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 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.


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:

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:
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.