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Understanding Infobutton Standards:

How to link EHRs and CDS

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Understanding Infobutton Standards:

How to link EHRs and CDS

HL7 Context-Aware Knowledge

Retrieval System

• HL7 International (Health Level Seven) and its

members provide standards for the integration of

health information

• Eliminate the “wild west” of integrations

• One of these standards is for the “Context-Aware

Knowledge Retrieval, Knowledge Request

Standard”

•Infobutton

• Clinical Decision Support Work Group

• First version was approved in September 2010

• Provides a specific framework and structure for

systems to submit knowledge requests to

resources

Provides clinicians and patients

with relevant resources to meet

your MU2 objectives

Infobutton

§170.314 (a) (8) Clinical Decision Support

§170.314 (a) (15) Patient-Specific Education Resources

• Clinicians need resources to find answers at the

point of care

• Infobutton provides a way to integrate resources

into the EHR or PHR system

• Provides a more efficient way to get to these

resources, so that they may be used more

frequently

1) Context-specific topic to support decisions

2) Specialized by user – Patients, physicians,

pharmacists, nurses

3) Access to authoritative information without

leaving workflow

• Enables interoperability

• Utilizes standard terminologies – ICD-9, ICD-10,

SNOMED, RxNORM, NDC, LOINC, CPT

ICD-10 E10.9

Diabetes Type 1

LOINC 2345-7

Fasting Blood Sugar

LOINC 4548-4 HbA1C

RxNorm 5856 Insulin

Patient Education

Handouts

Secure email

Patient Portal

Retrieves data from EHR and CDS content

Infobutton

Manager Third Party

Content Provider

Third Party

Content Provider

Parameter Value Description

patientPerson.administativeG

enederCode.dn

Male Specifies the display name for this

patient’s gender is male

mainSearchCriteria.v.cs 2.16.840.1.113883.6. 3 Specifies the ICD-10 code system

mainSearchCritera.v.c J15.9 ICD-10 code for unspecified

bacterial pneumonia

age.v.u A Specifies the age unit (a=years)

age.v.v 65 Specifies the age value

subTopic.v.dn Treatment Specifies the subtopic description

URL Representation:

mainSearchCriteria.v.c=J15.9&mainSearchCriteria.v.cs=2.16.840.1.

113883.6.3&mainSearchCriteria.v.csn=ICD10

patientPerson.administativeGenderCode.dn=Male&

Age.v.v=65&age.v.u=a&

subTopic.v.dn=treatment

Generated XML:

-<resourceRequest>

-<mainSearchCriteria>

-

<value code="J15.9"codeSystem="2.16.840.1.113883.6.3"codeSystemName="IC

D10">

<displayName value=""/>

</value>

</mainSearchCriteria>

</resourceRequest>

Example Content Return

BACTERIAL PNEUMONIA

Background › Pathophysiology › Diagnostics › - History › - Physical Exam › - Dx Testing › - Dx Imaging › Differential

Dx › Treatment › - Antibiotics › Disposition › References

Treatment

ABCs

Support O2 & consider Venous access prn

Bronchodilator medications (if wheezing)

Sepsis evaluation if <8 wks old & fever on toxic child

Consider use of antibiotics if bacterial pathogen likely

Empiric antibiotics based on

Age

Season

Clinical factors

Labs

Epidemiology

Antibiotic Recommendations

Outpatient ABx dosages

Inpatient antibiotic therapy

Infobutton Study:

•Needs dependent on context and clinician type

•All clinicians: institution-specific protocols

•MDs: unfamiliar domains

•RNs: physician order rationales

•NPs: Similar to MDs and RNs

•Suggestion: Infobutton should tailor anticipated questions

by clinician type

Collins, Sarah A, Leanne M. Currie, Suzanne Bakken and James J. Cimino. Information Needs, Infobutton Manager Use, and Satisfaction

by Clinician Type: A Case Study. Journal American Medical Informatics Association. 2009 Jan-Feb; 16(1): 140-142

Specialized Resources

Pediatric Dosing

Calculator

Nursing Considerations,

Patient Teaching AHFS Spanish education

handout

Parameter Value Description

informationRecipient

PAT

Specifies the intended recipient is

a patient

performer.languageCode.c en Specifies the language of the user

(en=English)

informationRecipeint.languag

eCode.c

es Specifies the language of the

patient is Spanish (es=Spanish)

Performer.healthCareProvide

r.c.dn

Registered Nurse Display name of the performer is

RN

mainSearchCriteria.v.cs 2.16.840.1.113883.6.69 Specifies the NDC code set

mainSearchCriteria.v.c 49502-693-03 NDC code for Albuterol sulfate

inhalation solution 1.25 mg

URL Representation:

informationRecipient=PAT&

Performer.languageCode.c=en&

informationReciient.languageCode.c=es&

Performer.healthCareProvider.c.c=160W00000X&performer.health

Careprovider.c.dn=Registered Nurse&

mainSearchCriteria.v.c=49502-693-

03&mainSearchCriteria.v.cs=2.16.840.1.113883.6.9&mainSearchCri

tiera.v.dn=Albuterol+sulfate&mainSearchCriteria.v.ot=Albuterol+Sulf

ate+inhalation_solution+1.25mg

HTTP POST example: <input

name="InfobuttonEventNotification"value=”infobuttonEventNotification.effectiveTi

me.v=20060706001023&holder.assignedEntity.n=OrganizationUsername&holder.as

signedEntity.certificateText=organizationpassword&patientPerson.administrative

GenderCode.c=F&patientPerson.administrativeGenderCode.dn=Female&age.v.v

=8&age.v.u=a&ageGroup.v.c=D002648&ageGroup.v.cs=2.16.840.1.113883.6.177&

taskContext.c.c=MEDLISTREV&performer=PROV&informationRecipient=PAT&p

erformer.healthCareProvider.languageCode.c.c=en&informationRecipient.patien

tPerson.languageCode.c=es&performer.healthCareProvider.c.c=163W00000X&p

erformer.healthCareProvider.c.dn=RegisteredNurse&mainSearchCriteria.v.c=495

0269303&mainSearchCriteria.v.cs=2.16.840.1.113883.6.69&mainSearchCriteria.v.

dn=Abuterol+sulfate&mainSearchCriteria.v.ot=Albuterol+sulfate+inhalation+solution

+1.25+mg”/>

Example Content Return – Patient

NOMBRE GENÉRICO: Albuterol Print

¿PARA CUÁLES condiciones o enfermedades se prescribe este medicamento?

Albuterol se usa para prevenir y tratar síntomas como resoplo (silbido al respirar), respiración entrecortada y

contractura toráxica, provocados por enfermedades pulmonares como el asma y la enfermedad pulmonar obstructiva

crónica (COPD por su sigla en inglés; un grupo de enfermedades que afectan al pulmón y a las vías aéreas).

Pertenece a una clase de medicamentos llamados broncodilatadores. Funciona al relajar y abrir los bronquios,

permitiendo el paso normal de aire a los pulmones, facilitando la respiración.

¿CÓMO se debe usar este medicamento?

Albuterol viene envasado en forma de tabletas, como jarabe, y como tabletas de liberación lenta (acción prolongada)

para tomar por vía oral. Por lo general las tabletas y el jarabe se toman 3 ó 4 veces al día. Las tabletas de liberación

lenta por lo general se toman 1 vez cada 12 horas. Tome este medicamento alrededor de las mismas horas todos los

días. Siga cuidadosamente las instrucciones en la etiqueta del medicamento y pregúntele a su doctor o farmacéutico

cualquier cosa que no entienda. Use el medicamento exactamente como se indica. No use más ni menos que la

dosis indicada ni tampoco más seguido que lo prescrito por su doctor. Tome las tabletas de liberación lenta enteras,

con un vaso de agua o de otro líquido. No las parta, mastique ni aplaste. Su doctor podría comenzar con una dosis

baja del medicamento y aumentarla de manera gradual. Albuterol puede ayudar a controlar los síntomas pero no

cura su condición. Continúe usando este medicamento aunque se sienta bien. No deje de tomar albuterol sin antes

conversar con su doctor. Llame a su doctor si sus síntomas empeoran o si siente que el albuterol ya no los controla.

Example Content Return – Pharmacist

Albuterol (Systemic, Oral Inhalation)

Class: 12:12.08.12 Selective beta-2-Adrenergic Agonists

AccuNeb®, Combivent®, DuoNeb®, ProAir® HFA, Proventil®, Proventil® HFA, Ventolin® HFA, VoSpire® ER,

Introduction

Bronchodilator; relatively selective, short-acting β2-adrenergic agonist.(j)

Uses

Bronchospasm in Asthma

Symptomatic management or prevention of bronchospasm in patients with reversible, obstructive airway disease

(e.g., asthma).(132)(139)(154)(181)(241)(249)(255)(282)

Exercise-induced Bronchospasm

Prevention of exercise-induced bronchospasm.(132)(181)(249)

Chronic Obstructive Pulmonary Disease

Albuterol sulfate in fixed combination with ipratropium bromide: Symptomatic management of reversible

bronchospasm associated with COPD in patients who continue to have evidence of bronchospasm despite regular

use of an orally inhaled bronchodilator and who require a second bronchodilator.(233)(250)(251)(252)

Albuterol sulfate: Symptomatic management of reversible bronchospasm associated with COPD† when given on an

as-needed or regular (e.g., 4 times daily) basis, either alone or concomitantly with other inhaled

bronchodilators.(181)(206)(251)(266)(267)(268)(269) Regular use of a selective, short-acting inhaled β2-adrenergic

agonist (e.g., albuterol) in the management of COPD, in contrast to that in asthma, does not appear to be

detrimental.(206)(247)(250)(251)

Example Content Return – Physician

ALBUTEROL

Adult Dosing

Acute Bronchospasm

0.5 mL of 0.5% solution (2.5 mg) nebulized q6hr

Inhaler: 2 puffs q4-6hr

Tabs 2-4 mg PO TID/QID

Severe bronchospasm

0.5 mL of 0.5% soln (2.5 mg) nebulized q20min or continuous x1 hr

Exercise-induced Bronchospasm: 180 mcg (2 puffs) inhaled 15-30 min before exercise; up to 12 puffs/24hr

Administration

Inhaler should be shaken well & test-sprayed into the air before initial use or if it has not been used for a prolonged time

Place inhaler well into the mouth, lips firmly closed around it

Extended release tablets should not be chewed, crushed or mixed with food

See also combo with ipratropium (Combivent/DuoNeb)

Pediatric Dosing

Inhaler

>4 yo: as adult

Nebulizer

2-12 yo, >15 kg: 0.63-2.5 mg TID/QID

Adjust flow rate of albuterol delivery over period of 5-15 min

Tabs

• Use observation studies and clinical context

information to guide use of Infobuttons

• Usage logs showing use of context-specific

information resources

• What is hypothetically useful vs. what is

empirically useful?

Cimino, JJ. The Contribution of Observational Studies and Clinical Context Information for Guiding the Integration of Infobuttons into

Clinical Information Systems. AMIA Annual Symposium Proceedings. 2009 Nov 14;2009:109-13.

- Problem List

- Medication List

- Medication Allergy List

- Demographics

- Lab Tests and Values/Results

- Vital signs

Provide patients with

information to manage

and maintain their own

health

- Problem List

- Medication List

- Lab Results

What to look for when choosing a content

provider

• Standardized terminology - improves retrieval results of

Infobutton content

• Both clinician and patient information

• Evidence-based medicine; unbiased drug data

• Strategic partnership

Hypertensive Emergency

Pathophysiology

1. Mechanism

• Systolic blood pressure (SBP) ≥

180 mmHg and/or diastolic blood

pressure (DBP) ≥ 120 mmHg

• Usually asymptomatic, but

some may experience

headaches or anxiety

• Hypertensive urgency indicates

that BP is high enough to cause

serious risk of sudden, life-

threatening events but not

currently occurring

• Could quickly develop

them if blood pressure not

quickly brought under

control

2. Etiology/Risk Factors

• 90% risk of developing HTN in

(even if normotensive at 55 yo)

• Two types based on cause

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