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Leading a Horse to Water: Using Automated Reminders to Increase Use of Online Decision Support

Leading a Horse to Water: Using Automated Reminders to Increase Use of Online Decision Support. James J. Cimino and Dmitriy Borovtsov NIH Clinical Center and Department of Biomedical Informatics Columbia University College of Physicians and Surgeons. Knowledge Resources are Underused.

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Leading a Horse to Water: Using Automated Reminders to Increase Use of Online Decision Support

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  1. Leading a Horse to Water:Using Automated Reminders to Increase Use of Online Decision Support James J. Cimino and Dmitriy Borovtsov NIH Clinical Center and Department of Biomedical Informatics Columbia University College of Physicians and Surgeons

  2. Knowledge Resources are Underused Clinicians (physicians) with questions in clinical practice: • sought answers only 45% of the time • found answers only 34% of the time • used online resources 18% of the time * Ely JW, Osheroff JA, Maviglia SM, Rosenbaum ME. Patient-care questions that physicians are unable to answer. J Am Med Inform Assoc. 2007 Jul-Aug;14(4):407-14.

  3. Health Resources • Available from main menu • Static list of resources • No assistance with retrieval

  4. Infobuttons • Links inserted next to clinical information • Resources selected based on likely information need • Links are customized to assist with retrieval

  5. Log File of HR vs IB 2006 7000 6000 5000 4000 3000 2000 1000 0 M o n t h l y U s a g e Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2006 Health Resources Infobuttons

  6. Log File of HR vs IB 2006, 2007 7000 6000 5000 4000 3000 2000 1000 0 M o n t h l y U s a g e Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2006 2007 Health Resources Infobuttons

  7. Educational Interventions • Orientation for new housestaff • Orientation for new medical students • Infobutton exercises for new medical students

  8. Educational Interventions 450 400 350 300 250 200 150 100 50 0 M o n t h l y U s a g e Jun Jul Aug Sep Oct Nov Dec 2006 Medical Students Housestaff

  9. Educational Interventions 450 400 350 300 250 200 150 100 50 0 M o n t h l y U s a g e Jun Jul Aug Sep Oct Nov Dec 2006 2007 Medical Students Housestaff

  10. Usage of IB vs HR in Inpatient Meds 1400 1200 1000 800 600 400 200 0 M o n t h l y U s a g e Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Health Resources Infobuttons

  11. Usage of IB in Outpatient Meds 800 700 600 500 400 300 200 100 0 M o n t h l y U s a g e Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Health Resources Infobuttons

  12. Hypothesis Users of the Health Resources page in a particular context will be especially receptive to a suggestion to use Infobuttons in the same context.

  13. Intervention IB Used in past 2 months? Yes Stop No Reminder Sent in past 2 months? Yes Stop No Send Reminder HR used in OM HR = Health Resources Page OM = Outpatient Medications

  14. E-Mail Date: Fri, 2 Mar 2007 06:00:11 -0500 (EST) From: James Cimino <jjc7@columbia.edu> To: xxx@columbia.edu Subject: Getting Drug Information while Using WebCIS Dear WebCIS User: I am writing to let you know about a handy feature in WebCIS called the "infobutton". You will see it in places like the Outpatient Medication list - it is a little purple circle with a white letter "i". If you click on it, it will give you a list of topics that you can select to get more information about the drug next to the infobutton. I hope you'll find it useful. --Jim Cimino, Infobutton Project Manager

  15. Reminders Sent • 522 messages • 371 users • 80 attending physicians • 189 housestaff • 29 nurses • 24 students • 49 other/unknown • 173 users received two messages • 1 user received three messages • Average 89.9 days between messages

  16. Usage of Infobuttons by Reminder Recipients • 371 recipients of 552 reminders • 111 (20.1%) eventually used IBs in OM • 52 (9.4%) “early responders” • 26 housestaff • 18 attending physicians • 8 other/unknown • 201 used either IB or HR within one month • 25.9% “early responders with opportunity” • 9 early responders used IBs 8 to 97 times in subsequent months

  17. Intervention versus Control P<0.05 by Day 4 Days to First Use of Infobuttons after First Use of Health Resources Page 552 Intervention 525 Control

  18. Effect of delay

  19. Adverse Effects • 522 reminders • 12 replies • All were positive • Most were thanking us for infobuttons

  20. Discussion • Traditional training method appears to have limited effect • Simple, spam-like reminder appears to have an effect on a substantial fraction (26%) of users • Sustained effect in some (17%) of the early responders

  21. Limitations • Impersonal message • Timing of reminder less-than ideal • However: Logfile+e-mail approach is application independent • Quasi-experimental design • Convenience sample of controls • However: Strong temporal association between intervention and outcome

  22. Conclusions • Automated, context-specific reminders are technically feasible, requiring few resources • Reminders to use online information resources appear to be effective • Timing of message is critical to success

  23. Acknowledgments This work was supported in part by: National Library of Medicine Grant R01LM07593 NIH Clinical Center intramural research funds National Library of Medicine intramural research funds The authors also thank: Dr. Jianhua Li for technical support Dr. Rick Gallagher for log files Dr. Krystl Haerian for statistical support

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