Medical Informatics Practice & Education

-the challenges & solutions

Syed Tirmizi, MDMedical Informatician

Health TechNetNovember 15, 2008

VA Trainee Workforce Over 100,000 trainees annually

Medical Education (~50%) Affiliations with 107/125 US allopathic and 15/25 osteopathic

medical schools Associated Health Education (~50%)

Annual budget $0.5 Billion (direct costs) $0.5 Billion (indirect costs) ~80% devoted to GME

VA is the second-largest supporter of GME in the U.S. (after CMS)

Academic Affiliation draws expert clinicians and

researchers to the VA affiliations allow VA to

provide veterans “a much higher standard of medical care

mutually beneficial by affording each party access to resources that would otherwise be unavailable

medical schools gain access to invaluable undergraduate and graduate medical education opportunities

faculty with joint VA appointments are afforded opportunities for research funding (restricted to VA employees)

70 percent of VA physicians hold joint medical school faculty positions

Academic Affiliation 130 VA medical centers

have affiliations with 107 of the 126 allopathic medical schools

Physician education represents half of the over 100,000 VA health professions trainees

Medical residents contribute approximately 1/3 of the VA physician workforce

2007 Learners Perception Survey Before training 21 percent

of medical students and 27 percent of medical residents likely to consider VA employment

After training 57 percent of medical students and 49 percent of medical residents.

Goals Expand resident positions in specialties of

greatest need to veterans Address uneven geographic distribution of

residents and improve access to care Foster innovative models of resident education Assume VA’s proportionate share in

addressing the physician workforce shortage Enhance VA’s leadership role in GME

Scope Restore VA-funded GME positions to 10-11% of

U.S. total First expansion of VA GME in over 15 years

2,000 new positions over 5 years Critical Needs (CN) & Emerging Specialties (ES) New Affiliations (NA) and New Sites of Care (NS) Educational Innovation (ED INN)

Estimated incremental cost: $250 million VA is presently the only GME payer increasing

support for education

Approved Positions by State

Top 10CA 111TX 100FL 90

OH 36OR 29GA 24NY 23CO 21AZ 20NC 20

Institutional Eligibility Innovation

Transform educational processes Redesign clinical care models

Commitment Protect teaching time Support professional development

Assessment Measure educational and care outcomes Participate in cross-site program evaluation

Educational Innovation AwardsFacility Specialty Innovation

Bedford Psych Mentoring and leadership development

Cleveland Int Med Inter-professional team training

Indianapolis Int Med Risk analysis and reduction

Indianapolis Int Med Collaborative care

Phoenix Gen Surg Laparoscopic/endoscopic simulation

San Francisco Int Med Mentoring and leadership development

San Francisco Int Med Continuity of care

Augusta Int Med Patient values and palliative care

Summary VA is expanding residency training positions

in ways that will: Address specialty and geographic needs Expand veterans’ access to care Enhance residents’ clinical training experiences Contribute to reform and innovation in medical

education, while improving care delivery

Challenges to Medical EducationViewpoint Paper

The Clinical Data Repository: A Challenge to Medical Student EducationMichael Altman, MD*

Department of Medicine and Augusta Webster, MD, Office of Medical Education, Northwestern University Feinberg School of Medicine, Chicago, IL.

J Am Med Inform Assoc. 2007 November-December;14(6):697-699.

Challenges to Medical Education-the need for students to have data

management skills, to operate with

sensitivity to ethical and legal issues raised by greater access to patient data

to become adept at using decision support tools

lost in the task of interpreting data without understanding why or how the data generated

Challenges to Medical Education-solutions technological advances

applied to improve medical student clinical education

partnerships can produce educational tools to support the acquisition and reinforcement of some very basic physician skills

tools to prepare medical students to operate in information-rich clinical environment

Challenges to Informatics Education-solutions AMIA 10x10 AAMC NLM Medical Informatics

fellowships Public Health Informatics

Fellowships AMIA academic forum Nursing informatics board

certification

Student & Resident Orientation

Informatics projects VeHU VHA 5-tiered approach

Online open courseware CME/CE Heath IT certification Graduate degree Medical informatics

fellowships

Towards a “Virtual Health System” Electronic Health Records (EHRs)

Widespread Use of High Performance, Robust Electronic Health Records (EHRs)

Personal Health Records (PHRs) Full copy of one’s own health information along with

personalized services based on that information Standards

Health Data & Communication Standards Health Information Exchange

Connectivity Among the EHRs, PHRs, and related health entities

Single longitudinal health record is immediately available in

•Outpatient •Inpatient &•Long-term care settings

Clinical Clinical requirementsrequirements

Diabetes Patient Dialog for processing multiple reminders:

• Diabetic Foot Care Education• Diabetic Foot Exam• Diabetic Eye Exam• Recommended Labs• Other Health Activities

Acquisition of health data beyond care delivered exclusively through VHA

Standardized Data Elements

Links Reminder

With Actions

With Documentation

Bar-Code Medication Administration (BCMA)

Virtually Eliminates Errors at the Point of Administration

. . . Coming Soon: Bar-Coded Lab Specimen, Blood Administration, & more

BCMA Assures:

Right Medication

Right Dose

Right Patient

Right Provider

Right Time

PHRPersonal Health Record

Research – Harris Interactive• Two in five adults in the US keep their own personal and

family health records.• 13% keep them electronically• 40% planning to do so in the future

• More women (45%) than men (38%) kept records.• 58% of the over-65s filed information about their

treatment.• 84% of all surveyed welcomed the Personal Health Record

(PHR) concept.• Out of the 13% in the Harris survey who kept electronic

records, only one in thirteen kept them online at a health record website.

Source: Harris Interactive, August 2004

22

23

5.56

4.80

2.56

3.00

5.65

4.64

2.47

2.85

4.25*

2.89*

3.97*

3.57*

2.32*

3.10*

1.0

2.0

3.0

4.0

5.0

6.0

7.0

Doctor Hospital Employer Pharmacist Pharmaceut. Sp Int Grp Insurer/Payer

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Clinician/Stakeholder (n=95)

How comfortable would you be if an PHR was provided, sponsored, and/or maintained by:

Improved Outcomes

Productive Interactions

DeliverySystemDesign

DecisionSupport

EHRSelf-Management

Support

Health SystemResources and Policies

Community Organization of Health Care

Informed,Empowered Patient

and Family

Prepared,Proactive Practice

Team

The Chronic Disease Care Model

Patient-Centered

Coordinated

Timely and Efficient

Evidence-based and Safe

My PHRMy PHR

Home Telehealth Technologies

Benefits to Providers

Transfer the “ownership” of chronic disease management to the patient.

Offers more complete picture of patient’s health conditions and health care, including care at non-system providers

Reallocation of time in practice to more complex cases.

Ability to communicate and collaborate with patients more easily. A study by McKay et al* found that patients who

participated in an online diabetes education and support group lowered their blood glucose levels significantly more than controls did.

However

This is NOT about technology…

It is about RESULTS:

Improved Health Care Quality Improved Health Outcomes

Clinical Decision SupportRationale - 1 CDS demonstrated to be effective in a number of settings

over the past 30-40 years Impact

best practices error reduction pay for performance cost effectiveness chronic disease management prevention Bio-surveillance etc.

Yet slow dissemination and adoption

Clinical Decision Support Rationale - 2 A number of barriers can be cited

including technical, organizational, cultural, and financial As a result, much reinvention of the wheel Will only get worse

More info available Informed consumer

Health care knowledge, provider performance data More complexity

genomics, competing technologies/workup strategies, targeted therapies

cost and time pressures, prior authorization, pay for performance

A Roadmap for National Action on Clinical Decision SupportAMIA White paper, June 13,

2006Prepared by:

Jerome A. Osheroff, MD, Jonathan M. Teich, MD, PhD, Blackford F. Middleton, MD, MPH, MSc, Elaine B. Steen, MA, Adam Wright, Don E. Detmer, MD, MA

Enhanced Health and Healthcare Through Enhanced Health and Healthcare Through CDSCDS

BestKnowledgeAvailable

WhenNeeded

HighAdoption &

EffectiveUse

ContinuousImprovement

of Knowledge

& CDS Methods

Pillars of CDS

AMIA White paper, June 13, 2006

Stakeholder DiscussionsConduct discussions

with stakeholder organizations on how CDS can advance their objectives and how their support can facilitate execution of the roadmap.

Identify NextSteps

AddressLegal,

Regulatory& Financial

issues

GeneralizeLessonsLearned

ImplementDemonstration

Projects

ShowFeasibility,Scalability,

Value

PromoteDisseminationand Adoption

StakeholderDiscussions

RoadmapExecutionSteeringGroup

AMIA White paper, June 13, 2006