Update on the ONC Health IT Curriculum Project

It has been a while since I provided an update of the Office of the National Coordinator for Health Information Technology (ONC) Health IT Curriculum Project. I had the opportunity to give a presentation about the curriculum at this week's HIMSS Conference, so will use the preparation for that to give an update here.

The major news from the project is that the third version of the curriculum will be released in the next month. Version 3 will have the same component names and structure, but the content has been substantially revised and improved. In addition, there will be much more consistency of the slide formats as well as file content and naming. The content itself has been revised based on feedback obtained by a variety of mechanisms, including contracting with the American Medical Informatics Association (AMIA) and expertise they garnered in a process last summer. The materials also have improved accessibility for those with disabilities.

Some have expressed some concern that the project "ends" on April 2, 2012. While it is true that the ONC grant ends on that date, the Web site will continue to be available beyond then. ONC is also considering a no-cost extension of the grants. Stay tuned for more details.

As with Version 2, the Version 3 materials will be made available to the general public. Anyone will be able to go to the Web site of the National Training & Dissemination Center (NTDC) Web site and create a login to enable downloading of the materials.

Other news includes a mention of the curriculum as one of the major accomplishments of ONC for 2011, according to the National Coordinator, Dr. Farzad Mostashsari.

Another useful accomplishment was the addition of a search capability to the NTDC Web site. The search engine allows searching over all text-containing documents. The search engine output allows list the files containing the search terms and allows downloading of the individual file or the unit .zip file that contains the file. The search engine indexed the 1342 Word documents and 460 Powerpoint files and has made them available for word-based searching. (For language trivia buffs, there are 37,485 unique words in these files.)

Additional news about the project includes data about the size of the Version 2 materials as well as download data since its release, including public users.

The entire collection of materials, including the slides, voice-over narration of the slides, and other materials, is 7.84 gigabytes in size. There are a total of 33,172 files. This actually does not include the VA VistA for Education electronic health record system, which has an installer file that is another 770 megabytes in size. VistA requires a license for the Intersystems Cache system, which is freely available to academic institutions but not others. The narration of the slides, available as both Flash-based "video" as well as MP3 audio files, totals 125.6 hours. As noted above, the materials have 1342 Word documents and 460 Powerpoint files. The latter contain a total of 8913 slides.

We also have details about the downloading of Version 2, covering the period from the public rollout to the end of 2011, about one-half year. Before delving into detail about the downloads, it is important to remember the structure and contents of the curriculum. The curriculum consists of 20 components, each aiming to be comparable in size to a three-credit college course. These courses are part of the various workforce roles around which the ONC community college workforce development program is organized, but of course can be used independently either as a whole course or even broken into parts. Each component is broken down into 8-12 units. Each unit contains voice-over-Powerpoint lectures (with transcripts), self-assessment quizzes, and other learning activities (such as discussions and hands-on exercises).

The NTDC web site is structured for downloading by units. The workforce for someone downloading is to create a login (or, in the case of community college faculty users, have a login created, which allows access to additional curricular support) and then navigate through the components to the individual units (packaged in .zip files) for downloading. (We do plan to implement the ability to download entire components in 2012.) Also available for downloading is .zip file containing all the component blueprints (syllabus-like documents) as well as the installer and a help file for VistA for Education.

All told, there were 284,398 downloads of Version 2 units and other files between May-June and the end of 2011. It is important to put this large number in context, which it represents the number of items downloaded. These downloads were carried out by 537 community college faculty and 4680 public users. The public users came from 31 different countries, although the vast majority were from the US. Many of the registering public users did not provide the information the system asked when creating the login, so their background and demographics are not accurately characterized, but browsing of the log shows many educators as well as individuals connected to health care organizations.

The components with the largest number of downloads were Components 3 (22,645), 5 (19,504), and 1 (18,920). The average number of unit downloads per component varied from 2102 for Component 1 to 931 for Component 13. The component blueprints file and VistA for Education installer were downloaded 3255 and 3136 times respectively.

Additional insight can be gained from looking at the minimum and maximum amount of downloads of units within each component. This provides a sense of how many users are downloading one or more units within a component. The minimum number of units downloaded within a component tend to be much closer across the components than the total number of downloads or the maximum. For example, one of the units of Component 5 was only downloaded 925 times, which was not much more than the most minimally downloaded unit of Component 20 (923). This implies that there might be two downloader types: those who take everything for a given component and those who pick and choose.

All told, we are pleased that the ONC Health IT Curriculum has become a substantial global resource. It will be improved with Version 3 that is coming shortly. We are also exploring ways to sustain it beyond the end of the HITECH funding.

eHealth Initiative Report on Hiring in Health Information Exchanges

The eHealth Initiative (eHI), a health information exchange (HIE) advocacy group, recently released a report stating that while HIEs are likely to generate jobs in health information technology (HIT), few of those jobs have gone to those trained by the workforce development programs of the Office of the National Coordinator for Health Information Technology (ONC). As one who is associated with the ONC workforce development programs, I was naturally alerted to the report as well as an article in the trade publication, Health Data Management.

My overall reaction to the eHI report is that while I do not disagree what its findings and conclusions, I do believe those findings and conclusions need to be viewed as part of a larger perspective about HIE and HIT employment. I also believe that the reporting of the methodology used for the report is incomplete, leading to some uncertainty about the meaning of its findings and conclusions. In particular, I wonder whether the report authors or those surveyed fully understand the ONC workforce program or even the HIT workforce itself. There may be more information about this report in one of eHI's proprietary publications, but I cannot find anything on their Web site. (Although I support the work of eHI, I am not a member.)

I do acknowledge up front that I have a vested interest in the ONC workforce development program. I am funded on two grants, one devoted to curriculum development for the six-month community college programs and another for university-based training in the Oregon Health & Science University (OHSU) graduate program in biomedical informatics. I also believe it is fair for anyone to question the value of these programs and whether the investment being made is productive.

My main problem with the report is that its methodology is incompletely described. To begin with, the report itself has no listed author(s) or contact information. Who carried out this report and how can they be contacted?

A related concern is whether those who developed the report's survey or those who answered it are sufficiently knowledgeable about the ONC workforce program itself.  The report does not describe how the question(s) about the ONC programs was/were asked or how knowledgeable the respondents were about the different programs. Many people, for example, are unaware that the program is larger than just the six-month community college certificate programs. Are they knowledgeable, for example, of the university-based training (UBT) programs, which have a workforce role called "Health Informatics Management & Exchange Specialist" that is likely to be most amenable to work in HIEs? This workforce role has been the most subscribed workforce role among the six covered by the UBT programs.

By the same token, the report does not put employment within HIEs in perspective. While I certainly believe that HIEs are a critical element to the larger success of HIT adoption, it is important to remember that the number of people employed in HIEs will be a relatively small part of the overall HIT workforce. For any given state or region, there are many healthcare organizations whose HIT systems will feed into one or a small numbers of HIEs. Although there will be many important jobs for those who implement, lead, and utilize HIEs, their numbers will be modest relative to the large number of HIT professionals in hospitals, physician offices, and other health-related organizations. It is just simple math.

Also important to remember is that many HIEs are still early in development, where the critical skills are more around planning and development than implementation. It is not surprising to see consultants being heavily used, as opposed to professionals just out of their education programs without a great deal of workforce experience. Related to this, the report seems to look only at direct hiring of ONC workforce program graduates by HIEs. We do not know how many graduates of ONC programs work for consultants, vendors, or others as opposed to being hired directly by HIEs, on which the report seems to focus

We also need to remember that HIE jobs vary in the same way that HIT and clinical informatics jobs do. As such, those trained in the ONC programs might not be a fit for the jobs available in HIE. In fact, it is likely that HIE jobs require a great deal of HIT workforce experience, which ONC workforce program graduates by definition do not have.

The Health Data Management article also goes off on a tangent and raises some issues about the ONC HIT curriculum. Some of these are valid criticisms, but it is also important to remember that these curricular materials are designed for HIT teachers, who are encouraged to use them creatively to offer a meaningful learning experience and not just a rote curriculum out of the box. Some of the community colleges have done this better than others in this regard.

While I applaud eHI for brining the workforce issue in the context of HIE to light, I also believe that their report raises more questions than it answers. I do hope that someone will come forth and explain the details of the report's methodology and its findings. I will certainly make a postscript to this entry in my blog if anyone does so. I also encourage dialogue about the value of the ONC workforce programs and how we can improve them not only for content, but also the employability of their graduates.

Is Medicine an Information Science? Perspective from Physician Time Studies

We tend to think of medicine as a health science or a life science, yet in many ways it is an information science, and may be becoming more so with the growth of data generated in the care of patients. If medicine is indeed an information science, then there is a critical role for  biomedical and health informatics, which is the field that uses information to improve some aspect of health, healthcare, and biomedical research.

A couple years ago I reviewed in this blog  two articles that had recently been published about the role of information in medicine. One article, by Stead et al. posited that the quantity and complexity of information in medicine requires a fundamental paradigm shift from the "power of the individual brain" to the "collective power of systems of brains" [1]. The authors noted that the numbers of facts per clinical decision will likely increase exponentially, especially as our knowledge moves beyond the phenotype to include the genotype (e.g., genomic variation, proteomics, etc.). The second article, by Shortliffe, was published about the same time in a special issue of JAMA devoted to medical education [2]. He noted that while medical education (rightly so) goes to great lengths at teaching students how to assess, interact with, and treat patients, it devotes very little effort to obtaining, using, and analyzing another critical component of medical care, namely information.

What evidence is there that medicine is an information science? After all, most modern knowledge workers - i.e, professionals in financial analysis, aviation, and  marketing to name a few - make critical use of information in their work too. A number of studies have looked at how physicians spend their time, and provide clear evidence that information is critically important to their work. Some might think that physicians spend the majority of their time with patients, such as examining them or performing procedures on them. However, these time studies show that physicians spend more time interacting with information, such as reviewing data and documenting patient care, than interacting directly with patients.

These studies assess the tasks of physician work and the time spent doing them. Some of the tasks primarily involve using information. (It  is unfortunate that others in the healthcare environment have not been studies, but as often happens, physicians are the targets whom researchers have chosen to study.) Enough of these studies have been done to lead Tipping and colleagues to perform a systematic review [3]. In addition, four more studies have been done since the completion of the systematic review by Kim et al [4], Tipping et al. [5], Yousefi [6], and Chisholm et al. [7].

The systematic review points out that the studies are heterogeneous and cannot be group to do something like a meta-analysis. Yet the results are surprisingly consistent. The systematic review develops a classification to which most studies relatively adhere. The studies all measure in some manner "direct" patient care, where the physician interacts directly with the patient. They likewise describe "indirect care" of the patient, where the physician reviews patient data, performs documentation, and communicates with various people, such as members of the care team, the patient and/or their family, insurance companies, and others. Finally, most studies have some sort of "other" category that includes travel (either within a healthcare facility or between them), education, and personal time (such as eating). The systematic review and three of the follow-up studies focused physicians who work on hospital wards (i.e., hospitalists), although one of the more recent studies looked at emergency department physicians [7]. The studies have been somewhat though not exclusively weighted toward academic facilities and physicians in training.

Even with the variation in definition of the categories and tasks within them, the results are remarkably consistent. While the range is wide, most of the studies show that physicians spend about 15-17% of their time in direct patient care. Conversely, they spend about 64-67% of their time in indirect patient care, often relatively evenly divided between reviewing results, performing documentation, and engaging in communication. The tasks of reviewing results and carrying out documentation are clearly information-focused in nature, which means that physicians spend about 35-40% of their time engaged with information. One could also probably argue that aspects of direct patient care are information-focused as well, as the physician is gathering information about the patient. The education component of the other category is of course very information-oriented.

Some additional interesting tidbits come of the individual studies. The newer Tipping et al. study took place in a setting of full electronic health record (EHR) implementation and noted 34% of physician time was spent interacting with the EHR [4]. This study and two others by O'Leary et al. [8] and Westbrook et al. [9] in the Tripping et al. systematic review looked at multitasking, finding it was being done during 16-21% of physician work time. O'Leary et al. also found physicians received 3-4 pages per hour [8], while Westbrook et al. noted an average of 2.9 interruptions per hour [9]. Kim et al. found that the amount of direct care was higher at the beginning of shifts while indirect care was higher toward the end of shifts [5]. They also noted that 7% of physician time was spent in travel within the healthcare facility, wondering whether this might be an area where efficiency of work can be improved [5].

In their study of emergency department physicians, Chisholm et al. noted that somewhat more time was spent in direct patient care (31% for academic settings and 38% for community settings) and less in indirect care (55% for academic settings and 50% for community settings) [7]. They also found these emergency physicians were interrupted on the order of 10 times per hour.

These studies collectively show that physicians in hospitals and in emergency departments spend a substantial amount of their time interacting with information. Going forward, the amount and complexity of information is likely to increase. It will come from diverse sources, such as patients entering data into their personal health record (PHR), clinical data coming being provided via health information exchange (HIE), and the growing amount of data from genomics and related areas. This makes the science of biomedical and health informatics even more critical to the medical field.

References

1. Stead, W., Searle, J., et al. (2010). Biomedical informatics: changing what physicians need to know and how they learn. Academic Medicine, 86: 429-434.
2. Shortliffe, E. (2010). Biomedical informatics in the education of physicians. Journal of the American Medical Association, 304: 1227-1228.
3. Tipping, M., Forth, V., et al. (2010). Systematic review of time studies evaluating physicians in the hospital setting. Journal of Hospital Medicine, 5: 353-359.
4. Tipping, M., Forth, V., et al. (2010). Where did the day go?--a time-motion study of hospitalists. Journal of Hospital Medicine, 5: 323-328.
5. Kim, C., Lovejoy, W., et al. (2010). Hospitalist time usage and cyclicality: opportunities to improve efficiency. Journal of Hospital Medicine, 5: 329-334.
6. Yousefi, V. (2011). How Canadian hospitalists spend their time - a work-sampling study within a hospital medicine program in Ontario. Journal of Clinical Outcomes Management, 18: 159-164.
7. Chisholm, C., Weaver, C., et al. (2011). A task analysis of emergency physician activities in academic and community settings. Annals of Emergency Medicine, 18: 117-122.
8. O'Leary, K., Liebovitz, D., et al. (2006). How hospitalists spend their time: insights on efficiency and safety. Journal of Hospital Medicine, 1: 88-93.
9. Westbrook, J., Ampt, A., et al. (2008). All in a day's work: an observational study to quantify how and with whom doctors on hospital wards spend their time. Medical Journal of Australia, 188: 506-509.

One Patient's View of the Optimal Personal Health Record

In teaching current and future informatics professionals, I often speak about the Internet-savvy baby boomers who will interact more with the healthcare system as they get older, which will likely usher in the era of patient-centered informatics more than anything heretofore. I recently had some activities in this role, which gave me some firsthand thoughts about the personal health record (PHR) and interacting with the healthcare system through the PHR and other Web-based means.

There are many views about the role of the PHR and how it should be optimally used. Should it, for example, be primarily connected (sometimes called tethered) to the electronic health record (EHR) of the organization where one receives most or all of their care. While few people desire a truly standalone PHR (i.e., not connected to any data), some advocate it is more important that we move toward an integrated PHR that can interact with data from many sources, from one's own healthcare system to health-related data they capture, such as diet and exercise logs [1, 2].

I recently had the opportunity to interact with my healthcare provider system (OHSU) and its PHR offering (MyChart, tethered to its Epic EHR system). I am fortunate to be in good enough health to not be a major consumer of OHSU healthcare services, but in these interactions, I did come to realize that I want my healthcare system to provide the same kinds of online services that I routinely use for banking, travel, and consumer purchases (e.g., books, electronics, music, etc.). In this regard, OHSU, like many healthcare organizations, falls short.

My experience showed me that what I really want is not so much a PHR (thought it is part of the mix), but rather the ability to manage my data and information with a PHR as well as the ability to carry out all of my interactions with the healthcare system. This includes everything from appointment scheduling and prescription refills to tracking my personal health.

What led to this interaction was what turned out to be a spurious slightly elevated fasting blood sugar. Although I am not overweight, I do have a family history of Type II diabetes, so this is something important to monitor. I also have a number of other cardiac risk factors, including some that are not modifiable (family history), which I try to mitigate with healthy living, namely diet and exercise.

(My cardiac family history is like a roulette table. I have a maternal grandmother and her father who lived to over 100. My maternal grandfather, on the other hand, died of coronary heart disease in his early 50s. Likewise, my maternal grandparents had diabetes and heart disease but lived into their 80s. My father had coronary bypass surgery just before age 50 but is alive and has been symptom-free over 30 years later. Both my maternal grandfather and my father would likely have their coronary heart diseases treated differently in the modern era, with our present array of medications and procedures such as angioplasty. I note that I am also different from them in that they were both smokers. The question is whose genes for coronary disease I have inherited, which is perhaps something our bioinformatics colleagues will be able to answer in the future.)

I also have mild hypertension and a mixed lipid panel, with normal total cholesterol but a sometimes low HDL. In the process of checking a lipid panel, my physician also ordered a metabolic panel, which included a blood glucose. I have always had a fasting glucose at the high end of normal at around 100.

In MyChart, results are released to patients after being reviewed by the provider. This is probably a good idea, although for more routine things, it might not be, since it delays the patient (including knowledgeable ones like me) from getting their results. My initial glucose (along with my lipid profile, which was originally my main concern in getting the blood drawn) was released within hours of the blood being drawn. I was not so lucky for the follow-up tests.

I was impressed to get an email notification within a few hours after the blood was drawn for the first set of tests directing me to MyChart, where my results and a brief message from my physician were waiting. The results showed a fasting blood sugar of 107, which is classified nowadays as "prediabetes." My physician suggested the next step should be to wait and check it again in three months. However, given my family history and other cardiac risk factors, I wanted to know more. In particular, I wanted to know what a two-hour postprandial glucose and a hemoglobin A1C level would show.

My personal physician is also a professional colleague at OHSU and someone I have known since I arrived there 21 years ago. I chose to contact him through the MyChart messaging functionality, although did not get a reply. So I sent him a regular email, to which he responded promptly and ordered the additional tests. I do know that some physicians have trouble keeping up with the stream of email that comes in via MyChart. I do not blame them as much as I blame our healthcare system that only pays for face-to-face medical encounters  and not overall care of the patient, although perhaps that will change with accountable care organizations (ACOs) [3].

I had the second set of tests done on a Friday morning and was hoping for the same quick turnaround as my other tests. This time, that did not happen, and I did not hear back from my physician until late the following Monday. The time lag was certainly not critical for my health, but I did have a desire to learn the results as quickly as possible. I did receive excellent news. Not only was the fasting glucose 97 this time, but my postprandial glucose was 80 and my hemoglobin A1C was 5.1. Not even a hint of diabetes!

Another encounter with the OHSU health system having nothing to do with MyChart but related to electronic interaction with the health system happened about this same time. As noted above, I also have mild hypertension, which is easily controlled with 10 mg of amlodipine daily (and no doubt my healthy diet and dedicated exercise regimen). I get refills for my amlodipine using the OHSU Mail Order Pharmacy. I can request a refill by sending an email to an address on their web site.  There are several problems with this approach. One is that getting my refill in a timely manner is dependent not only on my remembering to send an email a week or so before I run out, but also the timely processing of my request by the pharmacy, which does not always seem to happen. A modern PHR connected to my health system would send a reminder at the appropriate time that let me order the renewal with a click or two.

Another PHR-related activity with my blood pressure comes from the recent home blood pressure monitoring machine I purchased. I am impressed that it stores my results and, when I connect it to a USB port of my computer, uploads the data to my account in Microsoft HealthVault. Of course, it would be more ideal if this data were integrated with my MyChart account, but that does not yet happen. Speaking of HealthVault, I have to say that although I am not always a big fan of Microsoft software or their business practices, they did get it right with HealthVault. It makes sense to have built a PHR platform rather just an application. I could see in the long run how secure cloud-based storage of all our data, even that in the EHR, would be optimal. (Of course, security and availability would need to be rock-solid.)

As mentioned above, I do try to mitigate my cardiac risk factors with diet and exercise. My diet mostly follows the advice of Michael Pollan, "Eat [real] food, mostly plants, not too much" [3]. My exercise consists of running three days a week and cross-training with weights two days a week. I actually pursue this lifestyle less for future benefits and more for the present, as it gives me more energy and makes me feel better here and now. Any later-life benefits will be a plus. I do track my exercise and weight in a spreadsheet but have never felt compelled to take the time to collect any more detail or enter it online.

All of these experiences made it clear to me that what I want most in my online patient experience is not just a PHR, but rather the ability to manage my data integrated with my interactions with all of my healthcare providers. In addition, I want to be able to handle routine transactions in a modern eCommerce-like manner, such as making appointments and ordering prescription refills online. Some may argue that there is not a business case for healthcare organizations to act this way, since our current healthcare system pays clinicians for doing things and not for providing comprehensive, integrated care. I hope, however, that this is not the future, and that healthcare organizations like OHSU will need to serve its customers online because its Internet-savvy baby boomer customers will come to expect it and might seek care elsewhere if they do not get it.

References

1. Detmer, D., Bloomrosen, M., et al. (2008). Integrated personal health records: transformative tools for consumer-centric care. BMC Medical Informatics & Decision Making, 8: 45.
2. Tang, P. and Lee, T. (2009). Your doctor's office or the Internet? Two paths to personal health records. New England Journal of Medicine, 360: 1276-1278.
3. Fisher, E., McClellan, M., et al. (2009). Fostering accountable health care: moving forward in Medicare. Health Affairs, 28: w219-w231.
4. Pollan, M. (2009). In Defense of Food: An Eater's Manifesto. New York, NY. Penguin.