James J. Cimino MD, Jianhua Li MD,Suzanne Bakken RN DNSc, Vimla L. Patel PhD

Department of (Bio)Medical InformaticsColumbia University

New York, New York, USA

Approaches to Resolving the

Clinical Information System Users

Theoretical, Empirical, and Practical

Unmet Information Needs of

Information Needs of CIS Users

• Unmet information needs in practice

• Unmet needs lead to deferred or uninformed decisions (errors!)

• Information needs of CIS users not studied

Why Care about CIS Users?

• Needs occur when learning new information

• Needs occur during decision making

• Simple setting suggests predictable needs

• Setting is conducive to resolving needs

• Retrieval may be accomplished automatically (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)

Theoretical Approach

• Theory: Information needs are situated• Hypothesis: needs arising during use of a CIS

are predictable based on context• IF {detect the context} THEN {predict need}• IF {predict need} THEN {address need}• IF {address need} THEN {reduce unmet needs}• IF {reduce unmet needs} THEN {reduce errors}

Context-Dependent Information Needs

Age Sex TrainingRole DataTask

Context

? !

Institution

Empirical Approach

• Direct observation of CIS users• “Think aloud” about information needs• Data capture: video (screen) and audio• Transcription: articulation of needs• Coding: characterize needs and contexts• Summariation: needs and contexts

Portable Usability LabUser’s Workstation

Microphone

Video Converter

75 foot cable

Converter Controller

Cassette Recorder VCRHeadphones

Video Monitor

Practical Approach

• Context passed to Infobutton Manager (IM)

• IM matches context to information needs

• Search strategies are instantiated

• Questions (links) are returned to user

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 <>?

<a href="Javascript:get_info('35702')"><img src="info.gif"></a>

function get_info(mc){ var infowin = window.open("","INFO"); infowin.focus(); document.INFO.info_med.value=mc; document.INFO.submit(); }

<form method="POST" name=“INFO” action="wc_infomanage.cgi"><input type="HIDDEN" name="info_med" value=""><input type="HIDDEN" name="info_context" value="LabDetail"><input type="HIDDEN" name="info_institute" value="CPMC"><input type="HIDDEN" name="DOB" value="1951-05-26"><input type="HIDDEN" name="SEX" value="F"><input type="HIDDEN" name="USER" value="ciminoj"></form>

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

Status Report

• Infobutton Manager built• Web-based table management tools built• Log files being collected• Three nursing stations, CCU and clinic• 5 days of data• 15 hours of audio/video• Needs coded along six dimensions

– patient/institution– administrative/health knowledge– foreground/background– explicit/implicit– human/computer/paper– success/failure/deferred

Discussion

• Empirical method is detecting needs• Summarizarion is next step• Technical approach is feasible• Evaluation should detect impact• Information needs may be universal• Our approach is institution independent

Context Parameters

• Patient: age, gender

• User: physician, nurse, student, patient, …

• Setting: lab reports, medications, …

• Concept of interest: lab test, drug, …

• Institution: CPMC, RMRS, LDS, …

<form method="POST" action="wc_infomanage.cgi"><input type="HIDDEN" name="info_med" value=“35702"><input type="HIDDEN" name="info_context" value="LabDetail"><input type="HIDDEN" name="info_institute" value="CPMC"><input type="HIDDEN" name="DOB" value="1951-05-26"><input type="HIDDEN" name="SEX" value="F"><input type="HIDDEN" name="USER" value="ciminoj"></form>

<form method="POST" action="wc_infomanage.cgi"><input type="HIDDEN" name="info_med" value=“DIGOXIN|.."><input type="HIDDEN" name="info_context" value="LabDetail"><input type="HIDDEN" name="info_institute" value=“RMRS"><input type="HIDDEN" name="DOB" value="1951-05-26"><input type="HIDDEN" name="SEX" value="F"><input type="HIDDEN" name="USER" value="ciminoj"></form>

Conclusions

• Theoretical, empirical and practical approaches are working synergistically

• Satisfaction of CIS users’ needs is feasible

• Other institutions can share if they have:– Web-based CIS– Users with information needs

Acknowledgments

• National Library of Medicine grant R01-LM07593

• Research assistants:– Anne-Marie Ramierez– Mark Graham– Leanne Currie