Monthly Archives: November 2013

Panel 3 Informationist and Rounding Services by Libraries

Librarian/informationist rounding was pioneered in the 1970s by Gertrude Lamb.  She would go on rounds, go back to library, conduct searches, and then connect articles to patient charts (LATCh – Literature Attached to Chart service).  R01 grants by NIH provides grants for Administrative Supplements for Informationist Services in NIH-Funded Research Projects.

Blair Anton, MS, MLIS – Johns Hopkins University

  • challenge: are they asking a reason due to clinical-problem that might lead to research or is a research question with clinical implications?
  • Setting: general internal medicine, held monthly, not at patient bedside,
  • residents come up with question about patient they have seen and share question with librarian team –>later debrief comparing/contrasting evidence found by resident vs librarian
  • particular emphasis on study design during discussion
  • Impact of GIM EBM rounds
    • information literacy
    • resource selection
    • efficient use of databases
    • precision searching: high quality, highly relevant information
    • *not only our students are searching for Practice Guidelines by entering guidelines into a search bar
  • WICU Pilot study
    • observational study to record clinical questions and what happens to them
    • ~38% were not answered
    • questions persisted and morphed over the course of the shift
  • Informationist participation impacting clinical practice
    • JHU Hospital Ethics Committee
    • Education Planning Curriculum Committee
    • Nursing Standards of Care Committee
    • Pediatric Staff Development Committee (allied health – social work, speech path, etc)
    • Emergency Medicine EBM Conference
  • Value indicators
    • increased grant proposal submissions
    • increased publication rates and authorship (journal articles, book chapter and updates, guideline development and updates, comprehensive reviews, systematic reviews)
    • 41% of time spent on comp and systematic reviews, writing methods sections, and more

Jonathan Hartmann, MLS – Georgetown University Medical Center

  • starting to use text mining to help with info retrieval
  • using diagnostic tools to help (DXplain, Isabel)
  • rounds are in internal medicine and PICU
  • carry iPad mini now – previously was done with mobile phone
  • NN/LM SEA Express Hospital awards to market the service
  • librarian vs infobuttons: librarian offers greater ability to respond, refine, and re-search

Terrie Wheeler, AMLS – National Institutes of Health

  • NIH Library Informationist program
  • 2011 JAMA article recognizes the contributions of these programs to medicine
  • Activities:
    • Instruction
    • Search/synthesize
    • Participate in clinical rounds (using iPads)
    • Write and edit manuscripts
  • Examples
    • Alicia Livinski, MPH, MA – Expertise: Social Media, Public Health
    • HHS Committee investigating allocation of medical resources after nuclear detonation
    • Info Intervention: literature search and analysis; working editor-in-chief of special journal supplement on topic
    • Impact: first article on this topic
    • Nancy Terry, MLS – Expertise: Public Health
    • NICHD and HHS Office of Disease Prevention and Health Promotion
    • Info Intervention: ID nutrition studies on children for birth-24 months; answering research questions for the Dietary Guidelines for Americans, 2015
    • Impact: 2015 Dietary Guidelines form the basis for federal public health food and nutrition programs – but how much money does this save? how does this impact patient health?
  • Clinical Search: Clinical Information System has links to NIHL bedside tool

Lauren Yaeger, MA, MLIS – St. Louis Children’s Hospital/Washington University

  • Positioned in the hospital
  • Involved with Resident EBM Curriculum/Resident Journal Club
    • iPass created by residents and given to librarian PRIOR to interaction, so librarian knows the context, abbreviations, etc ahead of time
  • Non-clinical rounds (ex: cleft palate and craniofacials rounds) – aim on interdisciplinary care
  • Worked on integrating library resources into EHR
    • Unless someone is standing there with the care provider and showing them how to use it, care providers won’t use EHR-linked resources

Questions

  • How is this role effective when you are a generalist and when you are a subject matter expert?
    • Subject expertise is important to service users, according to NIH project
    • General skill most needed is finding information quickly, but the subject background helps users not have to explain things quite as thoroughly, according to JHU
    • Rounding with residents tends to have questions and conversations at a more accessible level, but knowing the acronyms or nuances are helpful with searching and reviewing results, Georgetown
    • Teaching hospitals are also good environments, since the culture is teaching and introducing people
  • These services are all for the clinicians, not the patients

Panel 2 InfoButtons and Meaningful Use

Infobuttons and Meaningful Use
Guilherme Del Fiol, MD, PhD University of Utah, Moderator and presenter

  • Glycemic Management in a Patient with Type 2 Diabetes — NEJM NEJM 2013; 369:1370-1372 – case vignette
  • Clinician Info Needs
    • 20 patients a day
    • 12 info needs
    • 6 pursued
    • 4 meet
    • 4 = treatment alternatives
  • Reasons why info needs are not met
    • no time
    • doubt answers exist
    • not urgent
    • referred to specialist
    • deferred and forgotten
  • Positive impact on info seeking
  • 2-3 minutes max time spent searching
  • Implications
    • 60% of info needs not met
    • not getting better: less time, complex patients and knowledge
    • missed opportunity for improved care and lifelong learning
  • Informatics opportunities
    • efficient tools (30s-1m timeframe)
    • decision under complexity
    • EHR to become a learning environment, not just a documentation burden
    • integrate with maintenance of certification/CE
  • 1995 – release date for Columbia; 2002- Intermountain
  • Impact of Infobuttons
    • answers to 85% of questions
    • decision enhancement or learning in 62% of sessions
    • median session time: 35s
    • User satisfaction (69% to 92%)
    • Slow but growing usage (Partners Healthcare ~100k sessions/month
  • EHRs
  • Implementations
  • References

Nathan Hulse, PhD – Intermountain Healthcare

  • URL-based
  • primary effort on ‘developer’s side’ is to populate the right data points
  • content provided as metadata or presentation layer
  • launching PHR infobutton – this arena raises new questions regarding greater contextual question, reading level
  • Supported infobutton resources
      • local content
      • genetic home reference
      • gene review
      • Cochrane
      • MerckIndex
  • Resource selection considerations
    • clinical
    • usage patterns
      • how many hits
      • where are they originating from
      • cost per click
      • unique users
    • overall cost
    • perceived value
    • CME credit integration
    • Overlaps in content coverage
  • Achieving meaningful use
    • integrating infobuttons in multiple, overlapping systems
    • ‘documenting’ that education materials were given
    • new coverage in areas like imaging, allergies, and other domains

Consumer Health Information and InfoButtons
Leslie Kelly Hall, Healthwise

  • infobutton more contextually relevant as it is in workflow
  • provides conversation shift from where to find things to relevancy review of articles

Stratton Lloyd, BA – EBSCO Information Services

  • new model for aggregating content
    • actionable content, contextual searching, integrating into tools
    • Point of Care tools
      • PEMSoft
      • Nursing Reference Center
      • Social Work Reference Center
  • Content access via EMR/EHR
  • 2 key content sets: patient education  vs clinical reference content
  • patient ed requires significant effort in EMR system, but clinical reference does not

Overall, infobuttons are just getting on the roadmap for EHRs

Panel 1 The Role of Standard Vocabularies in Meaningful Use

The Role of Standard Vocabularies in Meaningful Use: LOINC
Clement J. McDonald, MD, FACMI
Director, NLM Lister Hill National Center for Biomedical Communications (LHNCBC)

  • average patients have 4 visits per year – 1/2 to primary care and 1/2 to specialists
  • LOINC – one of 3 NLM systems required in meaningful use (others are RxNorm and SNOMED)
    • has 6 major parts and can include up to 13 different parts
    • variables have synonyms, descriptions, links to references, data types, cardinality, and more
  • used in 157 countries, incl. national standard for 10 countries (Australia, Canada, France, Germany) and translated into 16 languages
  • has 2k most common items listed
  • web browser search/nav option
  • hospital labs must report individual lab tests and some clinical measurements with LOINC codes.  For example,
    • tests reported to public health
    • cancer tumor registry

SNOMED CT and Meaningful Use
James Case, DVM, PhD, FACMI – NLM – SNOMED

  • ID structure composed of extension item ID, namespace ID, partition ID, and check digit
  • 890k relationships
  • 777k descriptions
  • 297k concepts
  • IHTSDO – manages SNOMED and change request submissions

RxNorm and Meaningful Use
Patrick McLaughlin, MLIS – NLM

  • grew out of UMLS
  • followed HL7 drug model – based upon clinician prescribing rather than pharmacy ordering/fulfillment
  • two important driving factors: 1) improved interoperability 2) patient safety concerns
  • collection of commonly-used public and private drug vocabs (ex: Micromedex, Multum, Gold Standard, MeSH, SNOMED, VA National Drug File, FDA Structure Product Labels aka DailyMed, Anatomical Therapeutic Chemical Classification System, Medi-Span, First DataBank)
  • finding names is easy, but finding strengths is challenging
  • RXCUI (RxNorm concept unique identifier) – for what would be prescribed to the patient
  • How RxNorm is Structured
    • SCD – generic drug (~20k)
    • SBD – branded drugs (~10.5k)
    • GPCK – generic pack (multiple drugs in same pack) 333
    • BPCK – branded pack 410
  • medication standard for Stage 2 of meaningful use
    • medication reconciliation across multiple settings or care providers
    • MedlinePlus Connect – links EHR/PHR to MedlinePlus consumer health information via RXCUI match-up –> meets patient-specific information
  • need to register with UMLS for license but the license is free

Achieving Meaningful Use: Using Standards to Bring Medical Information to Practitioners and Patients

Marc Overhage, MD, PhD, FACMI
Chief Medical Informatics Officer, Siemens Healthcare
Member, Meaningful Use workgroup, U.S. Health IT Policy Committee

  • When you have a pumpkin, it’s not just about having it but using it meaningfully, such as for pumpkin pie
  • Stage 2 anticipated for being pushed back an additional year
  • Meaningful use as an escalator system towards EHRs use
  • 2011-2014 – carrot (financial subsidy); 2015+ – stick (financial penalty, such as for readmissions within 30 days, etc)
  • Nobody’s figured out how providers benefit from EHRs yet, but meaningful use subsidies can cover up to 2/3 cost of EHR implementation for ambulatory settings
  • Improving Quality of Care and Safety mechanisms
    • Stage 1+2
      • Structured data
      • CPOE
      • CDS
      • Progress notes
      • Safety (drug-allergy checks, medication reconciliation)
      • Population management
    • Stage 3
      • CDS
      • Order tracking
      • real-time dynamic dashboards
      • medication adherence
      • patient safety
  • Eligible providers (outpatient) (n=527k)
    • 9% doing nothing
    • 8% signed up with Regional center to help
    • 21% signed up on federal website (yes, this one worked)
    • 15% registered and intend to get EHR
    • 47% have EHR
  • 3-5% of providers last year said they were out due to shifting groups, restructuring/remodeling practice, or just being totally done with EHRs
  • Hospitals
    • 5% not there
    • 2% signed up with Regional center to help
    • 7% signed up on federal website (yes, this one worked)
    • 13% registered and intend to get EHR
    • 73% have EHR
  • medical group ownership has shifted from 69% physician owned in 2005 to 39% in 2010; 26% hospital owned in 2005 has increased to 58% in 2010 – trend due to reimbursement rate primarily, but consolidated EHR systems benefit from the shift; going out-of-business by some EHRs will lead to greater movement of physicians to larger health systems and then impacts pricing negotiations for services
  • CMS now driving EHR adoption, less so than ONCHIT
  • trends in 90 day performance – there’s no major change
  • transitions of care and reportable lab results were least popular feature at hospitals
  • Herfindalh-Hirschman Index Change by HRR 2006-10 – documents evolution of HIT market (doi:10.1136/amiajnl-2011-000769).  Part of the impetus of the HITECH Act was to increase the market, resolve failure to by
  • only 76 EHRs are certified for Stage 2
    • this has led to some physicians who had invested in a system, but gets kicked out, has to start over, or even lose data because of other systems falling out of the market
  • adoption is a massive challenge – Siemens can make the bells and whistles you want, but most adopters are getting systems with all features turned off to complete slow roll out due to training burden
  • interoperability schmoperability
    • certification has helped
    • teaching to the test (bare minimum) but not getting folks to move beyond the most basic expectations
    • while they can create the patient file via HL7, there is no secure method for transmission to other provider(s)
  • Quality measure madness
    • about 10% of measures are designed to support e-initiatives
    • CMS checklist
  • Documentation burden
    • 690k physicians hours per year = cost of EHR adoption (approx. 1 hour per day added)
    • challenge to put data into structured format
    • $19bn of tax payer investment pales to provider costs
  • Patient Engagement or Just Friends
    • more HIPAA violations through this initiative than entire past history of Siemens (patients leaving it behind, throwing it away in regular trashcans, etc)
    • patients like just booking appts online, getting lab results online
    • haven’t found the secret sauce to get patients more engaged
  • 2/3 of things in the meaningful use list aren’t things people want
  • HITECH Act’s HIT education has had little to no effect on improving the foundation of a workforce to help with implementation
  • Stage 3 is being defined now