AMIA 2009 Symposium Proceedings Page - 109

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1 Th Contribution of Obsrvational Studis and Clinical Contxt Information for Guiding th Intgration of Infobuttons into Clinical Information Systms Jams J. Cimino, MD Laboratory for Informatics Dvlopmnt, National Instituts of Halth Clinical Cntr, Bthsda, Maryland, USA Dpartmnt of Biomdical Informatics, Columbia Univrsity, Nw York, Nw York, USA Abstract Th intgration of information rsourcs into clinical information systms may b basd on a varity of approachs, including what is practical to provid, what is hypothtically usful, and (basd on usr studis) what is mpirically usful. Rsourc slction may also b basd on th usr s contxt (rol, task, patint dmographics, concpt of intrst, tc.). Mthods: Two yars of log fils showing th contxt-spcific us of information rsourcs, spcially via us of an infobutton managr (IM), wr xamind for pattrns of usag. Rsults: 3483 known uniqu usrs (and an unknown numbr of anonymous usrs) accssd information rsourcs 65,128 tims, including th us of th IM 21,907 tims by at last 2367 uniqu usrs. providd in rspons to mpirical information nds accountd for 16 of th total links and 32 of th accsss to information rsourcs. that wr providd basd on patint dmographics accountd for 29 of th total links and 13 of th accsss to information rsourcs. that wr providd basd on th usrs concpt of intrst accountd for 21 of th total links and 13 of th accsss to information rsourcs. Conclusion: Knowldg of obsrvd information nds and of contxt attributs is usful for guiding automatd slction of rsourc links by an Infobutton Managr. Introduction Clinical information systm (CIS) dvloprs us a varity of stratgis for intgrating halth knowldg rsourcs (or simply, rsourcs ) into thir systms to addrss thir usrs information nds. On common approach is to provid a static list of links to whatvr rsourcs ar availabl. W rfr to this as th practical approach. Rcntly, CIS dvloprs hav bgun to provid links to rsourcs dmd rlvant, givn th usr s contxt, which can b charactrizd by attributs such as th usr s rol and task, th patint s ag and gndr, and th clinical concpts rlatd to th task such as a particular tst rsult or mdication. 1 Such dynamic slction of rlvant information rsourcs gos by a varity of nams, including infobuttons and infobutton managrs (IMs). 2 Th mchanism by which information rsourcs ar slctd by a CIS for a givn contxt may b through hardcoding links to spcific rsourcs dirctly into th CIS or mploying an IM to dynamically match contxt paramtrs to rsourcs. Ultimatly, howvr, th CIS dvloprs (or thir collaborators, such as informaticians and librarians) must dcid which rsourcs ar to b providd by links and IMs. A common approach to rsourc slction is for a dvlopr to hypothsiz about th nds that would b appropriat givn a particular situation and thn slct rsourcs from among th availabl, practical choics. This approach may includ input from CIS usrs, as was don by Dl Fiol and collagus who usd focus groups to guid th inclusion of contxtrsourc knowldg in th IM at LDS Hospital. 3 Bcaus this mthod involvs hypothsizing about th rsourcs that will b usful in an actual situation, w rfr to this as th hypothtical approach. Many rsarchrs hav obsrvd clinicians to idntify information nds that aris in actual clinical practic, with th ida that th obsrvations will lad to a bttr undrstanding of th rsourcs that should b providd in th patint car stting. 4 Svral information nds studis hav conductd at Columbia Univrsity in a numbr of sttings 5 and hav bn usd to inform th addition of links to an IM. 6 W rfr to this as th mpirical approach. Whil a grat dal of work has bn carrid out to study clinician information nds, to construct solutions (such as infobuttons and IMs), and study th bnfits of such solutions, littl or no work has bn publishd dscribing how th us of obsrvational vidnc and contxt knowldg impacts th us of CIS-intgratd rsourcs. Th prsnt study analyzs log fils to bttr undrstand such impact. Background Clinicians at th Columbia Univrsity Mdical Cntr campus, including thos at Nw York Prsbytrian Hospital, us two major CISs: WbCIS (dvlopd at Columbia 7 ) and Sunris Clinical Managr (Eclipsys Corporation, Boca Raton, FL). Usrs of WbCIS (but not of th Eclipsys systm) can accss a Wb AMIA 2009 Symposium Procdings Pag - 109

2 pag calld Halth Rsourcs (HR) that provids a list of links to a varity of national, local, and commrcial rsourcs. WbCIS usrs can accss th Columbia IM by clicking on i icons nxt to clinical information such as mdications and tst rsults. Eclipsys usrs can accss th Columbia IM by clicking on a standard Itm Info button that is associatd with ordrabl itms (laboratory tsts, mdications or nursing activitis). Whn a usr slcts an IM link, contxt information (th mdical concpt and task and, in th cas of WbCIS, th usr ID, and th patint ag and gndr) is passd to th IM. Th HR pag contains practical links, indpndnt of th usr s contxt, basd on advic from th Columbia Halth Scincs librarians about availabl rsourcs. Many of th links providd by th IM ar basd on hypothtical us, prdictd by th Columbia infobutton rsarchrs and othrs at Columbia. For xampl, th chair of th Dpartmnt of Mdicin blivd that links to guidlins for us of drugs such as warfarin and hparin should b providd whnvr clinicians wr ordring thos drugs or rviwing rlvant laboratory rsults. Tabl 1 shows xampls ach of ths typs of links. W hav prviously carrid out obsrvations of clinicians using WbCIS and Eclipsys in a varity of clinical sttings. 5,6 Analysis of vidotap allowd us to idntify information nds that aros and to charactriz th contxtual factors rlatd to thos nds. Using ths findings, w addd mpirical Tabl 1: Exampls of links from various application contxts, including practical (p) links availabl through th HR pag in WbCIS, and hypothtical (h) and mpirical () links availabl through th IM in WbCIS and Eclipsys. Som links ar slctd by th IM basd on patint dmographics (d) or concpt of intrst (c). Contxt Rsourc - Topic CPMC Lab Manual - Gnral Information Lab Tsts Onlin - Gnral Information UpToDat - Gnral Information Dxplain - Diffrntial Typ h p,h p,h,c Calculator - Anion Gap h,c Commnts Obsrvd nd for normal rangs and collction instructions Basic information rsourc on lab tsts Basic information rsourc on lab tsts Offrd if lab tst is rlatd to a finding (.g., glucos tst rlatd to hyprglycmia Offrd for sodium, pottassium, chlorid, bicarbonat tsts PubMd Toxicity p,h,c Offrd if tst masurs a drug List Outpatint Outpatint Outpatint Nursing Ordrs NYPH Guidlin - Pdiatric Warfarin Micormdx - Brast Fding Rstrictions NYPH Guidlins Antibiotics Micromdx - Prgnancy Rstrictions Brs Critria - Drug Dosing Mrriam-Wbstr - Dfinition Lxi-Comp - Spanish Patint Information Lxi-Comp - Pill Apparanc Lxi-Comp - Pdiatric Information Eclipsys Documntation - Training h,d,c p,h,d,c h,c p,h,d h,d,c,d Offrd if tst masurs ffct of warfarin (prothrombin tim or INR) and patint is child Offrd if tst masurs a drug and patint is child-baring-ag fmal Offrd if drug is an antibiotic Offrd if patint is a child-baring ag fmal Offrd if patint is ldrly and drug is in Brs Critria class Obsrvd nd for dfinitions of diagnosis trms Obsrvd nd for patint information Obsrvd nd to know what pills look lik Obsrvd nd for patint information, offrd whn patint is a child Obsrvd nd for accss to Eclipsys training matrials AMIA 2009 Symposium Procdings Pag - 110

3 links to th IM that would provid, givn th appropriat contxt, links to rsourcs to addrss th nds. For xampl, w found that rsidnts in th mdical clinic wondrd aloud about th apparanc of mdications, so w found a rsourc that containd pill imags and instructd th IM to provid a link to th rsourc whnvr a usr was ordring or rviwing patint mdications. 5 Tabl 1 shows xampls of such mpirical links providd by th IM. W furthr notd that spcific aspcts of th contxt, bsids th gnral task, could b usd to limit th dynamic slction of links. For xampl, whn a usr is ordring mdications, patint dmographic information (ag and gndr) could b usd by th IM to dtrmin whthr or not links to rsourcs rlatd to risks of brast fding and prgnancy should b slctd. Similarly, whn a usr is rviwing laboratory tst rsults, th concpt of intrst (that is, th spcific tst) could b usd by th IM to dtrmin whthr links to rsourcs rlatd to mdication dosing and advrs ffcts (whn th tst is a drug lvl) should b providd. Th IM uss such additional contxt information to slcti both thortical and mpirical links. Tabl 1 shows xampls of links that ar slctd basd on dmographic and concpt information. Mthods W hav prviously dscribd th log fils availabl from WbCIS and th IM. 8 Brifly, WbCIS, th HR pag, and th IM rcord ach action carrid out by thir usrs. By looking for instancs whr WbCIS usrs vokd th HR or IM and thn locating th immdiatly prcding log rcord for th sam usr, on can infr th contxt in which th usr vokd th HR or IM. It is thrfor possibl to rconstruct usr activity immdiatly prcding accss to rsourcs, whthr through practical, hypothtical or mpirical links. Log fils wr procssd to idntify all instancs of HR, IM, and rsourc us. Contxtual information was rtaind, whr availabl, including usr, application contxt, and concpt of intrst. Usr job titls ar availabl through th Columbia Univrsity Mdical Cntr s Lightwight Dirctory Accss Protocol (LDAP) Dirctory. Job titls wr charactrizd as attnding (physician), nurs, housstaff, studnt (any typ), and othr. Whn usrs with multipl job titls (largly du to th accumulation of prvious titls) wr mappd to multipl typs, thy wr charactrizd at th most advancd acadmic lvl, so that attnding/housstaff wr considrd attndings, nurs/studnts wr considrd nurss, tc. All rols took prcdnc ovr othr, whil attnding and housstaff took prcdnc ovr nurs. * IM log fil rcords associatd with us of th Eclipsys systm do not includ usr ID. Such rcords wr thrfor attributd to an unknown usr typ. Instancs of HR, IM and rsourc us wr compild for ach of th application contxts in which th IM can b vokd. Rsourc us was charactrizd with rspct to practical (via th HR), mpirical (via th IM, basd on obsrvd information nds) and hypothtical (via th IM, but not basd on obsrvd information nds). IM rsourc uss wr furthr charactrizd as to whthr thy wr rlatd to particular aspcts of th usr s contxt (providd by th IM basd on patint ag, patint gndr or concpt of intrst) or not (always providd by th IM for a givn application, rgardlss of othr contxt paramtrs). Additional analyss wr conductd to idntify any intrsting pattrns of us basd on usr typ, patint dmographics, or concpt of intrst. Rsults Log fils from 2007 and 2008 wr analyzd. During this priod, th HR pag was accssd 134,837 tims by 4092 usrs, 2962 of whom usd th HR pag to accss rsourcs 127,276 tims. Whn only th contxts in which th IM was availabl wr considrd, 2107 usrs accssd th HR pag 44,541 tims, with 1921 of ths usrs (418 attndings, 747 housstaff, 259 nurss, 275 studnts and 22 othrs) accssing rsourcs 43,221 tims. During th sam priod, th IM was accssd 40,140 tims by 5365 known usrs (plus additional Eclipsys usrs), 2367 of whom (433 attndings, 420 housstaff, 436 nurss, 432 studnts and 645 othrs) usd th IM to accss rsourcs 16,771 tims, plus an additional 5136 tims by unknown usrs through Eclipsys. A total of 805 known usrs (178 attndings, 266 housstaff, 123 nurss, 150 studnts and 88 othrs) accssd rsourcs by both mthods. Thus, at last 3483 uniqu usrs mad us of rsourc links 65,128 tims, with at last 68 of th usrs choosing IM-supplid links 34 of th tim in applications whr both HR and IM wr availabl. Tabl 2 shows th numbr of uss of practical, hypothtical and mpirical rsourc links for ach of th application contxts in which th IM was availabl, with brakdown by usr typ. Th most common application contxt was Laboratory Rsults Rviw. In this contxt, 65 links wr availabl: 26 (40) practical links providd by th HR, 34 (52) hypothtical links providd by th IM, and 5 (8) mpirical links providd by th IM. * A controvrsial but pragmatic solution. AMIA 2009 Symposium Procdings Pag - 111

4 Tabl 2: Usrs slction of links, by typ (p=practical, h=hypothtical, =mpirical), within ach application contxt, by usr typ. Th full tabl can b found at Contxt List Lab Ordrs Typ Usr Typ Attnding Housstaff Nurss Studnt Othr Unknown Th 34 hypothtical links accountd for 15 of th rsourcs slctd, whil th 5 mpirical links accountd for 7. Thus, in this contxt, mpirical links wr mor popular on a pr-link basis. Th application contxt most notabl for us of IM links ovr HR links was th. In this contxt, 55 links wr availabl: 26 (47) practical links providd by th HR, 25 (46) hypothtical links providd by th IM, and 4 (7) mpirical links providd by th IM. Th 26 practical links accountd for 27 of th rsourc slctd, whil th 25 hypothtical links accountd for 57 and th 4 mpirical links accountd for 16. Thus, in this contxt, hypothtical and mpirical links wr mor popular, on a pr-link basis, than th practical links, with mpirical links again having th dg. On contxt with a notabl us of mpirical links was th Lab Ordrs. In this contxt, 22 links wr availabl: 20 (91) hypothtical links and 2 (9) mpirical links (no practical links wr availabl bcaus th HR is not availabl in this Eclipsys contxt). Th 20 hypothtical links accountd for 31 of th rsourcs slctd, whil th 2 mpirical links accountd for 69. Anothr contxt with notabl us of mpirical links was th List. In this contxt, 36 links wr availabl: th usual 26 (72) practical links providd by th HR, 6 (17) hypothtical links providd by th IM, and 4 (11) mpirical links providd by th IM. Th 26 practical links accountd for only 40 of p h p h p h p h p h th rsourc slctd, whil th 6 hypothtical links accountd for 26, and th 4 mpirical links accountd for 35. Thus, in this contxt, both hypothtical and mpirical links wr mor popular, on a pr-link basis, than th practical links, with mpirical links again njoying th gratst popularity. Ovrall, for th thirtn contxts whr th IM was availabl, thr wr 201 nonuniqu links, of which 169 (84) wr hypothtical and 32 (16) wr mpirical. Th hypothtical links accountd for 68 of th IM rsourc usag whil th mpirical links accountd for 32. As shown in Tabl 2, pattrns of rsourc slction varid by usr typ, with attndings and housstaff using practical links most oftn (81 and 90, rspctivly), followd by hypothtical links (15 and 8, rspctivly) and rlativly littl us of mpirical links (4 and 2, rspctivly), although this trnd was markdly rvrsd in th and Outpatint s. Nurss and studnts, manwhil, mad us of practical links much lss oftn (46 and 42, rspctivly), with much highr us of hypothtical links (34 and 40, rspctivly) and mpirical links (20 and 18, rspctivly), whn compard to physicians. Tabl 3 shows th numbr of uss of rsourc links with rspct to th us of patint dmographic information (ag and gndr) by th IM to slct rsourcs for th usr. Ovrall, 43 of 201 (21) of th links wr basd on patint dmographics, AMIA 2009 Symposium Procdings Pag - 112

5 Tabl 3: Usr of sourc links basd on whthr th IM uss patint dmographics (d) or not (n) to slct thm. Full tabl at Contxt Drug Ordrs Outpatint Outpatint Drug Ordrs accounting for 2785 of 21,902 (13) of th IM link usag. In th outpatint stting (Outpatint and Outpatint Drug Ordrs), th dmographics wr usd to slct 10 of 50 (20) of th IM links but accountd for 519 or 1655 (31) of links usd. Thr wr no usag pattrns rlatd to usr typ. Tabl 4 shows th numbr of uss of rsourc links with rspct to th us th concpt of intrst by th IM to slct rsourcs for th usr. Ovrall, 58 of 201 (29) of th links wr basd on concpt of intrst, accounting for 2771 of 21,902 (13) of th IM link usag. Most usag was rlatd to accss to drug rsourcs whn th concpt of intrst was a drug tst. Thr wr no pattrns rlatd to usr typ. Conclusions Typ In this study of information rsourc us by clinicians, knowldg of obsrvd information nds and of rlvant contxtual attributs appars to hav bn usful for guiding automatd slction of rsourc links by an Infobutton Managr. This is th first study that corrlats obsrvd nds with actual usag and dmonstrats that contxtual aspcts ar rlatd to rsourc slction. Acknowlgmnts Usd Usd n d n d n d n d n d n d This work is supportd by intramural rsarch funds from th NIH Clinical Cntr and th National Library of Mdicin. Th Infobutton projct at Columbia Univrsity is supportd in part by NLM grant R01LM Th author thanks Rick Gallaghr for providing log fil xtracts, Suzann Bakkn, Lann Curri and Sarah Collins for thir Tabl 4: Us of sourc links basd on whthr th IM uss th concpt of intrst (c) or not (n) to slct thm. Full tabl at Contxt Drug Ordrs Typ Usd Usd n c n c n c n c tirlss work on th prior obsrvational studis, and Andria Cimino for ditorial assistanc. Rfrncs 1. ins/uvds/uvds_contxt-awarinformationrtriva l(infobutton).htm 2. Cimino JJ, Li J, Bakkn S, Patl VL. Thortical, mpirical and practical approachs to rsolving th unmt information nds of clinical information systm usrs. Proc AMIA Symp. 2002: Dl Fiol G, Haug PJ, Cimino JJ, Narus SP, Norlin C, Mitchll JA. Effctivnss of topic-spcific infobuttons: a randomizd controlld trial. J Am Md Inform Assoc Nov-Dc;15(6): Jndrs RA, Dl Fiol G, Kawamoto K, Sailors RM. Standards in clinical dcision support: activitis in halth lvl svn. AMIA Annu Symp Proc Nov 6: Curri LM, Graham M, Alln M, Bakkn S, Patl V, Cimino JJ. Clinical information nds in contxt: an obsrvational study of clinicians whil using a clinical information systm. AMIA Annu Symp Proc. 2003: Cimino JJ, Li J, Bakkn S, Patl VL. Thortical, mpirical and practical approachs to rsolving th unmt information nds of clinical information systm usrs. Journal of th Amrican Mdical Informatics Association. 2002;9 (suppl.): Hripcsak G, Cimino JJ, Sngupta S. WbCIS: larg scal dploymnt of a Wb-basd clinical information systm. Proc AMIA Symp. 1999: Chn ES, Cimino JJ. Automatd discovry of patint-spcific clinician information nds using clinical information systm log fils. AMIA Annu Symp Proc. 2003: AMIA 2009 Symposium Procdings Pag - 113