Thursday, January 17, 2013

What Do Twenty-First Century Healthcare 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 healthcare 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 healthcare 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 healthcare, really apply to any healthcare 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 underlined 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, healthcare, 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. 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 healthcare must change, so must the education of its clinicians. Informatics is one excellent means of fostering interprofessional learning and interaction.


  1. Great summary on the many challenges in healthcare informatics.

    As a physical therapist who is interested in electronic health records, I am happy to see that you are thinking about how these challenges affect other non-physician healthcare professionals and I have some comments on these challenges from a different perspective.

    Our healthcare system is specifically designed for those of you in the "curing disease business", like physicians and nurses.

    Physical therapists, Occupational Therapists and other rehabilitation professionals are in the "restoring function" business. There is a big difference.

    Some examples:

    ICD-9 is about diseases, not function. CPT codes are largely designed by physicians with little input from rehabilitation professionals. As a result, the main tools we have to classify our patients (ICD-9) and to report the procedures we perfomed with our patients (CPT) do a very poor job from a physical therapist's perspective.

    As an illustration of this "information gap" caused by the disease and medical procedure based classifications we have today, CMS is now aware of the problem and has taken steps to try to get better information about functional impairment and functional improvement by instituting a new, unique set of claim requirements on PT, OT, and Speech this year.

    EMRs are generally desinged for the "disease business" and those systems are very difficult for rehabilitation professionals to implement and use effectively. In addition, there is still little or no integration between the "big" hospital EHR systems, and the systems that are acutally designed for rehabilitation professionals.

    Just my 2 cents on the subject from a different perspective. Thanks again for your summary. I enjoy your blog.

    1. Jerry,

      Thanks for your comments. I like to think that physicians and nurses too are also in the business of restoring and maintaining health, but I agree with your assessment about your profession. Our patient-centered data-driven health system of the future must include the full spectrum of maintaining health, treating, disease, and restoring health when appropriate.