest X rayCongestive

Heart Failure

Intravascular CK Test

CreatineKinase

Chest X ray 2 View

Cardiac Enzyme

Angina

Lab :1/1/99 Lab :1/1/99 Cardiac Enzyme TestCardiac Enzyme Test

Radiology :2/23/99 Radiology :2/23/99 Chest X RayChest X Ray

Radiology :2/28/96 Radiology :2/28/96 Head CTHead CT

Lab :12/28/96 Lab :12/28/96 Sickle Cell TestSickle Cell Test

Admission :3/14/96 Admission :3/14/96 StrokeStroke

Admission :2/14/98Admission :2/14/98AnginaAngina

Lab :1/1/99 Lab :1/1/99 Blood Type TestBlood Type Test

Radiology :2/1/97 Radiology :2/1/97 Knee X RayKnee X Ray

Concept-oriented(Heart)

Heart Disease

Chest

Discharge :1/15/99Discharge :1/15/99 CHFCHF

Discharge :1/15/99Discharge :1/15/99 CHFCHF

Admission :2/14/98Admission :2/14/98AnginaAngina

Lab :1/1/99 Lab :1/1/99 Cardiac Enzyme TestCardiac Enzyme Test

Radiology :2/23/99 Radiology :2/23/99 Chest X RayChest X Ray

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline - dietary planning• Dxplain Button - understand findings• QingCIS

EMR and Decision Support

- problem-oriented views• PatCIS - patient education

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline - dietary planning• Dxplain Button - understand findings• QingCIS - problem-oriented views• PatCIS

EMR and Decision Support

- patient education• Lab Infobutton - patient information

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline - dietary planning• Dxplain Button - understand findings• QingCIS - problem-oriented views• PatCIS - patient education• Lab Infobutton

EMR and Decision Support

- patient information• Microbiology Infobuttons - infection control

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline - dietary planning• Dxplain Button - understand findings• QingCIS - problem-oriented views• PatCIS - patient education• Lab Infobutton - patient information• Microbiology Infobuttons

EMR and Decision Support

- infection control• Mammography Guideline - screening

• The Medline Button - understand conditions• Pharmacy Infobutton - review and teach• Cholesterol Guideline - dietary planning• Dxplain Button - understand findings• QingCIS - problem-oriented views• PatCIS - patient education• Lab Infobutton - patient information• Microbiology Infobuttons - infection control• Mammography Guideline

EMR and Decision Support

- screening• Pap Smear Infobutton - screening

Summary• Decision making requires high-quality, up-

to-date, timely information• The EMR generates information needs• The EMR can help satisfy information needs• The Web makes the rest easy• Further study needed:

– When do users need information?– What information do they need? – What terminology is needed?– What are the right resources?– How can retrievals be facilitated?– How do we present results?