Friday, September 23, 2011

Update: Clinical Informatics Subspecialty Approved

Several months ago, I described the proposal to establish a medical subspecialty in clinical informatics. I am pleased to report that  this week, the American Board of Medical Specialties (ABMS) approved the subspecialty, as noted in a news release from AMIA.

Although administered by the American Board of Preventive Medicine, the subspecialty will be available to all physicians who have a primary board certification. The first offering of the examination will likely take place in the fall of 2012 for those who meet the criteria for "grandfathering" of the training requirements. In the long run, physicians wanting to subspecialize in clinical informatics will need to complete formal fellowship training.

The approval of this subspecialty is a recognition of the critical professional role played by clinical informaticians. As information is so critical to 21st century medicine, whether in the need for healthcare to be more accountable for its operations or in the coming complexity of clinical decision-making from the data "tsunami" due to advances in genomics and related areas, there will be increasing need for those who work at the interface of medicine and information systems.

There are a number of uncertainties in this development. For example, what will be the criteria for grandfathering of the training requirements. Also, what career pathway will there be for physicians who are not certified in a primary board or have let that certification lapse? Another concern is what will be the evolving role for graduate-level educational programs, such as our program at Oregon Health & Science University.

Although there are a number of details still forthcoming, this new development is an exciting one for the informatics field. I also hope that there will be other pathways for comparable certification not only for physicians who are not eligible for ABMS certification but also for informatics professionals of other backgrounds, both clinical and non-clinical.

Sunday, September 11, 2011

More Studies Assessing Quality Improvement Using Electronic Health Records

Earlier this year, the informatics world was abuzz with a study published in Archives of Internal Medicine by Romano and Stafford that found a lack of improvement in healthcare quality measures for patients whose physicians had adopted electronic health records (EHRs) [1]. As I detailed in a posting to this blog, as well as in a co-authored letter to the editor that was published in Archives [2], this study had a number of flaws. My main complaint with the study was that the quality measures assessed were independent of the EHR intervention, hence any association, positive or negative, was indirect at best.

The furor about the paper died down, and most people got back to working on implementing meaningful use. No one disagreed that we need more research on whether EHR systems do improve healthcare quality, including studies with better methodology.

Last month, another study came along. Published in the New England Journal of Medicine (NEJM) by Cebul et al., this study used a somewhat similar methodology to assess 46 practices in the Cleveland area, 33 of which had adopted EHRs [3]. The study assessed the outcomes of 27,207 patients with diabetes mellitus who were followed by a total of 569 providers. The study looked at four process measures and five outcome measures in those diabetic patients, comparing them for providers who had and had not adopted EHRs. Overall composite quality measures were developed for the process and outcome measures, and found to be 35.1% higher in the former and 15.2% higher in the latter. The difference was found to persist across all insurance types and, even more gratifying, for "safety net" clinics that historically see more complicated patients of lower socioeconomic status.

This study did use a roughly similar methodology to the Romano and Stafford study, and as such must be viewed as having a weaker form of evidence than a direct randomized controlled trial (RCT). Of course, in reality, such an RCT would be near impossible to do, i.e., randomizing patients to receive their care from a provider having an EHR or not. We also know that there can be confounders between practices utilizing and not utilizing EHRs.

Nonetheless, this study did have advantages over similar studies done before it, including the Romano and Stafford study. One clear advantage was that the study had complete data on all patients (unlike the Romano and Stafford study that only relied on a data set from the CDC National Center for Health Statistics (NCHS). The researchers also had precise data on the providers, the EHR implementation, and how the quality measures were integrated into the provision of care.

While this new study received a great deal of press, another study that received less press, which was published shortly after the publication of the Romano and Stafford study, should have received more [4]. Although still not an RCT design,  this study did use a before-and-after methodology to examine change in compliance with 16 quality measures before and after implementation of a commercial EHR in a large academic internal medicine practice. The results showed improvement after the EHR was implemented.

In an editorial accompanying the Cebul et al. study, Classen and Bates noted that the new NEJM study showed the "meaning in meaningful use" [5]. They correctly point out that implementing EHRs is not what HITECH should be about, but rather showing that the technology can be used to make meaningful improvement in the health of patients whose providers use it. As in most areas of medicine, we cannot wait for the perfect study or studies to answer all questions unequivocally, but the evidence base is growing for the value of informatics, especially when systems are implemented properly.

1. Romano, M. and Stafford, R. (2011). Electronic health records and clinical decision support systems: impact on national ambulatory care quality. Archives of Internal Medicine, 171: 897-903.
2. Mohan, V. and Hersh, W. (2011). EHRs and health care quality: correlation with out-of-date, differently purposed data does not equate with causality. Archives of Internal Medicine, 171: 952-953.
3. Cebul, R., Love, T., et al. (2011). Electronic health records and quality of diabetes care. New England Journal of Medicine, 365: 825-833.
4. Persell, S., Kaiser, D., et al. (2011). Changes in performance after implementation of a multifaceted electronic-health-record-based quality improvement system. Medical Care, 49: 117-125.
5. Classen, D. and Bates, D. (2011). Finding the meaning in meaningful use. New England Journal of Medicine, 365: 855-858.

Monday, September 5, 2011

Update of Site, What is Biomedical & Health Informatics?

Years ago, I used to get asked on a regular basis, What is Medical/Biomedical/Health Informatics? To answer this question, I created a Web site that attempted to answer it. Later on, I added some voice-over-Powerpoint lectures, which also provided me the opportunity to demonstrate the technologies we use in our distance learning program at Oregon Health & Science University (OHSU). In 2007, the site was accepted for listing in the Association of American Medical College (AAMC) online medical educational resource, MedEdPortal.

Keeping a site like this up to date is no small feat, especially at a time like this, when many people in the field are very busy carrying out work related to the Health Information Technology for Clinical and Economic Health (HITECH) Act. As readers of previous postings in this blog know, I have been very busy leading OHSU's contributions to the HITECH Workforce Development Program.

For this reason, the site had grown out of date, with its last major update in 2009, when the HITECH Act had just been passed. I am pleased to announce that I have now updated the  lecture and references on the site to include not only everything related to HITECH, but also advances in other areas of biomedical and health informatics, including bioinformatics, information retrieval, and telemedicine.

The site still includes my voice-over-Powerpoint lectures, which have now expanded to about 2 hours and 40 minutes, but are still divided into seven segments. On almost every slide, I could go into even more detail. If nothing else, this site will hopefully whet peoples' appetites for the 10x10 program, the OHSU graduate program, or other programs.

The educational methods I use on this site mirror my on-line teaching. I have always found great value in voice-over-Powerpoint lectures, especially using the Articulate tool that provides the slides and sound in Flash format and also allows easy navigation among the slides. I also provide MP3 files of the slide audio (one MP3 per segment) as well as PDF files of the slides themselves (one PDF per segment). In addition, I provide another PDF that has references to all of the papers, reports, books, and other citations in the lecture. The site also contains a list of key textbooks as well as links to some of my papers and to important organizations and other sites for the field.

I look forward to receiving feedback from people and take full responsibility for any errors in any of the materials I have produced.