Nunzia Bettinsoli Giuse

Evolution of a Mature Clinical Informationist Model

Achieving evidence-based practice will require new approaches to providing information during health care delivery and to integrating evidence and informatics at the point of care. To support evidence-based practice, Vanderbilt University Medical Centers Eskind Biomedical Library (EBL) introduced the role of clinical informationist, an information specialist with sufficient knowledge and insight to function as a true partner in the health care team. To further disseminate evidence-based knowledge, the Vanderbilt University Medical Centers (VUMC) electronic medical record system and pathway development processes integrate advanced information synthesis capabilities provided by clinical informationists. Combining clinical informationist expertise with informatics tools is an effective strategy for delivering the evidence needed to support patient care decisions.

Towards computer-assisted maintenance of medical knowledge bases

Abstract The problem of knowledge acquisition is especially severe for medical knowledge bases. At least two strategies can help alleviate the problem: creating computer-based tools which assist experts in entering knowledge into the knowledge base, and promoting situations where several organizations contribute simultaneously and independently to a single knowledge base. This article describes a set of tools currently under development at the Section of Medical Informatics of the University of Pittsburgh which incorporate both strategies. The tools, which operate within the framework of the Quick Medical Reference (QMR) knowledge base, perform tasks ranging from checking syntax and semantics to suggesting initial skeletons for new knowledge base entries. Extensive use of interactive direct-manipulation techniques and built-in knowledge of many details of the knowledge base makes these tools very effective in supporting the creation and maintenance of new knowledge base entries.

Information Needs of Health Care Professionals in an Aids Outpatient Clinic as Determined by Chart Review

OBJECTIVE To examine the information needs of health care professionals in HIV-related clinical encounters, and to determine the suitability of existing information sources to address those needs. SETTING HIV outpatient clinic. PARTICIPANTS Seven health care professionals with diverse training and patient care involvement. METHODS Based on patient charts describing 120 patient encounters, participants generated 266 clinical questions. Printed and on-line information sources were used to answer questions in two phases: using commonly available sources and using all available medical library sources. MEASUREMENTS The questions were divided into 16 categories by subject. The number of questions answered, their categories, the information source(s) providing answers, and the time required to answer questions were recorded for each phase. RESULTS Each participant generated an average of 3.8 clinical questions per chart. Five categories accounted for almost 75% of all questions; the treatment protocols/regimens category was most frequent (24%). A total of 245 questions (92%) were answered, requiring an average of 15 minutes per question. Most (87%) of the questions were answered via electronic sources, even though paper sources were consulted first. CONCLUSIONS The participating professionals showed considerable information needs. A combination of on-line and paper sources was necessary to provide the answers. The study suggests that present-day information sources are not entirely satisfactory for answering clinical questions generated by examining charts of HIV-infected patients.

Providing Evidence-Based Answers to Complex Clinical Questions: Evaluating the Consistency of Article Selection

Purpose Health care providers must maintain familiarity with current biomedical evidence, but clinicians struggle to maintain their awareness of current research because of the demands of daily practice and the exponential growth of medical knowledge. Clinical information specialists (informationists), trained experts in reviewing and filtering the medical literature in response to complex clinical queries, may be able to assist practicing clinicians. This study compared informationists and two categories of physicians in their article selection in response to two complex clinical questions. Method The study was performed at Vanderbilt University Medical Center. A total of 15 faculty and staff from three groups were recruited (five general physicians, five physicians trained in research methodology, and five informationists). The participants reviewed two previously selected clinical questions, worked in focus groups to define the pertinent facet questions of the questions, and then ranked the articles by pertinence to the clinical questions. Results In general, both informationists and physicians trained in research methodology had a high degree of intergroup agreement for ranking article pertinence, while the generalists were less likely to agree on pertinent articles. Conclusions These findings suggest that informationists consistently select articles relevant to answering complex clinical queries and may assist practicing clinicians by providing information relevant to patient cases.

Medical knowledge bases.

No abstract available.

Guiding Oncology Patients Through the Maze of Precision Medicine

As the role of genomics in health care grows, patients increasingly require adequate genetic literacy to fully engage in their care. This study investigated a model for delivering consumer-friendly genetic information to improve understanding of precision medicine using health literacy and learning style principles. My Cancer Genome (MCG), a freely available cancer decision support tool, was used as a testbed. MCG content on a melanoma tumor mutation, BRAF V600E, was translated to a 6th-grade reading level, incorporating multiple learning modalities. A total of 90 patients and caregivers were recruited from a melanoma clinic at an academic medical center and randomized to 3 groups. Group A (control) received an exact copy of text from MCG. Group B was given the same content with hyperlinks to videos explaining key genetic concepts, identified and labeled by the team as knowledge pearls. Group C received the translated content with the knowledge pearls embedded. Changes in knowledge were measured through pre and post questionnaires. Group C showed the greatest improvement in knowledge. The study results demonstrate that providing information based on health literacy and learning style principles can improve patients’ understanding of genetic concepts, thus increasing their likelihood of taking an active role in any decision making concerning their health.

Integrating best evidence into patient care: a process facilitated by a seamless integration with informatics tools

The Vanderbilt University paper discusses how the Eskind Biomedical Library at Vanderbilt University Medical Center transitioned from a simplistic approach that linked resources to the institutional electronic medical record system, StarPanel, to a value-added service that is designed to deliver highly relevant information. Clinical teams formulate complex patient-specific questions via an evidence-based medicine literature request basket linked to individual patient records. The paper transitions into discussing how the StarPanel approach acted as a springboard for two additional projects that use highly trained knowledge management librarians with informatics expertise to integrate evidence into both order sets and a patient portal, MyHealth@Vanderbilt.

Paper: Consistency enforcement in medical knowledge base construction

Some aspects of knowledge base creation can be partially or completely automated, resulting in higher quality and smaller effort. Computer assistance is particularly valuable in ensuring the internal consistency of a knowledge base. The article describes several techniques for consistency enforcement in QMR-KAT, an interactive knowledge base editor for the INTERNIST-I/QMR medical knowledge base. Two strategies that improve consistency are applicable to a wide range of situations. The first strategy prevents simple (but common) inconsistencies. The second strategy reveals facts that are potentially (but not necessarily) inconsistent with known data, and may require further evaluation. Both strategies use the contents of the existing knowledge base in the evaluation of new facts.

A temporal analysis of QMR.

Objective : To understand better the trade-offs of not incorporating explicit time in Quick Medical Reference (QMR), a diagnostic system in the domain of general internal medicine, along the dimensions of expressive power and diagnostic accuracy. Design : The study was conducted in two phases. Phase I was a descriptive analysis of the temporal abstractions incorporated in QMRs terms. Phase II was a pseudo-prospective controlled experiment, measuring the effect of history and physical examination temporal content on the diagnostic accuracy of QMR. Measurements : For each QMR finding that would fit our operational definition of temporal finding, several parameters describing the temporal nature of the finding were assessed, the most important ones being: temporal primitives, time units, temporal uncertainty, processes, and patterns. The history, physical examination, and initial laboratory results of 105 consecutive patients admitted to the Pittsburgh University Presbyterian Hospital were analyzed for temporal content and factors that could potentially influence diagnostic accuracy (these included: rareness of primary diagnosis, case length, uncertainty, spatial/causal information, and multiple diseases). Results : 776 findings were identified as temporal. The authors developed an ontology describing the terms utilized by QMR developers to express temporal knowledge. The authors classified the temporal abstractions found in QMR in 116 temporal types, 11 temporal templates, and a temporal hierarchy. The odds of QMRs making a correct diagnosis in high temporal complexity cases is 0.7 the odds when the temporal complexity is lower, but this result is not statistically significant (95% confidence interval = 0.27–1.83). Conclusions : QMR contains extensive implicit time modeling. These results support the conclusion that the abstracted encoding of time in the medical knowledge of QMR does not induce a diagnostic performance penalty.

Institute of Medicine Measures of Social and Behavioral Determinants of Health: A Feasibility Study

INTRODUCTION Social and behavioral factors are known to affect health but are not routinely assessed in medical practice. To date, no studies have assessed a parsimonious panel of measures of social and behavioral determinants of health (SBDs). This study evaluated the panel of SBD measures recommended by the Institute of Medicine and examined the effect of question order. METHODS Adults, aged ≥18 years, were recruited using ResearchMatch.org for this randomized, parallel design study conducted in 2015 (data analyzed in 2015-2016). Three versions of the SBD measures, sharing the same items but in different orders of presentation (Versions 1-3), were developed. Randomized to six groups, participants completed each version at least 1 week apart (Weeks 1-3). Version order was counterbalanced across each administration and randomization was stratified by gender, race, and age. Main outcomes were effect of question order, completion time, and non-response rates. RESULTS Of 781 participants, 624 (80%) completed the Week 1 questionnaire; median completion time for answering all SBD questions was 5 minutes, 583/624 participants answered all items, and no statistically significant differences associated with question order were observed when comparing responses across all versions. No significant differences in responses within assignment groups over time were found, with the exception of the stress measure for Group 5 (p=0.036). CONCLUSION Question order did not significantly impact participant responses. Time to complete the questionnaire was brief, and non-response rate was low. Findings support the feasibility of using the Institute of Medicine-recommended questionnaire to capture SBDs.