Keywords
medical informatics - medical education - internship and residency - strategies for
health IT training
Background and Significance
Background and Significance
The demands and challenges facing biomedical and clinical informatics highlight the
need for the development of a pipeline of future informaticians who can bridge the
complex issues of clinical medicine with the innovative solutions of information technology.
Already, opportunities for education in clinical informatics are becoming more prevalent
throughout the spectrum of medical training. The American Medical Informatics Association
(AMIA) High School Scholars Program pairs accepted high school students with a mentor
to work on a biomedical informatics project and present at the AMIA Annual Symposium.[1] At the University of Pittsburgh, high school students have been exposed to biomedical
and pathology informatics through an 8-week summer course since 2009 in anticipation
of the escalated demand for informaticians.[2] Increasingly, college courses are incorporating a discussion of information sciences
into biological and health care-related topics.[3]
[4]
[5] With support from the National Library of Medicine, Masters and PhD-level graduate
school programs in biomedical informatics have been particularly well developed.[6]
[7]
[8] Many medical school curricula include a discussion of the role of information technology
in medicine.[5]
[9]
[10]
[11] Following residency, physicians have the opportunity to engage in further informatics
training through the clinical informatics fellowship or the practice pathway.[12]
[13]
[14]
[15] However, there exists a gap of clinical informatics training at the residency level.
While tapping into this group can be fraught with challenges due to residents' intense
clinical obligations, residents are uniquely positioned to be receptive to and contribute
to the field of informatics. As front-line clinicians, residents are a key demographic
of electronic health record (EHR) users whose daily workflow is directly impacted
by the structure of the EHR. Residents are intimately aware of a system's strengths
and have a vested interest in fixing shortcomings at the sharp end of care delivery.
They represent a potential source of collaborative solutions and practical feedback.
Because of the nature of their training, residents are also well acquainted with the
intricacies of various workflows including people and processes in a given institution.
Residents represent a large proportion of the workforce at many hospitals, increasing
the points of contact for collaboration. Furthermore, as a result of the opportunities
prior to residency, as previously described, recent generations of residents are increasingly
adept with the technologies used in clinical informatics, although their familiarity
with the principles may be lacking. Engagement of resident physicians in hospital
informatics efforts can accelerate implementation of meaningful improvements, while
preparing residents to become proficient physicians in the electronic era.
Based on traditional models of clinical subspecialty fellowships, the majority of
applicants to clinical informatics fellowships are likely to come directly from residency
training. To provide a glimpse into potential fellowships, programs require several
clinical rotations that provide in-depth contact with core principles, daily activities,
and potential mentors in the field. A rotational correlate does not exist at most
training institutions for clinical informatics, although some have successfully established
medical student and resident electives.[16]
[17]
[18] Until recently, little had been published on the education of residents in the field
of medical informatics since 1999.[19] In 2017, the University of California, Los Angeles (UCLA) Health Informatics program
shared their approach consisting of a longitudinal program where accepted residents
and fellows follow a yearlong curriculum covering major topics in clinical informatics,
learn to develop new tools in the EHR, and partner with a mentor to develop and implement
an informatics project.[20] Comprehensive programs like these improve the visibility of clinical informatics
as a potential career option for trainees. However, this approach required substantial
resources, including monthly lectures, an application acceptance program, and a monetary
project stipend after completion of the program. Scaling up these educational initiatives
in this critical period may be difficult without such resources.
In this article, we present a model of a clinical informatics curriculum that has
been in place at Children's Hospital of Philadelphia, a large urban academic pediatrics
hospital, since 2012. The pediatrics residency program consists of 163 residents.
The Department of Biomedical and Health Informatics supports a clinical informatics
fellowship with 4 fellows and 10 board-certified faculty educators. This model for
resident education in clinical informatics includes options such as an introductory
elective, a longitudinal experience, and a resident working group. We also present
residents' perceptions of the impact of different curricular elements, as well as
their career trajectories after elective participation.
Key Components of Informatics Educational Model
Key Components of Informatics Educational Model
During the 3-year pediatric residency training program, residents have exposure to
informatics education at multiple levels. These range from required experiences for
all residents to optional, short- and long-term informatics educational opportunities
([Table 1]). The central pillars of the model include a health informatics elective, a longitudinal
experience, and a resident working group.
Table 1
Resident experiences in clinical informatics
|
Curricular
|
Extracurricular
|
|
Required
|
• EHR case simulations[23]
• Introductory informatics lecture
• Knowledge management lecture
|
• EHR efficiency workshops
|
|
Optional (short-term)
|
• Elective rotation
|
• Mentorship by informatics faculty, fellows, staff, and peers
• Informatics committee meetings
• Invited lecturers
• Regional and national informatics conferences
|
|
Optional (long-term)
|
• Longitudinal experience
|
• Resident informatics working group
• Independent project
|
Abbreviation: EHR, electronic health record.
Short-Term Experience—Health Informatics Elective
The health informatics elective combines structured didactics with skill-building
online EHR training modules. The elective is 2 to 4 weeks in duration and offered
throughout the year. Participants in the elective meet with the course director prior
to or at the start of the elective to assess the participant's knowledge and proficiency
in health informatics to personalize their goals and objectives for the rotation.
This approach aims to provide a foundation of informatics knowledge, but emphasizes
exploration within the individual resident's interest area. Activities include viewing
online recorded lectures, reading select textbook chapters and journal articles, and
participating in various informatics-related meetings and conferences (see sample
objectives and activities in [Appendix Tables A1]
[A2]
[A3]
[A4]). In addition to meeting with other faculty, participants continue to meet weekly
with the course director to follow-up on progress and to adjust their activities to
meet their individualized objectives. For each resident in the elective, this structure
requires approximately 2 hours per week of time commitment from the course director
as well as approximately 2 hours per week of ad hoc meetings with other faculty members
or Information Services (IS) staff with expertise in the resident's area of interest.
During the elective, residents are encouraged to complete projects, providing hands-on
experience where they apply newfound informatics knowledge to clinically relevant
scenarios. The course director and the participant specify a project that will be
feasible within their time commitment, that will be appropriately mentored, and that
will align with their personalized goals and objectives. Depending on the resident's
interest, their contribution to the project may be limited to the duration of the
rotation or continue to evolve after the elective. Of note, nearly all successful
projects were started during the elective and then benefitted from crowdsourcing through
the resident working group described below.
As part of their projects, elective participants may be given access to an EHR sandbox
development environment, which does not migrate to the production environment. This
environment exists as a space to test new functionality without disrupting operational
processes. Residents are required to complete a set of training modules hosted by
the EHR vendor ([Appendix Table A3]) in addition to a 1-hour review of best practices with the informatics course director.
The course director subsequently works with our IS department to provide the resident
with sandbox development environment access. Residents are expected to use this access
to augment their skills in other core competencies, like performing workflow analyses,
understanding the impact of EHR build on patient care, and aligning user needs with
EHR capabilities. Residents have the option of presenting their work to a hospital
committee, who may then decide to migrate their work to production. Aside from time
invested by the course director and that of IS, there is no additional cost associated
with providing residents with this access.
Longitudinal Experience
All pediatric residents at Children's Hospital of Philadelphia have the option of
applying to participate in a longitudinal track, which allows residents to increase
their exposure to academic domains outside of traditional clinical experiences. Examples
include bioethics, health care disparities, as well as clinical informatics. Residents
in this informatics track engage in advanced didactics (both directed and self-guided),
meet with faculty mentors throughout the remainder of their training, attend committee
meetings, and work on a long-term project with goal of completion prior to graduation
from residency. At graduation, this advanced skill participation is acknowledged on
their diploma along with the participant's training in pediatrics.
Resident Informatics Working Group
Following the establishment of the formal educational curriculum, a group of residents
interested in workflow improvement started a resident informatics working group in
2013. This group, also known as the New EHR Resident Development (NERD) Squad, meets
in the evenings every 1 to 2 months to discuss resident workflow issues with potential
EHR solutions. As part of the NERD Squad, residents are encouraged to pursue the elective
in health informatics and offered a wide array of opportunities to be involved in
hospital initiatives. Faculty and fellows within clinical informatics also routinely
attend meetings, providing mentorship and guidance on core informatics principles.
These meetings often take place in the evening following resident shifts with funding
for meals provided by the clinical informatics department.
The NERD Squad serves as a forum for nontechnically oriented residents to voice their
concerns. As a result, it creates an informal space for crowdsourcing, accelerating
the incorporation of user input in the design process of resident-led projects. Example
projects resulting from collaborations of residents with informatics faculty are detailed
in [Table 2]. The majority of resident efforts has involved enhancing documentation support and
peer education. All content created by residents requires a faculty mentor to review
before presentation at an EHR operational meeting. Following approval, the content
is incorporated into standard change control processes.
Table 2
Examples of resident projects
|
Project
|
|
Handoff templates for common admission diagnoses
|
|
Discharge summary templates for common diagnoses
|
|
Standardized inpatient discharge instructions for common diagnoses
|
|
Documentation template for medically complex foster children[a]
|
|
Templated list of common contingency plans
|
|
EHR simulation curriculum for interns
|
|
EHR training sessions
|
|
Health hackathon
|
Abbreviation: EHR, electronic health record.
a Initiated and completed within a 4-week elective; all other projects were initiated
during an elective but completed in conjunction with the resident working group.
Example Resident Project
The following example of a resident-led project serves to highlight the interplay
between the informatics elective, longitudinal experience, mentors, and resident working
group. Previously, residents were required to free-text all discharge instructions
once a patient was ready for discharge contributing to documentation burden and variation
in discharge care for common diagnoses. During the clinical informatics elective,
one pediatric intern proposed reviewing the top 20 admission diagnoses to prioritize
creation of standard templates. In conjunction with faculty mentorship from clinical
informatics, she drafted several templates and incorporated feedback from the resident
working group and clinical faculty. After implementation into the EHR production environment,
she presented this work to the resident working group, and other interested residents
began adding content. These contributions expanded the number of discharge diagnoses
and grew into a longitudinal project for the original resident. This experience allowed
the resident to learn key informatics principles in workflow analysis, change management,
and stakeholder engagement.
Participation
Pediatrics residents have one elective block during their first year, two during their
second year, and four during their third year. The incoming resident cohort ranges
from 48 to 54 residents. Since the resident health informatics elective was established
in 2012, 23 residents have completed the elective, of whom 4 (17%) pursued further
education through the longitudinal experience, and 10 (43%) participated in the resident
working group. From each residency class, on average, 5% of residents participated
in the elective. An additional 33 residents have participated in the resident working
group without engaging in other informatics opportunities.
Resident Perceptions
We contacted all 23 prior participants of the health informatics elective for feedback
on how components of the educational model influenced their informatics knowledge
and career choices ([Fig. 1]). Although this was not a formal evaluation of the model, many elective participants
also interacted with other components of the educational model including the longitudinal
experience, the resident working group, as well as mentorship activities and a clinical
informatics project. Among the 19 respondents, 79% (15/19) found the elective to be
very or extremely influential on their knowledge base and 60% (6/10) who had completed
residency and were still involved in informatics felt similarly about the elective's
impact on their career choice. In addition to the elective, the majority of respondents
highlighted that participation in a clinical informatics project, mentorship activities,
and the resident working group were similarly influential on their knowledge base
and career choices.
Fig. 1 Factors influencing residents' knowledge of clinical informatics and residency graduates'
career choices.
Career Trajectories
Following residency, five elective participants went on to pursue additional training
through the clinical informatics fellowship. From those who provided feedback, all
14 postresidency participants indicated some continued involvement in clinical informatics
or related activities, with 4 of 14 (29%) acting as an “EHR clinical champion,” 3
of 14 (21%) participating in a clinical decision support committee, 8 of 14 (57%)
participating in informatics related research, 8 of 14 (57%) incorporating informatics
into quality improvement work, and 6 of 14 (43%) acting as informatics educators.
Discussion
Using a model focused on resident education, project experience, and a grassroots
community, we have improved resident engagement in clinical informatics at our institution.
This approach has led to organizational benefits in the form of tangible projects
and increased front-line provider participation in clinical informatics efforts. Additionally,
residents have noted that these educational opportunities influenced their knowledge
in clinical informatics and career choices, with all participants incorporating informatics
training into their careers in some capacity and a growing number of residents choosing
to specialize in clinical informatics.
Residency training represents a critical window of opportunity for the education and
recruitment of future physicians into the field of clinical informatics. However,
residents have very little free time outside of clinical duties, limiting chances
for exposure to clinical informatics without a prior interest. One of the key lessons
learned as we have developed this educational model is that wider engagement can be
achieved through educational opportunities commensurate with the resident's level
of interest. For residents without previous experience, the resident working group
offers exposure to clinical informatics in a social setting without necessitating
the commitment of an elective. For those who want to learn more, the health informatics
elective provides residents an opportunity to increase their knowledge base, to meet
mentors, and to lead a project. As residents gain a deeper interest, the longitudinal
experience offers a chance for advanced skill development throughout residency. This
approach meets the individualized educational needs of residents with varying levels
of interest. Since inception of this educational model, five participants are pursuing
clinical informatics fellowship training, suggesting that this investment may grow
the applicant pool to fill an unmet clinical need.[21]
The descriptive discussion was not intended to prove that the organizational benefits
and increased resident engagement were caused by the educational model presented here.
The feedback solicited from previous elective participants was not gathered from a
validated scientific instrument, but rather was intended to inform whether residents
perceived the components of the educational model as influential on their clinical
informatics knowledge and career trajectories. We also did not assess this model compared
with alternatives. Nonetheless, in the setting of these educational opportunities,
we have seen a sharp increase in awareness of clinical informatics within the residency
program, the number of interested residents pursuing additional training, the impact
of resident-led projects, and the participation of residents in operational informatics
initiatives. Additionally, while we anticipate that this model would be generalizable
to other settings, our institution benefits from facilitators such as a large number
of clinical informatics faculty and clinical champions, a department focused on informatics
and education, and a fellowship program.
To our knowledge, the only other published informatics curriculum focused on residents
is the UCLA Health Resident Informatics Program, where moderate investments in an
application process, didactic training, a project stipend, and faculty mentorship
have led to impressive accomplishments and resident engagement.[20] In contrast, our model requires fewer funding resources to support the resident
working group, although faculty time for mentorship and meetings remains critical.
Nonetheless, we have seen growing interest in resident-led activities through the
working group despite concerns about resident workload and training gaps.[22]
Conclusion
Clinical informatics is increasingly permeating into the practice of medicine. Residency
is a vital time to educate physicians about the field of clinical informatics to support
their clinical work and to inspire the next generation of leaders. Our institution
has created a combination of short-term and longitudinal opportunities to expose residents
to the field. This exposure has in turn led to a cultural shift, resulting in the
dissemination and spread of informatics knowledge within the residency program and
has generated a pipeline of informatics fellowship applicants. Even among residents
who did not pursue an advanced degree in clinical informatics, all postgraduate residents
now incorporate clinical informatics in their careers in some capacity. While we cannot
distinguish the impact of this educational model from increasing familiarity with
technology, elective participants indicate that these educational experiences influenced
their knowledge and career choices. We have also seen tangible organizational benefits
from projects initiated during electives, supported by a resident working group, and
incorporated into longitudinal experiences. Expansion of this and similar models to
promote resident engagement in clinical informatics across training programs has the
potential to accelerate healthcare improvements and develop the clinical informaticians
of the future.
Clinical Relevance Statement
Clinical Relevance Statement
Opportunities for clinical informatics education extend from high school to beyond
clinical fellowship training, but a gap exists during residency. We describe a low-resource,
but potentially high-impact educational support structure that appears to have influenced
not only participants' knowledge of clinical informatics, but also their future career
activities. Similar models to promote resident engagement in clinical informatics
have the potential to accelerate health care improvements and develop the clinical
informaticians of the future.
Multiple Choice Question
During which stage of medical training is there a clear gap in informatics education?
-
High school
-
Medical school
-
Residency
-
Fellowship
-
Postfellowship
Correct Answer: The correct answer is option c. Opportunities for education in clinical informatics
are becoming more prevalent throughout the spectrum of medical training. The AMIA
High School Scholars Program pairs accepted high school students with a mentor to
work on a biomedical informatics project and present at the AMIA Annual Symposium.
Increasingly, college courses are incorporating a discussion of information sciences
into biological and health care-related topics. Masters and PhD-level graduate school
programs in biomedical informatics have been particularly well developed. Many medical
school curricula include a discussion of the role of information technology in medicine
with some incorporating biomedical and clinical informatics. Following residency,
physicians have the opportunity to engage in further informatics training through
the clinical informatics fellowship or the practice pathway. However, there exists
a gap of clinical informatics training at the residency level, as most institutions
do not offer an elective rotation in clinical informatics.
An Example of an Individualized Curriculum for the Health Informatics Elective for
a Resident Interested in Usability
Appendix Table A1
Sample learning objectives
|
1. State and understand how the discipline of clinical informatics intersects with
and influences the three domains of clinical care, local and national health care
systems, and information and communications technologies
|
|
2. Describe and understand the role of a clinician in applying the principles of health
informatics in the daily practice of pediatrics
|
|
3. Participate in simple usability projects with faculty mentors in health informatics
focused on optimization of electronic health record systems
|
|
4. Facilitate discussions related to the ongoing improvements of clinical information
systems as a “clinician champion” or liaison between the clinical informatics team
and your clinical peers
|
Appendix Table A2
Didactic materials
|
Selected readings for all elective participants
|
|
• Selected chapters from: Shortliffe EH and Cimino JJ. Biomedical Informatics: Computer
Applications in Health Care and Biomedicine, 2006
• Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order
entry: the importance of special people. Int J Med Inform. 2003;69(2–3):235–250
• Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593–600
• Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, et al. Ten commandments
for effective clinical decision support: making the practice of evidence-based medicine
a reality. J Am Med Inform Assoc. 2003;10(6):523–530
• Han YY, Carcillo JA, Venkataraman ST, Clark RSB, Watson RS, Nguyen TC, et al. Unexpected
increased mortality after implementation of a commercially sold computerized physician
order entry system. Pediatrics. 2005 Dec;116(6):1506–1512
For an example resident interested in usability
• Selected chapters from: Zhang J, Walji M. Better EHR, Usability, workflow and cognitive
support in electronic health records. 2014
• Selected chapters from: Patel VL, Kannampallil TG, Kaufman DR, editors. Cognitive
Informatics for Biomedicine: Human Computer Interaction in Healthcare. 2015
• Zhang J, Walji MF. TURF: Toward a unified framework of EHR usability. J Biomed
Inform. 2011 Dec;44(6):1056–1067
• Hettinger AZ, Roth EM, Bisantz AM. Cognitive engineering and health informatics:
applications and intersections. J Biomed Inform. 2017;67:21–33
|
|
Recorded lectures
|
|
• Larry Weed's 1971 Internal Medicine Grand Rounds (https://www.youtube.com/watch?v=qMsPXSMTpFI)
• Selected lectures from the CHOP Department of Biomedical and Health Informatics
YouTube channel (https://www.youtube.com/user/chopcbmi1/)
• Selected videos from Workforce Development Programs: Health IT Curriculum Resources
for Educators Module 15 (Usability and Human Factors) from the Office of the National
Coordinator for Health Information Technology (https://www.healthit.gov/providers-professionals/health-it-curriculum-resources-educators)
|
Appendix Table A3
EHR build modules
|
Topic
|
Number of videos
|
Duration
|
|
Building note templates
|
3 videos
|
25 min
|
|
Building order sets
|
3 videos
|
42 min
|
|
Building alerts
|
2 videos
|
28 min
|
Abbreviation: EHR, electronic health record.
Appendix Table A4
Sample activities during elective
|
Participation in EHR operational meetings
• Clinical champions meeting (1 h biweekly)
• Clinical decision support workgroup (1 h biweekly)
• Clinical IT advisory committee (2 h monthly)
Faculty lecture series
• DBHI visiting faculty series (1 h monthly)
• Penn Institute for Biomedical Informatics Forum (1 h monthly)
• DBHI section meeting (1 h monthly)
Meeting with faculty and fellows
• Course director (1 h weekly)
• Cognitive informatics expert (2 h)
• Usability expert (2 h)
• EHR outcomes measurement expert (1 h)
• Clinical informatics fellows (2 h)
|
Abbreviations: DBHI, Department of Biomedical and Health Informatics; EHR, electronic
health record; IT, information technology.
