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Integration of Health Information Resources into Electronic Health Records. Guilherme Del Fiol, MD, MS Intermountain Healthcare University of Utah, Salt Lake City, UT

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Integration of health information resources into electronic health records

Integration of Health Information Resources into Electronic Health Records

Guilherme Del Fiol, MD, MSIntermountain HealthcareUniversity of Utah, Salt Lake City, UT

James J. Cimino, MD Department of Biomedical Informatics, Columbia University, New York, NYSaverio Maviglia, MD, MScPartners Healthcare System, Boston, MANick AckersonThomson Micromedex, Greenwood Village, CO


Point of care information needs

Most answers can be Health Recordsfound on the Web

Barriers

Used less than10% of the time

Errors: 770,000 injuries and

deaths annually in the US

Point-of-care information needs

2 questions out of every 3 patients seen

i

Most questions left unanswered


Topics of this panel
Topics of this Panel Health Records

What are the benefits?

Are people using infobuttons?

How can I have infobuttons in my institution?

Have content providers bought into this?

Healthcare

organizations

EHR developers

Contentproviders

Are there any standards?


Integration of health information resources into electronic health records1

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
The Columbia/NYPH Infobutton Manager Health Records 

  • 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
Infobuttons at My Institution Health Records 

  • 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 institution1
Infobuttons at My Institution Health Records 

  • 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 Health Records 

s

Clinical System

Infobutton

Context

Infobutton

Manager

Page

of

Hyperlinks

Infobuttons vs. Infobutton Manager


Infobuttons at my institution2
Infobuttons at My Institution Health Records 

  • 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 institution3
Infobuttons at My Institution Health Records 

  • 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
How Does the Infobutton Manager Work? Health Records 

Clinical Application/User’s Browser

Integrate

Link

https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi?

MRN=<xxx>&info_institute=<xxx>&info_med=<xxx>&info_context=<xxx>&info_usertype=<xxx>&info_age=<xxx>&info_sex=<xxx>


How does the infobutton manager work1

Fill in Health Records 

Parameter

Values

How Does the Infobutton Manager Work?

Clinical Application/User’s Browser

Integrate

Link

https://flux.cpmc.columbia.edu/webcisdev13/wc_infomanage.cgi?

MRN=3131313&info_institute=GENERIC&info_med=sodium&

info_context=LabDetail&info_usertype=MD&info_age=22&

info_sex=F


How does the infobutton manager work2

Fill in Health Records 

Parameter

Values

User Clicks

On Link

Write to

Log File

Identify

Terminology

Translate to Terms of Interest

How Does the Infobutton Manager Work?

Clinical Application/User’s Browser

Integrate

Link

Institute=CPMC & Context=LabDetail

Concept=“sodium”

Terms=

CPMC Serum Sodium Test

Sodium Ion

Hypernatremia

Hyponatremia

CU/NYPH Infobutton Manager


How does the infobutton manager work3

User Clicks Health Records 

On Link

Call

Resource

Fill in

Parameter

Values

Display Page

Of Links

User Clicks

On Link

Write to

Log File

Generate List of

Questions/Links

Write to

Log File

Identify

Terminology

Match Parameters

to Contexts

Translate to Terms of Interest

How Does the Infobutton Manager Work?

Clinical Application/User’s Browser

Integrate

Link

CU/NYPH Infobutton Manager


Infobuttons at my institution4
Infobuttons at My Institution Health Records 

  • 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 institution5
Infobuttons at My Institution Health Records 

  • 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

Agree on Domain Health Records 

And Terminology

Identify

Resources

Identify

Questions

Determine Method for

Automated Retrieval

Identify

Contexts

Integrate with Clinical

System to Pass Parameters

Add Everything to the

Infobutton Manager Manager

How do I integrate the Infobutton Manager?

Contact me:

[email protected]


Infobuttons at my institution6
Infobuttons at My Institution Health Records 

  • 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 institution7
Infobuttons at My Institution Health Records 

  • 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
Use of the CU/NYPH Infobutton Manager Health Records 

  • WebCIS (CU/NYPH)

  • Eclipsys (NYPH)


Use of the cu nyph infobutton manager1
Use of the CU/NYPH Infobutton Manager Health Records 

  • WebCIS (CU/NYPH)

  • Eclipsys (NYPH)

  • Psyckes (NYSPI)


Use of the cu nyph infobutton manager2
Use of the CU/NYPH Infobutton Manager Health Records 

  • WebCIS (CU/NYPH)

  • Eclipsys (NYPH)

  • Psyches (NYSPI)

  • RMRS (Regenstrief)


Use of the cu nyph infobutton manager3
Use of the CU/NYPH Infobutton Manager Health Records 

  • WebCIS (CU/NYPH)

  • Eclipsys (NYPH)

  • Psyches (NYSPI)

  • RMRS (Regenstrief)

  • NextGen (Crystal Run Healthcare)


Use of the cu nyph infobutton manager4
Use of the CU/NYPH Infobutton Manager Health Records 

  • WebCIS (CU/NYPH)

  • Eclipsys (NYPH)

  • Psyches (NYSPI)

  • RMRS (Regenstrief)

  • NextGen (Crystal Run Healthcare)


Infobuttons at my institution8
Infobuttons at My Institution Health Records 

  • 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 institution9
Infobuttons at My Institution Health Records 

  • 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
Do you want to use the Columbia IM? Health Records 

  • Contact me: [email protected]

  • Help with terminology/context/questions

  • Adoption of HL7

  • Librarian Infobutton Tailoring Environment (LITE)

  • Supported by NLM Grant R01LM07593

  • For more information:

    http://www.dbmi.columbia.edu/cimino/Infobuttons.html


Knowledgelink

KnowledgeLink Health Records 

S68: Integration of Health Information Resources into EHRs

Saverio Maviglia, MD, MSc

Partners Healthcare System

Harvard Medical School

Boston, MA


Knowledgelink v1
KnowledgeLink v1 Health Records 

“digoxin”

HTML

Source Application

(LMR)

Target Reference

(Micromedex or Skolar)


Kl v1 typical use
KL v1: Typical Use Health Records 

  • Infrequent

    • 2.3x/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
EFFECTIVENESS AND SATISFACTION Health Records 

  • 84% of all KnowledgeLink queries are answered

  • 17% of physician use results in a change in management, 33% among specialists

  • >=80% rated KnowledgeLink positively on

    • Ease of use

    • Relevance

    • Speed

    • Impact on patient care


Comments
Comments Health Records 

  • 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
User Requests for KL II Health Records 


Knowledgelink v2

LMR Health Records 

eMAR

Results

Source Applications

KnowledgeLink v2

Micromedex

Skolar

UpToDate

KnowledgeLink Manager

BWH guidelines

Target References


  • Links chosen and ordered according to Health Records 

    • Context (meds, labs, disease)

    • Source app (LMR, eMAR, Results)

    • Provider (MD, RN, Pharm, other)

    • Clinic

  • Easy to modify/change search, restrict to patient information links, or print


Knowledgelink sessions
KnowledgeLink Sessions Health Records 


Knowledgelink users
KnowledgeLink Users Health Records 


95% medications Health Records 

3% lab results

2% diseases

75% Micromedex

19% Partners

3% Skolar

1% eMedicine


Usage by role
USAGE BY ROLE Health Records 

40-75% of patient encounters (WebMAR)

1% of patient encounters (LMR)


Kl session characteristics
KL Session Characteristics Health Records 


Summary
Summary Health Records 

  • 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


Hl7 standard for infobutton integration

HL7 Standard for Infobutton Integration Health Records 

Guilherme Del Fiol, MD, MSIntermountain Health CareUniversity of UtahSalt Lake City, UT


Why do we need a standard
Why do we need a standard? Health Records 

  • There is not a common integration language

    • Query parameter names

    • Terminologies used for content searchretrieval

  • 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
Multiple ways of Health Records  “asking” the same question

What is the dose of azithromycin ?

i

http://resource1.com/search = “azithromycin AND dose”

http://resource2.com/

query = "azithromycin"[MeSH Terms] AND dose[All Fields]

http://resource3.com/

searchConcept = 3333 ^ azithromycinfilter = 11 ^ dosage


No standard in place
No standard in place Health Records 

Resource 1

API

http://resource1.com/search.cgi?search = “azithromycin AND dose”

http://resource2.com/

query = "azithromycin"[MeSH Terms] AND dose[All Fields]

Clinical

Information

System

Infobutton

Manager

Resource 2

i

API

API

http://www.resource3.com/search.cgi?searchConcept = 3333^ azithromycinfilter = 11 ^ dosage

Resource 3

API


Standard based integration

Resource 1 Health Records 

HL7

Infobutton

Manager

Resource 2

HL7

HL7

Resource 3

HL7

Standard-based integration

HTML

Clinical

Information

System

i

HTML


Participants
Participants Health Records 

  • HL7 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
Example 1 Health Records 

  • 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?”


< Health Records  patientContext>

<gendercode="C10173" displayName="Male"/>

<agevalue="77" unit="y"/>

<ageGroupcode="D000368“ displayName="Aged"/>

<taskContextcode="11"

displayName="Problem List Review"/>

<mainSearchCriteriacode="D018410" codeSystem="2.16.840.1.113883.6.177" displayName="Bacterial Pneumonia"/>

<subTopiccode="Q000628" displayName="therapy"/>

  • HL7 code for “Male”

  • Age in years

  • MeSH code for “65 and older”

  • HL7 code for “Problem list review”

  • MeSH code for “Pneumonia”

  • MeSH code for “Therapy”


http://www.e-resource.com/api? Health Records 

patientContext.gender.c=C10173patientContext.gender.dn=Female

age.v=77&age.u=y

ageGroup.c=D000368

ageGroup.dn=Aged

taskContext.c=11taskContext.dn=Problem list review

mainSearchCriteria.c=D018410mainSearchCriteria.dn=Bacterial Pneumonia

subTopic.c=Q000628subTopic.dn=therapy


Example 2
Example 2 Health Records 

  • 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.


< Health Records  patientContext>

<age value="32" unit="y"/>

<gender code="C10174" displayName=“Female"/>

<taskContext code=“5"/>

<performer><healthCareProvider>

<discipline code="S13232" displayName="RN"/>

<language code="eng" displayName=“English"/>

<informationRecipient><patient>

<language code=“spa" displayName=“Spanish"/>

<mainSearchCriteria code="59762-3080-01" displayName="Azithromycin"/>

  • HL7 code for “Female”

  • “Medications list review”

  • User is “care provider”

  • HL7 code for “RN”

  • ISO 639-2 for “English”

  • Content recipient is “patient”

  • ISO code for “Spanish”


http://www.hl7.org/v3ballot/html/ Health Records  welcome/environment/index.htm


Current status
Current Status Health Records 

  • XML version

    • Approved at committee level

    • Membership level in January 2007

  • URL version

    • Implementation guide (not-normative)

    • 1st ballot in January 2007

  • Reference implementations


Commercial infobutton applications content vendors perspective

Commercial InfoButton Applications Health Records  Content Vendors Perspective

Nick Ackerson

Product Manger – Integrated Solutions

Thomson Healthcare


Infobutton snapshot
InfoButton Snapshot Health Records 

  • Growing list of HCO’s adopting principle of embedded CDS (InfoButtons)

  • Growing list of HIS vendors realizing benefits of CDS/customer pull

  • Thought leading academia prevalent and well known. Leading push

  • InfoButton API’s now available with commercial access, not just academics

  • HCO’s striving for comprehensive, unbiased standardization of access to clinical content investments. (HL7)


Clinical deployment results a case study wake med
Clinical Deployment Results Health Records  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
Wake Med’s Clinical Motivators Health Records 

  • Manual upkeep of drug policies and procedures

  • Regulation compliance

  • Practice variation

  • Medical errors

  • Adverse events


Other motivators
Other Motivators Health Records 

  • The need to centralize and streamline accessibility to clinical knowledge

  • Assess impact of deploying evidenced-based drug content

  • Analysis of staff time and productivity

  • Improved decision making/Empower clinicians

  • Optimization of content workflow tools to improve performance



Results of deployment
Results of Deployment Health Records 

  • Over 55% of Wake Meds surveyed respondents were using InfoButton

  • 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 Health Records 


Benefits realized by users institution
Benefits Realized by Users/Institution Health Records 

  • 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
Benefits for Institution Health Records 

  • 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
Peer Groups Implementing IB applications Health Records 

  • Metropolitan Hospital

  • Miami Baptist

  • Sentara Health (Epic)

  • Marshfield Clinic

  • Texas Health Resources (Epic, Baylor)

  • University Medical Center (Eclipsys)

  • Froedtert Hospital (Epic)

  • WakeMed

  • Alverno/Central Washington

  • Ohio Health

  • Cedars Sinai

  • University of North Carolina Healthcare - Chapel Hill

  • Salem Hospital (Epic)


Lessons learned
Lessons Learned Health Records 

  • Flexible, scaleable, HL7-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

  • InfoButtons are used by health care providers of all disciplines

  • InfoButtons 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


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