Information needs of clinical teams: analysis of questions received by the Clinical Informatics Consult Service.

OBJECTIVES: To examine the types of questions received by Clinical Informatics Consult Service (CICS) librarians from clinicians on rounds and to analyze the number of clearly differentiated viewpoints provided in response. DESIGN: Questions were retrieved from an internal database, the CICS Knowledge Base, and analyzed for redundancy by subject analysis. The unique questions were classified into ten categories by subject. Treatment-related questions were analyzed for the number of viewpoints represented in the librarian's response. RESULTS: The CICS Knowledge Base contained 476 unique questions and 71 redundant questions. Among the unique queries, the top two categories accounted for 67%: treatment (36%) and disease description (31%). Within the treatment-related subset, 138 questions (59%) required representation of more than one viewpoint in the librarian's response. DISCUSSION: Questions generated by clinicians frequently require comprehensive, critical appraisal of the medical literature, a need that can be filled by librarians trained in such techniques. This study demonstrates that many questions require representation of more than one viewpoint to answer completely. Moreover, the redundancy rate underscores the need for resources like the CICS Knowledge Base. By critically analyzing the medical literature, CICS librarians are providing a time-saving and valuable service for clinicians and charting new territory for librarians.

The Patient Informatics Consult Service (PICS): an approach for a patient-centered service.

The Patient Informatics Consult Service (PICS) at the Eskind Biomedical Library at Vanderbilt University Medical Center (VUMC) provides patients with consumer-friendly information by using an information prescription mechanism. Clinicians refer patients to the PICS by completing the prescription and noting the patient's condition and any relevant factors. In response, PICS librarians critically appraise and summarize consumer-friendly materials into a targeted information report. Copies of the report are given to both patient and clinician, thus facilitating doctor-patient communication and closing the clinician-librarian feedback loop. Moreover, the prescription form also circumvents many of the usual barriers for patients in locating information, namely, patients' unfamiliarity with medical terminology and lack of knowledge of authoritative sources. PICS librarians capture the time and expertise put into these reports by creating Web-based pathfinders on prescription topics. Pathfinders contain librarian-created disease overviews and links to authoritative resources and seek to minimize the consumer's exposure to unreliable information. Pathfinders also adhere to strict guidelines that act as a model for locating, appraising, and summarizing information for consumers. These mechanisms--the information prescription, research reports, and pathfinders--serve as steps toward the long-term goal of full integration of consumer health information into patient care at VUMC.

Developing a culture of lifelong learning in a library environment.

Between 1995 and 1996, the Annette and Irwin Eskind Biomedical Library (EBL) at Vanderbilt University Medical Center (VUMC) radically revised the model of service it provides to the VUMC community. An in-depth training program was developed for librarians, who began to migrate to clinical settings and establish clinical librarianship and information brokerage services beyond the library's walls. To ensure that excellent service would continue within the library, EBL's training program was adapted for library assistants, providing them with access to information about a wide variety of work roles and processes over a four to eight-month training period. Concurrently, customer service areas were reorganized so that any question--whether reference or circulation--could be answered at any of four service points, eliminating the practice of passing customers from person to person between the reference and circulation desks. To provide an incentive for highly trained library assistants to remain at EBL, management and library assistants worked together to redesign the career pathway based on defined stages of achievement, self-directed participation in library-wide projects, and demonstrated commitment to lifelong learning. Education and training were the fundamental principles at the center of all this activity.

Diagnostic certainty and hospital resource use.

OBJECTIVE: To determine whether the house staff's subjective probability estimates of their initial admitting diagnoses are independent predictors of in-hospital resource consumption. DESIGN: Descriptive correlational study. SETTING: Academic medical center inpatient setting. PATIENTS: Patients admitted to general medicine wards. MEASUREMENTS: A visual analog scale with hash marks at 0, 25, 50, 75 and 100 was used to obtain a subjective probability estimate that the house staff's initial admitting diagnosis was a correct diagnosis. This provided the measure of diagnostic "certainty" at the time of admission. Patient demographic data, prior hospital stays, distance from hospital, MedisGroups scores, outlier status and vital status at discharge were obtained from administrative systems. Length of stay, total charges, cost estimates (total departmental), and number of consultations were obtained from the hospital-based transaction master database. RESULTS: House staff evaluated 1,778 admissions, 77.2% were assigned a diagnostic certainty rating of 75% or higher. In univariate analysis, the certainty rating did not vary with the MedisGroups score, outlier status or vital status at discharge. It varied with prior stays and measures of resource use. In multivariate analysis, the certainty rating was a significant factor accounting for variation in each of the measures of resource utilization with the exception of adjusted pharmacy charges. CONCLUSIONS: Even in a teaching hospital only a small proportion of patients had an "uncertain" diagnosis (22.8%). Nonetheless, the certainty variables were significantly related to measures of resource consumption including length of stay, total costs and number of consults obtained.

Preparing librarians to meet the challenges of today's health care environment.

OBJECTIVE: Refine the understanding of the desirable skills for health sciences librarians as a basis for developing a training program model that reflects the fundamental changes in health care delivery and information technology. DESIGN: A four-step needs assessment process: focus groups developed lists of desirable skills; the research team organized candidate skills into a taxonomy; a survey of a random sample of librarians and library users assessed perception of importance of individual skills; and the research team framed, as a unifying hypothesis, a training model. SURVEY METHODS: The survey was distributed to random samples of 150 librarians, stratified by type of library, and 150 library users, stratified by type of use. A non-randomized sample was obtained by mounting the survey on a World Wide Web server. The survey instrument included 96 distinct skills organized into 13 categories. Respondents rated the importance of each skill on a Likert scale and provided a separate ranking by identifying the ten most important skills for the profession. RESULTS: Among the participants, 51% of librarians and 36% of library users responded to the survey. All categories of skills were rated above the midpoint of priority on the Likert scale. All groups rated personality characteristics and skills as most important, with an understanding of the health sciences, education, and research being rated comparably to technical skills. CONCLUSIONS: Health sciences librarians need a new educational model that provides them with broad-based tools to discover new roles and new resources for acquiring individual skills as the need arises. A unifying training model would involve trainees in developing their learning plan in a way that promotes proactive inquiry and self-directed learning, and it would rotate the trainees through projects to provide skills and an understanding of end-user work processes.

Integrating health sciences librarians into biomedicine.

Vanderbilt University Medical Center (VUMC) developed a model training program to prepare current and future health sciences librarians for roles that are integrated into the diverse fabric of the health care professions. As a complement to the traditional and theoretical aspects of a librarian's education, this mixture of supplemental coursework and intensive practical training emphasizes active management of information, problem-solving skills, learning in context, and direct participation in research, while providing the opportunity for advanced academic pursuits. The practical training will take place under the auspices of an established Integrated Advanced Information Management Systems (IAIMS) library that is fully integrated with the Health Center Information Management Unit and Academic Biomedical Informatics Unit. During the planning phase, investigators are analyzing the model's aims and requirements, concentrating on (a) refining the current understanding of the roles health sciences librarians occupy; (b) developing educational strategies that prepare librarians to fulfill expanded roles; and (c) planning for an evaluation process that will support iterative revision and refinement of the model.

Educational software evaluation process.

The Active Digital Library at the Vanderbilt University Medical Center has created and implemented an educational software evaluation process to facilitate the timely recommendation for product acquisition. Using this process, breadth and depth of subject coverage, clarity of presentation, quality of construction, and ease of use are being assessed by content and technical experts. The process uses a team approach, employing a bi-level evaluation instrument based on existing software evaluation forms and system bug reports.

Evaluation of long-term maintenance of a large medical knowledge base.

OBJECTIVE: Evaluate the effects of long-term maintenance activities on existing portions of a large internal medicine knowledge base. DESIGN: Five physicians who were not among the original developers of the knowledge base independently updated a total of 15 QMR disease profiles; each updated submission was modified by a review of group serving as the "gold standard, " and the pre- and post-study versions of each updated disease profile were compared. MEASUREMENTS: Numbers and types of changes, defined as any difference between the original version and the final version of a disease profile; reason for each change; and bibliographic references cited by the physicians as supporting evidence. RESULTS: A total of 16% of all entries were modified by the updating process; up to 95% of the entries in a disease profile were affected. The two most common modifications were changes to the frequency of an entry, and creation of a new entry. Laboratory findings were affected much more often than were history, symptom, or physical exam findings. The dominant reason for changes was appearance of new evidence in the medical literature. The literature cited ranged from 1944 to the present. CONCLUSIONS: This study provides an evaluation of the rate of change within the QMR medical knowledge base due to long-term maintenance. The results show that this is a demanding activity that may profoundly affect certain portions of a knowledge base, and that different types of knowledge (e.g., simple laboratory vs expensive or invasive laboratory findings) are affected by the process in different ways.

Cross-platform hypermedia examinations on the Web.

The authors developed a multiple-choice medical testing system delivered using the World Wide Web. It evolved from an older, single-platform, locally-developed computer-based examination. The old system offered a number of advantages over traditional paper-based examinations, such as digital graphics and quicker, easier scoring. The new system builds on these advantages with its true cross-platform design and the addition of hypertext learning responses. The benefits of this system will increase as more medical educational resources migrate to the Web. Faculty and student feedback has been positive. The authors encourage other institutions to experiment with Web-based teaching materials, including examinations.

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.

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.

Evaluating consensus among physicians in medical knowledge base construction.

This study evaluates inter-author variability in knowledge base construction. Seven board-certified internists independently profiled "acute perinephric abscess", using as reference material a set of 109 peer-reviewed articles. Each participant created a list of findings associated with the disease, estimated the predictive value and sensitivity of each finding, and assessed the pertinence of each article for making each judgment. Agreement in finding selection was significantly different from chance: seven, six, and five participants selected the same finding 78.6, 9.8, and 1.6 times more often than predicted by chance. Findings with the highest sensitivity were most likely to be included by all participants. The selection of supporting evidence from the medical literature was significantly related to each physician's agreement with the majority. The study shows that, with appropriate guidance, physicians can reproducibly extract information from the medical literature, and thus established a foundation for multi-author knowledge base construction.

Comparing contents of a knowledge base to traditional information sources.

Physicians rely on the medical literature as a major source of medical knowledge and data. The medical literature, however, is continually evolving and represents different sources at different levels of coverage and detail. The recent development of computerized medical knowledge bases has added a new form of information that can potentially be used to address the practicing physician's information needs. To understand how the information from various sources differs, we compared the description of a disease found in the QMR knowledge base to those found in two general internal medicine textbooks and two specialized nephrology textbooks. The study shows both differences in coverage and differences in the level of detail. Textbooks contain information about pathophysiology and therapy that is not present in the diagnostic knowledge base. The knowledge base contains a more detailed description of the associated findings, more quantitative information, and a greater number of references to peer-reviewed medical articles. The study demonstrates that computerized knowledge bases, if properly constructed, may be able to provide clinicians with a useful new source of medical knowledge that is complementary to existing sources.

An interlingua for electronic interchange of medical information: using frames to map between clinical vocabularies.

The proliferation of medical knowledge has led to the development of extensive dictionaries for electronically accessing information resources. The task of standardizing terminology used for electronic hospital records and for knowledge bases for medical expert systems and indexing the medical literature cannot easily be met by developing a single, monolithic "official" medical vocabulary. Developing a monolithic vocabulary would require a massive effort, and its existence would not guarantee its use by third-party payors, by practicing clinicians, or by developers of electronic medical information systems. Recognizing this, the National Library of Medicine (NLM) has begun to develop the Unified Medical Language System (UMLS) as a means of promoting electronic information exchange among systems with controlled vocabularies. The authors describe a frame-based system developed as an experimental approach to mapping between controlled clinical vocabularies.