Supporting Medical Decision Making with Electronic Medical Records

Supporting Medical Decision Making with Electronic Medical Records James J. Cimino Departments of Medicine and Medical Informatics Columbia University

Decision Making for Patients and Providers • Access to (electronic) health records generates information needs • Information needs go unmet • “Best evidence”, educational material, training programs can address these needs

One-Stop Information Shopping? Health Practitioner World Wide Web (The Hyperdocument) Information Resources Bibliographic Database Textbook Expert System

One-Touch Information Shopping Health Practitioner World Wide Web (The Facilitator) Information Resources Bibliographic Database Textbook Expert System

Information for Decision-Making ? MRSA

Intelligent Decision Support MRSA Result ! ? Query

Infobutton: Automating the Process • Questions can be anticipated • Match information source to question • Automate the retrieval • Query can use patient information

New York Presbyterian Hospital Information Architecture • • Central repository Data Access Modules Medical Entities Dictionary Med. LEE CIS Web. CIS Pat. CIS

Central Controlled Terminology

MED Semantic Network Medical Entity Substance Chemical Laboratory Specimen Anatomic Substance M Substance Laboratory Test en Glucose Diagnostic Procedure Laboratory Procedure im Bioactive Substance c pe Carbohydrate nce a t s d Subample S s. S Ha Plasma Specimen Event easured Plasma Glucose Test Part of CHEM-7

Automated Decision Support 4 Resource Terminology 5 2 Automated Translation Get Information From EMR 6 MRSA Querying Understand Information Needs 3 Resource Selection 1 7 Presentation

Translations with the MED Summary Reports Intravascular Gentamicin Tests Serum Gentamicin Level is-a t Sub st Gentamicn Sensitivity Test Injectable Gentamicin ance Mea sure n die re d Gentamicin resy u s a it Me nsitiv Se g n i s Ha Decision Rule Eti olo gy Gentamicin Toxicity Drug Information Expert System

EMR and Decision Support • The Medline Button - understand conditions • Pharmacy Infobutton - review and teach

EMR and Decision Support • The Medline Button - understand conditions • Pharmacy Infobutton - review and teach • Cholesterol Guideline - dietary planning

EMR and Decision Support • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning DXplain Button - understand findings

From Test Result to Finding 32412 Intravascular Specimen 32308 Intravascular Glucose Tests 31987 Glucose 32703 Serum Glucose Tests 42486 Decreased Abnormal Finding in Body Substance 42485 Elevated Abnormal Finding in Body Substance 1600 Gluc 42527 Abnormal Level of Blood Glucose 1600 44 L 42541 Hyperglycemia 3286 Hypoglycemia

EMR and Decision Support • • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings Qing. CIS - problem-oriented views

Smarter Retrievals from the Record • Repository stores events and results • Clinical problems at a different level of granularity • Re-use knowledge to map from problems to clinical data • Produce problem-specific views of the medical record

Concept-oriented (Heart) Heart Disease Congestive Heart Failure Angina Cardiac Enzyme Creatine Kinase Intravascular CK Test Admission : 3/14/96 Stroke Lab : 12/28/96 Sickle Cell Test Admission : 2/14/98 Angina Lab : 1/1/99 Blood Type Test Discharge : 1/15/99 CHF Lab : 1/1/99 Cardiac Enzyme Test Chest X ray 2 View Radiology : 2/28/96 Head CT Radiology : 2/1/97 Knee X Ray Radiology : 2/23/99 Chest X Ray

EMR and Decision Support • • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings Qing. CIS - problem-oriented views Pat. CIS - patient education

EMR and Decision Support • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings Qing. CIS - problem-oriented views Pat. CIS - patient education Lab Infobutton - patient information

EMR and Decision Support • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings Qing. CIS - problem-oriented views Pat. CIS - patient education Lab Infobutton - patient information Microbiology Infobuttons - infection control

EMR and Decision Support • • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings Qing. CIS - problem-oriented views Pat. CIS - patient education Lab Infobutton - patient information Microbiology Infobuttons - infection control Mammography Guideline - screening

EMR and Decision Support • • • The Medline Button - understand conditions Pharmacy Infobutton - review and teach Cholesterol Guideline - dietary planning Dxplain Button - understand findings Qing. CIS - problem-oriented views Pat. CIS - patient education Lab Infobutton - patient information Microbiology Infobuttons - infection control Mammography Guideline - screening Pap Smear Infobutton - screening

Summary • Decision making requires high-quality, up-to-date, timely information • The EMR generates information needs • The EMR can help satisfy information needs • The Web makes the rest easy • Further study needed: – When do users need information? – What information do they need? – What terminology is needed? – What are the right resources? – How can retrievals be facilitated? – How do we present results?