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

1. Theoretical, and Practical Empirical, Approaches to Resolving the Unmet Information Needs of Clinical Information System Users James J. Cimino MD, Jianhua Li MD, Suzanne Bakken RN DNSc, Vimla L. Patel PhD Department of (Bio)Medical Informatics Columbia University New York, New York, USA

2. 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

3. 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)

4. 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)

5. 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}

6. Context-Dependent Information Needs ! ? Age Sex Role Training Task Data Institution Context

7. 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

8. Portable Usability Lab User’s Workstation 75 foot cable Video Monitor Converter Controller Microphone Video Converter Headphones VCR Cassette Recorder

10. Practical Approach • Context passed to Infobutton Manager (IM) • IM matches context to information needs • Search strategies are instantiated • Questions (links) are returned to user

11. Matching Context to Need Infobutton Manager I n f o b u t t o n s Context Matching Context Table Question Selection Question Table Instantiation C o n t e x t

12. Context Parameters • Patient: age, gender • User: physician, nurse, student, patient, … • Setting: lab reports, medications, … • Concept of interest: lab test, drug, …

13. 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 <>?

15. <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>

19. 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

20. 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

21. 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

22. Context Parameters • Patient: age, gender • User: physician, nurse, student, patient, … • Setting: lab reports, medications, … • Concept of interest: lab test, drug, … • Institution: CPMC, RMRS, LDS, …

23. <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>

24. <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>

25. 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

26. Acknowledgments • National Library of Medicine grant R01-LM07593 • Research assistants: • Anne-Marie Ramierez • Mark Graham • Leanne Currie