Informatics for librarians
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Informatics for librarians



Discovering the roles for librarians in EHRs.

Discovering the roles for librarians in EHRs.



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  • With the help of health IT, health care providers will have: Accurate and complete information about a patient's health. That way they can give the best possible care, whether during a routine visit or a medical emergency. The ability to better coordinate the care they give. This is especially important if a patient has a serious medical condition. A way to securely share information with patients and their family caregivers over the Internet, for patients who opt for this convenience. This means patients and their families can more fully take part in decisions about their health care. Information to help doctors diagnose health problems sooner, reduce medical errors, and provide safer care at lower costs. Widespread use of health IT can also: Make our health care system more efficient and reduce paperwork for patients and doctors. Expand access to affordable care. Build a healthier future for our nation.
  • Sometimes called as Man-Machine Interaction or Interfacing, concept of Human-Computer Interaction/Interfacing (HCI): “ HCI in the large is an interdisciplinary area. It is emerging as a specialty concern within several disciplines, each with different emphases: computer science (application design and engineering of human interfaces), psychology (the application of theories of cognitive processes and the empirical analysis of user behavior), sociology and anthropology (interactions between technology, work, and organization), and industrial design (interactive products).” Computer science : provide knowledge about the capability of the technology and idea about how this potential can be harnessed Psychology and cognitive science: • understanding human behaviour and the mental processes that underlie it (information processing) • understanding the nature and causes of human behaviour in the social context Sociology and anthropology • interactions between technology, work, and organization • Industrial design • interactive products Ergonomics • understand the user’s physical capabilities • Linguistics; artificial intelligence; business; graphics design; technical writingThe main terms that should be considered in the design of HCI: functionality and usability Library/information science: information retrieval, organizing, searching for, and managing Usability Job titles: User-Centered Design, User Experience, User Interaction Design, User Interface Design, Information Architect, User Experience Architect, Usability Specialist… Methods (not job titles) define the expertise: From how users are studied through design and development Centered on information based tasks
  • Tablets said to date back to 2000 B.C. represent the earliest medical writings so far discovered. The history of the medical library (defined as a place where a collection of medical writings is kept) is traced through ancient and medieval civilizations, and the dependence of advancement or decline on the attitude toward learning and knowledge is demonstrated. The oldest medical library, though, is the Pennsylvania Hospital library (1763). Its first catalog was published in 1790 Paper chart has been used for decades. In 1901 Dr. Henry Stanley Plummer, a very young "techie doc" joined the Mayo Clinic. By all accounts Dr. Plummer had both the peculiarities and the single mindedness of true genius. He was, of course an excellent physician, but his largest contribution to modern medicine was the Medical Record. In 1907 Dr. Plummer and his assistants deployed a novel way of keeping patient records. Up to that point patient records were kept in ledgers. The multiple offices at Mayo each had its own ledger. Once the initial visit was entered in a ledger, all following visits and procedures were added to that page, sometimes in crowded text on the margins. One patient could have entries scattered across a multitude of ledgers. Dr. Plummer introduced a centralized medical record consisting of a big envelope where all doctors would aggregate all the information regarding a particular patient. Each patient was assigned a unique identifier and his/her own dossier of clinical documents. The medical record would follow the patient everywhere at Mayo and all physicians would have access to all records. Paper chart often dismissed as primitive, archaic, useless…Focus on limitations and problems Rich history of information design discarded in EMR. Designed to support care, search and retrieval – with clinicians Managed, maintained and designed by professional medical librarians!
  • EMR has tabs just like a paper chart, but they were copied in a very superficial way. It seems there was little study of the information tasks performed during care and/or an exploration of the potential of the new electronic medium to support those tasks. Paper tabs fully utilized characteristics of their medium; electronic tabs do not. While html hyperlinks have indicated a status of “visited” for almost 20 years (blue vs purple), EMR tabs rarely provide something as simple and useful. Electronic tabs could include simple visual indicators to represent, “You have/have not reviewed this section,” but this could be taken even further to indicate, “There are abnormal results in this section,” or “This
  • One of the first librarian members of MLA, Grace Whiting Myers of Massachusetts General Hospital's Treadwell Library Grace Whiting Myers was the Massachusetts General Hospital’s first librarian, working with medical records from 1879 to 1925. She was also a pioneer in medical records management. In addition to being a force for introducing professional concerns of librarians into the affairs of MLA, she was instrumental in the founding of an association for medical record professionals. In 1912, she wrote of the link between library materials and patient records. Medical Library Association, American Health Information Management Association The Medical Library Association (MLA) is founded as the Association of Medical Librarians on May 2, 1898, by four librarians and four physicians in the office of the Philadelphia Medical Journal at the invitation of George M. Gould, M.D., editor of the journal. The object of the association was the fostering of medical libraries and the maintenance of an exchange of medical literature among its members. Membership was limited to librarians representing medical libraries of not less than 500 volumes and with regular library hours and attendance. 1907 The name of the association is changed to the Medical Library Association. AHIMA traces its history back to 1928 when the American College of Surgeons established the Association of Record Librarians of North America (ARLNA) to "elevate the standards of clinical records in hospitals and other medical institutions." This farsighted recognition of the importance of medical record quality to patient care and research underlies the organization today. Since its formation, the organization known now as AHIMA has undergone several name changes that reflect the evolution of the profession. In 1938 the Association changed its name to the American Association of Medical Record Librarians (AAMRL) for a more succinct representation of the membership. AAMRL moved forward with the creation of standards and regulations that established its members as medical record experts. When the Association became the American Medical Record Association in 1970, medical record professionals had increased their involvement in hospitals, community health centers, and to other health service facilities outside the hospital. They had also begun to play a critical role at their institutions in the administration of federal programs such as Medicare. As the healthcare industry underwent restructuring and decision-making became increasingly driven by data, the Association changed its name in 1991 to the American Health Information Management Association. Its current name captures the expanded scope of clinical data beyond the single hospital medical record to health information comprising the entire continuum of care. If there is a hospital library, records should be kept in close proximity to it, and, if possible, come under the supervision of the library. With theory and fact thus brought into close relation, an atmosphere is created of study and investigation which to the doctor has a value beyond estimate [2].
  • America’s Interstate Highway System celebrates 55 years On Feb. 13, 2009, Congress passed the American Recovery and Reinvestment Act of 2009 at the urging of President Obama, who signed it into law four days later. A direct response to the economic crisis, the Recovery Act has three immediate goals: Create new jobs and save existing ones Spur economic activity and invest in long-term growth Foster unprecedented levels of accountability and transparency in government spending The Recovery Act intended to achieve those goals by providing $787 billion in: Tax cuts and benefits for millions of working families and businesses Funding for entitlement programs, such as unemployment benefits Funding for federal contracts, grants and loans
  • Specifically with the EHR, President George W Bush set the goal in 2004 that every American would have an EHR by the year 2014
  • Lots of new language to learn. These three terms give a good picture, I think, of the potential for HIE Disaster, such as hurricanes Rita & Katrina The need for universal EHRs became particularly apparent after Hurricane Katrina where thousands were left without any medical those except the ones thru US Dept of Veterans affairs EMR: An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization. EHR: An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.
  • Outpatient (ambulatory) Inpatient (acute) Department specific EMR applications Operating Room, Emergency Department Radiology, Pharmacy, Labs Cardiology, Oncology… ADT (Admission, Discharge and Transfer) EMR functionality/tasks Patient care Order entry including medications, labs, procedures, imaging studies… Order results Documentation Patient education/instructions Manage resources Supply chain and materials management Staffing Scheduling of visits and procedures Managing business Finance/revenue Billing… Budget planning
  • The EMR is becoming ubiquitous in the hospital Touches almost every job US hospitals employ 5 million people * Hospitals support 1 out of 10 US jobs 1.9 trillion of economic activity EMR/HIT implementation a growing profession Our inpatient EMR went live in January 8,000/11,000 staff trained on use of EMR ≈ 50% are non-clinicians 269 EMR Roles (and counting) 900+ parameters define a role Physician, Nurse Practitioner, Nurse, Counselors, Therapists, Technicians, Clerks, Environmental Services, Billing, Report analysts, Finance, Research and more Those who never use the EMR, but are influenced by its functionality and data Executives and management
  • The Patient! It is their chart and their care Patient as EMR users EMR vendors building “patient portal” applications Connect the patient to their physician(s), hospital, clinics Scheduling, refills, lab results… Access to their patient information Patient education Hospital as trusted source of medical information Shared Decision Making (SDM) Physicians and patients using technology to collaborate and decide on treatment jointly Consumer or Patient Centered Health
  • Patient-centered care is based on the idea that patients are active participants in developing a health strategy for themselves. This means that both physicians and patients have responsibilities in communicating information and concerns.
  • Locating policies. Creating policies. Maintaining policies. Context sensitive linking of important policy documents is an advantage over online repositories that have to be searched Poorly managed Updated frequently Access at point of care when/where it is needed 5815 hospitals in the US (2008)* Community, academic, for profit, government, rural, urban, large, medium, small… Annual stats (2008)* 950,000 inpatient beds, 35 million inpatient admissions 118 million ED visits 481 million outpatient visits 4 million births Expenses = $700,000,000,000 1/3 hospitals operate at a loss All motivated to implement an EMR/HIT Investment in HIT promises to pay back with Medicare/Medicaid reimbursements - Meaningful Use All facing implementing some of the most complex technology ever
  • storing and retrieving information on demand. Embedded links in individual patient records EBP Health sciences librarians are involved in finding ways to link primary research and the best medical evidence to specific patient records The theoretical and practical problems of building EHRs are about structuring information for effect and efficient retrieval and use—the main domain of librarians
  • Training and education is everywhere Physicians and Nurses Continuing physician and nurse training required for certification Continuing Medical Education (CME) and Contact Hours Nursing Massive additional training requirements The Nurse Educator Other staff Everyone in the hospital receives training on infection control, safety, fire… and much more . Environmental services Patient/Family Education How can the educational resources of a hospital be delivered to patients?
  • 29 iSchools /developing healthcare informatics programs The iSchools are interested in the relationship between information, people and technology. This is characterized by a commitment to learning and understanding the role of information in human endeavors. The iSchools take it as given that expertise in all forms of information is required for progress in science, business, education, and culture. This expertise must include understanding of the uses and users of information, as well as information technologies and their applications. “ It isn't just about computer science anymore, either. That isn't where you go to find out how technology changes people's lives, and where it fails them, or how to make it less intrusive and more humane. Those are the questions people are taking up at the Schools of Information that have sprung up at research universities like UCLA, Toronto and Washington — iSchools, for short. It's a different i-, but it too stands in for a connection between technology and the social world.” You can read the complete transcript or listen to the story on the NPR website. About the iSchools Organization The iSchools organization was founded in 2005 by a collective of Information Schools dedicated to advancing the information field in the 21st Century. These schools, colleges, and departments have been newly created or are evolving from programs formerly focused on specific tracks such as information technology, library science, informatics, and information science. While each individual iSchool has its own strengths and specializations, together they share a fundamental interest in the relationships between information, people, and technology.
  • The Infobutton is designed to contribute to the solution of this problem. The Infobutton is a key standard, originally developed at Columbia University by Dr. Jim Cimino and others and now being developed as an HL7 standard. The Infobutton has been very quickly accepted and implemented by the vendor community. The beauty of the Infobutton is that it can be tailored to the class of the user – one set of information for the professional, another for the lay person. The Infobutton provides context-sensitive links to information that can be seamlessly built into the clinical information system. It uses an SOA framework, sending queries to the CDSS using data from the EHR. The CIS places an Infobutton next to a data element such as a diagnosis, lab result (which may be abnormal) or a drug. When clicked, the Infobutton causes a query based on the context of the interaction, the patient, the data, the activity and the user. This context-sensitive interaction between data and knowledge is an extremely powerful tool.
  • MedlinePlus Connect is a free service of the National Library of Medicine (NLM), National Institutes of Health (NIH), and the Department of Health and Human Services (HHS). This service allows health organizations and health IT providers to link patient portals and electronic health record (EHR) systems to MedlinePlus, an authoritative up-to-date health information resource for patients, families, and health care providers. MedlinePlus Connect accepts requests for information on diagnoses (problem codes) and medications. NLM mapped MedlinePlus health topics to two standard diagnostic coding systems used in EHRs: ICD-9-CM and SNOMED CT CORE Problem List Subset. When an EHR submits a problem code to MedlinePlus Connect, the service returns the mapped health topic as a response. MedlinePlus Connect also links EHR systems to drug information written especially for patients. For medication codes, MedlinePlus Connect accepts RXCUIs and NDCs. The service also conforms to the HL7 Context-Aware Knowledge Retrieval (Infobutton) Knowledge Request URL-Based Implementation specification. MedlinePlus responds to problem code requests in either English or Spanish. Currently, it supports requests for drug information in English only. NLM is working on adding laboratory test responses to MedlinePlus Connect. It will also support an XML-based Web service at a future date. Advantages of MedlinePlus Connect Implementing MedlinePlus Connect has a number of advantages: It is FREE – no licensing or registration. It may help your hospital or practice group achieve one of the 10 menu criteria for Meaningful Use of Health Information Technology. For more information about meaningful use, see: The “Meaningful Use” Regulation for Electronic Health Records. Blumenthal D, Tavenner M. N Engl J Med 2010 Aug 5; 363(6):501-4 (See PMID 20647183). There is no need to use MedlinePlus Connect exclusively – most systems can be configured to link to more than one source of patient information. Implementing MedlinePlus Connect will make a global change; you do not need to create individual links. MedlinePlus Connect utilizes existing standards. Health Care Organizations Organization Name Location Aurora Health Care Eastern WI and Northern IL Buffalo Medical Group, P.C. Buffalo, NY Cleveland Clinic Cleveland, OH Halifax Regional Medical Center Roanoke Rapids, NC Indian Health Service Serves members of federally-recognized Tribes Institute for Family Health New York, NY LSU Health Shreveport, LA NewYork-Presbyterian Hospital/ Columbia University Medical Center New York, NY Texas Health Resources Arlington, TX University of Utah Salt Lake City, UT EHR Systems Product AlphaFlexCMS 1.0 ChiroSuite EHR ClinicTree ComChart EMR Dexter Solutions eZDocs Epic MyChart MedcomSoft Patient Portal MedcomSoft Record 5.0.6 Procentive Resource and Patient Management System (RPMS) EHR Rise Health Patient Relationship Manager SmartPHR ICD-9-CM (International Classification of Diseases, 9th edition, Clinical Modification) SNOMED CT® (Systematized Nomenclature of Medicine, Clinical Terms). Note: MedlinePlus Connect coverage of SNOMED CT focuses on CORE Problem List Subset codes (Clinical Observations Recording and Encoding) and their descendants. For medication requests, MedlinePlus Connect supports: RXCUI (RxNorm Concept Unique Identifier) NDC (National Drug Code)
  • Choose training in one of these six roles: Practice workflow and Information Management Redesign Specialist Assists in reorganizing workflow and operations to take full advantage of health information technology to improve health care. Clinician/Practitioner Consultant Emphasizes the background and experience of a professional licensed health care practitioner in a leadership role to improve workflow and operations. Applicants must have a degree and/or credential to provide clinical care. Implementation Support Specialist Provides on-site user support before and during the implementation of health IT systems. Technical/Software Support Staff Supports the technology deployed in the clinical/public health setting on an ongoing basis. Maintains systems, including patches and upgrades to software and help desk support. Implementation Manager Provides on-site management of mobile adoption support teams for the period of time before and during implementation of health IT systems. Trainer Designs and delivers training programs, using adult learning principles, to employees in clinical and public health settings. Columbia University Duke University Johns Hopkins University Oregon Health & Science University University of Alabama at Birmingham
  • EMR implementations as only the first step “ Optimization” as reconfiguring the EMR to meet objectives for clinicians, patients, outcomes… For many, this can only be realized once the system has been deployed May be an opportunity for LIS professionals to be integrated in the process EMR training and experience However, difficult to arrange and expensive for those outside the build team Education: Many in LIS may be perfectly suited as EMR trainers (and receive EMR training themselves) Integration of the EMR to educational content repositories Data base and reporting skills Data is the “raw material” of information in healthcare IT often demonstrates skills at the system end LIS can provide the next step – providing information that people can use Clinical experience Familiarity with clinical environments, roles, tasks, workflow… Research methods Analysis of EMR impact, before, during and after implementation Contribute to new evidence based decision support systems
  • Adding data analysis and database skills seems a natural fit for LIS professionals What questions are you trying to answer? Realizing questions may not be fully formed Combine “ Patron” interview Knowledge of the collection (technology + data) LIS expertise applied to data – knowledge transformation LIS professionals can go beyond the role of “report writer” to being part of the team addressing issues the data reveals Improve outcomes, process, safety, patient satisfaction, clinician workflow… and more LIS traditional dedication to service should not be underestimated in this line of work Lists, lists and more lists Almost every task requires a search activity Medications, diagnosis, procedures, instruments, supply items… endless User frustration and poor data quality result from ineffective design/implementation LIS concepts and methods Precision and Recall Categorization and indexing Vocabulary problem Thesauri and synonyms Examples from the OR: Scheduling the right procedure The surgical instrument count list Pulling the right supplies for a case Finding a supply item out of 18,000 items Creating a naming convention for all OR supply items (18,000) Building a list of “reasons for delay” Finding a recalled implant/device
  • Design of the EMR presentation of growth charts revealed the potential for physicians to select the incorrect growth chart for premature infants Observed physicians in practice selecting the wrong chart for preemies Data analysis from the EMR showed only 75% of preemie visits were using the correct chart Solution: Vendor notified to implement new designs Interim fix: Addressed with system defaults and communication The definition of health care quality has changed over time from having the right things to doing things right to having the right things happen
  • A Chicago area hospital has agreed to pay $8.25 million to settle a lawsuit brought by the parents of an infant boy who died at the institution after a series of medical errors. The hospital determined that a pharmacy technician had entered information incorrectly when processing an electronic IV order for the baby, resulting in a massive sodium chloride overdose in the solution. The problem would have been identified by automated alerts in the IV compounding machine, but those were not activated when the customized bag was prepared for the baby. The hospital also found that the outermost label on the IV bag administered to the baby didn’t reflect its actual contents. And while a blood test on the infant had shown abnormally high sodium levels, a lab technician assumed the reading was inaccurate.
  • Organize Structure Store and Retrieve information on demand

Informatics for librarians Informatics for librarians Presentation Transcript

  • INFORMATICS FORLIBRARIANS12 APRIL 2012Jacqueline Leskovec, MLIS, MA, RNOutreach, Planning & Evaluation CoordinatorNational Network of Libraries of MedicineGreater Midwest Region
  • ObjectivesParticipants will:•Be provided with an overview of the EMR•Be given a history of the role of the librarian in medicalrecords•Explore ideas on the roles of librarians with HIT
  • HIT?• Health information technology (health IT) makes it possible for health care providers to better manage patient care through secure use and sharing of health information. Health IT includes the use of electronic health records (EHRs) instead of paper medical records to maintain peoples health information. The Office of the National Coordinator for Health Information Technology:
  • What is Human Computer Interaction(HCI)?• Multi disciplinary• Usability job titles• Methods define the expertise
  • In the beginning…The History of Medical Libraries from 2000 B.C. to 1900 A.D. Kathleen P. Birchette
  • Disciplines & Departments
  • Librarians and HIT• 1898: AML• 1907: MLA• 1928: ARLNA• 1938: AAMRL• 1970: AMRA• 1991: AHIMA Grace Whiting Myers
  • June 29, 1956 February 13,2009
  • EMR? EHR? HIE?• EMR: Electronic Medical Record • Electronic record of health-related information on an individual • Within one health care organization• EHR: Electronic Health Record • Electronic record of health-related information on an individual • Across more than one health care organization• HIE: Health Information Exchange • Electronic movement of health-related information among organizations • Involves networks • Local, state, and national HIE initiatives
  • The Electronic Medical Record• Complex set of integrated applications• Outpatient/inpatient• Department-specific• Functionality/tasks
  • The Ideal EMR• Rapid accessibility and response time• Intelligent and flexible data presentation• Consistency• Contextual sensitivity• Prioritization• Promotion of quality improvement• Electronic communication• Patient involvement Society of General Internal Medicine Blue Ribbon Panel, 2007
  • Who uses the EMR?
  • The Most Important User
  • Medical Model Vs. Patient-Centered Model
  • Hospitals as Information Environments• “…altogether the most complex human organization ever devised.” • Peter Drucker, 1993 American Hospital Association
  • The Librarian
  • AAFP 2003
  • HIT and Educational Content• Training and education opportunities everywhere • Physicians and Nurses • Nursing • Other staff • Patient/Family Education
  • I is for Information•
  • Infobutton
  • • ICD-9-CM• SNOMED CT®• CORE Problem List Subset codes• RXCUI• NDC
  • Training. Free. Yes, FREE.• Practice workflow and Information and Information Management Redesign Specialist• Clinician/Practitioner Consultant• Implementation Support Specialist• Technical/Software Support Staff• Implementation Manager• Trainer
  • EMR Optimization• “We are running out of time, let’s just get it up and running and fix the problems later.”
  • Patient Education• Trusted source of information – Your doctor – Your hospital• Develop online patient education libraries – Well developed content – Easy to find what you need
  • Data – Information - Knowledge
  • Clinical HCI• Optimization Case Study • Observation • Data analysis• Solution • New design implementation
  • Safety and Error Prevention• Information system configuration/use• Process design• Communication• Labeling• Education
  • Research - Clinical Guidelines
  • Doing what we do best…•What are you doing??
  • Questions/comments?•• SlideShare: leskovec• 1.800.DEV-ROKSThis project has been funded in whole or in part with Federal funds from the National Library of Medicine, National Institutes ofHealth, Department of Health and Human Services, under Contract No. HHS-N-276-2011-00005-C with the University of Illinois at Chicago.