Integration of Health Information Resources into Electronic Health Records

Guilherme Del Fiol, MD, MSIntermountain Healthcare

University of Utah, Salt Lake City, UT

James J. Cimino, MD Department of Biomedical Informatics, Columbia

University, New York, NY

Saverio Maviglia, MD, MScPartners Healthcare System, Boston, MA

Nick AckersonThomson Micromedex, Greenwood Village, CO

Point-of-care information needs

2 questions out of every 3 patients seen

Most questions left unanswered

Most answers can be found on the Web

Used less than10% of the time

Barriers

Errors: 770,000 injuries and deaths annually in the US

Contentproviders

EHR developers

Healthcareorganizations

Topics of this Panel

What are the benefits?Are people using infobuttons?

How can I have infobuttons in my institution?

Are there any standards?

Have content providers bought into this?

Integration of Health Information Resources into Electronic Health Records

James J. Cimino, M.D.

Department of Biomedical Informatics

Columbia University College of Physicians and Surgeons

2006 AMIA Fall Symposium

The Columbia/NYPH Infobutton Manager

• Are people using infobuttons?

• What are the benefits?

• Are there any standards?

• Are content providers bought into this?

• How can I have Infobuttons in my institution?

Infobuttons at My Institution

• What is an Infobutton Manager?

• How does the CU/NYPH Infobutton Manager work?

• How do I integrate the CU/NYPH Infobutton Manager

• Who is using the CU/NYPH Infobutton Manager?

• How can I use the CU/NYPH Infobutton Manager

• What is an Infobutton Manager?

• How can I use the CU/NYPH Infobutton Manager?

Infobuttons vs. Infobutton Manager

Pageof

Hyperlinks

InfobuttonClinical System Resourc

InfobuttonManager

Context

• What is an CU/NYPH Infobutton Manager?

How Does the Infobutton Manager Work?

IntegrateLink

Clinical Application/User’s Browser

https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi?MRN=<xxx>&info_institute=<xxx>&info_med=<xxx>&info_context=<xxx>&info_usertype=<xxx>&info_age=<xxx>&info_sex=<xxx>

IntegrateLink

Fill inParameter

Values

https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi?MRN=3131313&info_institute=GENERIC&info_med=sodium&info_context=LabDetail&info_usertype=MD&info_age=22&info_sex=F

IntegrateLink

CU/NYPH Infobutton Manager

User ClicksOn Link

Write toLog File

IdentifyTerminology

Translate to Terms of Interest

Fill inParameter

Values

Institute=CPMC & Context=LabDetailConcept=“sodium”Terms=

CPMC Serum Sodium TestSodium IonHypernatremiaHyponatremia

IntegrateLink

CU/NYPH Infobutton Manager

User ClicksOn Link

Write toLog File

IdentifyTerminology

Translate to Terms of InterestMatch Parameters

to Contexts

Generate List ofQuestions/Links

Display PageOf Links

User ClicksOn Link

CallResource

Write toLog File

Fill inParameter

Values

How do I integrate the Infobutton Manager?

Contact me:jjc7@columbia.edu

Agree on DomainAnd Terminology

IdentifyResources

Determine Method forAutomated Retrieval

Integrate with ClinicalSystem to Pass Parameters

IdentifyQuestions

IdentifyContexts

Add Everything to theInfobutton Manager Manager

Use of the CU/NYPH Infobutton Manager

• WebCIS (CU/NYPH)

• Eclipsys (NYPH)

• Psyckes (NYSPI)

• Eclipsys (NYPH)

• Psyches (NYSPI)

• RMRS (Regenstrief)

• Eclipsys (NYPH)

• Psyches (NYSPI)

• NextGen (Crystal Run Healthcare)

• Eclipsys (NYPH)

• Psyches (NYSPI)

• NextGen (Crystal Run Healthcare)

Do you want to use the Columbia IM?

• Contact me: jjc7@columbia.edu

• Help with terminology/context/questions

• Adoption of HL7

• Librarian Infobutton Tailoring Environment (LITE)

• Supported by NLM Grant R01LM07593

• For more information:

http://www.dbmi.columbia.edu/cimino/Infobuttons.html

KnowledgeLink

S68: Integration of Health Information Resources into EHRs

Saverio Maviglia, MD, MScPartners Healthcare System

Harvard Medical School

Boston, MA

KnowledgeLink v1

Source Application

Target Reference

(Micromedex or Skolar)

“digoxin”

KL v1: Typical Use

• Infrequent– 2.3x/mo average (0.5 median, range 0.1-100)– 0.7% of patient encounters, varying by

• Provider role (0.8% primary care MDs, 0.3% specialist MDs, 1.1% NPs, 0.3% other)

• Provider gender (females 1.0%, males 0.5%)• Target resource (0.9% MDX, 0.3% Skolar)• Site (range 0-18% of encounters)

• Quick– 4 pages accessed per use (only 1 content page)– 21 sec spent per content page

KnowledgeLink Hits by User Role

MD51.8%

NP25.9%

Admin.1.8%

Not Specified0.5%

RN29.0%

Other clinical16.9%

non-NP3.1%

EFFECTIVENESS AND SATISFACTION

• 84% of all KnowledgeLink queries are answered

• 17% of physician use results in a change in management, 33% among specialists

• >=80% rated KnowledgeLink positively on– Ease of use– Relevance– Speed– Impact on patient care

Comments

• General Praise– Knowledge link is fantastic. VERY useful.– Great resource!!– I love knowledge link

• Quality of Care– …very helpful with patient-directed questions during the visit– I was able to quickly answer the patient’s question …the patient

had been promptly served on his needs– This info actually saved me from making a medical error…I rarely

use this feature of the LMR, but this time it really helped me

• Convenience– Knowledge Link is a great time saver…handy and easy to use.– I really like having the ability to look up drugs without having to

change screens– I really like having the information available one click away from

the med list– I was very happy to be able to click on the information link as I was

pulling up the prescription– To have info on meds right at my fingertips is a great timesaver– it is very helpful to have all the information right at my finger tips

instead of browsing through multiple book sources

Assertion%

agreeing(n=59)

KL should be extended to problems and diseases. 79%

KL should be extended to lab results and reports. 67%

I would like to be able to specify more precise KL queries.

I would like to be able to specify to which resource KL goes.

User Requests for KL II

KnowledgeLink v2

Target References

Micromedex

Skolar

UpToDate

KnowledgeLink Manager

Source Applications

Results BWH guidelines

• Links chosen and ordered according to•Context (meds, labs, disease)•Source app (LMR, eMAR, Results)•Provider (MD, RN, Pharm, other)•Clinic

• Easy to modify/change search, restrict to patient information links, or print

KnowledgeLink Sessions

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

1/03: KL I study (18 clinics)

8/04: KL II launched

2/04: KL I opened to all clincs

3/05: eMAR

8/06: MGHOE

KnowledgeLink Users

1/03: KL I study (18 clinics)

8/04: KL II launched

2/04: KL I opened to all clincs

3/05: Live in eMAR

8/06: Live in MGHOE

4/06: Live in PAML

Usage By Application

WEBMAR63%

LMR20%

Results2%

Handbook3%

AdultRx9%PAML

0%MGHOE3%

95% medications

3% lab results

2% diseases

75% Micromedex

19% Partners

3% Skolar

1% eMedicine

USAGE BY ROLE

Ancillary3%

Pharm11%

Other2%

1% of patient encounters (LMR)

40-75% of patient

encounters (WebMAR)

KL Session Characteristics

Num of links viewed

Time Spent (median sec)

Medications 1.3 7

Labs 1.2 11

Diseases 1.2 12

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

Total MDX

MDX via KL

Summary

• Infobuttons are utilized and valued by all types of care providers, not just MDs– Rapid adoption despite lack of training or

introduction– Extremely positive feedback overall

• Infobuttons are effective (84% answer rate)

• Infobuttons can have significant impact on patient care even when used infrequently, but direct measurement of effect is difficult

• A minimal implementation can be both technically simple and clinically effective

HL7 Standard for Infobutton Integration

Guilherme Del Fiol, MD, MSIntermountain Health Care

University of UtahSalt Lake City, UT

Why do we need a standard?

• There is not a common integration language– Query parameter names– Terminologies used for content

search retrieval

• Hundreds of resources available– Not designed for infobutton

integration: suboptimal results– Labor intensive integration: just a few

are actually used

http://resource1.com/search = “azithromycin AND dose”

What is the dose of azithromycin ?i

Multiple ways of “asking” the same question

http://resource3.com/

searchConcept = 3333 ^ azithromycin

filter = 11 ^ dosage

query = "azithromycin"[MeSH Terms] AND dose[All Fields]

Resource 3

Resource 1

Resource 2InfobuttonManager

No standard in place

Clinical Information

System i

http://resource1.com/search.cgi? search = “azithromycin AND dose”

http://www.resource3.com/search.cgi? searchConcept = 3333 ^ azithromycin filter = 11 ^ dosage

query = "azithromycin"[MeSH Terms] AND dose[All Fields]

Clinical Information

System i

Resource 3

Resource 1

Resource 2

InfobuttonManagerHL7

Standard-based integration

Participants

• HL7 Clinical Decision Support Technical Committee

• Health care academic institutions– IHC, Columbia University, Partners

Healthcare, Cedars-Sinai, Kaiser Permanente

• Content providers– ACP, Wolters Kluwer, Micromedex,

First Data Bank, Elsevier, Zynx• EHR vendors

– GE, Epic, Eclipsys

Example 1

• The user is looking at a problem list of a male, 77 years-old patient with Bacterial Pneumonia. The user clicks on an infobutton that presents a series of questions. The user selects “How do I treat Bacterial Pneumonia?”

•HL7 code for “Problem list review”

•HL7 code for “Male”

•Age in years

•MeSH code for “Therapy”

•MeSH code for “Pneumonia”

•MeSH code for “65 and older”

http://www.e-resource.com/api?patientContext.gender.c=C10173 patientContext.gender.dn=Femaleage.v=77&age.u=yageGroup.c=D000368ageGroup.dn=Aged

taskContext.c=11 taskContext.dn=Problem list review

mainSearchCriteria.c=D018410 mainSearchCriteria.dn=Bacterial PneumoniasubTopic.c=Q000628 subTopic.dn=therapy

Example 2

• The user (an RN) is looking at a medication list of a female, Spanish speaker, 32 years-old patient. The user clicks on the infobutton next to “Azithromycin” and is presented with a series of links. The user selects the “patient education" link.

•“Medications list review”

•User is “care provider”

•HL7 code for “RN”

•ISO 639-2 for “English”

•ISO code for “Spanish”

•HL7 code for “Female”

•Content recipient is “patient”

http://www.hl7.org/v3ballot/html/welcome/environment/index.htm

Current Status

• XML version– Approved at committee level– Membership level in January 2007

• URL version– Implementation guide (not-normative)– 1st ballot in January 2007

• Reference implementations

Commercial InfoButton Applications

Content Vendors Perspective

Nick AckersonProduct Manger – Integrated

SolutionsThomson Healthcare

InfoButton Snapshot

• Growing list of HCO’s adopting principle of embedded CDS (InfoButtons)

• Growing list of HIS vendors realizing benefits of CDS/customer pull

• Thought leading academia prevalent and well known. Leading push

• InfoButton API’s now available with commercial access, not just academics

• HCO’s striving for comprehensive, unbiased standardization of access to clinical content investments. (HL7)

Clinical Deployment ResultsA Case Study: Wake Med

• 851 Bed Integrated Health Care System, Research Triangle, Raleigh NC

• 444,360 Outpatient Visits• 13,702 Inpatient Surgery & Endoscopy• 25,954 Outpatient Surgery & Endoscopy• 24,908 Cardiovascular procedures• Ranks #1 in volume among all North Carolina

Hospitals, highest volume Heart Center• North Carolina’s first freestanding Children’s ED

~40,000

Wake Med’s Clinical Motivators

• Manual upkeep of drug policies and procedures

• Regulation compliance • Practice variation• Medical errors• Adverse events

Other Motivators

• The need to centralize and streamline accessibility to clinical knowledge

• Assess impact of deploying evidenced-based drug content

• Analysis of staff time and productivity• Improved decision making/Empower

clinicians• Optimization of content workflow tools

to improve performance

Online Injectable Administration

Results of Deployment

• Over 55% of Wake Meds surveyed respondents were using InfoButton

• Altered course of treatment 20% of the time

• Overall satisfaction was excellent• Integration time was 2 – 4 weeks• Training was communicated in

newsletter.

Wake Med Usage

Benefits Realized by Users/Institution

• Reduces time/effort to answer key clinical questions - little/no training required

• More care, less searching - used frequently

• Needed knowledge more directly into workflow - affects decisions

• Context/patient-specific information - more responsive to needs

Benefits for Institution

• Enhanced care sooner: – Quick/easy integration; hosted data– less training

• Promotes best clinical practices: – Reduce unanswered/un-pursued clinical ?s

and negative care impact – Alters medical/treatment decision 15-20% of

the time*

• Leverages existing subscriptions– Summary/infobutton -> drill down to richer

content

*Health Management Technology “Delivering Informed Care” Feb 2006, Maviglia

*Wake Medical Health and Hospitals Survey, 2006

Peer Groups Implementing IB applications

• WakeMed• Alverno/Central

Washington• Ohio Health• Cedars Sinai• University of North

Carolina Healthcare - Chapel Hill

• Salem Hospital (Epic)

• Metropolitan Hospital• Miami Baptist• Sentara Health (Epic)• Marshfield Clinic• Texas Health Resources (Epic, Baylor)• University Medical Center (Eclipsys)• Froedtert Hospital (Epic)

Lessons Learned

• Flexible, scaleable, HL7-compliant technology key to meet realities of HIS vendors and HCOs (API’s)

• Granular content leveraging robust Content Management System is key asset

• Testing protocols and implementation team is key to successful deployment and usage

• Demonstrated value from dynamic delivery of information relevant to the clinician’s task

• Academic research and ongoing market analysis are key to continuous improvement

• InfoButtons are used by health care providers of all disciplines

• InfoButtons are convenient, intuitive, effective, and relatively simple to implement

• Standardized messaging should increase specificity and utility over time, Build out technology

• Efficient, intuitive, productive and proven to improve care and prevent ADE’s

Integration of Health Information Resources into Electronic Health Records

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