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Monday, April 22, 2013

What do 21st Century health care professional students need to learn about informatics?

I am increasingly involved in efforts to determine the content and competencies in informatics for 21st Century clinicians. Not only medical students at Oregon Health & Science University (OHSU) but also other healthcare professionals, such as nurses, physical/occupational therapists, nutritionists, and others at OHSU and some other health science universities.

This effort is congruent with the growing push for interprofessional education. The rationale behind inter professional education is that if the health care system is to embrace the vision of team-based coordinated care, then clinicians of the future must have at least some of their education together. The 21st Century clinician needs to understand that the care they provide will be monitored for quality, safety and cost. This will hopefully be done in a constructive and self-improving way, but also making sure that mistakes and waste are not swept under the proverbial rug of the paper chart (or not documented at all).

Informatics can be viewed as the ultimate interprofessional activity. There is really very little about informatics that is specific to any health care professional. Yes, physicians, nurses, and others need to learn the informatics applications specific to their work. But the underlying concepts of informatics, i.e., the use of information to improve health and health care, really apply to any health care professional (not to mention the patient, the researcher, and others!)

So what does the 21st Century clinician need to know about informatics? Rather than provide a list, I will explain my thoughts in narrative form, showing the key informatics concepts that might comprise a list bolded so that they may form a list later.

A first critical concept is that informatics is not the same as computer literacy. Computer literacy is one of many requirements to use informatics successfully, but knowing how to use a computing device (PC, tablet, or smartphone) is not the same as having skills in informatics, i.e., using that device to improve health, health care, public health, or research.

Certainly one fundamental skill for 21st Century clinicians is something we began teaching in the late 20th Century, which is how to find information to apply to patient care. This is not just knowing what terms to enter into a search engine, but the whole process of asking answerable questions, finding information to answer them, critically appraising that information, and applying it to patients (or populations). The skills of the 21st Century clinician start, and not stop, with the knowledge of how to enter simple queries into Google or Pubmed. The 21st Century clinician should a power searcher, a skill we often associate with librarians or informaticians. Not that there is no roles for librarians and informaticians, but they should be more teachers and consultants when it comes to finding information.

Starting from the beginning, the 21st Century clinician must be skilled information retrieval, what some might term search or others might term knowledge management. Whatever we call it, the 21st Century clinician must know how to formulate a clinical question as an answerable one, and then be able to select the appropriate resource and make optimal use of it.

This use needs to include knowing what content is in different search systems. This clinician must know that Google has almost all pages on the "visible" Web but not the part that is hidden from its indexing crawlers, while Pubmed is a bibliographic database that indexes biomedical and clinical journal literature. The 21st Century clinician must know about specialized resources such as the AHRQ Guidelines Clearinghouse and the CDC Travel site. He or she should also have an understanding of the major commercial publishers as well as what their professional societies offers.
,br />Once they know how to use a search site, they must be able to phrase an appropriate query. Even sites like Google, with its ultra-simple interface, has additional features that can greatly enhance its retrieval capabilities. Pubmed has a myriad of features of great value to clinicians, probably the most important being the Clinical Queries interface that help focus the content of the search on more evidence-based articles. But it also offers much more.

Finally, once information is retrieved, the 21st Century clinician must know how to critically appraise information retrieved and apply it to the patient (or population). As with searching, the type of appraisal varies with the search engine used. With output from general search engines like Google, the clinician must be able to assess the trustworthiness of the information. Google's algorithm of ranking pages by number of others that link to it actually does a pretty good job of promoting reputable sites to the top of the output. But it is not perfect, and the user must be discriminating. (Back in the 1990s, we used to teach clinicians to avoid using general search engines, since they did not discriminate well among good vs. poor sites, but that is less of an issue, not only because search engines are better but also because people are more savvy about the Web.)

Of course, clinician competency in informatics in the 21st Century goes well beyond searching. The modern clinician must also know how to make optimal use of patient data and information. He or she must know how to use informatics to strive for Berwick's triple aim of better health, better care, and lower cost. In my mind, the best vision for this approach comes from the recent Institute of Medicine (IOM) report, Best Care, Lower Cost. This report creates a framework from which essentially all informatics competencies can be contextualized. It presents a compelling vision for a healthcare system that is patient-centered, learning, and population-based, concepts to be explained more fully below.

This also means an understanding that the patient record is more than "charting," and that its value goes beyond being able to read it. Certainly the 21st Century clinician must be facile with all aspects of the electronic health record (EHR), being able to easily move from one system to another, and to understand why it is critical for health information exchange (HIE) to make any one record as complete as possible. But the EHR is more than looking up information about a patient. It becomes critically important as healthcare moves from a focus on quantity to one of value. The notion of value includes quality, patient safety, and attention to cost. This requires coordination of care, and not just providing medical procedures, nursing interventions, therapies, etc. in isolation. Coordination requires teamwork and communication.

In this context, the health record is no longer a passive collection of information used mainly to justify billing. Rather, it is a source of data, organized into coherent information, that allows the healthcare team to deliver the best, safest, and most cost-effective care. As such, the 21st Century clinician must have a basic understanding of informatics issues, such as capturing data that is correct and complete as well as consistent in its expression. He or she must be able to work in partnership with informatics professionals to achieve what we know is so critical in the application of informatics, such as adhering to standards, achieving system interoperability, appropriately and optimally implementing clinical decision support, and maintaining security to assure privacy and confidentiality.

This view also requires that the 21st Century clinician have some understanding of areas like quality measurement and improvement. If nothing else, he or she should understand quality measures because his or her work will increasingly be measured, used to assess quality and how to improve it, and maybe even influence their level of pay. But they should also understand the rationale for measuring quality, including how consistent quality of care is now, and how to work with clinical leaders to select, implement, and improve measures.

Another important area of safe, effective, and coordinated care is patient engagement. Not only is patient engagement the best thing to do from a healthcare standpoint, but 21st Century patients, especially aging and Internet-savvy baby boomers, will demand it. Patients will want healthcare that adapts the online features of other modern industries, such as being able to view their own data and interact with their clinicians and healthcare system (e.g., online scheduling of appointments, prescription refills, and even consultations that are appropriate for online). These will likely take the form of a personal health record, accessible from a patient portal that allows access to all information, not just that from the system of the provider organization.

The 21st Century clinician must also have some knowledge and understanding of the appropriate use of telemedicine and telehealth, done both to remote locations as well as more locally in patient's homes and other settings.

Complementary to the patient-centric view, the 21st Century clinician must also understand population-based care and the informatics underlying it. The clinician and their team will be caring for populations of patients. They must be able to view their care needs and results across their patient population. When a new test or treatment comes along that is determined to be highly effective, they must be able to quickly identify patients who are candidates for it. They must also be able to identify outliers in their populations who require intervention, such as those with excessively high blood pressure or blood sugar, missed appointments or screen tests, or those at risk for hospital (re-)admission.

I also believe there are other areas where 21st Century clinicians should have an understanding. One of these is bioinformatics, especially as it relates to personalized medicine. No, the modern clinician need not understand complicated gene sequencing algorithms, but he or she should have an understanding of how genomics and related areas are transforming our understanding of maintaining health, diagnosing disease, and treating it. If the vision of personalized medicine comes to pass, the 21st Century clinician will need the help of decision support and other tools for help in applying it to individual patients. He or she should at least have a basic understanding of genomewide association studies and their ramifications.

The 21st Century clinician must also understand the strengths and limitations of clinical research. He or she must understand the differences and value contributed by experimental and observational studies. Ideally, the student will have participated in research while in their training. But even if not, he or she should understand issues like data quality, study design, and the limitations that come from the sharp focus perspective of a clinical study. The 21st Century student should more generally be able to participate well in the learning health system laid out in the vision of groups like the IOM.

There is certainly a great deal of informatics for the 21st Century clinician to learn and be able to apply. From the pedagogical standpoint, there is also the issue of how to deliver it. One way not to deliver it is to have its own separate course, isolated from the rest of the curriculum. There will be a need for educators who are specialists in informatics to (collaboratively with clinical educators) design the learning and to deliver that which is appropriate for lecture, group discussions, and other didactic settings. But informatics is one of those topics that is best infused throughout the curriculum, especially in clinical settings where it is being used.

Curriculum change can be hard. Academia can be one of the most tradition-bound settings, resistant to change. But just as health care must change, so must the education of its clinicians. Informatics is one excellent means of fostering interprofessional learning and interaction.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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