Context-Aware Knowledge Delivery into Electronic Health Records (Utah)

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Summary:

A main cause of errors in the health care system is gaps in information available to providers, particularly at the point of care. When providers have access to the best and most up-to-date information at the time when that knowledge is needed, they can give patients optimal care. Such information is also essential to clinicians presenting care options and enables patients and providers to make better decisions.

This project identified clinicians’ information needs and designed, developed, implemented, and evaluated a knowledge-delivery prototype to help clinicians meet those needs.

The specific aims of this project were to:

  • Build a knowledge base of providers’ knowledge needs.
  • Design and develop a scalable, standards-based knowledge-delivery service.
  • Conduct a pilot evaluation of a prototype knowledge-delivery tool that automatically summarizes contextually relevant information from multiple online resources.

The project team conducted a systematic literature review of MEDLINE, CINAHL, and Scopus on clinician’s information needs. The review was guided by four primary questions: how often do clinicians raise information needs; how often do clinicians pursue information needs they raise; how often do clinicians succeed at meeting the information needs that they pursue; and what types of questions are asked? The project team observed the care of complex older adults by audio-recording providers during all activities related to a patient visit, including preparing for a visit, interacting with the patient, and concluding the visit. Following the visits, clinicians were interviewed regarding information needs that had arisen. The literature review showed that out of 20 patients seen in a primary care practice, clinicians raise 12 information needs, pursue six, and successfully meet four of the needs. In the care of complex aging patients, clinicians raised two information needs per patient seen and 60 percent of these needs were not met.

This work led to the development of the HL7 Context-Aware Knowledge Retrieval Standard, also known as the Infobutton Standard, which enables the integration between online health knowledge resources and EHR systems. A cross-sectional study was conducted to evaluate the challenges, strengths, limitations, and uptake of this standard. In order to help disseminate Infobutton capabilities in health care organizations, the project team developed OpenInfobutton, a standards-based, open-source Web service. Finally the team developed and evaluated a prototype knowledge-delivery intervention that automatically summarizes contextually relevant information from multiple online resources.

The HL7 Infobutton Standard has been widely adopted and became a requirement for EHR certification in the Meaningful Use Program. OpenInfobutton has been deployed at several health care organizations, including Intermountain Healthcare, the Veterans Health Administration, the University of Utah, and Duke University.

Context-Aware Knowledge Delivery into Electronic Health Records - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-087: Mentored Research Scientist Research Career Development Award (K01)
  • Grant Number: 
    K01 HS 018352
  • Project Period: 
    September 2009 – July 2013
  • AHRQ Funding Amount: 
    $575,729
  • PDF Version: 
    (PDF, 214.81 KB)

Summary: A main cause of errors in the health care system is gaps in information available to providers. The provision of just-in-time access to relevant knowledge is essential for the implementation of new care models. Immediately available information helps patients and providers make better decisions. It helps providers explain patient care options and retrieve and manage the best, up-to-date knowledge available at the point of care.

Dr. Del Fiol is developing, implementing, and evaluating a prototype for a scalable and widely deployable knowledge delivery service (the “knowledge broker”) that is capable of automatically delivering context-specific information from online resources into electronic health record (EHR) systems via a “knowledge dashboard.”

A systematic literature review in combination with focus groups is documenting provider knowledge needs and informing the development of the knowledge dashboard. Once developed, the knowledge dashboard will be integrated into an EHR for use by providers.

Four core design requirements drive the development of the knowledge broker to guarantee its scalability and deployability: 1) the architecture must be open, independent, standards-based, and services-oriented; 2) the knowledge base will be expandable to accommodate additional knowledge needs in various contexts; 3) the knowledge broker will be able to deliver knowledge through mechanisms other than a knowledge dashboard, such as info buttons; and 4) the knowledge broker will be able to account for the needs of and deliver knowledge to providers and patients. This approach will help the dashboard be a potential national model for knowledge delivery at the point of need.

As part of this Mentored Research Grant, Dr. Del Fiol is investigating why, how, and when users interact with the knowledge dashboard, as well as the effect of these interactions on the fulfillment of knowledge needs and decisionmaking. Finally, he will identify areas and opportunities for system enhancement and expansion. An exploratory data analysis will determine the feasibility and planning of a future large-scale quantitative investigation.

Specific Aims:

  • Build a knowledge base of patients’ and providers’ knowledge needs. (Ongoing)
  • Design, develop, and evaluate the usability of a scalable, widely deployable knowledge delivery service in a laboratory setting. (Ongoing)
  • Conduct a mixed-method assessment of a pilot implementation of the knowledge broker in a real-world medical home environment. (Upcoming)

2012 Activities: The data abstraction was finalized for three of the study questions. The systematic review was completed and Dr. Del Fiol began writing the final results. The clinician observations study has been completed at all three sites. The analysis has been completed and Dr. Del Fiol is preparing a manuscript of the publication.

The first pilot project, which focused on depression and Alzheimer’s treatment, has been completed. The pilot indicated that the information needs could be narrowed to publications that include comparative effectiveness studies only. The second pilot, which focused on automatic summarization of comparative effectiveness studies, was also completed. The focus of the second pilot is to automatically summarize study results from PubMed citations of comparative effectiveness studies on specific topics with a focus on depression. Analysis of the results of the system against widely accepted standards was begun.

The HL7 Infobutton Standard has been included as a required criterion in the proposed Centers for Medicare & Medicaid Services Meaningful Use Stage 2 Standards Certification Criteria. Dr. Del Fiol was the lead author of this standard and has been developing and promoting its dissemination since 2003.

Preliminary Impact and Findings: The findings of the systematic review indicate that clinicians decide not to pursue more than 60 percent of their information needs. The clinician observations show that information need is four times greater than the literature has previously reported, which is primarily on non-specific populations. With increasing complexity of health issues, clinicians did not look for additional information if they were time constrained. It appears that clinicians under time pressure avoid complexity by focusing not on overall health issues, but on individual-specific issues, thus prioritizing their information needs.

The systematic review of literature is showing significant recall bias among physicians on information not related to specific patient encounters. This recall bias results in a general underestimation of the number of questions that they have about patient care. Real-time observation is the most accurate way to understand information needs further. As a result, the project will take that approach.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Context-Aware Knowledge Delivery into Electronic Health Records - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-087: Mentored Research Scientist Research Career Development Award (K01)
  • Grant Number: 
    K01 HS 018352
  • Project Period: 
    September 2009 - July 2013
  • AHRQ Funding Amount: 
    $575,729
  • PDF Version: 
    (PDF, 176.43 KB)

Summary: A main cause of errors in the health care system is gaps in information available to providers. The provision of just-in-time access to relevant knowledge is essential for the implementation of new care models. Immediately-available information helps patients and providers make better decisions. It helps providers explain patient care options and retrieve and manage the best, up-to-date knowledge available at the point of care.

This research project is developing, implementing, and evaluating a prototype for a scalable and widely deployable knowledge delivery service (the "knowledge broker") that is capable of automatically delivering context-specific information from online resources into electronic health record (EHR) systems via a "knowledge dashboard."

A systematic literature review in combination with focus groups is documenting provider knowledge needs and informing the development of the knowledge dashboard. Once developed, the knowledge dashboard will be integrated into an EHR for use by providers.

Four core design requirements drive the development of the knowledge broker to guarantee its scalability and deployability: 1) the architecture must be open, independent, standards-based, and services-oriented; 2) the knowledge base will be expandable to accommodate additional knowledge needs in various contexts; 3) the knowledge broker will be able to deliver knowledge through mechanisms other than a knowledge dashboard, such as info buttons; and 4) the knowledge broker will be able to account for the needs of and deliver knowledge to providers and patients. This approach will help the dashboard be a potential national model for knowledge delivery at the point of need.

This project will investigate why, how, and when users interact with the knowledge dashboard, as well as the effect of these interactions on the fulfillment of knowledge needs and decisionmaking. Finally, the study will identify areas and opportunities for system enhancement and expansion. An exploratory data analysis will determine the feasibility and planning of a future large-scale quantitative investigation.

Specific Aims:

  • Build a knowledge base of patients' and providers' knowledge needs. (Ongoing)
  • Design, develop, and evaluate the usability of a scalable, widely deployable knowledge delivery service in a laboratory setting. (Ongoing)
  • Conduct a mixed-method assessment of a pilot implementation of the knowledge broker in a real-world medical home environment. (Upcoming)

2011 Activities: Dr. Del Fiol worked on the systematic review, completing the full-text data extraction and working on search strategies for other databases. A complete abstract screening of EMBASE, CINAHL, and PubMed citations yielded a total of 21,445 abstracts. Two reviewers conducted a full-text screening and data abstraction of 200 articles with excellent agreement between reviewers.

Dr. Del Fiol evaluated the info button standard related to implementation. There is a lack of such evaluation studies and few organizations have done work in this area before from which inferences can be drawn. A broad sample of 17 health care organizations, EHR vendors, and knowledge publishers were interviewed regarding the info button standard, which provided important insights for this aspect of the project.

Substantial progress was made on the development of the knowledge broker software, which was completed in February 2011. There is an open-source agreement signed between the three partners and their institutions. The software was deployed at the University of Utah and the Veteran's Administration successfully integrated it into their Web-based EHR.

A significant amount of time was dedicated to the development and submission of three grants, based partly on the results of this K01 project.

Preliminary Impact and Findings: The systematic review of literature is showing significant recall bias among physicians on information not related to specific patient encounters. This recall bias results in a general underestimation of the number of questions that they have about patient care. Real-time observation is the most accurate way to understand information needs further. As a result, this is the approach that the project will take.

Target Population: Adults

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Context-Aware Knowledge Delivery into Electronic Health Records - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS09-087: Mentored Research Scientist Research Career Development Award (K01)
  • Grant Number: 
    K01 HS 018352
  • Project Period: 
    September 2009 – July 2013
  • AHRQ Funding Amount: 
    $575,729
  • PDF Version: 
    (PDF, 946.71 KB)


Target Population: Adults

Summary: The Institute of Medicine (IOM) report, Crossing the Quality Chasm: A New Health System for the 21st Century, called for an overhaul of the U.S. health care system, declaring that new models of care should make health care more safe, effective, patient-centered, timely, efficient, and equitable. New models of care have been proposed that are in line with IOM’s aims, such as the American Academy of Pediatrics’ Medical Home and the Future of Family Medicine’s project New Model.

A main cause of errors in the health care system is gaps in the information available to providers. The provision of just-in-time access to relevant knowledge is essential for the implementation of new models of care. Immediately-available information helps patients and providers make better decisions. Information delivered immediately helps providers explain patient care options and retrieve and manage the best, up-to-date knowledge available at the point of care.

The goal of the proposed research is to develop, implement, and evaluate a prototype for a scalable and widely-deployable knowledge delivery service, (the “knowledge broker”), that is capable of automatically delivering context-specific information from online resources into electronic health record (EHR) systems via a “knowledge dashboard.” This will help providers address their knowledge gaps and will lead to better and more informed decisions.

A systematic literature review in combination with focus groups will document provider knowledge needs. This information will inform the development of the knowledge dashboard. Once developed, the knowledge dashboard will be integrated into an EHR for use by providers.

Four core design requirements will drive the development of the knowledge broker to guarantee its scalability and wide deployability: 1) the architecture will be open, independent, standards-based, and services-oriented; 2) the knowledge base will be expandable to accommodate additional knowledge needs in various contexts; 3) the knowledge broker will be able to deliver knowledge through mechanisms other than a knowledge dashboard, such as infobuttons; and 4) the knowledge broker will be able to account for the needs of and deliver knowledge to providers and patients. This will help the dashboard be a potential national model for knowledge delivery at the point of need.

This project will investigate why, how, and when users interact with the knowledge dashboard, as well as the effect of these interactions on the fulfillment of knowledge needs and decisionmaking. Finally, the study will identify areas and opportunities for system enhancement and expansion. An exploratory data analysis will determine the feasibility and planning of a future large-scale quantitative investigation.

Specific Aims:
  • Build a knowledge base of patients’ and providers’ knowledge needs. (Ongoing)
  • Design, develop, and evaluate the usability of a scalable, widely deployable knowledge delivery service in a laboratory setting. (Ongoing)
  • Conduct a mixed-method assessment of a pilot implementation of the knowledge broker in a real-world medical home environment. (Upcoming)

In addition, as part of his Mentored Research Scientist Research Career Development Award (K01), Dr. Del Fiol has completed additional training in clinical and health services research and leadership through the Duke University School of Medicine Clinical Research Training Program.

2010 Activities: A protocol for the systematic literature review was completed and the literature review initiated. A total of 8,800 abstracts were screened in the first round and yielded 718 full-text articles that met the criteria for the second phase. A second reviewer protocol was developed and reliability testing completed. Seventy eight full-text articles met the inclusion criteria; data from these will be abstracted.

The Dr. Del Fiol adapted work that was done with the Veteran’s Administration (OpenInfobutton) to build some of the knowledge-delivery service infrastructure, and the project entered into a system testing phase. Institutional Review Board (IRB) approval for focus groups was granted. Dr. Del Fiol engaged in significant training in clinical and health services research as part of his educational objectives.

Dr. Del Fiol changed his employment to the University of Utah and transferred the project, including IRB approvals, with him. Collaborations were established with the Salt Lake Veterans Affairs Medical Center, Intermountain Healthcare, University of Utah Center on Aging, and the University of Utah Health Sciences Library.

Preliminary Impact and Findings: The project does not have any findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Context-Aware Knowledge Delivery into Electronic Health Records - Final Report

Citation:
Del Fiol G. Context-Aware Knowledge Delivery into Electronic Health Records - Final Report. (Prepared by the University of Utah under Grant No. K01 HS018352). Rockville, MD: Agency for Healthcare Research and Quality, 2013. (PDF, 549.92 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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