Sunday, April 13, 2014

Additional OHSU Contributions to Clinical Informatics Subspecialty Training

In addition to having our own clinical informatics fellowship, Oregon Health & Science University (OHSU) will be contributing to training in the subspecialty in other ways. One of main activities by which we will be contributing will be through providing courses in our biomedical informatics distance learning program to other programs. This is actually something we have been doing for a number of other university programs for several years, and now we are excited to do it for clinical informatics fellowship programs.

Our approach will be straightforward, as fellows in other programs will enroll as OHSU distance learning students. In discussion with colleagues directing the programs that will take part, the emerging preference for them appears to be our Graduate Certificate Program, which requires eight academic-quarter three-credit courses. Trainees will take one or two courses at a time. We also hope to enroll students from participating programs as a cohort and provide interactive opportunities for fellows in our program and those from other institutions who take our courses.

We anticipate fellows will be interested in a variety of our courses that are offered online, though have designated five courses as core to their studies, indicated by asterisks below:
BMI 510 - Introduction to Biomedical and Health Informatics*
BMI 512 - Clinical Information Systems*
BMI 513 - Electronic Health Record Laboratory
BMI 514 - Information Retrieval
BMI 515 - Ethical, Legal and Social issues in Biomedical Informatics
BMI 516 - Standards and Interoperability in Healthcare
BMI 517 - Organizational Behavior and Management*
BMI 518 - Project Management*
BMI 519 - Business of Healthcare Informatics*
BMI 520 - Consumer Health Informatics
BMI 521 - Public Health Informatics
BMI 523 - Clinical Research Informatics
BMI 537 - Healthcare Quality
BMI 544 - Databases
BMI 548 - Human-Computer Interaction
BMI 549 - Health Information Privacy and Security
BMI 560 - Design & Evaluation in Health Informatics

In order to help program directors determine the best course of study for their fellows, we have mapped all of our courses to American Board of Preventive Medicine (ABPM) core content in clinical informatics. For each course, the linked document shows whether the core content item is covered by lecture (L), article (A), reading (R), book (B), and/or exercise (E). The first five columns, highlighted in yellow, represent the content of the core courses as defined above. (We offer even more courses than this, some of which are only offered on-campus, but the entire list can be found in our course catalog.)

One question I commonly get from Program Directors concerns our tuition costs. Our tuition schedule for the 2014-2015 academic year is shown in the image below. The full cost for eight three-credit courses in the Graduate Certificate program is about $19,000. We hope to add value to that by facilitating interaction among fellows in our program and others.

I look forward to clinical informatics fellowship programs launching and OHSU playing a role in a number of them. Just as our distance learning program has led to a virtual community forming among our entire student population, I hope that a similar group will emerge among clinical informatics fellows.

Thursday, April 10, 2014

OHSU Launches Clinical Informatics Fellowship

I am pleased to announce that Oregon Health & Science University (OHSU) is formally launching its clinical informatics fellowship for physicians. We are now accepting applications for those wanting to start in July, 2014. This fellowship does not replace any of our existing fellowships or other educational programs, which include programs for physicians and non-physicians alike, but is another addition to the OHSU family of informatics educational programs.

The OHSU Clinical Informatics Fellowship will provide physicians with training in clinical informatics that will enable them to achieve board certification in the new subspecialty of clinical informatics. The program will follow the format of the guidelines recently published by the Accreditation Council for Graduate Medical Education (ACGME). The fellowship is currently applying to obtain ACGME accreditation, which will be awarded to programs starting later this year. Fellows will divide their time between informatics project work, didactic courses leading to the awarding of the Graduate Certificate in Biomedical Informatics, and clinical practice in their primary specialty. Per ACGME rules, this is a two-year fellowship that must be done full-time and completed on-site at OHSU.

The fellowship is affiliated with the OHSU Department of Medicine, with additional administrative support provided by the OHSU Department of Medical Informatics & Clinical Epidemiology (DMICE). Physicians of all medical specialties may apply. More information has been posted to the DMICE Web site, including a link to the application form.

As defined by the ACGME, clinical informatics is the subspecialty of all medical specialties that transforms health care by analyzing, designing, implementing, and evaluating information and communication systems to improve patient care, enhance access to care, advance individual and population health outcomes, and strengthen the clinician-patient relationship. Eligibility for subspecialty certification is not limited to any particular medical specialty. The new specialty was launched in 2013, with physicians already working in the field able to sit for the certification exam by meeting prior practice requirements. Starting in 2018, this "grandfathering" pathway will go away, and only those completing an ACGME-accredited fellowship will be board-eligible.

This new fellowship does not replace any existing OHSU informatics fellowship or other informatics educational program. It is a new addition to the OHSU family of informatics educational opportunities that includes a graduate program, a research fellowship funded by training grants from the NLM and other sources, and clinical fellowships offered by the Portland VA and Kaiser Permanente Northwest.

OHSU will also be providing educational content to other clinical informatics fellowship programs around the country through our online educational program. I will provide more information about this in the near future.

Wednesday, April 2, 2014

Who is Using the ONC Health IT Curriculum?

Who are the users of the Office of the National Coordinator for Health Information Technology (ONC) Curriculum? Clearly one audience is the community colleges who were funded by ONC to develop short-term training programs using the materials (82 originally, perhaps fewer now that ONC funding for the community college programs has ended).

Those of us developing the materials always knew there was a much wider audience for them, and this was borne out recently from a discussion thread on the public listserv of the AMIA Education Working Group. In early 2014, a list member posted a simple query: "Please respond to this message if you are using the educational content developed by ONC. It would be helpful to know what content you are using, the courses, and the name of the academic program."

There were a total of 15 distinct replies, and I collated them, removing all the names of those who posted as well as their institutions. The responses indicated a great diversity of users utilizing the ONC curricular materials in a variety of contexts and in different types of training opportunities:

1. We are using the HIPAA and History material in coursework for Psychiatric and Mental Health Nurse Practitioner (MSN) students.
- Assistant Professor, Nursing Informatics Specialty Coordinator, University

2. I use some materials on standards in a course for translational medicine students.
- Professor, Health Informatics, University

3. We are using some materials for a new health informatics course for allied health undergraduates at a university in Botswana.
- Professor, Epidemiology, University

4. I use the instance of the VA's VistA in an EHR lab course.
- Assistant Professor, Department of Medical Informatics, University

5. I used the material to develop a course on health culture and another on IT security for informatics students.
- Professor, Department of Medicine, University

6. Our Health Informatics Program is using the instance of Vista.
- Professor, Nursing Informatics, University

7. I am using sections for developing a Project Management course.
- Assistant Professor, University

8. We are using elements of Components 1 and 2 in an introductory course on the health care system.
- Instructor, Health Informatics Graduate Program, University

9. I am using portions for a Dental Informatics course in a Dental Hygiene Degree Completion Program.
- Instructor, College

10. I am currently developing a health informatics course for MSN Nursing Administration Students and am planning to use some of the lectures.
- Professor, University

11. I am using the Component 10, Fundamentals of Health Workflow Process Analysis and Redesign, in one-semester, 3-credit-hour, completely on-line course.
- Instructor, University

12. I am using it in several graduate courses: 1) Electronic Health Records - 4 unit course - Masters of Health Informatics, 2) Applied Health Informatics - 4 Unit Course - Masters and PhD in Nursing Science and Leadership, and 3) Applied Health Informatics - 4 unit course - Masters Degree Nurse Practitioner and Physician Assistance courses.
- Associate Adjunct Professor, Health Informatics Graduate Program, University

13. We are using the content in our Introduction to Health Informatics course developed as a first course for certificate and graduate students, incorporating video for several of the content areas across the 15 week modules.
- Associate Professor, University

14. ONC educational content has crossed the Pacific Ocean as well. I have used the following content:
A. Bachelor's Program in Information and Communication Technology (ICT) (Health IT Major)
A.1 Parts of Component 12 Units 1-12 for "Quality in Healthcare Organizations" class in the "Introduction to Health Care Systems" course
A.2 Parts of Component 7 Units 2-3 for "Hospital Services & Management" class in the "Introduction to Health Care Systems" course
A.3 Parts of Component 6 Unit 9 for "Departmental Information Systems and Management Information Systems" class in the "IT for Healthcare Services" course
B. Diploma and Master's Programs in Biomedical and Health Informatics
B.1 Parts of Component 1 Units 1a, 1b, 1c, 7a, for "Overview of Healthcare services" class in the "Fundamentals of Health Care and Medical Terminology" course
B.2 Parts of Component 1 Units 3a, 3b, 3c, 3d, 2c; Component 7 Unit 2a for "Operations in the Clinical Settings" class in the "Fundamentals of Health Care and Medical Terminology" course
B.3 Parts of Component 12 Units 1-12 for "Quality in Health Care Organizations" class in the "Fundamentals of Health Care and Medical Terminology" course
- Instructor, University, Bangkok, Thailand

15. I am teaching a course this semester on clinical decision support systems (required for our MS and PhD programs in Health Informatics), so I have borrowed from several of the components: EHR Component, Unit 2 on CDS; HIE Component, Unit 7 on CDS; HIM Component, Unit 5 on CDS
- Professor, University

One challenge for those using the curriculum is the sheer amount of material. Related to this is the lack of an outline of the entire curriculum. I recently had the opportunity to collate all of the components and units within them into a single outline, which I will include in this posting.

ONC Curriculum Topical Outline

1. Introduction to Healthcare and Public Health in the US
1. Introduction and History of Modern Healthcare in the US
2. Delivering Healthcare (Part 1)
3. Delivering Healthcare (Part 2)
4. Financing Healthcare (Part 1)
5. Financing Healthcare (Part 2)
6. Regulating Healthcare
7. Public Health (Part 1)
8. Public Health (Part 2)
9 Healthcare Reform
10. Meaningful Use

2. The Culture of Healthcare
1. An Overview of the Culture of Healthcare
2. Health Professionals – the People in Healthcare
3. Healthcare Settings – The Places Where Care is Delivered
4. Healthcare Processes and Decision Making
5. Evidence-Based Practice
6. Nursing Care Processes
7. Quality Measurement and Performance
8. Ethics & Professionalism
9. Privacy & Security
10. Sociotechnical Aspects:  Clinicians and Technology

3. Terminology in Health Care and Public Health Settings
1. Understanding Medical Words
2. Integumentary System
3. Musculoskeletal System
4. Blood, Lymphatic and Immune System
5. Cardiovascular System
6. Digestive System
7. Endocrine System
8. Ears, Nose, Throat, Eye and Vision
9. Nervous System
10. Reproductive System
11. Respiratory System
12. Urinary System
13. Public Health and Healthcare System Terminology
14. What is Health Information Management and Technology?
15. Electronic Health Records
16. Standards to Promote Health Information Exchange

4. Introduction to Information and Computer Science
1. Basic Computing Concepts, Including History
2. Internet and the World Wide Web
3. Computer Hardware
4. Computer Software
5. Computer Programming
6. Databases and SQL
7. Networks
8. Security
9. Information Systems
10. Future of Computing

5. History of Health Information Technology in the U.S.
1. Evolution of Health IT: The Early Years
2. Evolution of Health IT: The Modern Era
3. Evolution of Health IT: The HITECH Act
4. Evolution of Public Health Informatics
5. Evolution of Nursing Informatics and HIT Tools Used By Nursing
6. History of Electronic Health Records (EHRs)
7. History of Clinical Decision Support Systems
8. History of CPOE and E-Prescribing
9. History of Health Information Exchange
10. History of Privacy and Security Legislation
11. Software Certification and Regulation
12. History of Mobile Computing
13. History of Telemedicine
14. History of Quality Improvement and Patient Safety
15. Payment-Related Issues and the Role of HIT
16. History of Health IT Organizations

6. Health Management Information Systems
1. What is Health Informatics?
2. Health Information Systems Overview
3. Electronic Health Records
4. Computerized Provider Order Entry (CPOE)
5. Clinical Decision Support Systems
6. Patient Monitoring Systems
7. Medical Imaging Systems
8. Consumer Health Informatics
9. Administrative, Billing, and Financial Systems

7. Working with Health IT Systems (Lab)
1. Introduction & Overview: Components of HIT Systems
2. Under the Hood: Functions of HIT Systems
3. Understanding Information Exchange in HIT Systems
4. The Effective HIT System
5. Fundamentals of Usability in HIT Systems – What Does It Matter?
6. HIT Facilitated Error—Cause and Effect
7. Protecting Privacy, Security, and Confidentiality in HIT Systems
8. HIT System Planning, Acquisition, Installation, & Training:  Practices to Support & Pitfalls to Avoid
9. Potential Issues with Adoption and Installation of an HIT system
10. HIT and Aspects of Patient-Centered Care
11. Health IT in the Future

8. Installation and Maintenance of Health IT Systems (Lab)
1. Elements of a Typical EHR System
2. System Selection – Software and Certification
3. System Selection – Functional and Technical Requirements
4. Structured Systems Analysis and Design
5. Software Development Life Cycle
6. System Security Procedures and Standards
7. System Interfaces and Integration
8. Troubleshooting, Maintenance and Upgrades, and Interaction with Vendors, Developers, and Users
9. Creating Fault Tolerant Systems, Backups, and Decommissioning
10. Developing a Test Strategy and Test Plan
11. Pilot Testing and Full-Scale Deployment

9. Networking and Health Information Exchange
1. ISO Open Systems Interconnection (OSI)
2. Network Media and Hardware Communication Devices
3. National and International Standards Developing Organizations
4. Basic Health Data Standards
5. EHR Functional Model Standards
6. Health Data Interchange Standards
7. Supporting Standards for EHR Applications
8. Enterprise Architecture Models
9. Privacy, Confidentiality, and Security Issues and Standards
10. Health Information Exchange

10. Fundamentals of Health Workflow Process Analysis & Redesign
1. Concepts of Processes and Process Analysis
2. Process Mapping Theory and Rationale
3. Interpreting and Creating Process Diagrams
4. Acquiring Clinical Process Knowledge
5. Process Analysis
6. Process Redesign
7.  Facilitating Meetings for Implementation Decisions
8. Quality Improvement Methods
9. Leading and Facilitating Change
10. Process Change Implementation and Evaluation
11. Maintaining and Enhancing the Improvements

11. Configuring Electronic Health Records (Lab)
1. Migration to an Electronic Health Record System
2. Patient Care Clinical Workflow; Multiple Perspectives of Patient Care (VistA Demo)
3. Implementing Clinical Decision Support (VistA Demo)
4. Building Order Sets (VistA Demo)
5. Creating Data Entry Templates (VistA Demo)
6. Health Summary and Clinical Reminder Reports (VistA Demo)
7. Privacy and Security in the US
8. Meaningful Use and Implementation

12. Quality Improvement
1. Introduction to Quality Improvement and Health Information Technology
2. Principles of Quality and Safety for HIT
3. Introduction to Reliability
4. Reliability and Culture of Safety
5. Decision Support for Quality Improvement
6. Workflow Design
7. HIT Design to Support Teamwork and Communication
8. HIT and Infecting a Patient Safety Culture
9. HIT Implementation Planning for Quality and Safety
10. Measuring Quality
11. Data Quality Improvement
12. Learning from Mistakes. Error Reporting and Analysis and HIT

13. Public Health Information Technology
1. Overview & contribution to public health through Electronic Health Record use
2. Privacy, Confidentiality and Security of Public Health Information
3. Data Standards in Public Health Information Technology
4. Public health enabled electronic health records and the role of public health in health information exchange
5. Epidemiological databases and registries – Public health information tools
6. Biosurveillance, Situational awareness and disaster response
7. Public health reporting, alerts and decision support
8. The potential of public health IT for health promotion and chronic disease prevention
9. Quality Reporting
10. Encouraging adoption/use of population health functions for EHRs and Consumer functions for PHRs

14. Special Topics Course on Vendor-Specific Systems
1. Common commercial electronic health record (EHR) systems used in ambulatory and inpatient care settings
2. Certification of commercial Electronic Health Records (EHRs)
3. How do organizations select an EHR? Lessons from the front lines
4. Electronic Health Record (HER) Functionality
5. System and database architectures used in commercial EHRs
6. Vendor strategies for terminology, knowledge management, and data exchange
7. Assessing decision support capabilities of commercial EHRs
8. EHR Go-live strategies

15. Usability and Human Factors
1. People and technology, studies of technology
2. Requirements engineering
3. Cognition and Human Performance
4. Human factors and healthcare
5. Usability evaluation methods
6. Electronic health records and usability
7. Clinical decision support and usability
8. Approaches to design
9. Ubiquitous Computing
10. Designing for safety
11. Input and selection
12. Information visualization

16. Professionalism/Customer Service in the Health Environment
1. Customer Service in Healthcare IT
2. Professional Behavior in the Healthcare Environment
3. Overview of Communication Relevant to Health IT
4. Key Elements of Effective Communication
5. Regulatory Issues. HIPAA and Standard Precautions
6. Team and Small Group Communication
7. Conflict Resolution
8. Ethical and Cultural Issues Related to Communication and Customer Service
9. Personal Communications and Professionalism

17. Working in Teams
1. Health IT Teams: Examples and Characteristics
2. Forming and Developing a Team for HIT
3. Initial Tools for Teaming: Ground Rules & Action Plans for HIT Team
4. Team Strategies and Tools to Enhance Performance and Patient Safety: TeamSTEPPS
5. Leveraging Integration Techniques: Power of HIT Team Dynamics
6. Articulating Feedback and Feedforward: Tracking Success and Change
7. Leadership: All Members as Leaders – Leaderful Teams
8. Sharing Resources and Information: Tools to Optimize Performance of HIT Teams
9. Positioning for High Performance Teaming:  Challenges and Opportunities in the HIT Environment
10. Barriers to Success:  Reading Early Warning Signs of HIT Team Failure
11. Life Cycle of HIT Teams: Reforming and Repositioning Techniques

18. Planning, Management and Leadership for Health IT
1. Introduction to Leadership
2. The Management and Leadership Distinction
3. Key Concepts Associated with Leadership
4. Effective and Ineffective Leaders
5. Overview of the IT Strategic Planning Process
6. Achieving External Alignment
7. Team and Small Group Communication
8. Conflict Resolution
9. Purchasing and Contracting
10. Change Management

19. Introduction to Project Management
1. Overview of Health IT Projects
2. Project Life Cycles
3. Project Selection and Initiation
4. Project Planning Overview
5. Managing Project Scope
6. Managing Project Time, Cost, and Procurements
7. Managing Project Risk
8. Team Management and Communications
9. Project Monitoring and Control
10. Quality Management
11. Project Closure and Transition

20. Training and Instructional Design
1. Introduction to Training and Adult Learning
2. Needs Analysis
3. Creating a Lesson Plan
4. Selecting and Working with Media
5. Building & Delivering Effective PowerPoint Presentation
6. Assessments
7. Learning Management Systems
8. Web 2.0 and Social Networking Tools

Thursday, March 27, 2014

Needed: A Research Agenda and Program for Clinical Informatics

I recently had the opportunity to hear a talk by Philip Bourne, PhD, the new Associate Director for Data Science at the National Institutes of Health (NIH). I have always been impressed with Dr. Bourne's work in bioinformatics, and I welcome the NIH paying attention to data science throughout it new Big Data to Knowledge (BD2K) Program.

Dr. Bourne gave an excellent talk, laying out a vision for how data science will improve health. He also reiterated his view of "Big Data," published recently in Journal of the American Medical Informatics Association (JAMIA), which focused less on the quantity of data and more on clinical, research, and other health-related organizations making maximal use of all of their data assets [1]. This is in distinction, as noted by another commentary, about a certain vagueness when definitions of Big Data focus on the word "big" [2]. Dr. Bourne's utilitarian view makes more sense to me, since there are many "small" data issues around clinical data, such as quality, completeness, and provenance, that must be solved before we can trust and apply the output of Big Data systems [3].

Nonetheless, what I believe was under-appreciated in Dr. Bourne's talk, which is common among those coming from the bioinformatics world where data is more regular and complete, was the scientific issues underlying the challenges of clinical data. Yes, we are (finally!) entering an era when patient data is increasingly captured in electronic form. But just because clinical data is plentiful does not mean it is good data, and there is no evidence, as is sometimes asserted, that more plentiful quantities of data will overcome some of its quality problems. I certainly agree that clinical trials as we now perform them are small, expensive, and may not have generalizability. But that does not prove that multiple orders of magnitude larger quantities of observational data will be better.

I certainly have enthusiasm for using data in our clinical systems. I believe there will be tremendous opportunities for leveraging the value of data, especially when it is of high quality. We will, for example, be able to validate the results of experimental studies on a much larger scale. We will also be able to find many uses for predictive analytics, such as identifying patients where we can intervene to ward off poor outcomes or find ways to deliver healthcare services more efficiently. There is no end to the possible value of Big Data in healthcare and biomedicine.

But the fruits of more data will not be realized just by accumulating more of it in digital systems. One of the big challenges was eloquently stated by another attendee of the talk, Dr. Justin Starren of Northwestern University, who noted that while data science deals with important problems, it takes place outside of the workflows addressed by clinical informatics. On the front end, data science says very little about data entry, workflow, usability of EHRs, and other factors that have, according to a recent survey by Medical Economics magazine, made EHRs the bane of many clinicians [4]. On the back end, there are challenges too, such as whether the output of data analytical algorithms can be applied in ways that measurably benefit clinical outcomes [5].

These are important as growing criticism emerges from clinicians regarding currently used EHRs. We also know that while a good deal of research shows benefits of IT [6], other research raises concerns about its safety [7]. Clearly we have a ways to go before we solve the end-to-end goal of electronic record-keeping leading to improved health or healthcare delivery.

To this end, we need a research agenda for clinical informatics. The problem is that we do not have a well-funded federal agency devoted to research in this area. The National Library of Medicine (NLM) is an obvious home for such research, especially as many of us have careers that have been propelled by NLM funding. However, many people don't immediately think of a "library" for this kind of work. In addition, the NLM's research budget is small; for example, only 13 research grants were awarded last year. Another government agency that funds this kind of work might be the Agency for Healthcare Research & Quality (AHRQ), which has a rich health information technology (HIT) portfolio. However, as important as AHRQ studies are, they mostly focus on applications of HIT and do not get down to the core scientific issues addressed above. Some of the other institutes of the NIH fund informatics research, but is usually applied in disease-specifc ways (e.g., the National Cancer Institute and the National Institute of Diabetes and Digestive and Kidney Diseases). There are other government agencies that funded some general types of informatics research, such as the National Science Foundation (NSF), although NSF eschews disease-specific research.

I recognize we are in an era of tight federal research funding, with few dollars for investing in new programs. I am hopeful that the investments being made in data science will take a broad focus and include investigation into better ways to produce high-quality clinical data as well as optimally use it to improve health, clinical outcomes, and healthcare delivery. In the long run, however, our healthcare system really needs a research agenda and program for clinical informatics.

References

1. Bourne PE, What Big Data means to me. Journal of the American Medical Informatics Association, 2014. 21: 194-195.
2. Ward JS and Barker A, Undefined by data: a survey of big data definitions. Databases (cs.DB), 2014. http://arxiv.org/abs/1309.5821.
3. Hersh WR, Weiner MG, Embi PJ, Logan JR, Payne PR, Bernstam EV, et al., Caveats for the use of operational electronic health record data in comparative effectiveness research. Medical Care, 2013. 51(Suppl 3): S30-S37.
4. Verdon DR, Physician outcry on EHR functionality, cost will shake the health information technology sector, Medical Economics. February 10, 2014. http://medicaleconomics.modernmedicine.com/medical-economics/news/physician-outcry-ehr-functionality-cost-will-shake-health-information-technol.
5. Amarasingham R, Patel PC, Toto K, Nelson LL, Swanson TS, Moore BJ, et al., Allocating scarce resources in real-time to reduce heart failure readmissions: a prospective, controlled study. BMJ Quality & Safety, 2013. 22: 998-1005.
6. Jones SS, Rudin RS, Perry T, and Shekelle PG, Health information technology: an updated systematic review with a focus on meaningful use. Annals of Internal Medicine, 2014. 160: 48-54.
7. Anonymous, Health IT and Patient Safety: Building Safer Systems for Better Care. 2012, Washington, DC: National Academies Press.

Saturday, March 15, 2014

ONC Health IT Workforce: Funding Over But Activity Not

Although funding from the Health Information Technology for Economic and Clinical Health (HITECH) Act has ended, workforce development efforts continue at the Office of the National Coordinator for Health IT (ONC) and elsewhere.

Last week, the ONC Health IT Buzz Blog featured two retrospectives on the Workforce Development Program, one from Chitra Mohla, Director of the Community College Workforce Program, and the other from myself. Within her posting, Ms. Mohla linked to the final summative evaluation report of the workforce program, available both as a summary and in its full report. In my posting, I reiterated what the program accomplished from my perspective, and some of the challenges we faced. All of the data point to a successful investment of HITECH funding, both in meeting acute needs and building capacity for the longer term.

Even though funding has ended, there is still good news about the health information technology (HIT) workforce, some of which I have noted in past blog postings. Probably the best news is that job growth has exceeded all predictions, and is unlikely to abate as healthcare organizations need to use their information systems to improve quality and safety while staying economically competitive with their competitors. As I have noted before, the work and skills required will change as the focus of HIT shifts from implementing systems to making best of them, particularly using their data to achieve better health and healthcare delivery.

ONC continues to promote the workforce agenda as well, mainly through the Workforce Subgroup that is part of the ONC Health IT Policy Committee. I have enjoyed being a member of this subgroup, whose current major effort is a focus on trying to get one or more codes for health informatics added to the Bureau of Labor Statistics (BLC) Standard Occupational Classification (SOC), which is undergoing a revision now for its 2018 release. The value of one or more SOC codes will be to make jobs in the field part of US federal employment statistics.

Informatics will continue to be an important part of healthcare, and to that, careers in informatics will be plentiful and rewarding. Part of the challenge is getting out the word, especially to young people who have had less exposure to the healthcare environment. As such, they may not appreciate the problems in healthcare that informatics addresses and is poised to contribute the solutions.

Friday, February 21, 2014

ONC Health IT Curriculum Materials Are Moving

One of the most enduring artifacts from of the Health Information Technology for Economic and Clinical Health (HITECH) Act may well be the Office of the National Coordinator (ONC) Health Information Technology (HIT) Curriculum. I noted last year that the funding for the ONC health IT curriculum had ended, so the materials are no longer being updated. However, they still have value, and OHSU has continued to maintain the National Training and Dissemination Center (NTDC) Web site where they are currently housed. With OHSU's ability to fund the site ending, I am pleased to report that the materials will find an archival home in the AMIA Knowledge Center, where they will continue to be freely available. Around the end of February, the NTDC Web site itself will be retired.

Detailed documentation is available within the materials themselves, with a set of overview pages available from the links in the upper right portion of the main screen on the AMIA site. I have also provided overviews of the materials in past blog postings from 2012 and 2011. ONC still provides an overview of the program that created the materials on its Web site.

It is important to remember the main audience for these materials is educators, even though they are used by many others. But the materials are more designed to be fashioned by teachers into courses than to be used directly, even though many people do the latter.

The uncompressed size of the final (Version 3) materials is 11.2 gigabytes, contained in 18,072 files. The 20 components of the curriculum contain 9,974 Powerpoint slides and audio lasting over 136 hours (5 days, 16 hours, and 4 minutes, to be precise!). Of course, not all of the curriculum consists of narrated slides. There are also exercises, including those involving hands-on use of an educational version of VistA for Education (VFE), a fully functional version of the VA VistA electronic health record system, which is also included with the materials.

The curricular materials consist of 20 components, each of which is comparable in depth to a college course. The components are subdivided into 8-12 units, each of which contain a variety of activities appropriate to the topic, including voice-over-Powerpoint narrated lectures, references, suggested readings, exercises, and more. All of the files for each unit are organized into .ZIP files for ease of downloading, and even further, all unit .ZIP files are bundled into a single component .ZIP file for ease of mass downloading.

The topic areas of the 20 components are:
  1. Introduction to Health Care and Public Health in the U.S.
  2. The Culture of Health Care
  3. Terminology in Health Care and Public Health Settings
  4. Introduction to Information and Computer Science
  5. History of Health Information Technology in the U.S.
  6. Health Management Information Systems
  7. Working with Health IT Systems
  8. Installation and Maintenance of Health IT Systems
  9. Networking and Health Information Exchange
  10. Fundamentals of Health Workflow Process Analysis & Redesign
  11. Configuring EHRs
  12. Quality Improvement
  13. Public Health IT
  14. Special Topics Course on Vendor-Specific Systems
  15. Usability and Human Factors
  16. Professionalism/Customer Service in the Health Environment
  17. Working in Teams
  18. Planning, Management and Leadership for Health IT
  19. Introduction to Project Management
  20. Training and Instructional Design
Each component also contains a blueprint document that provides an overview of the learning objectives and content for each unit. All of the components also have an instructor's manual that provides more detailed information, including listing of authorship and teaching information. The full set of blueprints have been rolled into a single PDF file and are available on the ONC Web site.

Three of the components are "lab" components that make use of an educational version of the Veteran's Administration (VA) VistA EHR. A version of VistA that runs under various versions of Microsoft Windows is provided on the Web site, courtesy of the VA. This version runs under the open-source GT.M version of M.

The materials are distributed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License. This means that all users of the curriculum can use, share, and adapt the materials but must attribute the originator of work, use the materials only for non-commercial purposes, and share any changes made under same license. Per the ONC, universities own the intellectual property for their components.

I am hopeful that continued usage of the materials will occur, and that some academic programs will undertake innovations with them. One example of an innovation is their organization into a Massive Open Online Course (MOOC) by the Health Informatics Forum. It may be possible that we, AMIA, and others might someday find additional funding to maintain, update, and expand the materials as well. But for now, they remain a valuable resource to the HIT community.

Thursday, February 20, 2014

Another Informatics Book!

Sure enough, shortly after my last post on the myriad of new informatics books that have come out lately, another one appears. This is also a general biomedical informatics textbook and, like the Shortliffe book, I have a chapter on information retrieval in this book as well.

But this book is in Spanish! Edited by my colleagues, Drs. Melchor Sánchez-Mendiola and Adrián Israel Martínez-Franco, this book provides a Spanish-language overview of biomedical informatics [1]. I adapted my chapter on information retrieval (or, as one would say in Spanish, recuperate información, or RI) for their audience, and then Dr. Martínez-Franco translated it into Spanish [2]. I had the opportunity to visit Drs. Sánchez-Mendiola and Martínez-Franco last year and was able to see up close the impressive work they have done in informatics curriculum development in the Faculty of Medicine at the Universidad Nacional Autónoma de México (UNAM), which they described in an article in Journal of the American Medical Informatics Association last year [3].

Below is a photo of myself holding the two new biomedical informatics books!


References

1. Sánchez-Mendiola, M and Martínez-Franco, AI, Eds. (2014). Informática Biomédica, 2a Edición. Mexico City, MX, Elsevier.
2. Hersh, W (2014). Estrategias Para Recuperar Información. In Informática Biomédica, 2a Edición. M. Sánchez-Mendiola and A. Martínez-Franco. Mexico City, MX, Elsevier: 75-85.
3. Sánchez-Mendiola, M, Martínez-Franco, AI, et al. (2013). Development and implementation of a biomedical informatics course for medical students: challenges of a large-scale blended-learning program. Journal of the American Medical Informatics Association. 20: 381-387.

Thursday, February 13, 2014

Books Are Not Dead, Especially Informatics Books

An article last fall in The New Republic noted that the book industry has not quite followed the music and film-camera industries in being disruptively innovated out of their traditional products [1]. Book publishing certainly has changed, but neither the decomposition of music albums into single songs has not happened with books, nor has the transition from a physical to digital medium undermined the basic economic model of books. Yes, the book industry has been transformed, particularly the role of brick-and-mortar booksellers. However, as this article points out, books themselves are still selling strong.

I have always been a book lover, one of those types who buys more books than he can possibly read. One can easily see this by walking into my work or home office, and finding the shelves lined with books. I run the gamut, from a small collection of antique medical books to rows of more recent volumes to those using the Kindle app (and other book apps) on my Mac, iPad, and iPhone.

I am also frequently asked to recommend textbooks in informatics. Certainly the most common, but not the only request is for an overview textbook. In recent years, that question comes qualified with "something I can use to study for the informatics board exam." But I do get requests for books on other topics and used in other contexts.

The last few months have seen a flurry of new books on informatics topics. Not only brand new editions of venerable general texts, but the publishing of new topics as well. I even have chapters in some of these books. I would therefore like to take the rest of this post to the describe the recently updated books, my contributions to them, and other relevant specialty books.

When one thinks of the single most comprehensive book in the field, they are no doubt thinking about the "Shortliffe book" that, in its new fourth edition, is edited by Drs. Edward Shortliffe and James Cimino [2]. One of the challenges with what we also sometimes call "Ted's book" is that the gap between editions has been longer than one might hope for in a rapidly advancing field. But the fourth edition is out now, and reflects the modern theory and practice of biomedical informatics. I have had a chapter in this book since the second edition on the topic of "Information Retrieval and Digital Libraries" [3].

This book went to press shortly after the death of an early legend of the informatics field, Dr. Homer Warner, of the University of Utah. This volume is dedicated to Homer, and there is a fascinating figure in the Preface that outlines the training descendants of all authors in the book, who can be traced back to Homer (including myself, through my fellowship mentor Dr. Robert Greenes, who in turn was mentored by Dr. Octo Barnett, who connected directly to Homer).


There is also another general book about the field that has come into its own through its now sixth edition, which is the volume edited by Dr. Robert Hoyt and Ann Yoshihashi [4]. This book has a more applied focus than the Shortliffe book, but has been an easy yet comprehensive read, especially in the gap between the third and fourth edition of the latter. Last year, when people wanted a single volume to prepare for the clinical informatics board exam, after advising people that one book could not cover the entire field in enough depth for the exam, I recommended Dr. Hoyt's book as a starting point. For this year's exam, of course, people will have updated versions of this book and Ted's book from which to choose. I have two chapters in the Hoyt book, one solo-authored on healthcare data analytics [5] and a second on evidence-based medicine co-authored with Dr. Hoyt [6]. The book also has a Web site that provides additional materials and provides links to obtaining the book in various paper and electronic formats. The Web site also features a link to a PDF of my analytics chapter.

In addition to these two general books, there are many specialty books of note, some of which have just been published or refreshed with new editions. The following discussion is not exhaustive, but does cover books I believe are helpful in gaining knowledge about aspects of the field.

Among the new books are those from the Springer Health Informatics series, which is the largest single series of informatics books by any publisher. This series includes the Shortliffe book. There are a couple other new and noteworthy books in this series. One is on informatics education and is edited by Dr. Eta Berner [7]. The other is the second edition of the series' volume on public health informatics, which is edited by Drs. JA Magnuson and Paul Fu [8]. In the Berner book, I have a couple chapters on the Office of the National Coordinator for Health IT (ONC) Workforce Development Program [9] and on the 10x10 ("ten by ten") program [10]. In the Magnuson and Fu volume, I have a chapter that places public health informatics in the larger context of biomedical and health informatics [11].

This series also includes my own book about information retrieval (from 2009, in its third edition, and which has an associated Web site of updates and errata) [12] and a couple informative volumes about standards, one from Tim Benson focused on standards generally [13] and another from standards expert and OHSU student Keith Boone focused more specifically on Clinical Document Architecture [14].

Some other informatics books of note from other publishers include a volume on informatics methods [15], an online-only volume devoted to translational bioinformatics [16], and a text on pathology informatics [17]. The latter actually covers informatics beyond just pathology, so is almost a general textbook, and some of its content appeared to be present in questions on the recent clinical informatics subspecialty board exam.

Finally, another category of books worth noting is those devoted to explaining healthcare systems, particularly the US system. These books can be very valuable to those entering the informatics field without substantial clinical backgrounds. One book started as a primer written by a couple medical students, Elisabeth Askin and Nathan Moore, and provides a succinct overview of the US healthcare system [18]. The other book, written by journalist TR Reid, is an excellent comparative overview of the different approaches to healthcare systems around the world [19].

As I noted at the onset of this posting, books are still viable, and the informatics-related book-publishing enterprise is thriving. Books are still an important means of conveying bodies of knowledge, and I suspect will continue to be, even if the medium of them continues its transition from paper to electronic form.

References

1. Hughes, E (2013). Books Don't Want to Be Free - How publishing escaped the cruel fate of other culture industries. The New Republic, October 21, 2013, 22-24. http://www.newrepublic.com/article/115010/publishing-industry-thriving.
2. Shortliffe, EH and Cimino, JJ, Eds. (2014). Biomedical Informatics: Computer Applications in Health Care and Biomedicine (Fourth Edition). London, England, Springer.
3. Hersh, WR (2014). Information Retrieval and Digital Libraries. In Biomedical Informatics: Computer Applications in Health Care and Biomedicine (Fourth Edition). E. Shortliffe and J. Cimino. New York, NY, Springer: 613-641.
4. Hoyt, RE and Yoshihashi, A, Eds. (2014). Health Informatics: Practical Guide for Healthcare and Information Technology Professionals, Sixth Edition. Pensacola, FL, Lulu.com.
5. Hersh, WR (2014). Healthcare Data Analytics. In Health Informatics: Practical Guide for Healthcare and Information Technology Professionals, Sixth Edition. R. Hoyt and A. Yoshihashi. Pensacola, FL, Lulu.com.
6. Hoyt, RE and Hersh, WR (2014). Evidence-Based Medicine & Clinical Practice Guidelines. In Health Informatics: Practical Guide for Healthcare and Information Technology Professionals, Sixth Edition. R. Hoyt and A. Yoshihashi. Pensacola, FL, Lulu.com: 323-350.
7. Berner, E, Ed. (2014). Informatics Education in Healthcare: Lessons Learned. London, England, Springer.
8. Magnuson, JA and Fu, PC (2014). Public Health Informatics and Information Systems. New York, NY, Springer.
9. Hersh, WR (2014). Informatics for the Health Information Technology Workforce. In Informatics Education in Healthcare: Lessons Learned. E. Berner. London, England, Springer: 93-107.
10. Hersh, WR (2014). Online Continuing Education in Informatics: The AMIA 10 × 10 Experience. In Informatics Education in Healthcare: Lessons Learned. E. Berner. London, England, Springer: 109-120.
11. Hersh, WR (2014). Context and Value of Biomedical and Health Informatics. In Public Health Informatics and Information Systems. J. Magnuson and P. Fu. New York, NY, Springer: 37-46.
12. Hersh, WR (2009). Information Retrieval: A Health and Biomedical Perspective (3rd Edition). New York, NY, Springer.
13. Benson, T (2012). Principles of Health Interoperability HL7 and SNOMED (Health Information Technology Standards), Second Edition. New York, NY, Springer.
14. Boone, KW (2011). The CDA Book. New York, NY, Springer.
15. Sarkar, IN (2014). Methods in Biomedical Informatics: A Pragmatic Approach. London, England, Academic Press.
16. Kann, M and Lewitter, F, Eds. (2013). Translational Bioinformatics. San Francisco, CA, Public Library of Science. http://www.ploscollections.org/translationalbioinformatics.
17. Pantanowitz, L, Tuthill, JM, et al., Eds. (2011). Pathology Informatics: Theory and Practice. Chicago, IL, American Society for Clinical Pathology.
18. Askin, E (2012). The Health Care Handbook. St. Louis, MO, Washington University School of Medicine.
19. Reid, TR (2010). The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York, NY, Penguin Books.

Monday, February 10, 2014

Seeking Input: Evidence Report for Health Information Exchange

Last fall, I reported that the Pacific Northwest Evidence-based Practice Center (EPC), housed in the Department of Medical Informatics & Clinical Epidemiology (DMICE) at Oregon Health & Science University (OHSU), had been awarded a contract from the Agency for Healthcare Research & Quality (AHRQ) to carry out an evidence report (also known as a systematic review) on the topic of health information exchange (HIE). I am Principal Investigator of the project.

AHRQ has a process in its Effective Healthcare Program for insuring public input into its evidence reports. The first step is called "topic refinement," and the investigators develop draft key questions that the systematic review will address that are derived from the AHRQ Scope of Work for the project. The next step is to have a public comment period for the draft key questions before the actual systematic review process begins. We have reached the public comment period in our project, which will remain open through February 26, 2014. The draft key questions and forms for commenting will be available during the open comment period at the following URL:
http://www.effectivehealthcare.ahrq.gov/research-available-for-comment/comment-key-questions/?pageaction=displayquestions&topicid=572&questionset=250

Please comment at the AHRQ site and not as a reply to this posting. We encourage constructive comments and suggestions on the draft questions, which are listed below for convenience. After the topic refinement begins, we will begin the work of the systematic review that will aim to both identify where evidence currently exists as well as define gaps where further research is required.

Draft Key Questions

1. Is health information exchange (HIE) effective in improving clinical (e.g., mortality and morbidity), economic (e.g., costs and resource use, the value proposition for HIE) and population (e.g., syndromic surveillance) outcomes?
Does effectiveness vary by type of HIE?
Does effectiveness vary by health care settings and systems?
Does effectiveness vary by IT system characteristics?
What evidence exists that the lack of HIE leads to poorer outcomes?

2. What harms have resulted from HIE? (e.g., violations of privacy, errors in diagnosis or treatment from too much, too little or inaccurate information, or patient or provider concerns about HIE)
Do harms vary by type of HIE?
Do harms vary by health care settings and systems?
Do harms vary by the IT system characteristics?

3. Is HIE effective in improving intermediate outcomes such as patient and provider experience, perceptions or behavior; health care processes; or the availability, completeness, or accuracy of information?
Does effectiveness in improving intermediate outcomes vary by type of HIE?
Does effectiveness in improving intermediate outcomes vary by health care settings and systems?
Does effectiveness in improving intermediate outcomes vary by IT system characteristics?
What evidence exists that the lack of HIE leads to poorer intermediate outcomes?

4. What is the current level of use and primary uses of HIE?
Do level of use and primary uses vary by type of HIE?
Do level of use and primary uses vary by health care settings and systems?
Do level of use and primary uses vary by IT system characteristics?

5. How does the usability of HIE impact effectiveness or harms for individuals and organizations?
How usable are various types of HIE?
What specific usability factors impact the effectiveness or harms from HIE?

6. What facilitators and barriers impact implementation of HIE?
Do facilitators and barriers that impact implementation vary by type of HIE?
Do facilitators and barriers that impact implementation vary by health care settings and systems?
Do facilitators and barriers that impact implementation vary by IT system characteristics?

7. What facilitators and barriers impact use of HIE?
Do facilitators and barriers that impact use vary by type of HIE?
Do facilitators and barriers that impact use vary by health care settings and systems?
Do facilitators and barriers that impact use vary by IT system characteristics?

8. What factors influence sustainability of HIE?

Thursday, January 23, 2014

OHSU Helps to Make the Electronic Health Record SAFER

It is important for all who work in informatics, especially those in academia, to acknowledge both the benefits as well as the harms of health information technology (HIT). As noted in a recent entry in this blog, an updated systematic review of HIT evaluation research shows there is clear value to the use of HIT in improve health and healthcare delivery outcomes.

But we also know that like any clinical intervention, HIT can have adverse effects. If not implemented safely, it can not only lead to harm, but also waste a great deal of money. We must therefore, just like with other interventions, implement HIT, especially the electronic health record (EHR), using best practices and keeping an eye for possible harms. The framework for HIT safety was laid out in a report from the Institute of Medicine in 2011. This report included a chapter on how to avoid "e-iatrogenesis". The lead author on the chapter was Oregon Health & Science University (OHSU) informatics faculty, Dr. Joan Ash, and I was one of her co-authors.

I are now pleased to report that Dr. Ash has co-led (along with Drs. Dean Sittig and Hardeep Singh of the University of Texas Health Science Center at Houston) important further contributions in HIT safety, which are the SAFER (Safety Assurance Factors for EHR Resilience) guides that were released by the Office of the National Coordinator for HIT (ONC) last week. These guides are based on the best known research evidence for optimizing implementation of the electronic health record (EHR) safety. Recent ONC Director Dr. Jacob Reider wrote in the ONC HIT Buzz Blog about the importance of the SAFER guides.

The SAFER guides, along with research about the value of HIT, also drive home the importance of informatics expertise in implementing HIT. Well-trained informaticians bring knowledge and experience to HIT implementation, including being aware of the existence of tools like the SAFER guides. These guides will allow informaticians and others to apply best practices to EHR implementation.

Tuesday, January 21, 2014

Clinical Informatics Fellowship: OHSU Plans

The complicated world of informatics training will become even more complicated with the advent of clinical informatics fellowships for physicians. As I have stated before, there are serious challenges for these fellowships, especially starting in 2018 when the "grandfathering" option is no longer available and the only way for a physician to become board-certified will be via a formal fellowship accredited by the Accreditation Council for Graduate Medical Education (ACGME).

We are developing plans to offer a clinical informatics subspecialty fellowship at Oregon Health & Science University (OHSU). The administrative home of the program will be the OHSU Department of Medicine (one of nine primary specialties designated by ACGME to be able to offer fellowships and have them accredited through their respective Residency Review Committee [RRC]), although physicians from any specialty can join the fellowship and become board-certified. The OHSU Department of Medical Informatics & Clinical Epidemiology (DMICE) will provide day-to-day administration and leadership of the program. We hope to launch the program in July, 2014.

Clinical informatics fellows will divide their time among three major activities (with approximate time proportions):
  1. Clinical informatics projects (40%) – project work under the auspices of program faculty, with a focus on systems for their clinical specialty
  2. Informatics education (40%) – taking classes in the OHSU informatics graduate program
  3. Clinical practice (20%) – seeing patients in their primary specialty
The current funding model for the fellowship will be for participating clinical specialties to fund the salary of the fellow, while DMICE will provide administrative support for the fellowship. A number of other clinical informatics fellowships around the country plan to use DMICE clinical informatics courses, which are online, for the educational portions of their programs. We hope to align all clinical fellows from around the country in our courses as a cohort as well as provide interactive journal clubs and conferences for trainees in all programs.

In the meantime, we anticipate many physicians (especially those not eligible for the board-certified pathway) as well as non-physicians will still want to train via the graduate education model. We plan no major changes in our graduate programs, other than their evolution to keep up with the field and provide new content options, such as those based on our collaboration with Epic. Of course, as certification for other (non-physician) professions emerges, we and others will need to develop programs that might train using the clinical fellowship model.

As I have written before, the biggest challenge for all who want to start clinical informatics fellowships is funding. Because all medical trainees in residency and fellowship programs are paid, the clinical fellowship model will require that someone pay the stipend and tuition of the fellow. I am hoping to convince some clinical departments as well as our hospital to fund some positions. We have a couple takers so far.

Of note, our hospital administration has a conservative interpretation of CMS rules regarding billing, and will not allow clinical informatics to bill in their primary specialties. This makes the funding model a lot more challenging, in that trainee stipends will not be fundable via clinical practice.

There is good enthusiasm at our institution for the fellowship, but enthusiasm does not always translate to funding. Without funding from the clinical departments or the heath system at our institution and elsewhere, the pipeline of future subspecialists may dry up and impede capacity for development of the subspecialty. In the long run, my hope is that ACGME and others will allow more innovation beyond the bounds of the current model of fellowship training.

Saturday, January 11, 2014

Live Streaming of OHSU Informatics Conference Launched

This past week we launched live-streaming of our weekly informatics conference. I was the speaker for the first conference, and can report that all went well. You can see for yourself by watching the video of event. (We have been recording videos of our conference for several years, which are all available). My slides can also be downloaded.

Our initial attendance was quite good, with about 50 people present at the live conference and the number connected by streaming as follows:
  • Start - 34
  • 15 minutes - 41
  • 30 minutes - 50
  • 45 minutes - 49
  • End - 45
We used Twitter for both "signing in" to the conference as well as posting questions and comments. We also captured the Twitter conversation. As can be seen in the video and Twitter dialogue, there was some great dialogue during the discussion. One thing we learned was that the ampersand symbol cannot be used in Twitter hash tags. As such, we will be changing the question hashtag to something like #QnA.

Nonetheless, this new method for widening the reach of our weekly conference, and our academic informatics program, was a great success. I look forward to this continuing in the future, and being able to further disseminate the value of our program.

Thursday, January 9, 2014

Reaffirming the Value of Health Information Technology

The year 2013 was not a great year for health information technology (HIT), punctated by events happening in the beginning, middle, and end of the year. The year started with a commentary in the journal Health Affairs, noting that the promises that drove the purported benefits for HIT in the US federal HIT investment were still unmet [1]. This came on the heels of the IOM report in late 2012 raising concerns about HIT safety [2]. In the middle of the year, growing concern rose over the ability of healthcare organizations to meet the various government regulatory requirements (typified by a news release from the American College of Physicians), from the meaningful use criteria to ICD-10. Late in the year, while not HIT per se, was the Healthcare.gov debacle, which tarnished the general image of IT for healthcare-related activities, especially those led by government agencies.

This new year has started better, in particular with the publication of an update of a systematic review that reaffirms the value, with some caveats, of what we are trying to accomplish in HIT. Systematic reviews do not report new primary research data, but instead synthesize all of the existing research to catalog and summarize our knowledge (sometimes generating new knowledge in the process through techniques like meta-analysis) as well as identify gaps that may exist. This week saw the publication of a systematic review that was the latest update in a series of systematic reviews about HIT dating back to 2006. The bottom line result was that the proportion of studies reporting beneficial results for HIT continues to be high, varying from 51-73% in the different categories of use that were assessed. When studies reporting mixed or neutral results were factored in, the proportion finding negative results only were small, varying from 0-16%. The functions most commonly assessed in the studies were clinical decision support and computerized provider order entry. A figure from a posting in the ONC Health IT Buzz Blog depicts this all graphically quite well.


There is another important finding reported in this analysis, which is that about half of all studies were done using commercial HIT systems. One of the most important "findings" of the earlier iterations of this systematic review was a preponderance of studies from a small number of "HIT leader" institutions, mostly using home-grown electronic health record systems. This always raised some concerns about generalizability, i.e., could other institutions without the resources of such institutions replicate what the leaders were able to accomplish.

The authors also noted some caveats to the evidence base and provided a set of recommendations for improving it going forward. One caveat is the limited nature by which systems have been studied, usually done as before-after analyses and often not providing adequate contextual description for the results. The authors also note a potential for publication bias, both in studies that may not be reported at all to adverse consequences that are not adequately measured or described in those that are published. I heartily concur with the authors' recommendations that future studies include more robust experimental designs and a focus on those that provide better understanding of the context of the findings and how they provide value for health and healthcare delivery.

Nonetheless, this new systematic review reaffirms the scientific evidence for work in informatics going forward. We still must try to build systems that meet the broadest needs and provide value, but also evaluate them with enlightened skepticism. I am also encouraged by the growing number of studies using commercial HIT systems and not taking place in informatics exemplar institutions. This affirms the value of the approach we are taking in the academic program at OHSU, which is to build a well-trained informatics workforce in our educational program to disseminate and apply the best science and practice. It also demonstrates the value of new partnerships we are establishing, such the one launched between OHSU and Epic that will allow research and education on top of a state-of-the-art commercial platform.

References

1. Kellermann, AL and Jones, SS (2013). What will it take to achieve the as-yet-unfulfilled promises of health information technology? Health Affairs. 32: 63-68.
2. Anonymous (2012). Health IT and Patient Safety: Building Safer Systems for Better Care. Washington, DC, National Academies Press.
3. Jones, SS, Rudin, RS, et al. (2014). Health information technology: an updated systematic review with a focus on meaningful use. Annals of Internal Medicine. 160: 48-54.

Monday, January 6, 2014

OHSU Informatics Live-Streaming Weekly Conferences

The Oregon Health & Science University (OHSU) Biomedical Informatics Program is undertaking something new with the beginning of the new year: live streaming of our weekly conferences. These conferences, which take place on Thursdays at 11:30 am Pacific time, will be available live from the following URL:
http://www.ohsu.edu/edcomm/flash/flash_player.php?params=1%60/dmice.flv%60live&width=640&height=480&title=DMICE%20Conference&stream_type=live

Our conferences have been offered to students, faculty, and others for over two decades, and we have been recording them and posting the videos on the Web dating back to 2007 at the URL:
http://oninformatics.com
We will continue to post the recordings 1-2 days after the conferences as we always have.

It should be noted that we sometimes have conferences at different times, due either to visitors speaking on a different day or when we are overloaded with student thesis defenses near the end of the academic term. There are also times when we will not be streaming the conferences, such as talks by job candidates or about student internship projects that had some proprietary nature to them. All of our conferences are posted on our department calendar. We are also in the process of creating a listserv for streamed conference announcements, with more details to appear on our Web site soon.

Of course, we still hope people who are local will come to the actual conference. We will continue to provide one incentive to show up in person, which is serving lunchtime pizza. (Unfortunately we will not be able to deliver pizza to those viewing remotely!)

We also hope to make the conference as interactive to the remote audience as we do to those in attendance, including the ability to ask questions of the speaker. We plan to do this via our Twitter feed, @OHSUInformatics, using the hashtag #q&a. The Twitter feed will be monitored during and after the talk, and in the event of too many questions, it will be up to the discretion of the speaker to choose. We will also want to give those in attendance the opportunity to ask questions as well.

I will be kicking off the first live-streamed conference on January 9, 2014 with a presentation on the state of the informatics field and our program: OHSU Informatics: State of the Field, State of the Program.

We (and others at OHSU) have streamed conferences before, so we do not anticipate any technical glitches. We suspect that our method for capturing speaker questions may need refinement over time, so may adjust our approach using Twitter. In any case, I am delighted that we are now adding live streaming of our conferences to the way we interact with the rest of the world.

Sunday, December 29, 2013

Annual Reflections at the End of 2013

It has become a tradition for this blog for my last posting of the calendar year to be a message reflecting on the past year and looking ahead to the following one. As such, this marks my fifth annual message, dating back to 20092010, and 2011, and 2012. I continue to enjoy writing this blog, with it serving as a venue to discuss issues of importance to myself and the biomedical and health informatics field.

This past year of 2013 was another gratifying year, as well as a transitional one, as the work and funding under the Health Information Technology for Clinical and Economic Health (HITECH) Act, at least for myself and our program at Oregon Health & Science University (OHSU), drew to a close. Indeed, this blog has paralleled the HITECH Act since the inception of both, getting its start in early 2009 around the time of the passage of the American Recovery and Reinvestment Act (ARRA), the economic stimulus legislation passed in 2009 in the early days of the Obama Administration. HITECH itself is now transitioning, as the most of its grant funding has ended and its incentive payments for EHR adoption are tapering off.

HITECH has certainly been a career-defining era for many of us working in informatics. As with many large initiatives, especially government ones, it has had its successes and failures. It is interesting to read my postings from the early days, after the legislation was passed but prior to it being implemented, followed by the reality that not everything in HITECH, nor the Obama Administration, has gone as we might have hoped. Nonetheless, I do feel comfortable that the government and the taxpayers received their money's worth for the work that our informatics program was funded to do. We created a useful new curricular resource and trained a number of people that resulted in new informatics careers being launched. But going forward, HITECH will increasingly be seen in the rear-view mirror.

In this transitional year, a number of other new initiatives came about, which point the direction of the future for myself and our program. For myself, 2013 is ending with my becoming a "board-certified" clinical informatician. While the new subspecialty is still a work in progress, I was pleased to be part of 450 or so individuals who passed the first offering of new board exam. I was also proud that 40 of those who passed received at least part of their informatics education in our program at OHSU. It was also great to see the press postings from OHSU as well as AMIA, with the former picked up by a local business magazine and the latter described in the health IT press.

For our department, one of the most important new initiatives of the last year was the launch of the Informatics Discovery Lab (IDL). I had the opportunity to give a talk about the IDL in an interesting format of 5 minutes total with exactly 15 seconds per slide at a local forum called IgniteHealth. The IDL was also described in an interview with its leader, faculty member Dr. Aaron Cohen, in Oregon Business, a local business magazine. We also received a good deal of notice about one of the first tangible outcomes of the IDL, which is our partnership with EHR vendor Epic to use their system for research and educational purposes. This initiative too made it into the HIT press: Healthcare IT News, Healthcare Informatics, and HIT Consultant.

Despite the end of the HITECH funding and the modest decline in enrollment expected after it, we are still moving forward and innovating with our educational program. A number of new initiatives are in the works and likely to reach fruition in 2014. Recognizing the need to stay relevant, we are forging ahead in new directions where we believe the field is headed. One of these initiatives is to add coursework in data analytics, with the eventual likelihood of an entire track in this area. In the meantime, we are also developing plans for a clinical informatics fellowship that will complement our other fellowship programs. We are also pleased to be working with other programs developing clinical informatics fellowships, being able to provide coursework and related expertise to them.

Another opportunity for our department has been to become involved in the curriculum transformation process for OHSU medical students. OHSU was also one of 11 medical schools receiving grants from the American Medical Association to accelerate change in education. My role in the grant is to develop competencies and curricula for the data-driven future of medicine that will be forthcoming as care delivery models change. The new OHSU curriculum will also feature more informatics than it ever has before.

Finally, I had the opportunity to weigh in on the year in review for the California Health Care Foundation iHealthBeat year in review.

As for what lies ahead in 2014, I believe it will mainly be built on the foundation of new post-HITECH activities started in 2013. The clinical informatics subspecialty will be important, although I also hope we will see more progress in professional recognition and certification for the larger majority of non-physician (and even non-clinical) informatics professionals. There is a large and important role for all who work in informatics, not only those in clinical (healthcare) areas, but other areas of the field as well. This will be especially so, for example, as advances in clinical research informatics enable other areas, from translational bioinformatics to public health informatics, disseminate their progress into healthcare and individual health spheres. Although each subarea of informatics is distinct, I expect their work to increasingly overlap going forward. For example, as bioinformatics and genomics have more impact in health and healthcare, the underlying informatics will necessarily become more similar.

From a program standpoint, I am equally certain that initiatives such as the IDL will be drivers of our research directions. While government sources of research support will still be important and form the bedrock for advancing the science, it will be equally critical to collaborate with industry and other partners to disseminate the fruits of that research. Academia is unexcelled for making discoveries but industry is just as critical to making them available to a wide audience. The era of "home-grown" informatics systems is receding, with the need to build and study on top of commercial platforms in widespread use becoming more critical.

As for this blog, I plan to continue in the same manner as in the past, with postings only when I have something I believe is interesting to write about, and not serving as my stream of consciousness. I have nothing against the latter types of blogs, but my preferred approach (and time availability!) is the former. I hope to maintain the focus on the issues in informatics that are most core to me, but not hesitating to branch out when appropriate.

Sunday, December 22, 2013

A Student Who Helped My Educator Aspirations

I believe that one of things that separates a good educator from a great one is that the latter is unafraid to have students who (a) know more about some or many topics than they do, (b) do not hesitate to point out errors in the teacher's content, or (c) are not afraid to speak their minds, including when they disagree with the teacher. I aspire to be a great teacher, and the attributes of trying to be one were reinforced to me this past fall when Keith Boone, aka @motorcycleguy, became a student in my introductory informatics course (and our Master of Biomedical Informatics program at Oregon Health & Science University).

I had been following Keith's health information technology (HIT) standards blog for a number of years when I started to get to know him. I always enjoyed and found value for my teaching in his explanations of HIT standards and related areas. Keith is one of those people who has a wealth of experience, providing knowledge and even wisdom, but without (until now) formal training. He is an excellent writer, not only in his tweets and blog, but also his book on CDA (Clinical Document Architecture). When Keith decided to pursue a formal education in informatics, I was thrilled when he chose our program.

In addition to being a diligent and successful student, Keith blogged and tweeted his way through his first term of courses this past fall. Some of his posts described his decision-making around going back to school and finding tools that worked for him. Others represented his reactions to discussion I try to elicit in the virtual classroom (which are manifested in threaded discussion forums), in particular on payment for physician-patient online communications, consumer health-related access to the Internet, and payment issues around telehealth. I replied to all of his posts in the class and to some of them on his blog.

Naturally some of his postings revolved around his area of expertise, namely standards. I thoroughly enjoyed his posting on noting the difficulty of using Pubmed to find information on standards, which also raised some issues around the academia-industry dichotomy in the standards community. I also got a chuckle out of his tweeting of my mentioning a new standards activity that is generating a great deal of interest and enthusiasm, which is the Fast Healthcare Interoperability Resources (FHIR, pronounced "fire"). I have to admit I felt a little anxiety going into the module on standards with Keith. He was already among my sources for expertise for the lecture, and naturally I wanted to make sure I had everything right. I am pleased to report that he provided some excellent corrections and feedback, mostly on the finer details, and this will benefit future students in having more precise explanations about the nuances of standards. (I also feel a little relief that I did not get anything wrong in a major way!)

I also enjoyed Keith's mid-course comments on what he was getting out of being a student and his wrap-up posting reflecting back on his first term in the program. While I cannot report his grade in the course due to FERPA (Family Educational Rights and Privacy Act, the educational equivalent of HIPAA), I can note that he did extremely well!

One of the most satisfying aspects of my work as an educator is seeing those I have taught go on to achieve great things. While the education I contributed to is never the sole reason for their success, it usually does contribute. Keith has already achieved a tremendous amount in his career, but I am confident I will feel even greater satisfaction when he achieves even more due in part to the education he received in our program.

Thursday, December 19, 2013

The Informatics Lessons of Healthcare.Gov

The debacle of the Healthcare.gov Web site rollout will serve as a case study in curricula of business, political science, informatics, and other fields of study for years to come. It is unfortunate that the toxic politics of healthcare reform obscure other interesting lessons to be learned about large-scale IT initiatives applied to complex problems, such as trying to match individuals to health insurance plans available in their area and determining who is eligible for federal subsidies.

I count myself among those who have waited years for healthcare reform, seen an imperfect (but better than the status quo) plan signed into law, and then observed its rollout botched from both a technical as well as a communications standpoint. My views on the Affordable Care Act (ACA, aka Obamacare), not the focus of this post, are that it was the best that could be achieved politically at the time, and that it will hopefully be improved over time. The goal of providing healthcare to all Americans, including those who are not insurable by market-based mechanisms, is still a laudable goal. I am also dismayed by those who want to see the ACA fail at all costs, almost as if the fact that real people will be losing real healthcare coverage (or not having it in the first place) did not matter. I also agree with those who note we cannot attribute blame of everything bad happening about health insurance to the ACA, i.e., health insurance costs continue to rise for reasons unrelated the ACA and employers would likely continue scaling back health insurance benefits regardless of whether or not the ACA were repealed. Well, maybe I did want to get some commentary in about the ACA after all, but the bottom line is that the pre-ACA status quo was not sustainable.

Nonetheless, what can we learn from the Heathcare.gov rollout from an informatics standpoint? One problem is clear, which is the federal procurement process for IT, about which even President Obama joked. This is issue is addressed well in context in a blog posting by Dr. David Blumenthal, the former Director of the Office of the National Coordinator for Health IT (ONC) who was appointed shortly after the first election of President Obama. Dr. Blumenthal noted the major differences between a typical large-scale federal IT procurement and the selection of an electronic health record (EHR) system for the large and venerable Partners Health System, which is anchored by two of the large Harvard Medical School teaching hospitals.

For the federal IT procurement, the agency (in this case, ONC) provides the specification and then in essence turns the process over to a separate contracting office in the government. This is in contrast to the Partners EHR decision, which was reached by a process that involved leadership guided by diverse expertise within the organization. This sounds to me like an informatics approach, from gathering the needs of the organization and giving voice to different stakeholders within it, to then seeing the entire selection process through to making a decision. Whether or not we call it "informatics," implementing a large complex IT project "takes a village" within organizations.

Another insightful blog posting comes from Clay Shirky, a well-known Internet commentator. He noted how the Healthcare.gov planning and rollout process defied well-known best practices for undertaking large, complex IT projects. Political necessities cannot bypass the reality of the incremental requirements gathering, setting reasonable timelines, and testing. Part of the problem, of course, is that the ACA needed to roll from a political standpoint in October, 2013. Delaying longer would push implementation into the middle of the 2014 elections, which would make those elections potentially more unpredictable.

But political timelines aside, everyone with knowledge of complex IT projects knows that no amount of political or other wishful thinking can make a project happen faster than is possible. John Halamka, a well-known informatics blogger, rightly pointed out that few people remember a project launching somewhat late, whereas more people remember for a longer time when projects go poorly and caused disruption, as Healthcare.gov has. I myself have always believed that one of the major limitations of the HITECH program was its highly compressed timeline, mostly related to its being funded by a short-term federal economic stimulus. This was certainly true for many of the grant-funded activities under HITECH, such as the regional extension centers (RECs) and the workforce development program. The RECs, which were funded at about the same as the workforce development programs, needed trained personnel immediately. Yet the workforce development training programs needed some lead time to be developed, and even furthermore the curriculum for those programs should have had enough development time before those.

In conclusion, while not everyone uses the word "informatics" in their descriptions of what happened and what should have been properly done with Healthcare.gov, it is clear that the type of approach advocated by most who are trained in informatics would be more likely to achieve the outcome resembling the Partners EHR implementation than the Healthcare.gov debacle. This is not to say that projects led by informatics experts never fail. However, the involvement of stakeholders, glued together by informaticians who understand healthcare, IT, and their interactions, would likely have a probability of greater success. I acknowledge the previous sentence is not evidence-based, since one cannot carry out randomized controlled trials in these sorts of complex interventions. But there is plenty of accumulated knowledge and wisdom on the best practices that emanate when sound informatics principles are applied [1-4], and these should guide any type of complex health IT implementation.

I am sure there will be more lessons that emerge from the Healthcare.gov experience, and hopefully honest scholars will be able to peel back the toxic politics and truly allow learning to take place. I also hope we can achieve sensible answers in our quest to provide basic, high-quality, and affordable healthcare to everyone in the United States.

References

1. Barnett, GO (1979). The use of computers in clinical data management: the ten commandments. Society for Computer Medicine Newsletter. 4: 6-8.
2. Bates, DW, Kuperman, GJ, et al. (2003). Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. Journal of the American Medical Informatics Association. 10: 523-530.
3. McDonald, CJ, Overhage, JM, et al. (2004). Physicians, information technology, and health care systems: a journey, not a destination. Journal of the American Medical Informatics Association. 11: 121-124.
4. Sittig, DF and Singh, H (2012). Rights and responsibilities of users of electronic health records. Canadian Medical Association Journal. 184: 1479-1483.