medical informatics practice & education - the challenges & solutions syed tirmizi, md...
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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
(1)
Ve
ry U
nc
om
fort
ab
le t
o (
7)
Ve
ry C
om
fort
ab
le General Pop. (n=235)
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
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