Clinical information needs in context: an observational study of clinicians while using a clinical information system.

Clinical Information Needs in Context: An Observational Study of Clinicians While Using a Clinical Information System Leanne M. Currie, RN, MS1,2, Mark Graham, PhD1, Mureen Allen, MB BS1, Suzanne Bakken, RN, DNSc1,2, Vimla Patel, PhD1, and James J. Cimino MD1 1 Department of Biomedical Informatics and 2School of Nursing, Columbia University, New York, NY ABSTRACT Introduction: The development of tools to meet the information needs of clinicians requires an understanding of the clinician and the context in which clinical decisions are being made. Methods: We conducted an observational study of clinicians' information needs via think-aloud protocols during which we observed physicians and nurses as they used the clinical information system. Protocol analysis was then used to identify the information needs events, the types of questions that were asked, the method of meeting that need, the success or failure of meeting the specific information need, and the context in which it arose. Results: Results indicated that a) unmet information needs occur frequently and that b) the predominant feature of these unmet needs is that they are patient-related or domain-specific. Two categories of context: laboratory and medical communication accounted for more than half of the events. INTRODUCTION Research seeking to identify the information needs of clinicians has been carried out in a variety of settings including private medical practices, acute care, ambulatory care, and health sciences libraries.1,2,3 This research consistently demonstrates that during encounters with patients, clinicians have frequent unmet information needs. Thus, even though the physicians may state that they have no information needs, observational studies demonstrate clinicians exhibiting information seeking behavior.1 No prior research has examined the information needs of clinicians while they are using a clinical information system (CIS). It is our contention that research seeking to empirically identify the clinical information needs of clinicians at the point of care, while the clinician is using a CIS, will provide important information about the contexts in which clinical questions arise. Further, once an information need and its context are identified, context-specific information resources can be created and tailored to meet the needs of the clinician during interactions with the CIS. The following observational study was conducted to examine the unmet clinical information needs of attending physicians, housestaff, nurses and medical and nursing students while they used the CIS in a variety of settings in a large academic medical center. We sought to characterize the types of needs, the contexts in which the needs arose, how the users attempted to address their needs, and how successful those attempts were. METHODS Physicians, nurses, and medical students and nursing students from three clinical sites (a general medical/surgical nursing station, the coronary care unit (CCU), and a general medical clinic) at the Columbia-Presbyterian campus of New York Presbyterian Hospital were chosen to participate in the study. Users of the CIS at these sites were observed via using a portable usability lab (PUL)4. The PUL uses a videoconverter, a videocassette recorder and an audiocassette recorder to capture audiotape recordings of the clinicians' voice, as well as videotape of the CIS screen. Informed consent was first obtained and the clinicians were subsequently observed during CIS encounters within the normal course of the day. The PUL was stored away from the clinicians, providing a very unobtrusive method of observation so as to not disrupt the clinicians' workflow. Work-sampling methodology was used to sample the clinicians as they carried out their normal practices. This methodology is based on the premise that randomly spaced observations of workers will provide a normally distributed range of events.5,6 As such, the data were collected over a period of four months at random times of the day and during random days of the week including nights and weekends, capturing a representative sample of individuals and experiences. The observation sites were selected based on this method as well as from system logs that identified clinical areas with high utilization of the CIS. Preliminary analysis of the data collected in the medical/surgical area revealed that AMIA 2003 Symposium Proceedings − Page 190 nurses were not well represented in the initial sample. This was largely due to nurses' limited use of the CIS in their daily tasks in this area. Examination of the log files indicated a high volume of nurses used the CIS in the CCU, which prompted subsequent data collection in this area. Information Need Event Type Subject (Patient) Related to subject (patient) Institution Related to particular place of practice Domain Related to medical or nursing domain Subject-Institution Intersection of subject and institution Subject-Domain Intersection of subject and domain DomainIntersection of domain and institution Institution Subject-DomainIntersection of subject, domain and Institution institution Foreground Subject (patient) management question Background Root question - (e.g. who? what?) Explicit Clinician verbally expresses an information need Implicit Clinician uses a resource other than CIS Resource Type Computer Computer based resource used Human Other clinician or human resource used Paper Paper resource e.g. paper chart or book Outcome Type Success Clinician sought & found information Deferred Clinician did not seek an answer Failure The clinician sought, but did not find desired information Context Laboratory All laboratory reports available on the CIS Patient Report Procedure report or other reports available on the CIS Communication Medical communication via the CIS e.g. Progress notes, medication list Non CIS Computer based resource not accessible Computer via the CIS e.g. Standards of Care Generic CIS General CIS areas such as physician's patient list or department list Non Computer Paper chart, conversation (telephone or in Resource person) Miscellaneous Computer applications, not directly related to domain or patient information Table 1. Information Need Event Coding Categories Once the data were collected, the audiotapes were transcribed and the videotapes were reviewed to identify 'Information Need Events'. The 'Information Need Event' was the unit of analysis for this study because, as has been demonstrated previously, the individual will usually express more than one information need for any given patient encounter.1,7 The Information Need Event was also characterized as the unit of analysis because the context-specific solution will address the Information Need Event not only in the context of the individual, but more importantly, in the context of CIS environment.8 A coding schema that accurately characterized the Information Need Events was developed based on theories related to eviden (...truncated)