Exploring Opportunities for Librarians in Healthcare Information Technology

Philadelphia Regional ChapterMedical Library Association, Annual Meeting

April 18, 2013

Dean Karavite, MSICenter for Biomedical Informatics (CBMi)

Children’s Hospital of Philadelphia (CHOP)

Center for Biomedical Informatics (CBMi)

Applying information technology to healthcare research

30-40 staff Clinicians, researchers, analysts,

statisticians, developers, study coordinators, education specialists and more

Human Computer Interaction (HCI)

Multi disciplinary field Human factors, information science,

experimental psychology, cognitive psychology, computer science, industrial design, anthropology and more

Research and methods applied to the design of information technology

Usability “The capacity of a system to allow users to

carry out their tasks safely, effectively, efficiently and enjoyably”

Study people and information and develop systems that support working with information in new ways

Connection Between HCI and Medical/Health Science Librarians?

University of Michigan, School of Information Evolved from SILS in 1996

Expanded curriculum to apply LIS methods and research to IT

LIS, Archives, HCI and more Recently developed new health

informatics program Jane Blumenthal – key role in

Michigan program Prudence Dalrymple - Drexel

iSchool has a similar program

NLM Helped Create My Job

NLM Challenge Grant Create EMR based clinical decision

support (CDS) for complex patients

Premature infants during first two years of life Multiple preventative health issues

Growth Nutrition Development Blood pressure screening Retinopathy of prematurity (ROP) Respiratory syncytial virus (RSV)

Fifth Presentation to Librarians

Participated in workshops put together by P.J. Grier “Peeling the Onion, Informatics

for Librarians”

Librarians Can’t “Get a Seat at the HIT Table” Why don’t those working with

HIT understand how health science librarians can contribute?

Meaningful Use

http://www.healthit.gov/policy-researchers-implementers/meaningful-use

The EMR Build

The build process is the configuration of the EMR One of the most complex IT projects imaginable Can take years, hundreds of IT staff and hundreds of millions of dollars

EMRs are built on database hierarchies representing every single component of a healthcare organization Buildings, floors, units, rooms, beds… Equipment, instruments, supplies… Meds, labs, procedures… Clinicians, doctors, nurse practitioners, nurses, techs…

EMR Build Example in the OR

Vendor, IT and OR staff working to design the OR status board Somewhat analogous to the flight

status screen at an airport, but with more information on each OR

Nobody thought to review existing literature on the design and assessment of these systems

EMR is Full of Search/Retrieval Tasks

Lists, lists and more lists Almost every task requires a search activity

Medications, diagnosis, procedures, instruments, supply items… endless

Poor EMR search design and/or poor EMR build = difficulty in search and retriveal Poor data quality

Assessing the patient1. Chief complaint2. Problem list3. Medications4. Immunizations5. Encounter history6. Surgical history7. Specialists visits/notes

Managing the visit1. EMR documentation template2. Immunizations to order3. Medications to order4. Procedures to order5. Patient education materials6. Referral to order7. Diagnostic code8. Follow up code

15 Search Tasks in 15 Minutes: Pediatric well visit + ear infection*

* After well visit and upper respiratory infection, ear infections are the most frequent reason for a pediatric visit

Preemie Assistant

Epiphany?

The reason people working in HIT don’t understand how health science librarians can help them is... Because they aren’t ready for you They are overwhelmed with building the EMR

So, what about when they are done?

EMR Optimization

EMR implementation is only the first step Many issues cannot be addressed in the build process Many issues aren't foreseen until the system goes live Vendors are constantly releasing upgrades with new features Meeting meaningful use criteria

“Optimization” is reconfiguring (rebuilding?) the EMR to meet objectives for clinicians, patients, outcomes, safety, errors… Optimization is endless

Optimization Example: Growth Charts for Preemies

EMR does not select/display correct charts for premature infants Even though it has the data to do so

Typical EMR optimization Make the EMR select/display the

correct charts Advanced EMR optimization

Augment the correct charts with additional information and integrate growth with nutrition, patient education and clinical documentation

Cataloged Growth Chart Collection

Preemie Assistant: Growth/Nutrition

Growth Chart Results

Data, Information, Knowledge Paradigm

DATA

Gestational Age = 29 weeksChronological Age = 5 monthsICD9 = 770.7

INFORMATION

This is a premature infant with chronic lung disease

KNOWLEDGE

According to the American Academy of Pediatrics policy statement, premature infants with CLD are at risk for RSV and should receive Palivizumab

Evidence Based MedicineGuideline Translation Process: Overview

GuideLines Into DEcision Support (GLIDES), Yale School of Medicine, AHRQ FundedProcess and tools toward translating clinical guidelines into EMR based decision support

Connecting the EMR to Knowledge Resources

“Info Button” HL7 International Context-Aware

Information Retrieval standard Search integrated with the EMR

Originally developed at Columbia over a decade ago

Search Code/Parameters

http://msnappdw001:8123/ebm.aspx?&age.v.u=mo&age.v.v=8&assignedAuthorizedPerson.id.root=AMBATTENDING&encounter.c.c=AMB&mainSearchCriteria.v.c=486&mainSearchCriteria.v.cs=2.16.840.1.113883.6.103&mainSearchCriteria.v.dn=Pneumonia&mainSearchCriteria.v.ot=Pneumonia&patientPerson.administrativeGenderCode.c=F&patientPerson.administrativeGenderCode.dn=Female&performer=PROV&taskContext.c.c=DIAGLISTE

Embedded in all that is the following information :“I am a primary care pediatrician seeing a female patient of 8 years old in the outpatient setting and I’m looking at the diagnosis list”Or“I am a nurse in a pediatric hospital emergency department seeing a 2 year old male.”

Up to Date

VisualDX

CHOP Labs

CHOP Intranet

AHRQ Guideline Clearing House 1/2

AHRQ Guideline Clearing House 2/2

Pub Med

EMR as Online Library =Many Opportunities for Librarians

Search Analytics and Search Engine Optimization (SEO) Technique used by Information Architects (a field that evolved directly

from library science) to assess and improve the effectiveness of web based search for corporate intranets and commercial websites

EMR with Info-button opportunities for EMR search analytics+ Evaluate systems to purchase/include Key role in implementing these systems Continual monitoring and optimization

Our CMIO get’s it – developing business case for hiring a librarian to manage this and similar work

Design / Education Surprise with Otitis Media (Ear Infections)

Added EMR educational materials for residents and medical students

Physicians used these materials, but not with their students, they used them with patients (parents) “Here is what an infected ear drum

looks like” “Here is why your child does NOT need

an antibiotic today”

Graphic presentationof clinical pathways

Instructionalimages

Education for Premature Infants

Physician comments from usability test:“Oh this is nice. ““This is awesome.”“Who the hell knew we even had all this?” “I have never given out one of these.”“In 15 minutes there isn’t time to cover everything. Patient education is the most important thing we do.”

Patient Portals and Shared Decision Making

Personal Health Record, Personal Medical Record, Patient Portal... EMR based systems that connect patient to hospital/physician

Very basic yet useful Prescriptions, lab results, messaging, scheduling,

immunization records... Can be integrated with education systems, but

yet another EMR “build” No excuses this time - librarians are a must

Expand portal capabilities to support shared decision making Asthma: Connecting parents and clinicians + education ADHD: Add teachers, psychologists and others to the mix

3 Organizations Partnering to Study PHRs for People With Disabilities

Department of Education, National Institute on Disability and Rehabilitation Research (NIDRR)

WGBH, National Center for Accessible Media (NCAM)

Pioneer of assistive media technology

Inglis Foundation 135 years managing the care of people with

disabilities

Center for Biomedical Informatics, The Children’s Hospital of Philadelphia

Enhancing decision support capabilities of EMR and PHR in a research setting

Potential Opportunities Left on the Cutting Room Floor

Genomics and full exome sequencing Identifying actionable results by mapping results continually evolving research Mapping actionable results to guidelines, pathways, CDS tools, education for

clinicians, patients and families Taxonomies, Codes and Concepts

ICD9/ICD10, CPT, Snomed-CT, LOINC, RxNorm... Hospital Reporting

Information analysis and display for clinical and administration Hospitals as education environments

Education content for clinicians Hospital staff – basic hospital training and professional development Organizing EMR training content

Ideas on “Getting a Seat at the HIT Table”

Find allies/champions Like our CMIO, someone who “get’s it” Clinicians, research, nursing education, patient education, genetics... IT?

Demonstrate: Show people what a librarian can do (and nobody else can) Do a lit search addressing some issue or challenge with the EMR Study Meaningful Use and identify a criteria you can help address If you can’t directly work on some issue, develop a proof of concept, create a mockup, storyboard,

prototype or write a report, analysis of some solution/approach Evaluate some knowledge system before/after purchase

Write a grant proposal and/or seek others to write one with you Publish an article in an informatics journal, blog, your website...

EMR/PHR training and experience If they won’t pay for it, see if you can sit in on classes, access online courses… Examine your own PHR or sign up for Microsoft Health Vault, Patients Like Me... Download health apps and experiment with them

Questions / Comments?

karavite@email.chop.edu

CBMi Informatics Symposium http://www.research.chop.edu/programs/cbmi/

Or Google “CBMi CHOP” Friday, April 26, Sheraton

$200

Monthly (or so) informatics talks at CHOP We can put you on the mailing list