Infobuttons are context-sensitive links embedded within a Clinical Information System (CIS) or PHR, which allow easy retrieval of relevant information. During patient care, clinicians frequently have need for information related to their clinical care activities. These questions often go unanswered due to lack of time or readily available resources. Estimates of information needs are as high as four questions per patient encounter(1). Failure to answer these questions may result in patient error and adverse outcomes. The Infobutton makes it easier for providers to access the information they need at the point of care.
Examples of URL following HL7 standard
A physician enters a chief complaint of “fever“ for a male, 39 years-old patient at the emergency room.
Patient is looking within a PHR for info on HbA1c test on LabTests.org
PHR Example Patient wants infomation from MedlinePlus on diagnosis of Alzheimer disease entered in his PHR
See HL7 URL implementation guide http://www.hl7.org/implement/standards/product_brief.cfm?product_id=22 for more info
The Infobutton functions by generating and sending queries to electronic health information resources using data extracted from the patient record. The CIS displays a button next to information such as diagnoses or medications. When clicked, the Infobutton formulates a query based on the context of the interaction, including patient demographics, activity being performed, as well as the user role.(2) Thus, a nurse preparing to administer a medication to a 70 year old woman will generate a different query than a physician reviewing the medication list of a 10 year old boy. The results of the query will then be displayed by the CIS itself, or by an Infobutton Manager, a concept proposed by James J. Cimino(3).
An Infobutton Manager is software that supports the implementation of Infobuttons in an institution and application independent manner.(3) The CIS passes parameters to the Infobutton Manager which generates an HTML document with a set of natural language questions which are hyperlinks to clinical information resources.
Infobutton systems have been created at Columbia University, Partners Healthcare System, and Intermountain Healthcare System. In addition a number of commercial Infobutton products are being developed or offered from companies such as Epic, Thompson Micromedex, and MDConsult. Since CIS systems may include products from multiple vendors, it is important to have a standard for passing information from the CIS to the Infobutton Manager and from the Infobutton Manager to the electronic resources. For this reason, there is a proposed HL-7 standard for the Infobutton API which is currently being reviewed.(2)
HL7's Context-Aware Knowledge Retrieval (Infobutton), Knowledge Request Standard, was approved in September 2010 as a normative ANSI/ISO HL7 standard. This specification provides a standard mechanism for clinical information systems to submit knowledge requests to knowledge resources. The specification also defines a shared context information model to be implemented by EHR/PHR systems and knowledge resources. The normative specification is included in the final EHR Meaningful Use Stage 2 Standards and Certification Criteria released by the Office of the National Coordinator of Health IT (ONC) on August 23, 2012. In addition, a URL-based implementation guide has been developed to specify knowledge request implementations using the HTTP protocol. A second implementation guide is a draft standard for trial use (DSTU) called Context-Aware Knowledge Retrieval, Service-Oriented Architecture (SOA). Both implementation guides were adopted as part of the reference source functional standard that includes the HL7 Version 3 Infobutton in the final EHR Meaningful Use Stage 2 criteria.
Studies have shown that doctors have a high need for information to answer the multitude of questions that arise during clinical care, and the majority of these questions go unanswered. Linking to knowledge-based resources at the point of care could be an effective means for addressing these needs and supporting evidence and guideline-based practice. Infobuttons have been used to provide context-sensitive links to relevant textual information from strategic locations in the EHR, There remains a need to study the efficacy of these systems in answering clinical questions and influencing medical decision making. One recent study at Partners HealthCare system showed the KnowledgLink medication infobutton to answer 84% of clinicians’ questions, thereby altering 15% of patient care decisions . Another study showed that 74% of infobutton users responding to a survey felt the system had a positive impact on their patient care decisions . A recent review of several methods for providing decision support to nurses at the point of care describes an infobutton implementation including usage statistics. The article emphasizes the need to integrate such contextual information links into clinical workflow in order to effectively support evidence-based nursing practice . Another recent study from Intermountain Healthcare, shows the usage of infobuttons steadily increasing over a four-year period. The highest number of uses came from the medication order entry infobuttons. The authors conclude that additional research and development is needed in order for the true benefits of infobutton implementation to be realized .
Del Fiol and colleagues followed this study with a randomized controlled trial to determine whether infobutton links that direct to specific content topics (“topic links”) are more effective than links that point to general overview content (“nonspecific links”) . Measurements included infobutton session duration, number of infobutton sessions, session success rate, and the self-reported impact the infobutton session produced on decision making. Ninety subjects and 3,729 infobutton sessions were analyzed, with those in the intervention group spending 17.4% less time attempting to obtain information (35.5 seconds vs. 43 second, p 0.008) than those in the control group. While the difference was not significant, the intervention group used infobuttons 20.5% (22 sessions vs. 17.5 sessions, p 0.21) more often than the control group. The success rate for information seeking was equally high in both groups (89.4% control vs. 87.2% intervention, p � 0.99), and a high positive clinical impact (i.e., decision enhancement or knowledge update) was reported in 62% of the sessions. The study was limited by exclusion of users with a low frequency of infobutton use and by the focus on medication-related information needs. In addition, the session outcomes measurement was based on clinicians’ self-assessment and therefore prone to bias. The authors conclude study results support the hypothesis that topic links are more efficient than nonspecific links in relation to the time elapsed in attempting to obtain information. Due to the study limitations the authors note, "It is unclear whether the statistical difference demonstrated will result in a clinically significant impact. However, the overall results confirm previous evidence that infobuttons are effective at helping clinicians to answer questions at the point of care and demonstrate a modest incremental change in the efficiency of information delivery for routine users of this tool." �
- Maviglia, S.M., et al., KnowledgeLink: impact of context-sensitive information retrieval on clinicians' information needs. J Am Med Inform Assoc, 2006. 13(1): p. 67-73.
- Cimino, J.J. Use, usability, usefulness, and impact of an infobutton manager. Proc AMIA Symp, 2006: p. 151-155.
- Bakken, S., et al., Integrating evidence into clinical information systems for nursing decision support. Int J Med Inform, 2007. [Epub ahead of print]
- Del Fiol, G., R.A. Rocha, and P.D. Clayton. Infobuttons at Intermountain Healthcare: utilization and infrastructure. AMIA ... Annual Symposium proceedings / AMIA Symposium, 2006: p. 180-4.
- Del Fiol, G., Haug, P.J., Cimino, J.J., Narus, S.P., Norlin, C, and Mitchell J.A. Effectiveness of Topic-specific Infobuttons: A Randomized
Controlled Trial.  J Am Med Inform Assoc. 2008;15:752–759. DOI 10.1197/jamia.M2725.
--Eweeks 16:46, 26 August 2012 (PDT)Submitted by Ericka Weeks: Update to "Infobuttons" (paragraph 5), and to "Updates on the Benefits of Infobuttons" (paragraph 2)
- Osherhoff SA, Forsythe DE, Buchanan BG, Bankowitz RA, Blumenfeld BH, Miller RA. Physicians’ information needs: analysis of questions posed during clinical teaching. Ann Intern Med. 1991; 114:576-81.
- Del Fiol G, Rocha R, Cimino JJ. HL-7 Infobutton standard API proposal. Draft Apr 24, 2004.
- Cimino JJ, Li J, Bakken S, Patel VL. Theoretical, empirical and practical approaches to resolving the unmet information needs of clinical information system users. Proceedings of the American Medical Information Association. 2002; 170-174