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An Integrated Approach to Computer-Based Decision Support at the Point of Care

An Integrated Approach to Computer-Based Decision Support at the Point of Care. James J. Cimino, M.D., FACMI, FACP Professor of Biomedical Informatics and Medicine Columbia University College of Physicians and Surgeons New York, New NY. Motivation: Errors and Information Needs.

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An Integrated Approach to Computer-Based Decision Support at the Point of Care

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  1. An Integrated Approach to Computer-Based Decision Support at the Point of Care James J. Cimino, M.D., FACMI, FACP Professor of Biomedical Informatics and Medicine Columbia University College of Physicians and Surgeons New York, New NY

  2. Motivation: Errors and Information Needs • Information needs are frequent and often unmet • Unmet needs  delayed/wrong decisions  errors • Barriers to information access: • Ignorance of the existence of a resource • Lack of familiarity with using a resource • Effort required (actual or perceived)

  3. Options: Computer-based Decision Support • Electronic patient records • Passive on-line knowledge resources • Calculators • Stand-alone expert systems • Alerting and reminders systems (“push”)

  4. Solution: Integrated Decision Support • Information needs often occur while using a computer • The computer has access to resources • The computer can use context to suggest resources • The computer can assist retrieval (“pull”) • But, build it and they may not come

  5. “Just in Time” Education

  6. “Just in Time” Education 1 Understand Information Needs

  7. “Just in Time” Education 2 Get Information From EMR 1 Understand Information Needs

  8. “Just in Time” Education 2 Get Information From EMR 1 Understand Information Needs 3 Resource Selection

  9. “Just in Time” Education 4 2 Get Information From EMR Resource Terminology 1 Understand Information Needs 3 Resource Selection

  10. “Just in Time” Education 4 5 2 Automated Translation Get Information From EMR Resource Terminology 1 Understand Information Needs 3 Resource Selection

  11. “Just in Time” Education 4 5 2 Automated Translation Get Information From EMR Resource Terminology 6 1 Querying Understand Information Needs 3 Resource Selection

  12. “Just in Time” Education 4 5 2 Automated Translation Get Information From EMR Resource Terminology 6 1 Querying Understand Information Needs 3 7 Resource Selection Presentation

  13. “Just in Time” Education 4 5 2 Automated Translation Get Information From EMR Resource Terminology 6 1 Querying Understand Information Needs 3 7 Resource Selection Presentation

  14. User’s Workstation 75 foot cable Video Monitor Converter Controller Microphone Video Converter Headphones VCR Cassette Recorder

  15. Initial Lessons: Observational Data • Log file analysis • Resource use varies with user type and task

  16. Context-Specific Resource Use

  17. Initial Lessons: Observational Data • Log file analysis • Resource use varies with user type and task • Direct observations • Information needs are frequent (1/5.5min) • Questions are fall into small number of patterns • Resources are available to answer questions • Resources are used infrequently (<50%) • Needs are frequently unmet (51%)

  18. Technical Solutions: Infobuttons • Infobuttons • Links as “i” icons in clinical information system • Capture context parameters • Patient age and gender • User • Task • Concept of interest • Pass information to Infobutton Manager • Infobutton Manager • Can be called from any system with Web access • Matches context to questions • Creates links to answer context-specific questions • Passes links back to user (“pull”)

  19. Evaluation • Popup questionnaires (195) • E-mail survey (73) • Log file analysis (2 years)

  20. Results: Pop-Up and E-Mail Surveys Pop-Up E-Mail Easy to use 83% 92% Question on list >50% of time 89% Answered question 69% Useful 77% Helpful >50% of time 90% Positive effect on care 74% Specific cases of improved care 14

  21. Results: Log Files • Questions chosen 48.7% (10.5%-78.7%) • 3/04 – 9/06: 2,160 users, 28,553 accesses • Monthly: >300 users, 1,200 access

  22. Resource Use by Context Laboratory Results Review Inpatient Drug Order Review Microbiology Sensitivity Results Diagnosis List Inpatient Lab Order Entry Inpatient Drug Order Entry

  23. Resource Use by Context - September

  24. Lessons Learned • Good: • Easy to use • Anticipates users’ questions • Fast • Useful • Positive impact on patient care • Room for improvement • Navigation of Infobutton Manager page • Additional questions needed • Adoption has been slow

  25. Conclusions • Context-specific access to health knowledge resources has been successfully accomplished • Impact on patient care decisions has been positive • Increased information resource use should result in clinicians making better informed patient care decisions

  26. Acknowledgments • This work is supported by NLM grant R01LM07593 • Evlauation plan: • Vimla Patel • Sue Bakken • Leanne Currie • Beth Friedman • Programming: Jianhua Li • Log files: Rick Gallagher

  27. Discussion?

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