anticipating and satisfying clinician information needs: the infobutton manager project james j....
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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• Needs are underestimated• Information needs may not be recognized• Resources are outdated or unavailable• Computers not used• Resolution may be deferred• Unsatisfied information needs are a potential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
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%
WebCIS Log Files Results
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%
WebCIS Log Files Results
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
WebCIS User Questionnaire Results
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
WebCIS User Questionnaire Results
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
WebCIS User Questionnaire Results
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
WebCIS User Questionnaire Results
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?
WebCIS User Questionnaire Results
HHH
HHH
HH
HH H
HH
HH
H
H
H
A AAA
AA
A
A
A
AA
A
AA
A
A
A
A
A
A P
N
A
Never <Monthly Monthly Weekly DailyInfobuttons
25
20
15
10
5
0
How does self-reporting correlate with log files?
WebCIS User Questionnaire Results
• 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
WebCIS User Questionnaire Results
• 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
Observational Results
Total Number of events: 154
Medical/Surgical 71 (46%)
CCU 35 (23%)
Ambulatory Care 48 (31%)
Observational Results
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
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
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Context Parameters
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• Setting: lab reports, medications, …
• Concept of interest: lab test, drug, …
• Institution: CPMC, RMRS, LDS, …
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