ACMI Senior Member Presentation
James J. Cimino, MD, FACMI
Laboratory for Informatics Development
NIH Clinical Center and
Lister Hill National Center for Biomedical Communications
National Library of Medicine
Bethesda, Maryland

Infobutton (noun): in' ·fō· but' ·tən – a link from one on-line information system to another that uses contextual information from the former to facilitate the retrieval of relevant information from the latter.
Example: links in clinical information systems that provide patient-data-specific links to health knowledge resources.
Decision Support.
Passive.
Anticipatory.

• The Why, When, and How of infobuttons?
• Research issues
• Infobutton and infobutton-like systems
• The HL7 standard
• AMIA 2007 demonstration
• Current status of commercial efforts
• Librarian Infobutton Tailoring Environment
(LITE)

Everybody is worried about losing their job to automation. They’re afraid they’ll be replaced by a button. But I’m smart. I’m going to get a job in the factory where they make the buttons.
- Jackie Gleason, The Jackie Gleason Show , circa 1968

G.O. Barnett
DXplain
Covel et al.
Information Needs
UMLS
Project
First Version of UMLS
Mosaic
PubMED
Infobutton
Manager
Standard
Web DXplain
Micromedex
Infobutton
Access
1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
ICD9

MeSH
WebCIS
Infobuttons
Medline
Button
DXplain
Button
Web-based
Generic Queries
Infobutton
Manager
Librarian
Infobutton
Tailoring
Environment
(LITE)

10
8
6
4
2
0 Cimino
Other
1997 1999 2001 2003 2005 2007
Beverly Collins, et al.
Attaching Context Sensitive Infobuttons to an EHR Options and
Issues.
SJ Darmoni, et al.
French Infobutton: an academic and… business perspective.
Per H Gesteland, et al.
Clinician Use and Acceptance of Population-Based Data about
Respiratory Pathogens: Implications for Enhancing Population-Based Clinical
Practice
Sookyung Hyun, et al.
Nurses’ Use and Perceptions of Usefulness of National Cancer
Institute’s Tobacco-related Cancer Information Service (CIS) Resources.
Robert A. Jenders, et al.
Standards in Clinical Decision Support: Activities in Health
Level Seven.

• Common tasks may have common needs
• System knows:
– Who the user is
– Who the patient is
– What the user is doing
– What information the user is looking at
• We may be able to predict the specific need
• User is sitting at a computer!
• We may be able to automate retrieval

MRSA

MRSA
1
Understand
Information
Needs

MRSA
2
Get Information
From EMR
1
Understand
Information
Needs

3
Resource
Selection
MRSA
2
Get Information
From EMR
1
Understand
Information
Needs

4
Resource
Terminology
MRSA
2
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection

4
Resource
Terminology
5
Automated
Translation
MRSA
2
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection

6
Querying
4
Resource
Terminology
5
Automated
Translation
MRSA
2
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection

6
Querying
4
Resource
Terminology
5
Automated
Translation
MRSA
2
Get Information
From EMR
1
Understand
Information
Needs
3
Resource
Selection
7
Presentation

• Columbia University’s Infobutton Manager
• Vanderbilt University’s PC-POETS
• LDS Hospital’s HELP system
• Partners Healthcare System’s Knowledgeliink

• Columbia University’s Infobutton Manager
• New York Presbyterian Hospital’s WebCIS
• New York Presbyterian Hospital’s Eclipsys
• New York State Psychiatric Institute’s PSYCKES
• Regenstrief Medical Record System
• Crystal Run Healthcare’s (Monroe, NY) (NextGen)

Clinical System
Infobutton
Resource s
Query
Knowledge
Base
Context
Infobutton
Manager
Page of
Hyperlinks

• Approved as Draft Standard for Trial Use
(DSTU)
• http://www.hl7.org/v3ballot2008MAY/html/ domains/uvds/uvds_ContextawareInformationRetrieval(Infobutton).htm

Example 1: In this example the user is looking at a coded problem list of a male, 77 years-old patient with Bacterial Pneumonia. The user clicks on an infobutton that presents a series of questions. The user selects “How do I treat Bacterial Pneumonia?”
The following message payload represents the communication between the Decission Support
System and the Information Resource.

<?xml version="1.0" encoding="UTF-8"?> <infobuttonEventNotification>
<effectiveTime value="20060706001023"/>
<subject1> <patientContext> <patientPerson>
<administrativeGenderCode code="M" codeSystem="2.16.840.1.113883.5.1" codeSystemName="AdministrativeGender" displayName="Male"/>
</patientPerson>
<subjectOf> <age>
<code code="30525-0" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LN" displayName="AGE"/>
<value value="77" unit="a"/>
</age> </subjectOf> </patientContext> </subject1>
<subject2> <taskContext>
<code code="PROBLISTREV" codeSystem="HL7-Infobutton" codeSystemName="HL7-infobutton" displayName="Problem List Review"/>
</taskContext> </subject2>
<subject3> <subTopic>
<code code="Q000628" codeSystem="2.16.840.1.113883.6.177" codeSystemName="MSH" displayName="therapy"/>
</subTopic> </subject3>
<subject4> <mainSearchCriteria>
<code code="D018410" codeSystem="2.16.840.1.113883.6.177" codeSystemName="MSH" displayName="Bacterial Pneumonia">
<originalText>Pneumonia</originalText>

http://www.e-resource.com/api? infobuttonEventNotification.effectiveTime
.
v =20060706001023& assignedEntity.name.r= Organization-
Username& assignedEntity.certificateText.r= organization-password& patientPerson.administrativeGenderCode
.
c =F& patientPerson.administrati
veGenderCode .
dn =Female age .
v .
v =77& age .
v .
unit =a ageGroup .
v .
c =D000368& ageGroup .
v .
cs= 2.16.840.1.113883.6.177& ageGrou p .
v .
dn= Aged taskContext.c.c
=PROBLISTREV& taskContext.c.dn
=Problem+list+review& subTopic.c.c
=Q000628& subTopic.c.cs
=2.16.840.1.113883.6.177& subTopic.
c.dn
=therapy mainSearchCriteria.c.c
=D018410& mainSearchCriteria.c.cs
=2.16.840.1.1138
83.6.177& mainSearchCriteria.c.dn= Bacterial+Pneumonia& mainSearchCriteria.c.ot= Pneumonia

• Health care & academic institutions
– Intermountain Healthcare, Columbia University,
Partners Healthcare
• Content providers
– Wolters Kluwer Health, ACP, EBSCO,
Thomson/Micromedex, UpToDate, Lexicomp

• Epic – InfoButton with direct connection to specific resources
• Eclipsys – Infobutton tab using HL7 standard

• University of Utah
– Applications: HELP2 Clinical Desktop, narrative practice guidelines
– HL7 compliant, but using original API
– Resources: Micromedex, Clineguide, MDConsult,
PubMed, Medline Plus, Genetics Home Reference,
Gene Tests, Uptodate, Ebsco (Cochrane and CINAHL),
ARUP Consult, ICD9 search web site, Intermountain
Care Process modules, Intermountain geriatric drug monographs
– Context parameters: task context, main search criteria, age, gender, subtopic, observation interpretation (for labs), content recipient, and authentication parameters

• Columbia University
– Applications: WebCIS, Eclipsys, Regenstrief Medical Record
System, generic
– HL7 compliant, but using original API
– Resources: Anion Gap Calculator, ARUP Reference Manual,
Beers Criteria, CancerWEB, CPMC Lab Manual,
DrugConsult, FirstConsult , Dxplain, ECG Interpreter,
Eclipsys Training, Harrisons Principles of Internal Medicine,
Lab Tests Online, LexiComp, MCW Pregnancy Calculator,
Medicine on the Net, Micromedex, Miriam-Webster, National
Guidelines Clearinghouse , NYPH Antibiotics Guidelines,
OneLook, Proquest, PubMed, Rhuematology.org, RxList,
UpToDate
– Context parameters: task context, main search criteria, age, gender, user type, user ID, medical record number, authentication parameters, “other available data”

• Thomson/Reuters
– Applications: Mediware Worx, Ex Libris, Crown, "Ask
Mayo“
– Limited HL7 compliance
– Resources: (Micromedex) Clinical Drug, Clinical
Disease, Clinical Lab, Consumer Drug, Consumer
Disease, Consumer Lab, Clinical Checkpoints
– Context parameters: Application, Care Setting,
Institution, Content Target, Language, Subtopics
• EBSCO
– Resources: Medline, Dynamed, CINAHL
– HL7 InfoButton Manager; working to extend functionality
– Translator

• Wolters Kluwer
– Resources: Clin-eguide
– HL7: Clin-eguide
– Parameters: Provider Information, ICD9-CM,
SNOMED CT, LOINC, RxNorm, result high/low, age, age group, subtopic, such as diagnosis or treatment
• Elsevier
– Resources: DrugConsult, FirstConsult
• PIER – currently in hibernation

Infobutton Manager
System
Maintainer
Infobutton Manager
Maintenance Tool
Functions:
Browse
Add
Update
Delete
Translation
Table
Context
Table
Infobutton
Table
Term
Translation
Context
Matching
Query
Construction
Clinician
Page of
Links

Librarian Infobutton Tailoring Environment (LITE)
Librarian Infobutton
Tailoring Environment
(LITE)
Context
Definition
Translation
Table
Infobutton Manager
Term
Translation
Clinician
Terminology
Specification
Context
Table
Context
Matching
Institution
Librarian
Question
Construction Infobutton
Table
Query
Construction
Resource
Selection
Page of
Links
Resource
Utilization
Infobutton
Manager
Log File
LITE Auditing
Infobutton Manager
Monitoring
LITE Monitoring
LITE
Log File

1) Establish librarian user community
2) Refine LITE features
3) Collect feedback from librarians
4) Develop documentation
5) Collect feedback from librarians
6) Go to (2)

• Infobuttons and infobutton-like applications have a long history of development in the informatics community
• Context-specific links improve patient care
• The World Wide Web made resources available and made integration feasible
• The HL7 standard is driving adoption by clinical system vendors and knowledge vendors
• Tools are needed to enable institution-specific customization
• Join LITE and help out

• Jianhua Li
• Many student contributors
• Steve Johnson
• Sue Bakken
• Leanne Currie
• Guilherme Del Fiol
• Saverio Maviglia
• Noemie Elhadad
• National Library of Medicine

Buttons.
- Jimmy Cimino, 1956