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Integration of Health Information Resources into Electronic Health Records Guilherme Del Fiol, MD, MS Integration of Health Information Resources into Electronic Health Records Guilherme Del Fiol, MD, MS Intermountain Healthcare University of Utah, Salt Lake City, UT James J. Cimino, MD Department of Biomedical Informatics, Columbia University, New York, NY Saverio Maviglia, MD, MSc Partners Healthcare System, Boston, MA Nick Ackerson Thomson Micromedex, Greenwood Village, CO

Point-of-care information needs Most answers can be found on the Web 2 questions out Point-of-care information needs Most answers can be found on the Web 2 questions out of every 3 patients seen i Barriers Used less than 10% of the time Most questions left unanswered Errors: 770, 000 injuries and deaths annually in the US

Topics of this Panel What are the benefits? Are people using infobuttons? Have content Topics of this Panel What are the benefits? Are people using infobuttons? Have content providers bought into this? Are there any standards? How can I have infobuttons in my institution? Healthcare organizations EHR developers Content providers

Integration of Health Information Resources into Electronic Health Records James J. Cimino, M. D. 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? 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 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

Infobuttons at My Institution • What is an Infobutton Manager? • How does the 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?

Infobuttons vs. Infobutton Manager Resource s Clinical System Infobutton Context Infobutton Manager Page of Infobuttons vs. Infobutton Manager Resource s Clinical System Infobutton Context Infobutton Manager Page of Hyperlinks

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link https: //flux. cpmc. How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link https: //flux. cpmc. columbia. edu/webcisdev 13/wc_infomanage. cgi? MRN=&info_institute=&info_med=&info_context =&info_usertype=&info_age=&info_sex=

How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link Fill in Parameter How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link Fill in Parameter Values https: //flux. cpmc. columbia. edu/webcisdev 13/wc_infomanage. cgi? MRN=3131313&info_institute=GENERIC&info_med=sodium& info_context=Lab. Detail&info_usertype=MD&info_age=22& info_sex=F

How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link User Clicks On How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link User Clicks On Link Fill in Parameter Values Institute=CPMC & Context=Lab. Detail Concept=“sodium” Terms= Write to Identify CPMC Log File Terminology Serum Sodium Test Sodium Ion Hypernatremia Translate to Terms of Interest Hyponatremia CU/NYPH Infobutton Manager

How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link User Clicks On How Does the Infobutton Manager Work? Clinical Application/User’s Browser Integrate Link User Clicks On Link Write to Log File Fill in Parameter Values Identify Terminology Translate to Terms of Interest CU/NYPH Infobutton Manager User Clicks On Link Call Resource Display Page Of Links Write to Log File Generate List of Questions/Links Match Parameters to Contexts

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

How do I integrate the Infobutton Manager? Contact me: jjc 7@columbia. edu Agree on How do I integrate the Infobutton Manager? Contact me: jjc [email protected] edu Agree on Domain And Terminology Identify Questions Identify Resources Identify Contexts Determine Method for Automated Retrieval Add Everything to the Infobutton Manager Integrate with Clinical System to Pass Parameters

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH)

Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Psyckes (NYSPI)

Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Psyches (NYSPI) • RMRS (Regenstrief)

Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Psyches (NYSPI) • RMRS (Regenstrief) • Next. Gen (Crystal Run Healthcare)

Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Use of the CU/NYPH Infobutton Manager • Web. CIS (CU/NYPH) • Eclipsys (NYPH) • Psyches (NYSPI) • RMRS (Regenstrief) • Next. Gen (Crystal Run Healthcare)

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

Infobuttons at My Institution • What is an CU/NYPH Infobutton Manager? • How does Infobuttons at My Institution • What is an CU/NYPH 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?

Do you want to use the Columbia IM? • Contact me: jjc 7@columbia. edu Do you want to use the Columbia IM? • Contact me: jjc [email protected] edu • Help with terminology/context/questions • Adoption of HL 7 • Librarian Infobutton Tailoring Environment (LITE) • Supported by NLM Grant R 01 LM 07593 • For more information: http: //www. dbmi. columbia. edu/cimino/Infobuttons. html

Knowledge. Link Saverio Maviglia, MD, MSc Partners Healthcare System Harvard Medical School Boston, MA Knowledge. Link Saverio Maviglia, MD, MSc Partners Healthcare System Harvard Medical School Boston, MA S 68: Integration of Health Information Resources into EHRs

Knowledge. Link v 1 “digoxin” HTML Source Application Target Reference (LMR) (Micromedex or Skolar) Knowledge. Link v 1 “digoxin” HTML Source Application Target Reference (LMR) (Micromedex or Skolar)

KL v 1: Typical Use • Infrequent – 2. 3 x/mo average (0. 5 KL v 1: Typical Use • Infrequent – 2. 3 x/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

EFFECTIVENESS AND SATISFACTION • 84% of all Knowledge. Link queries are answered • 17% EFFECTIVENESS AND SATISFACTION • 84% of all Knowledge. Link queries are answered • 17% of physician use results in a change in management, 33% among specialists • >=80% rated Knowledge. Link positively on – Ease of use – Relevance – Speed – Impact on patient care

Comments • General Praise – Knowledge link is fantastic. VERY useful. – Great resource!! 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

User Requests for KL II Assertion % agreeing (n=59) KL should be extended to User Requests for KL II 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. 65% I would like to be able to specify to which resource KL goes. 58%

Knowledge. Link v 2 Micromedex LMR Skolar e. MAR Up. To. Date Results Knowledge. Knowledge. Link v 2 Micromedex LMR Skolar e. MAR Up. To. Date Results Knowledge. Link Manager BWH guidelines Source Applications Target References

 • Links chosen and ordered according to • Context (meds, labs, disease) • • Links chosen and ordered according to • Context (meds, labs, disease) • Source app (LMR, e. MAR, Results) • Provider (MD, RN, Pharm, other) • Clinic • Easy to modify/change search, restrict to patient information links, or print

Knowledge. Link Sessions Knowledge. Link Sessions

Knowledge. Link Users Knowledge. Link Users

95% medications 3% lab results 2% diseases 75% Micromedex 19% Partners 3% Skolar 1% 95% medications 3% lab results 2% diseases 75% Micromedex 19% Partners 3% Skolar 1% e. Medicine

USAGE BY ROLE 1% of patient encounters (LMR) 40 -75% of patient encounters (Web. USAGE BY ROLE 1% of patient encounters (LMR) 40 -75% of patient encounters (Web. MAR)

KL Session Characteristics Num of links Time Spent viewed (median sec) Medications 1. 3 KL Session Characteristics Num of links Time Spent viewed (median sec) Medications 1. 3 7 Labs 1. 2 11 Diseases 1. 2 12

Summary • Infobuttons are utilized and valued by all types of care providers, not 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

HL 7 Standard for Infobutton Integration Guilherme Del Fiol, MD, MS Intermountain Health Care HL 7 Standard for Infobutton Integration Guilherme Del Fiol, MD, MS Intermountain Health Care University of Utah Salt Lake City, UT

Why do we need a standard? • There is not a common integration language 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

Multiple ways of “asking” the same question What is the dose of azithromycin ? Multiple ways of “asking” the same question What is the dose of azithromycin ? i http: //resource 1. com/ search = “azithromycin AND dose” http: //resource 2. com/ query = "azithromycin"[Me. SH Terms] AND dose[All Fields] http: //resource 3. com/ search. Concept = 3333 ^ azithromycin filter = 11 ^ dosage

No standard in place API http: //resource 1. com/search. cgi? search = “azithromycin AND No standard in place API http: //resource 1. com/search. cgi? search = “azithromycin AND dose” Resource 1 http: //resource 2. com/ Clinical Information System query = "azithromycin"[Me. SH Terms] i API Infobutton Manager AND dose[All Fields] API Resource 2 http: //www. resource 3. com/search. cgi? search. Concept = 3333 ^ azithromycin filter = 11 ^ dosage API Resource 3

Standard-based integration HTML HL 7 Clinical Information System i Infobutton HL 7 Manager HL Standard-based integration HTML HL 7 Clinical Information System i Infobutton HL 7 Manager HL 7 HTML Resource 1 Resource 2 Resource 3

Participants • HL 7 Clinical Decision Support Technical Committee • Health care academic institutions Participants • HL 7 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, 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? ”

• HL 7 code for “Male” • Age in years • Me. SH code for “ 65 and older” • HL 7 code for “Problem list review” “Pneumonia”

http: //www. e-resource. com/api? patient. Context. gender. c=C 10173 patient. Context. gender. dn=Female age. http: //www. e-resource. com/api? patient. Context. gender. c=C 10173 patient. Context. gender. dn=Female age. v=77&age. u=y age. Group. c=D 000368 age. Group. dn=Aged task. Context. c=11 task. Context. dn=Problem list review main. Search. Criteria. c=D 018410 main. Search. Criteria. dn=Bacterial Pneumonia sub. Topic. c=Q 000628 sub. Topic. dn=therapy

Example 2 • The user (an RN) is looking at a medication list of 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.

" src="http://present5.com/presentation/8683ce5b5eb332dcd361db76caa53fc8/image-70.jpg" alt=" " /> • HL 7 code for “Female” • “Medications list review” • User is “care provider” • HL 7 code for “RN” • ISO 639 -2 for “English” • Content recipient is “patient” • ISO code for “Spanish”

http: //www. hl 7. org/v 3 ballot/html/ welcome/environment/index. htm http: //www. hl 7. org/v 3 ballot/html/ welcome/environment/index. htm

Current Status • XML version – Approved at committee level – Membership level in Current Status • XML version – Approved at committee level – Membership level in January 2007 • URL version – Implementation guide (not-normative) – 1 st ballot in January 2007 • Reference implementations

Commercial Info. Button Applications Content Vendors Perspective Nick Ackerson Product Manger – Integrated Solutions Commercial Info. Button Applications Content Vendors Perspective Nick Ackerson Product Manger – Integrated Solutions Thomson Healthcare

Info. Button Snapshot • Growing list of HCO’s adopting principle of embedded CDS (Info. Info. Button Snapshot • Growing list of HCO’s adopting principle of embedded CDS (Info. Buttons) • Growing list of HIS vendors realizing benefits of CDS/customer pull • Thought leading academia prevalent and well known. Leading push • Info. Button API’s now available with commercial access, not just academics • HCO’s striving for comprehensive, unbiased standardization of access to clinical content investments. (HL 7)

Clinical Deployment Results A Case Study: Wake Med • 851 Bed Integrated Health Care Clinical Deployment Results A 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 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 • Other Motivators • The need to centralize and streamline accessibility to clinical knowledge • Assess impact of deploying evidencedbased drug content • Analysis of staff time and productivity • Improved decision making/Empower clinicians • Optimization of content workflow tools to improve performance

Online Injectable Administration Online Injectable Administration

Results of Deployment • Over 55% of Wake Meds surveyed respondents were using Info. Results of Deployment • Over 55% of Wake Meds surveyed respondents were using Info. Button • 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 Wake Med Usage

Benefits Realized by Users/Institution • Reduces time/effort to answer key clinical questions - little/no 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 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 • Metropolitan Hospital • Wake. Med • Miami Baptist Peer Groups Implementing IB applications • Metropolitan Hospital • Wake. Med • Miami Baptist • Alverno/Central • Sentara Health (Epic) Washington • Marshfield Clinic • Ohio Health • Texas Health • Cedars Sinai Resources (Epic, • University of North Baylor) Carolina • University Medical Healthcare - Center (Eclipsys) Chapel Hill • Froedtert Hospital (Epic) • Salem Hospital (Epic)

Lessons Learned • Flexible, scaleable, HL 7 -compliant technology key to meet realities of Lessons Learned • Flexible, scaleable, HL 7 -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 • Info. Buttons are used by health care providers of all disciplines • Info. Buttons 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