Sunday, May 24, 2009

Learning about Informatics and Health IT at OHSU

The interest in health IT and biomedical informatics continues to grow, fueled no doubt by federal policy efforts and the economic stimulus plan. One result is that many people have inquired to me about opportunities to learn more about the biomedical informatics field at OHSU. To that end, I am going to describe the options in this posting. If you have further questions, feel free to contact me individually.

OHSU's programs are open to people of all career backgrounds. Our programs have served a wide diversity of people over the years, including those with backgrounds in health care (e.g., medicine, nursing, hospital administration, etc.), IT (e.g., computer scientists, IT professionals, etc.), and many other areas (e.g., health administration, business, public health, law, etc.). There is room for everyone in the big tent of informatics!

While our certificate and degree programs are at the graduate level (i.e., you need to have a bachelor's degree), our 10x10 ("ten by ten") course is open to anyone, even those who do not have a bachelor's degree.

An excellent way to get a broad-based introduction to the field is our on-line introductory biomedical informatics course. This course is offered in a number of flavors, and there are upcoming opportunities for you to enroll. Whatever path you take through the course, you can (assuming you are eligible for graduate study) get credit in our graduate program and be eligible to take more courses in our program if you are interested.

The introductory course is completely on-line and has been completed by about 1000 individuals in the last decade. It covers all the major aspects of biomedical and health informatics, with a focus on informatics applied to health care. It is offered using a variety of asynchronous distance learning teaching modalities, so you do not need to be present on-line at any specific time, although you do need to keep up with the work during the academic term.

One way to take the course is through our regular graduate program. OHSU is on an academic quarter system. Due to continued demand, the introductory course has been offered every academic quarter. The next offering is over the summer quarter, which runs from June 22 to September 11. The course will be offered again in the fall quarter, which runs from September 28 to December 13. To take the course by this pathway, you need to enroll in the OHSU Graduate Certificate program, which is open to anyone with a bachelor's degree. For more information, follow this link to our department Web site and click on the link to the Prospective Students Portal on the lower right:

Another option to take essentially the same course is via the AMIA 10x10 program. This version of the course is offered in partnership with the American Medical Informatics Association (AMIA). The course is taught in the same on-line, asynchronous manner. It is offered over a slightly longer time period (decompressed with some "off" weeks) and adds an in-person session at the AMIA Annual Symposium, where all the students come together to meet and engage in additional learning. The AMIA Annual Symposium is one of the leading health IT meetings and will be held this year in San Francisco from November 14-18. Registration is already open for the next offering of the 10x10 course, which begins on July 30th and runs until the AMIA meeting. For more information, visit:

If you successfully complete the 10x10 course (and are eligible for graduate study), you can then get credit for the BMI 510 course in our graduate program. Once you are enrolled in the program, you can take additional courses. There is also a relatively easy pathway to advance beyond our Graduate Certificate into our master's degree program (and even the PhD program).

Here is a detailed outline of the introductory course content:

1. Overview of Field and Problems Motivating It
1.1 What is Health/Bio/Medical Informatics?
1.2 A Discipline Whose Time Has Come
1.3 Who Does Biomedical Informatics?
1.4 Problems in Health Care Motivating Biomedical Informatics
1.4 Seminal Documents and Reports
1.5 Resources for Field - Organizations, Information, Education

2. Biomedical Computing
2.1 Types of Computers
2.2 Data Storage in Computers
2.3 Computer Hardware and Software
2.4 Computer Networks
2.5 Software Engineering
2.6 Challenges for Biomedical Computing

3. Electronic Health Records
3.1 Clinical Data
3.2 History and Perspective of the Health (Medical) Record
3.3 Potential Benefits of the Electronic Health Record
3.4 Definitions and Key Attributes of the EHR
3.5 EHR Examples
3.6 Nursing Informatics

4. Clinical Decision Support; EHR Implementation
4.1 Historical Perspectives and Approaches
4.2 Medical Errors and Patient Safety
4.3 Reminders and Alerts
4.4 Computerized Provider Order Entry (CPOE)
4.5 Implementing the EHR
4.6 Use and Outcomes of the EHR
4.7 Cost-Benefit of the EHR

5. Standards and Interoperability; Privacy, Confidentiality, and Security
5.1 Standards: Basic Concepts
5.2 Identifier and Transaction Standards
5.3 Message Exchange Standards
5.4 Terminology Standards
5.5 Privacy, Confidentiality, and Security: Basic Concepts
5.6 HIPAA Privacy and Security Regulations

6. Secondary Use of Clinical Data: Personal Health Records, Health Information Exchange, Public Health, Health Care Quality, Clinical Research
6.1 Personal Health Records
6.2 Health Information Exchange
6.3 Public Health Informatics
6.4 Health Care Quality
6.5 Clinical Research Informatics

7. Evidence-Based Medicine and Medical Decision Making
7.1 Definitions and Application of EBM
7.2 Interventions
7.3 Diagnosis
7.4 Harm and Prognosis
7.5 Summarizing Evidence
7.6 Putting Evidence into Practice
7.7 Limitations of EBM

8. Information Retrieval and Digital Libraries
8.1 Information Retrieval
8.2 Knowledge-based Information
8.3 Content
8.4 Indexing
8.5 Retrieval
8.6 Evaluation
8.7 Digital Libraries

9. Imaging Informatics and Telemedicine
9.1 Imaging in Health Care
9.2 Modalities of Imaging
9.3 Digital Imaging
9.4 Telemedicine: Definitions, Uses, and Barriers
9.5 Efficacy of Telemedicine

10. Translational Bioinformatics
10.1 Translational Bioinformatics - The Big Picture
10.2 Overview of Basic Molecular Biology
10.3 Important Biotechnologies Driving Bioinformatics
10.4 Clinical Genetics and Genomics
10.5 Bioinformatics Information Resources
10.6 Translational Bioinformatics Challenges and Opportunities

11. Organizational and Management Issues in Informatics
11.1 Organizational Behavior
11.2 Organizational Issues in Failure and Success of Informatics Projects
11.3 Change Management

Monday, May 11, 2009

Crossing the Health IT People Chasm

I was recently at a dinner with Dr. Mark Leavitt, Chairman of the Certification Commission for Health Information Technology (CCHIT), who noted that the gap between the American Recovery and Reinvestment Act (ARRA) vision for health information technology (HIT) and our current status comes down to people. We have the technology already, and the money now with ARRA, but we still need the people, from the clinicians who will use the systems to the administrators who will fund them and the HIT professionals who will develop and implement them.

To borrow from the parlance of one of the early Institute of Medicine (IOM) reports that spurred health care's interest in HIT, we have a "chasm" between where we currently are and where we need to be.

A partial bit of good news is that some people are starting to do things to cross this chasm. Clearly one place we need to start is with the ultimate users of HIT, the clinicians and others in the health care trenches. We need to make it easy for them to use systems, not only to get data in and out, but also to use them to improve their practices by measuring quality and improving it by acting on the deficiencies they uncover. We also need to make it easier for administrators and others who run health care systems to make the investments in them, knowing they will benefit the care delivered and the bottom line.

And of course, another area where we need people is my passion, which is the HIT workforce. Unfortunately, most people still don't know exactly what biomedical and health informatics is all about. Some people who work in the field don't even agree with each other on its definition. Nonetheless, I believe that most people who do know about the field will agree that its work is absolutely essential to pull off the goals for HIT in the ARRA legislation. This is part of the reason for Section 3016 in the stimulus bill, which calls explicitly for a well-trained informatics workforce to carry out the health IT adoption elsewhere in the bill.

One challenge for the field of biomedical and health informatics is the heterogeneous nature of careers and education in the field. People who are called informaticians perform a variety of jobs from the highly technical development and implementation of hardware and software to the more people-oriented tasks of project management and institutional leadership. As such, there is no single career or educational pathway in this field.

But there is one attribute that defines people who call themselves informaticians, which is that they understand health care, IT, and the uniqueness that occurs at their intersection. This was pointed out in an article in the New York Times recently, which featured a quote from myself about how informatics was different from IT in being more focused on information and how it is used to improve health care than technology.

While most education in this field has historically been at the graduate level, combining careers in health professions, IT professions, and others, it is key to pay attention to the pipeline of the community colleges, undergraduate institutions, and others. We need to get the word out about the great opportunities and the career satisfaction that comes from working in this field. I would be interested in hearing from others on how to do that.

Sunday, May 3, 2009

EHRs on the Ground in Rural Oregon

I recently had the opportunity to participate in a discussion about practical health IT and EHR issues on the ground with several physician practices that participate in the Oregon Rural Practice-based Research Network (ORPRN). It is always extremely interesting for me to hear about real physicians and others who are trying to make this technology work. It is an effective antidote to participating in too many high-minded theoretical discussions, and an opportunity to test those theories against reality.

This entry is a summary of the minutes from a phone call I participated in with ORPRN members in February, 2009 concerning their health IT and EHR status. All of the participants have given me their approval to mention their names and comments. At the end, I will summarize the major themes discovered by Dr. LJ Fagnan of OHSU and myself.

This group is somewhat atypical, in that they represent practices that have agreed to participate in the rural practice-based research network. The fact that most have adapted EHRs sets them apart from average practices!

Topic of the phone call: Health Information Technology (HIT) in your practice – what do you have, what do you need, where do you go for assistance, how do you support your HIT needs?

William Hersh, MD, OHSU Department of Medical Informatics and Clinical Epidemiology Chair led the discussion about the representation of HIT in the economic stimulus package with an eye toward how Oregon can be positioned to receive stimulus dollars. There will be $17 billion in Medicare/Medicaid billing incentives and $2 billion toward standards development, IT workforce development, and other aspects of HIT infrastructure. Dr. David Blumenthal of Harvard has been appointed the new National Coordinator for HIT, so programs are likely to start being announced soon. A recent article by Dr. Blumenthal in the New England Journal of Medicine gives his views on a number of HIT issues. Finally, Dr. Hersh described the need for standards among electronic health/medical records (EHRs/EMRs) for helping to collect data for research.

Jon Schott, MD -Eastern Oregon Medical Clinic – Baker, OR

His practice has been using Centricity for 5 years. Local IT support is challenging as the clinic overwhelmed the capabilities of the local person. They now have IT support through Portland. The cost of the Centricity first cost about $5,000/seat and now is at $16,000, and so they feel trapped with the software.

Karl Ordelheide, MD -Lincoln City Medical Center

7 practitioners: IM-3, FP-2, Gyn-1, PA-1

Lincoln City, OR. Pop: 7000

His practice has been using Practice Partner since 2003. They have a one-way interface with medical manager office management system for demographics and with Meditech for lab, x-ray and hospital narrative reports. Also have interface to upload data to CDEMS Registry. There have been no changes to Practice Partner’s licensing fees and it is an affordable package. They have also had difficulty getting IT support to keep the system up and running; they are constantly behind. They bought the module for e-prescribing and it is not working. The company has apologized that it doesn’t work and cannot do anything more for them. Dr. Ordelheide’s group needs someone to dedicate time and energy to getting the module running. They also need someone to bring on new technology, to customize and set up the software and each box. In addition, communication with other systems is important.

Elizabeth Powers, MD - Winding Waters Clinic

Founded 1972, operates with 2 full-time MDs (Family Medicine), 1 part-time MD (Internal Medicine), 1 full-time NP (Family Medicine) and 1 part-time NP (Pediatrics).

Location - Enterprise OR with a satellite clinic in Wallowa, OR

Serves all of Wallowa County, population 6,991

Their practice involves 3 doctors and 2 NPs. They do not have an EHR, though do have electronic billing and e-prescribing. The hospital uses an EHR and allows their use of PAC for radiology and labs, but otherwise they use paper. They have wanted to switch to an EHR, but the two largest hurdles are: 1) Cost and logistics of installing the software, and 2) Finding an EHR that can talk to other systems. It would seem to be more feasible to use a personal health record instead. When referring patients to specialists, which they often do, will have to print to get the records to the specialists. A large benefit to having an EHR would be its function as a tool to manage population health. Currently they are tracking patient databases in Excel.

J. Bruin Rugge, MD, MPH -OHSU Scappoose

Founded in 1998 – 4 MDs (all FM) – 2 PAs – 2 FNP

Scappoose OR, population 6,500

Have been using OCHIN EPIC since 9/26/06

Sole source of health care for Scappoose OR, a community of 6,500 – see all ages and individuals from all backgrounds; and we provide the full scope of Family Medicine.

They use Epic through OCHIN (EHR for Safety Net clinics), though they have a more stripped-down version of Epic. He stated that the clinical outcome is not influenced by the charting method, and that providing excellent care can happen with paper charting. They do use e-prescribing, and have had problems. Also, being part of OCHIN, only so many seats are available for clinicians to use at a time, and he has had to try logging in multiple times in order to get into the record. The system has also gone down, and clinicians have had to log reports using hand-written forms that are later transcribed or scanned. He has noticed his workload taking on many more secretarial duties related to data entry and data housekeeping. When labs are received from outside sources, there is a considerable lag until it is scanned into the system, and often it may not be in the section he would anticipate finding it. One benefit is that when patients transfer care from another Safety Net Clinic to his that their records are available in the system.

Albert Thompson, MD

Practice—founded in 1982 with 1 provider, ABFP

Location Pacific City, unincorporated, primary drawing area ~ 4000. Lincoln City secondary area, ~10k

They have used SOAPWare for 10 years, and are using a hybrid version of it. He began using an installation that is all electronic as of December. He would like to use a different EHR, but it is too expensive to change systems currently. He is dissatisfied with SOAPWare for a variety of reasons, including that it lacks some basic functionality Microsoft Office users are accustomed to, like double-clicking to select text. However, the EHR has been extremely helpful for medication management, and he could not imagine going back to paper refills. SOAPWare is also an excellent report-writing tool and provides a patient instructions form with an assessment and plan that is very useful. Each encounter takes quite a bit of typing, and when his data entry demands increased, his patient count decreased. Currently they fax prescriptions to pharmacies and have not yet explored e-prescribing. Inter-connectivity is lacking and switching to Practice Partner is too expensive. They do have an IT specialist and the practice administrator also has IT skills that keeps their systems functional.

Robert Law, MD -Dunes Family Health Care, Reedsport, OR

Currently 5 family physicians (4 are partners), an FNP, and a PA-c.

Clinic uses paper charts, though they also use tele-radiology quite a bit, which they can access through the internet. They also use electronic billing. He and his colleagues suffer from EMR envy as they have wanted to get an EMR for 10 yrs, but the cost is daunting and they do not have the capital for licensing and implementation, though they do have the necessary hardware. Access to an IT person is also a serious limitation as they currently subcontract to the single person who maintains the hospital. There is not money in the budget to hire another person to fill that role. For population management, they have created registries using diagnostic data in their electronic billing records, and this has worked well for management and quality improvement. Overall, they are poised to make the leap, but have not yet done it.

Scott Graham, MD

Started practice August 1999. Solo practice in which he hired a FNP 5 years ago. Family Practice. Rural community, Population 1800.

He falls into the same category as Dr. Law. Their hospital and clinics continue to explore the option, but nothing has really been closely looked at. IT is a big concern. A program that communicates with each clinic and the hospital is another road block and cost is a huge concern. There is interest, but we are not excited about spending more money, hiring more staff, seeing less patients, having to spend more time at a computer and less with patients, and the headache of EMR, yet. He is not convinced this would be an easy transition and until something comes along that is user friendly and not so expensive, so they are sticking with paper.

Some discussion that followed those presentations:

Hersh – Epic has encouraged its customers like OHSU to work with smaller practices to use the software, as Epic doesn’t focus on the smaller market. This could be a good solution in some cases. Overall, the barriers presented by the Steering Committee members are not unknown in the HIT world, and all can be solved with resources. Dr. Tom Yackel, the Chief Health Information Officer at OHSU, could provide information related to some issues, including expanding Epic as well as secure email needs.

Fagnan – There is a group from NYC that uses eClinicalWorks for 1,200 clinicians in their area. Perhaps ORPRN could meet with their medical director, Dr. Farzad Mostashari, to explore the possibility of partnering with them and using it. This would provide an alternative to Epic. He also echoed the request by Liz Powers to explore personal health records as an option.

Hersh –The Director of the New York Health Department recently published a paper describing their approach in Health Affairs and ORPRN may wish to talk with him about the work he’s been doing. Dr. Hersh summarized by noting the impressive efforts by practices on the call and recognizing that there were three main challenges: support, costs, and integration of data across systems.

Hersh and Fagnan noted some clear themes from this discussion. There are three major barriers to EHR adoption and use in these small rural physician practices:

1. Cost and return on investment – there are substantial expenses and risks for those expenses in these practices.

2. IT and informatics support – need help both with basic IT as well as clinical issues, yet it is not readily available, especially locally. There are explicit difficulties with e-prescribing as well as decreased number of patients visits per day because of time to document.

3. Lack of interoperability – cannot move data across practices or to centers in larger urban areas. Despite electronic systems, providers must scan in reports and lab results, as there is a lack of interfaces with the local hospital.