Just In Time Education: Linking Clinical and Educational Systems

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Just In Time EducationLinking Clinical and
Educational Systems

• James J. Cimino, MD
• Professor of Medicine and Biomedical Informatics
• Columbia University
• May 19, 2004

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Studying Information Needs

• Covell DG, Uman GC, Manning PR. Information needs
  in office practice are they being met? Ann
  Intern Med. 1985 Oct103(4)596-9.

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Results of Observational Study

• 47 physicians
• Observed during a half day of typical practice
• Estimated 2-3 questions per physician per day
• 269 questions raised about patient management
• Only 30 were answered during the patient visit
• Usual resource was another physician

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Other Observational Studies

• The information needs of practicing physicians in
  northeastern New York State.
• Assessment of physicians' information needs in
  five Texas counties
• Information needs of rural health care
  practitioners in Hawaii.
• Knowledge management in clinical practice a
  systematic review of information seeking behavior
  in physicians
• Information needs and information-seeking
  behaviors of on-call radiology residents
• Expanding the concept of medical information an
  observational study of physicians' information
  needs
• Curbside consultation practices and attitudes
  among primary care physicians and medical
  subspecialists
• Information needs of health care professionals in
  an AIDS outpatient clinic as determined by chart
  review
• Methods for assessing information needs of
  clinicians in ambulatory care.
• Real-time information-seeking behavior of
  residency physicians
• Information seeking in primary care how
  physicians choose which clinical questions to
  pursue and which to leave unanswered
• Physicians' use of computer software in answering
  clinical questions.
• Residents' medical information needs in clinic
  are they being met?

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Findings

• 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

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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!

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Information for Decision-Making
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Information for Decision-Making
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Information for Decision-Making
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MRSA
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One-Stop Information Shopping?
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One-Touch Information Shopping
World Wide Web (The Facilitator)
Information Resources
Health Practitioner
Biblio- graphic Database
Textbook
Expert System
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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

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First Attempt The Medline Button

• CIS (WebCISs predecessor) on mainframe
• BRS/Colleague (Medline) on same mainframe
• Get them to talk to each other
• Search using patient diagnoses and procedures
• Kludge required

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First Attempt The Medline Button

• CIS (WebCISs predecessor) on mainframe
• BRS/Colleague (Medline) on same mainframe
• Get them to talk to each other
• Search using patient diagnoses and procedures
• Kludge required

• Technical success
• Practical failure

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From Data to Findings
Serum Cholesterol Test
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Education at the Moment of Need
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Education at the Moment of Need
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MRSA
Understand Information Needs
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Education at the Moment of Need
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Get Information From EMR
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MRSA
Understand Information Needs
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Education at the Moment of Need
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Get Information From EMR
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MRSA
Understand Information Needs
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Resource Selection
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Education at the Moment of Need
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Get Information From EMR
Resource Terminology
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MRSA
Understand Information Needs
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Resource Selection
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Education at the Moment of Need
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Get Information From EMR
Automated Translation
Resource Terminology
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MRSA
Understand Information Needs
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Resource Selection
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Education at the Moment of Need
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Get Information From EMR
Automated Translation
Resource Terminology
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MRSA
Querying
Understand Information Needs
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Resource Selection
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Education at the Moment of Need
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Get Information From EMR
Automated Translation
Resource Terminology
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MRSA
Querying
Understand Information Needs
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Resource Selection
Presentation
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Research Issues

• What are the information needs?

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Portable Usability Lab
Users Workstation
75 foot cable
Video Monitor
Converter Controller
Microphone
Video Converter
Headphones
VCR
Cassette Recorder
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Research Issues

• What are the information needs?

• Which context information is important?

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Context-Dependent Information Needs
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Research Issues

• 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?

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The Medical Entities Dictionary (MED)
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Research Issues

• 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?

• How are the data transmitted?

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The Coumadin Story

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

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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

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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

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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

• Voilá!

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Next Steps

• Repeat the observational study
• Look at system logs to see if
• Infobutton use is rising (7000 in first 10 weeks)
• Use of other resources is falling (not yet)
• Order entry Infobuttons
• Collaboration with Regenstrief and LDS
• Infobutton Manager to be an ANSI standard

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Conclusions

• Information needs arise while using CIS
• Infobuttons are easy to build
• Are they the right buttons?
• Can retrievals be standardized?
• Will information needs be satisfied?
• Will care improve?

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Acknowledgments

• National Library of Medicine
• The team
• Jianhua Li
• Sue Bakken
• Vimla Patel
• Mureen Allen
• Leanne Currie
• Mark Graham

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