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Just In Time Education: Linking Clinical and Educational Systems. James J. Cimino, MD Professor of Medicine and Biomedical Informatics Columbia University May 19, 2004. G.O. 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004.

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Just in time education linking clinical and educational systems l.jpg

Just In Time Education:Linking Clinical and Educational Systems

James J. Cimino, MD

Professor of Medicine and Biomedical Informatics

Columbia University

May 19, 2004


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G.O.

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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Covell et al.

Information Needs

G.O. Barnett

DXplain

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


Studying information needs l.jpg

Studying Information Needs

Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med. 1985 Oct;103(4):596-9.


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Results of Observational Study

  • 47 physicians

  • Observed during a half day of typical practice

  • Estimated 2-3 questions per physician per day

  • 269 questions raised about patient management

  • Only 30% were answered during the patient visit

  • Usual resource was another physician


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Other Observational Studies

The information needs of practicing physicians in northeastern New York State.

Assessment of physicians' information needs in five Texas counties

Information needs of rural health care practitioners in Hawaii.

Knowledge management in clinical practice: a systematic review of information seeking behavior in physicians

Information needs and information-seeking behaviors of on-call radiology residents

Expanding the concept of medical information: an observational study of physicians' information needs

Curbside consultation practices and attitudes among primary care physicians and medical subspecialists

Information needs of health care professionals in an AIDS outpatient clinic as determined by chart review

Methods for assessing information needs of clinicians in ambulatory care.

Real-time information-seeking behavior of residency physicians

Information seeking in primary care: how physicians choose which clinical questions to pursue and which to leave unanswered

Physicians' use of computer software in answering clinical questions.

Residents' medical information needs in clinic: are they being met?


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Findings

  • Information needs occur often

  • They are often unresolved

  • Computer-based resources are underused:

    • Lack of knowledge of existence

    • Lack of access

    • Lack of navigational skills

    • Perceived lack of time


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Information Needs of CIS Users

  • Stereotypical tasks suggest recurrent needs

  • System knows:

    • Who the user is

    • Who the patient is

    • What the user is doing

    • What information the user is looking at

  • User is sitting at a computer!


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Information for Decision-Making


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Information for Decision-Making


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Information for Decision-Making

?

MRSA


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One-Stop Information Shopping?

World Wide Web

(The Hyperdocument)

Information

Resources

Health

Practitioner

Biblio-

graphic

Database

Textbook

Expert

System


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One-Touch Information Shopping

World Wide Web

(The Facilitator)

Information

Resources

Health

Practitioner

Biblio-

graphic

Database

Textbook

Expert

System


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Covel et al.

Information Needs

Don Lindberg

UMLS

G.O. Barnett

DXplain

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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Unified Medical Language System

The purpose of the UMLS is to improve the ability of computer programs to “understand” the biomedical meaning in user inquiries and to use this understanding to retrieve and integrate relevant machine-readable information for users.

- Donald A.B. Lindberg


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Covel et al.

Information Needs

First Version

of UMLS

Don Lindberg

UMLS

G.O. Barnett

DXplain

ICD9

MeSH

Medline

Button

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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First Attempt: The Medline Button

  • CIS (WebCIS’s predecessor) on mainframe

  • BRS/Colleague (Medline) on same mainframe

  • Get them to talk to each other

  • Search using patient diagnoses and procedures

  • Kludge required


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First Attempt: The Medline Button

  • CIS (WebCIS’s predecessor) on mainframe

  • BRS/Colleague (Medline) on same mainframe

  • Get them to talk to each other

  • Search using patient diagnoses and procedures

  • Kludge required

  • Technical success

  • Practical failure


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Covel et al.

Information Needs

First Version

of UMLS

PubMED

Mosaic

Don Lindberg

UMLS

G.O. Barnett

DXplain

WebCIS

ICD9

MeSH

Medline

Button

Web-based

Generic Queries

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


Slide27 l.jpg

Covel et al.

Information Needs

First Version

of UMLS

PubMED

Mosaic

Don Lindberg

UMLS

G.O. Barnett

DXplain

Web DXplain

WebCIS

ICD9

MeSH

Medline

Button

DXplain

Button

Web-based

Generic Queries

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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From Data to Findings

Serum Specimen

Abnormalities of

Serum Cholesterol

Cholesterol

Serum

Hypercholesterolemia

Serum Cholesterol Test


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Covel et al.

Information Needs

First Version

of UMLS

PubMED

Mosaic

Don Lindberg

UMLS

G.O. Barnett

DXplain

Web DXplain

WebCIS

Infobuttons

ICD9

MeSH

Medline

Button

DXplain

Button

Web-based

Generic Queries

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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Education at the Moment of Need

MRSA


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Education at the Moment of Need

1

MRSA

Understand

Information

Needs


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Education at the Moment of Need

2

Get Information

From EMR

1

MRSA

Understand

Information

Needs


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Education at the Moment of Need

2

Get Information

From EMR

1

MRSA

Understand

Information

Needs

3

Resource

Selection


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Education at the Moment of Need

4

2

Get Information

From EMR

Resource

Terminology

1

MRSA

Understand

Information

Needs

3

Resource

Selection


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Education at the Moment of Need

4

5

2

Automated

Translation

Get Information

From EMR

Resource

Terminology

1

MRSA

Understand

Information

Needs

3

Resource

Selection


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Education at the Moment of Need

4

5

2

Automated

Translation

Get Information

From EMR

Resource

Terminology

6

1

MRSA

Querying

Understand

Information

Needs

3

Resource

Selection


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Education at the Moment of Need

4

5

2

Automated

Translation

Get Information

From EMR

Resource

Terminology

6

1

MRSA

Querying

Understand

Information

Needs

3

7

Resource

Selection

Presentation


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Research Issues

  • What are the information needs?


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Portable Usability Lab

User’s Workstation

75 foot cable

Video Monitor

Converter Controller

Microphone

Video Converter

Headphones

VCR

Cassette Recorder


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Research Issues

  • Which context information is important?

  • What are the information needs?


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Context-Dependent Information Needs

!

?

Age

Sex

Role

Training

Task

Data

Institution

Context


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Research Issues

  • What resources can satisfy needs?

  • How can retrieval be automated?

    • What context data are used?

    • How are the data translated?

  • What are the information needs?

  • Which context information is important?


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The Medical Entities Dictionary (MED)


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Research Issues

  • How are the data transmitted?

  • What are the information needs?

  • Which context information is important?

  • What resources can satisfy needs?

  • How can retrieval be automated?

    • What context data are used?

    • How are the data translated?


Slide54 l.jpg

Covel et al.

Information Needs

First Version

of UMLS

PubMED

Mosaic

Don Lindberg

UMLS

G.O. Barnett

DXplain

Web DXplain

WebCIS

Infobuttons

ICD9

MeSH

Medline

Button

DXplain

Button

Infobutton

Manager

Web-based

Generic Queries

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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The Coumadin Story

  • Chair of Medicine wants link to Coumadin protocol

  • First, I have to find the guidelines


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The Coumadin Story

  • Chair of Medicine wants link to Coumadin protocol

  • First, I have to find the guidelines

  • Then I have to add the question to the IM table


The coumadin story66 l.jpg

The Coumadin Story

  • Chair of Medicine wants link to Coumadin protocol

  • First, I have to find the guidelines

  • Then I have to add the question to the IM table

  • Finally, I link the question to the context


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The Coumadin Story

  • Chair of Medicine wants link to Coumadin protocol

  • First, I have to find the guidelines

  • Then I have to add the question to the IM table

  • Finally, I link the question to the context

  • Voilá!


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Next Steps

  • Repeat the observational study

  • Look at system logs to see if:

    • Infobutton use is rising (7000 in first 10 weeks)

    • Use of other resources is falling (not yet)

  • Order entry Infobuttons

  • Collaboration with Regenstrief and LDS

  • Infobutton Manager to be an ANSI standard


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Covel et al.

Information Needs

First Version

of UMLS

PubMED

Infobutton

Manager

Standard

Mosaic

Don Lindberg

UMLS

G.O. Barnett

DXplain

Web DXplain

WebCIS

Infobuttons

ICD9

MeSH

Medline

Button

DXplain

Button

Infobutton

Manager

Web-based

Generic Queries

1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004


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Conclusions

  • Information needs arise while using CIS

  • Infobuttons are easy to build

  • Are they the right buttons?

  • Can retrievals be standardized?

  • Will information needs be satisfied?

  • Will care improve?


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Acknowledgments

  • National Library of Medicine

  • The team:

    • Jianhua Li

    • Sue Bakken

    • Vimla Patel

    • Mureen Allen

    • Leanne Currie

    • Mark Graham

www.dmi.columbia.edu/homepages/ciminoj/Infobuttons.html


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