Infobuttons:Anticipatory Passive Decision Support

ACMI Senior Member Presentation

James J. Cimino, MD, FACMI

Laboratory for Informatics DevelopmentNIH Clinical Center

and

Lister Hill National Center for Biomedical CommunicationsNational Library of Medicine

Bethesda, Maryland

Infobutton (noun): in'·fō·but'·tən – a link from one on-line information system to another that uses contextual information from the former to facilitate the retrieval of relevant information from the latter.

Example: links in clinical information systems that provide patient-data-specific links to health knowledge resources.

Decision Support.

Passive.

Anticipatory.

Topics

• The Why, When, and How of infobuttons?

• Research issues

• Infobutton and infobutton-like systems

• The HL7 standard

• AMIA 2007 demonstration

• Current status of commercial efforts

• Librarian Infobutton Tailoring Environment (LITE)

Why Infobuttons?

Everybody is worried about losing their job to automation. They’re afraid they’ll be replaced by a button. But I’m smart. I’m going to get a job in the factory where they make the buttons.

- Jackie Gleason, The Jackie Gleason Show, circa 1968

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

G.O. BarnettDXplain

Covel et al.Information Needs

UMLSProject

First Versionof UMLS

ICD9MeSH

MedlineButton

Mosaic

Infobuttons

Web-basedGeneric Queries

InfobuttonManager

InfobuttonManagerStandard

PubMED

Web DXplain

DXplainButton

WebCIS

MicromedexInfobutton

Access

LibrarianInfobuttonTailoring

Environment(LITE)

The When of Infobuttons

Infobuttons in the Medical Literature

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2

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6

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10

Cimino

Other

Beverly Collins, et al. Attaching Context Sensitive Infobuttons to an EHR Options and Issues.

SJ Darmoni, et al. French Infobutton: an academic and… business perspective.Per H Gesteland, et al. Clinician Use and Acceptance of Population-Based Data about

Respiratory Pathogens: Implications for Enhancing Population-Based Clinical PracticeSookyung Hyun, et al. Nurses’ Use and Perceptions of Usefulness of National Cancer

Institute’s Tobacco-related Cancer Information Service (CIS) Resources.Robert A. Jenders, et al. Standards in Clinical Decision Support: Activities in Health

Level Seven.

The How of Infobuttons

• Common tasks may have common needs

• System knows:– Who the user is– Who the patient is– What the user is doing– What information the user is looking at

• We may be able to predict the specific need

• User is sitting at a computer!

• We may be able to automate retrieval

Research Issues

MRSA

Research Issues

UnderstandInformation

Needs

1MRSA

Research Issues

Get InformationFrom EMR

UnderstandInformation

Needs

1

2

MRSA

Research Issues

Get InformationFrom EMR

ResourceSelection

UnderstandInformation

Needs

1

2

3

MRSA

Research Issues

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

UnderstandInformation

Needs

1

24

3

MRSA

Research Issues

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

UnderstandInformation

Needs

AutomatedTranslation

1

254

3

MRSA

Research Issues

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

QueryingUnderstandInformation

Needs

AutomatedTranslation

1

254

6

3

MRSA

Research Issues

Get InformationFrom EMR

ResourceSelection

ResourceTerminology

Querying

Presentation

UnderstandInformation

Needs

AutomatedTranslation

1

254

6

3

7

MRSA

Infobutton and Infobutton-like Systems

• Columbia University’s Infobutton Manager

• Vanderbilt University’s PC-POETS

• LDS Hospital’s HELP system

• Partners Healthcare System’s Knowledgeliink

Deployment of Columbia’s Infobutton Manager

• Columbia University’s Infobutton Manager• New York Presbyterian Hospital’s WebCIS• New York Presbyterian Hospital’s Eclipsys• New York State Psychiatric Institute’s PSYCKES• Regenstrief Medical Record System• Crystal Run Healthcare’s (Monroe, NY) (NextGen)

NY Office of Mental Health (Psykes)

NY Office of Mental Health (Psykes)

Regenstrief Medical Record System

Crystal Run Healthcare (NextGen)

Infobuttons vs. Infobutton Manager

Pageof

Hyperlinks

InfobuttonClinical System Resourc

e

InfobuttonManager

ContextQuery

KnowledgeBase

s

The HL7 Standard

• Approved as Draft Standard for Trial Use (DSTU)

• http://www.hl7.org/v3ballot2008MAY/html/domains/uvds/uvds_Context-awareInformationRetrieval(Infobutton).htm

Example 1: In this example the user is looking at a coded 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?” The following message payload represents the communication between the Decission Support System and the Information Resource.

<?xml version="1.0" encoding="UTF-8"?> <infobuttonEventNotification> <effectiveTime value="20060706001023"/> <subject1> <patientContext> <patientPerson> <administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" displayName="Male"/> </patientPerson> <subjectOf> <age> <code code="30525-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="AGE"/> <value value="77" unit="a"/> </age> </subjectOf> </patientContext> </subject1> <subject2> <taskContext> <code code="PROBLISTREV" codeSystem="HL7-Infobutton" codeSystemName="HL7-infobutton" displayName="Problem List Review"/> </taskContext> </subject2> <subject3> <subTopic> <code code="Q000628" codeSystem="2.16.840.1.113883.6.177" codeSystemName="MSH" displayName="therapy"/> </subTopic> </subject3> <subject4> <mainSearchCriteria> <code code="D018410" codeSystem="2.16.840.1.113883.6.177" codeSystemName="MSH" displayName="Bacterial Pneumonia"> <originalText>Pneumonia</originalText> </code> </mainSearchCriteria> </subject4> </infobuttonEventNotification>

http://www.e-resource.com/api? infobuttonEventNotification.effectiveTime.v=20060706001023&

assignedEntity.name.r=Organization-Username&assignedEntity.certificateText.r=organization-password&

patientPerson.administrativeGenderCode.c=F&patientPerson.administrativeGenderCode.dn=Female

age.v.v=77&age.v.unit=a

ageGroup.v.c=D000368&ageGroup.v.cs=2.16.840.1.113883.6.177&ageGroup.v.dn=Aged

taskContext.c.c=PROBLISTREV&taskContext.c.dn=Problem+list+review&

subTopic.c.c=Q000628&subTopic.c.cs=2.16.840.1.113883.6.177&subTopic.c.dn=therapy

mainSearchCriteria.c.c=D018410&mainSearchCriteria.c.cs=2.16.840.1.113883.6.177& mainSearchCriteria.c.dn=Bacterial+Pneumonia& mainSearchCriteria.c.ot=Pneumonia

AMIA 2007 Demo Participants

• Health care & academic institutions– Intermountain Healthcare, Columbia University,

Partners Healthcare

• Content providers– Wolters Kluwer Health, ACP, EBSCO,

Thomson/Micromedex, UpToDate, Lexicomp

Current Status of Clinical Systems

• Epic – InfoButton with direct connection to specific resources

• Eclipsys – Infobutton tab using HL7 standard

Current Status of Infobutton Managers

• University of Utah

– Applications: HELP2 Clinical Desktop, narrative practice guidelines

– HL7 compliant, but using original API

– Resources: Micromedex, Clineguide, MDConsult, PubMed, Medline Plus, Genetics Home Reference, Gene Tests, Uptodate, Ebsco (Cochrane and CINAHL), ARUP Consult, ICD9 search web site, Intermountain Care Process modules, Intermountain geriatric drug monographs

– Context parameters: task context, main search criteria, age, gender, subtopic, observation interpretation (for labs), content recipient, and authentication parameters

Current Status of Infobutton Managers

• Columbia University– Applications: WebCIS, Eclipsys, Regenstrief Medical Record

System, generic – HL7 compliant, but using original API– Resources: Anion Gap Calculator, ARUP Reference Manual,

Beers Criteria, CancerWEB, CPMC Lab Manual, DrugConsult, FirstConsult , Dxplain, ECG Interpreter, Eclipsys Training, Harrisons Principles of Internal Medicine, Lab Tests Online, LexiComp, MCW Pregnancy Calculator, Medicine on the Net, Micromedex, Miriam-Webster, National Guidelines Clearinghouse , NYPH Antibiotics Guidelines, OneLook, Proquest, PubMed, Rhuematology.org, RxList, UpToDate

– Context parameters: task context, main search criteria, age, gender, user type, user ID, medical record number, authentication parameters, “other available data”

Current Status of Knowledge Sources• Thomson/Reuters

– Applications: Mediware Worx, Ex Libris, Crown, "Ask Mayo“

– Limited HL7 compliance– Resources: (Micromedex) Clinical Drug, Clinical

Disease, Clinical Lab, Consumer Drug, Consumer Disease, Consumer Lab, Clinical Checkpoints  

– Context parameters: Application, Care Setting, Institution, Content Target, Language, Subtopics 

• EBSCO– Resources: Medline, Dynamed, CINAHL– HL7 InfoButton Manager; working to extend

functionality– Translator

Current Status of Knowledge Sources• Wolters Kluwer

– Resources: Clin-eguide– HL7: Clin-eguide – Parameters: Provider Information, ICD9-CM,

SNOMED CT, LOINC, RxNorm, result high/low, age, age group, subtopic, such as diagnosis or treatment

• Elsevier– Resources: DrugConsult, FirstConsult

• PIER – currently in hibernation

Infobutton ManagerMaintenance Tool

Functions:Browse

AddUpdateDelete

Clinician

Infobutton Manager

TranslationTable

TermTranslation

ContextTable

ContextMatching

InfobuttonTable

QueryConstruction

Page ofLinks

SystemMaintainer

Institution Customization Tasks

Librarian Infobutton Tailoring Environment (LITE)Librarian Infobutton

Tailoring Environment(LITE)

InfobuttonManagerLog File

LITELog File

LITE Auditing

LITE Monitoring

Infobutton ManagerMonitoring

InstitutionLibrarian

ContextDefinition

ResourceUtilization

TerminologySpecification

QuestionConstruction

ResourceSelection

Clinician

Infobutton Manager

TranslationTable

TermTranslation

ContextTable

ContextMatching

InfobuttonTable

QueryConstruction

Page ofLinks

LITE Research Plan

1) Establish librarian user community

2) Refine LITE features

3) Collect feedback from librarians

4) Develop documentation

5) Collect feedback from librarians

6) Go to (2)

Conclusions

• Infobuttons and infobutton-like applications have a long history of development in the informatics community

• Context-specific links improve patient care

• The World Wide Web made resources available and made integration feasible

• The HL7 standard is driving adoption by clinical system vendors and knowledge vendors

• Tools are needed to enable institution-specific customization

• Join LITE and help out

Acknowledgments

• Jianhua Li• Many student contributors• Steve Johnson• Sue Bakken• Leanne Currie• Guilherme Del Fiol• Saverio Maviglia• Noemie Elhadad• National Library of Medicine

www.infobuttons.com

www.infobuttons.org

lite.dbmi.columbia.edu

Buttons.- Jimmy Cimino, 1956