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Challenges and Opportunities of Electronic Health Record and Residency Training

This article provides an informatics perspective on the challenges and opportunities of Electronic Health Record (EHR) systems in residency training. It discusses the realities and facts of informatics, the critical role of informatics for EHR success, problematic aspects of HIT implementation, threats and fallacies of EHR systems, and the unique information needs of surgeons. It also highlights the opportunities for surgeons to leverage successes and become stakeholders in HIT and informatics.

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Challenges and Opportunities of Electronic Health Record and Residency Training

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  1. Electronic Health Record and Residency TrainingThreats, Opportunities, RealitiesAn Informatics Perspective on the EHR Genevieve Melton-Meaux, MD, MA, FACS Assistant Professor, Department of Surgery Faculty Fellow, Institute for Health Informatics University of Minnesota, Minneapolis, MN ASSOCIATION OF PROGRAM DIRECTORS IN SURGERY2011 ANNUAL MEETING; BOSTON, MASSACHUSETTS March 26, 2011

  2. Overview • Informatics • Challenges with EHR Systems, Informatics, and Surgery • Next Steps

  3. Overview • Informatics • Challenges with EHR Systems, Informatics, and Surgery • Next Steps

  4. Informatics – Realities/Facts

  5. Informatics - Facts • Broadly the science of information • Studies the structure, algorithms, behavior, and interactions with information • Utilizes foundations from other fields • Computer science, statistics • Decision and cognitive science • Social engineering • Information and library science • Underlying application (healthcare, medicine)

  6. Informatics - Facts • Biomedical and Health informatics • Medical informatics • Bioinformatics • Definition: Discipline of improving healthcare, biomedical research, and public health through better use of information (Hersh, 2009) • About information, not technology

  7. Informatics - Facts not this *Adapted from Friedman C. “A ‘Fundamental Theorem’ of Informatics.” JAMIA 2009.

  8. Fact: Informatics is Critical for EHR Success • Improved use of information for quality, safety, and integration of care is a critical aspect of healthcare reform • Even more important with ARRA/HITECH and ACA legislation • Benefit of HIT? Systematic reviews show HIT intervention benefit • Most studies in small number of academic centers* *Garg. Effects of computerized clinical decision support on practitioner performance and patient outcomes: A systematic review. JAMA 2005. *Chaudhry. Systematic review: impact of HIT on quality, efficiency & costs. Ann Int Med 2006 *Goldzweig. Costs and benefits of HIT: new trends from literature. Health Aff 2010.

  9. Facts: Problematic HIT • HIT implementation can be problematic • Failure often to lack of understanding of clinical environment and workflow (Leviss, 2010; Einbinder, 2010) • Example: CPOE conflicting outcomes • Children’s Hospital of Pittsburgh Pediatric ICU: mortality rate increased from 2.8% to 6.6% (Han,2005) • Finding not seen at other centers with CPOE (Del Baccaro, 2006; Jacobs, 2006) • Adverse outcomes may have been avoided by changes in workflow and other best practice adherence (Phibbs, 2005; Sittig, 2006)

  10. Overview • Informatics • Challenges with EHR Systems, Informatics, and Surgery • Next Steps

  11. Challenges with EHR Systems, Informatics, and Surgery - Threats

  12. Vendor Dominated HIT - Threats • HIT system implementations are complex • Bulky legacy systems underlie each implementation • Each build is different/customized • Landscape of EHR systems/HIT dominated by large vendors • Limits our abilities to customize or refine HIT • Vendors remain non-liable for errors or problems (“hold harmless” clause)* *Koppel. HIT Vendors “Hold Harmless” Clause. JAMA. 2009.

  13. HIT Fallacies - Threats • Multiple fallacies with HIT (12)+ • Purchasing and using an EHR system does not mean that it will work • HIT is not a device – little oversight • Clinician “bad apple” fallacy (why do we resist?) • We computerized the paper, so we can go paperless fallacy • One size fits all fallacy +Karsh. HIT: Fallacies and Sober Realities. JAMIA 2010.

  14. Surgery Information Needs - Threats • Information needs of surgeons are great • Surgical care has unique characteristics • High-impact encounters • Time-sensitive information needs • Resource intensive • Multi-disciplinary care • Transitions in care, particularly 1) pre-operative assessment/planning and 2) post-operative care Melton. Biomedical and Health Informatics for Surgery. Advances in Surgery. 2010.

  15. Surgery Information Needs - Threats • EHRs not optimized for surgeon workflow • Detailed surgical information difficult to find • Not designed for peri-operative information needs • Flow of information between care settings • Surgeons have not been at the table • Most systems have been designed for primary care physicians/internists in mind • Lack of stakeholders historically Melton. Biomedical and Health Informatics for Surgery. Advances in Surgery. 2010.

  16. Overview • Informatics • Challenges with EHR Systems, Informatics, and Surgery • Next Steps

  17. Next Steps - Opportunities

  18. Surgeons should leverage successes • Model Implementations of Secondary Data Use • Society of Thoracic Surgeons Database • NSQIP • Multiple successful registries (i.e., trauma) • Focus on improving automation of these and similar programs • “Collect Data Once” and “Use Many Times” • Become stakeholders in HIT and Informatics

  19. Opportunities - NIH Clinical and Translational Science Awards (CTSAs) • NIH University-based infrastructure awards to medical centers to improve and transform how biomedical research is conducted • Total of 60(+) centers (NIH Roadmap) • Informatics and automation of clinical (and biomedical) data for research is key to CTSAs • Most centers with CTSAs will or currently have improved access to EHR data for research

  20. Organizations • AMIA – American Medical Informatics Association • Academic home for informaticians • Actively involved with HIT policy • HIMSS – Healthcare Information and Management Systems Society • Organization geared towards HIT implementers/leaders (CIO/CMIO/IT) • Some but inconsistent connections to informatics • Integrally connected with vendors

  21. Training Opportunities • Graduate programs in informatics • Masters, PhD • NLM-NIH Training Programs (T15 fellowship) • AMIA 10X10 certificate program • New ONC Initiatives (Stimulus Bill) • Clinical Specialization in Informatics (via Preventative Medicine) • https://amia.org/informatics-academic-training-programs

  22. Opportunities - HITECH Aims for ~50,000: Workforce Development • Community College Consortia to Educate HIT Professionals Program ($70M) • Five regional consortia of 70 community colleges offering short‐term training for 10,000 individuals per year • Curriculum Development Centers Program ($10M) • Competency Exam for Community College Programs ($6M) • Program of Assistance for University‐Based Training ($32M) • Funding for education of individuals requiring university‐level training at 9 universities (including UMN) • Emphasis on short‐term certificate programs delivered via distance learning

  23. Overview • Informatics • Challenges with EHR Systems, Informatics, and Surgery • Next Steps

  24. Summary • EHR systems increasingly important • Informatics can help improve our ability to implement and utilize EHR systems effectively • Surgery Informatics is a wide open area • Few stakeholders • Much at stake • Many opportunities to become a stakeholder

  25. Questions? Genevieve Melton-Meaux gmelton@umn.edu

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