Integration of Health Information Resources into Electronic Health

Records Using HL7

Guilherme Del Fiol, MD, MSBiomedical Informatics Department, University of Utah

Intermountain Healthcare, Salt Lake City, UT

James J. Cimino, MD Department of Biomedical Informatics, Columbia

University, New York, NY 

Saverio Maviglia, MD, MScPartners Healthcare System, Boston, MA

Outline

• Background• HL7 infobutton standard• Demonstration participants

– Infobutton Managers– Information resource providers

• Live demonstration

Infobuttons

Background

?MRSA

Information for Decision-Making

Addressing Information Needs with Infobuttons

• Clinical information systems evoke information needs

• Clinician’s computer has access to resources

• Context can be used to predict need• Context can be used to automate

retrieval

Context-Dependent Information Needs

Age Sex TrainingRole DataTask

Context

? !

Institution

Infobuttons vs. Infobutton Manager

Pageof

Hyperlinks

InfobuttonClinical System Resourc

e

InfobuttonManager

ContextQuery

KnowledgeBase

s

Overview

Infobutton standard

Why do we need a standard?

• There is not a common integration language– Parameter names– Terminologies used for content

search retrieval

• Hundreds of resources available– Not designed for infobutton

integration: suboptimal results– Labor intensive integration: just a few

are actually used

http://resource1.com/search = “azithromycin AND dose”

What is the dose of azithromycin ?i

Multiple ways of “asking” the same question

http://resource3.com/

searchConcept = 3333 ^ azithromycin

filter = 11 ^ dosage

http://resource2.com/

query = "azithromycin"[MeSH Terms] AND dose[All Fields]

Resource 3

Resource 1

Resource 2InfobuttonManager

API

API

API

API

No standard in place

Clinical Information

System i

http://resource1.com/search.cgi? search = “azithromycin AND dose”

http://www.resource3.com/search.cgi? searchConcept = 3333 ^ azithromycin filter = 11 ^ dosage

http://resource2.com/

query = "azithromycin"[MeSH Terms] AND dose[All Fields]

ElectronicHealthRecord i

Resource 3

Resource 1

Resource 2

HL7

HL7

HL7

HL7

Standard-based integration

Intermountain

Columbia

Partners

HL7

HL7

HL7

Key points

• XML and URL-based syntax• Recommends adoption of a set of

standard terminologies (e.g., RxNorm, LOINC, SNOMED-CT, MeSH)– Aligned with national initiatives

• Flexible requirements to allow faster adoption

Example

• The user is looking at a problem list of a female, 94 years-old patient with Heart Failure. The user clicks on an infobutton that presents a series of questions. The user selects “How do I treat Heart Failure?”

<informationRecipient><patient> <language code=“eng"/><patient>

<informationRecipient>

<gender code=“F" displayName=“Female"/>

<age value=“94" unit=“a"/>

<taskContext code=“PROBLISTREV"/>

<mainSearchCriteria code="428“ codeSystem="2.16.840.1.113883.6.103"

displayName=“Heart Failure"/><subTopic code="Q000628"codeSystem="2.16.840.1.113883.6.177" displayName="therapy"/>

<mainSearchCriteria code="428“ codeSystem="2.16.840.1.113883.6.103"

displayName=“Heart Failure"/>

<patientContext> <gender code=“F" displayName=“Female"/> <age value=“94" unit=“a"/> <taskContext code=“PROBLISTREV"/>

<mainSearchCriteria code="428" codeSystem="2.16.840.1.113883.6.103" displayName=“Heart Failure"/><subTopic code="Q000628" codeSystem="2.16.840.1.113883.6.177" displayName="therapy"/>

URL-based message

• Simpler implementation– Support industry backwards

compatibility– Faster adoption

• Rules for automated conversion– URL can be automatically derived

from XML model

taskContext.c.c=LABRREV

mainSearchCriteria.c.c=2823-3mainSearchCriteria.c.cs=2.16.840.1.113883.6.1mainSearchCriteria.c.dn=Serum potassiummainSearchCriteria.c.ot=K

interpretationCode.c.c=L

administrativeGenderCode.c=F

age.v=56age.u=a

http://www.e-resource.com/api?patientPerson.administrativeGenderCode.c=Fage.v=56&age.u=a

taskContext.c=LABRREV

mainSearchCriteria.c=2823-3mainSearchCriteria.cs=2.16.840.1.113883.6.1mainSearchCriteria.dn=Serum potassiummainSearchCriteria.c.ot=K

Demonstration

Participants

Content providers

• ACP PIER• Clin-eguide (Wolters Kluwer Health)• Dynamed (Ebsco)• Lexicomp• Micromedex (Thomson Healthcare)• UpToDate

Infobutton Managers

• Intermountain Healthcare– First production version in 2001– Infobutton Manager since 2005– Medication order entry, problem list,

lab results– 1,000+ users per month– Knowledge base: resources and

questions configured in XML files

Infobutton Managers

• Columbia University– Concept of interest translated into

controlled terminology– Related concepts identified– Topics/questions matched to concept

classes and other context parameters– XML table of topics (along with

javascript) returned to the user– Links are initiated from user’s browser

Infobutton Managers• Columbia University – usage

– Infobuttons available since 1996– Infobutton manager version 1 2002– Available in:

• WebCIS: lab results, micro results, sensitivity results, inpatient drugs, outpatient drugs, problem list

• Eclipsys: lab orders, drug orders, nursing orders• Regenstrief Medical Records System: drug orders• NY State Psych Institute: drug orders• NextGen: lab results

– 700+ users per month– 2100+ uses per month

Infobutton Managers

• Columbia University – benefits– Easy to use: 92%– Question on list >50% of time: 89%– Answered question: 69%– Useful: 77%– Helpful >50% of time: 90%– Positive effect on care: 74%

Infobutton Managers

• Partners Healthcare– Live since 2002– Medication order entry, problem list,

lab results (8 clinical apps)– Federated search engine for 2 library portals– 50K sessions by 5K unique users per month

• 60% RN, 15% MD, 11% PharmD• 1-50% of patient encounters• 90% medication queries• Median session duration under 15 seconds!• 85-90% success rate

– Resources and context triggers configured in SQL/Access – no terminology or lexical analysis

http://www.hl7.org/v3ballot/html/welcome/environment/index.htm