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Emergency Medicine Informatics Section Newsletter - August 2011

circle_arrowFrom the Incoming Chair - EM Informatics Section Newsletter, September 2011
circle_arrowUpcoming Annual Meeting - Emergency Medicine Informatics Section Newsletter, September 2011
circle_arrowFantasy, Reality, & Electronic Health Records - EM Informatics Section Newsletter, September 2011
circle_arrowSEMI Journal Club - EM Informatics Section Newsletter, September 2011
circle_arrowFarewell Angela! - EM Informatics Section Newsletter, September 2011
circle_arrowThe ACEP-AMIA Informatics Transition Course enters its Fourth Year - EM Informatics Section Newsletter, September 2011
circle_arrowNews from SAEM Informatics - EM Informatics Section Newsletter, September 2011
circle_arrowACEP Section Grant Awarded - EM Informatics Section Newsletter, September 2011
circle_arrowStatus of ABMS Subspecialty Certification in Clinical Informatics - EM Informatics Section Newsletter, September 2011
circle_arrowBath Salt Blues and Federated Alerting - EM Informatics Section Newsletter, September 2011

From the Incoming Chair - EM Informatics Section Newsletter, September 2011

Jeff Nielson, MD, MS 

Jeff Nielson, MD, MSThe future of informatics has never been brighter.  We are better funded, more heralded, and have the chance better than ever to show what we really can do.  At the same time, we are under greater scrutiny than ever before. I didn’t think I’d ever be tired of hearing about informatics on the news, but it happened with all the news coverage and debate.

The Gartner Hype Cycle proves useful means of looking how people view EHRs. From Gartner’s website, these are the steps of development in an emerging technology:

Technology Trigger: A potential technology breakthrough kicks things off. Early proof-of-concept stories and media interest trigger significant publicity. Often no usable products exist and commercial viability is unproven. 

Peak of Inflated Expectations: Early publicity produces a number of success stories—often accompanied by scores of failures. Some companies take action; many do not. 

Trough of Disillusionment: Interest wanes as experiments and implementations fail to deliver. Producers of the technology shake out or fail. Investments continue only if the surviving providers improve their products to the satisfaction of early adopters.  

Slope of Enlightenment: More instances of how the technology can benefit the enterprise start to crystallize and become more widely understood. Second- and third-generation products appear from technology providers. More enterprises fund pilots; conservative companies remain cautious. 

Plateau of Productivity: Mainstream adoption starts to take off. Criteria for assessing provider viability are more clearly defined. The technology’s broad market applicability and relevance are clearly paying off. 

(http://www.gartner.com/technology/research/methodologies/hype-cycle.jsp)

Since my ED is with an “integrated solution” we are just now entering the slope of enlightenment. On the other hand, I see the public and the press vacillating between “inflated expectations” and “disillusionment.”  Of note, despite my best efforts, my department chair is there, too. Managing expectations can be difficult.

Similarly, I write this on a night shift at the hospital where Alcoholics Anonymous started (St. Thomas in Akron, OH) and it’s hard not to draw parallels between the highs and lows of addiction and the highs and lows of EHR implementation. I also see the difficult path we have addiction. As informaticians we walk a narrow path as we implement these systems: difficult mountains (of effort) one side and a sheer cliff (of failure) on the other. Although ultimately most of us will emerge victorious there will surely be career casualties along the way.

For next two years, I’ll be president of the section and my goal is to help us in these endeavors. I plan to formalize committees by year’s end to organize and bolster our efforts. We’ll start with a curriculum committee, newsletter committee, and member education committee. This trial will help bring together like minded individuals so that they can have aligned goals and be productive. We are seeking volunteers and the section needs your support. Again, I look forward to serving you these years as they will surely be exciting times. Jeff Nielson JeffNielson@gmail.com 


Upcoming Annual Meeting - Emergency Medicine Informatics Section Newsletter, September 2011

salogo Annual Meeting - October 16

Our annual section meeting will be on Sunday, October 16 from 12:30 noon – 3:30 pm at the San Francisco Hilton, the room has yet to be announced.     


Fantasy, Reality, & Electronic Health Records - EM Informatics Section Newsletter, September 2011

Don Kamens, MD, FACEP

It would be best to eliminate all bits and pieces of bamboozle from our lives, and especially from our lives as healthcare providers and advisors. “Bamboozle” you say, “why, what do you mean?”  Well, for example, hardly any—including many physicians--are inclined to believe the almost fantastic promises being made about healthcare IT. Physicians, for the most part—despite any other derogation that might be attributed to them by non-physicians, tend at minimum to be realistic and practical. Hence, having heard fantastic promises enough throughout the practice of medicine, they are likely to call them for what they are.

Thus, physicians will, for the most part, have antennae that can distinguish between their own hopes and the realities in which they practice. Most all hope for smooth working electronic health records (EHRs) that facilitate, and never impair, their practice. Likewise, we should rein in our expectations vis-à-vis the adoption of EHRs that will lower—rather than increase—the tasks and consequently the costs of medical care. Why? Why doubt? After all, this has been a time characterized by unfiltered trust; a post-Maddofian, post-AIG, period in which our pennies of confidence are a gamble away. Why not healthcare information?  One must remember, though that is not only health, but also hopes, dreams, and expectations that remain at stake.

Indeed, post made-off, Americans will be suspicious of agents of leverage. So medicine—already on a slippery slope in the region of trust—must take care when making promises, not to over-leverage hopes, dreams, and expectations.

Consider the words of John Halamka, MD

“……….incentives should result in a major increase in electronic record adoption in the U.S., and hopefully will bring us past a “tipping point” which will result in nearly complete adoption. This will result in higher quality, safer care, and lower costs. These are goals that all Americans want and can embrace.” 

This is committed statement of promise, and there are parts that are true:  we want it, we can embrace it, and likely nearly complete adoption will occur. But will it really “result in higher quality, safer care, and lower costs?”  Did the computer revolution in the 1980’s really result in lives being less complicated, better, and easier to deal with?  Come on!  About as much as computer viruses, teenage text messaging, facebook indulgence, and the proliferation of internet pornography. A dose of reality, please.

Face the shadow, face the dark side. It would be better for all of us to just speak plainly. There are points at which quality may suffer, maybe even be significantly impaired. Safety may be compromised by the very systems that we envision are doing the job of improving it, and costs are quite likely to rise as the equipment, software, maintenance, and training for them all accelerate.

It is likely that Dr. Halamka, who happens to be a wonderful and honest-hearted contributor to the cause of better healthcare, does not see his own shadow. His editorial letter, contributed to by fellow Harvard-Partners based physician-informaticists Bradford Middleton and David Bates was a response to the WSJ March 11, 2009 article "Obama's $80 Billion Exaggeration" by Jerome Groopman and Pamela Hartzband, which said, among other things:

“………..we spoke with fellow physicians at the Harvard teaching hospitals, where electronic medical records have been in use for years. All of us were dumbfounded, wondering how such dramatic claims of cost-saving and quality improvement could be true.” 

This moment in time, provides tremendous opportunity not to be squandered. One of those opportunities is to gather together the lessons of our lives and use them appropriately. Do not mislead. Electronic medical records are a needed step; they are a step in the right direction. They are also in their infancy. Expectations should not be inappropriately raised or disappointment will result, and the disappointment will reflect back negatively, not only on the medical profession, but also on the healthcare IT establishment, and on the political environment that allowed such false expectations to arise.

Who knows with certainty how quality and safety will be impacted by various implementations of EHR systems as time moves forward?  One can say that, given the complexity of the data that increasingly is being managed, it would be nearly impossible to address without EHRs.  But to say that we need EHRs is a different statement than to say that they will result in higher quality, safer care, and lower costs.

Our patients, our colleges, deserve realism, and realism always includes both the positive and negative, the light and the shadow. Leaving out half the story is a recipe for further mistrust.


SEMI Journal Club - EM Informatics Section Newsletter, September 2011

Adam Landman, MD
Brigham and Women’s Hospital, Boston, MA
 

Patient Emergency Medical Cards Provide Useful Clinical Information 

adamlandmanAs we work towards comprehensive, accurate, and up-to-date health information exchange, gaps persist where providers evaluate patients without access to their medical records, especially in the emergency setting. Researchers at Intermountain Healthcare developed a tool that allows patients to generate and print an emergency medical card (EMC) from their hospital electronic medical records, including demographics, insurance/financial information, current problems, medications, allergies, blood group, advance directives, contact lenses, religious preference, and pacemaker information. A survey of 31 physicians, PAs, and medical students on the value of this EMC found it useful in enhancing medical decision making (94%), decreasing encounter time (100%), and influencing treatment decisions (94%).

Comment: There are significant methodology limitations with this study including using medical students as subjects and relying on overall assessment of EMC utility without clinical context or comparison. While this work suggests EMCs could be valuable, more work is needed to define high yield, standardized clinical content and more robust evaluation is needed using emergency providers and clinical scenarios.

Citation: C.H.O. Olola, et al., The perception of medical professionals and medical students on the usefulness of an emergency medical card and a continuity of care report in enhancing continuity of care, Int. J. Med. Infom. (2011), in press

Health Information Technology Studies are Predominantly Positive 

The 2009 American Recovery and Reinvestment Act provides $14 - $27 billion to support the adoption and “meaningful use” of electronic medical records to improve health care delivery. This study reviews the evidence base for HIT including MEDLINE publications from 2007 – Feb 2010. Of the 154 included studies, 62% were positive with improvement in one or more aspect of care and no aspects worse off. The majority (92%) were mixed positive, with overall positive conclusion, but at least one negative aspect. Ten studies were overall negative, many of which stemmed from provider dissatisfaction with systems, including poor usability and negative effects on workflow and efficiency.

Comment: This review from the Office of the National Coordinator for Health Information Technology suggests HIT is having a predominantly positive impact. Robust methods were used with assumptions clearly delineated. The study builds on previous systematic reviews by including the latest studies as well as qualitative study results, but does not weigh individual studies by study design and is limited to published findings, potentially missing non-published negative findings. Continued rigorous evaluation of HIT, with emphasis on identifying solutions to negative concerns, is needed.

Citation: M.B. Buntin, et al., The benefits of health information technology: A review of the recent literature shows predominantly positive results, Health Affairs. 30, 3 (2011): 464-471.


Farewell Angela! - EM Informatics Section Newsletter, September 2011

Angela Franklin will be joining the staff of the National Quality Forum as Senior Director for Quality Measures and will report to Heidi Bosely, Vice President of Performance Measures. This is a tremendous development in her career and we are excited for her. She served as this section’s ACEP liaison since 2006 and her help has been indispensible. She kept us abreast of government issues, lobbied for us, and helped us navigate ACEP. Her presence will be greatly missed. We wish her well in advancing her career and thank her for years of support. 


The ACEP-AMIA Informatics Transition Course enters its Fourth Year - EM Informatics Section Newsletter, September 2011

Jim McClay, MD, FACEP 

1209McClayTwenty pioneering emergency physicians have enrolled in the fourth annual ACEP-AMIA Informatics Transition Course. This 12 week on-line course is an adaption of the Oregon Health & Science University (OHSU) introductory informatics course where students complete weekly assignments and participate in online discussions. At the end of the course they meet face-to-face at the ACEP Scientific Assembly where they present their projects and discuss common themes. The online design of the course proved adaptable for a widely varied enrollment. They will join 96 alumni from 6 countries as leaders in emergency medical informatics.

The Informatics Transition Course evolved four years ago when ACEP teamed up with the American Medical Informatics Association (AMIA) to adapt one of the AMIA sponsored introductory biomedical informatics courses to the needs of emergency physicians and other emergency providers. This partnership grew out of the recognition growing importance of advanced information management in emergency medicine research and practice. Informatics Trained Emergency Physicians are positioned to take leadership roles in clinical information management at their institutions, utilize informatics techniques in research and to contribute to the national effort to reform healthcare practices using advanced information technology.

Two major developments have occurred since we began to offer this course. First, was the requirement for universal adoption and “Meaningful Use” of health information technology as defined by the HITECH act of the ARRA legislation in 2009 and the second is the offer of a subspecialty certification in clinical informatics to be offered through the American Board of Medical Specialties. Our own Ben Munger has been instrumental in shepherding this subspecialty application through the approval process (see article in this newsletter).

Further information about the course is available at http://www.acep.org/content.aspx?id=39762&terms=informatics 


News from SAEM Informatics - EM Informatics Section Newsletter, September 2011

Nicholas Genes, MD 

nicholasgenesSAEM’s Academic Informatics Interest Group (AIIG) met in Boston during the Annual Meeting in June. Kevin Baumlin called the meeting to order, and we were updated on activities from group members over the past year.

Ideas for future SAEM didactic sessions in informatics were proposed. Kevin Baumlin described ACEP’s White Paper on EMR safety, to be written in conjunction with ACEP’s Informatics Section and QIPS, the Quality Improvement and Patient Safety section. The White Paper will concern the safety of emergency department information systems, with a literature review and consideration of human factors, implementation strategies, and minimizing use errors.

EM informatics fellowship training initiatives were reviewed. While there are just a handful of academic departments offering EM informatics fellowships, it was felt that highlighting each site’s offerings and distinguishing characteristics is good for candidates and for programs; Steven Horng noted that an online clearinghouse would be desirable. Future efforts may soon be featured at the redesigned SAEM.org, or on an independent website.

From fellowships, discussion turned to a more formalized informatics curriculum at the level of medical students, residents and fellows. Models for the curriculum included didactics, master classes, or a standardized set of articles to know. Another idea, to generate an online course – with material contributions from EM informatics fellowship sites and IG participants, was met with enthusiasm.

Finally, the topic of an EM informatics textbook was broached. It wasn’t clear whether this would be an academic tome or a go-to reference for community ED docs looking to implement EDIS, though the latter seemed more popular to the group and probably to publishers. Chapters would be drawn from the previously proposed core curriculum, and it could be used as a replacement of Shortliffe’s book for some EM informatics training. An outline is already under development.


ACEP Section Grant Awarded - EM Informatics Section Newsletter, September 2011

Kevin M. Baumlin, MD 

kevinbaumlinThe Quality Improvement and Patient Safety (QIPS) and EM Informatics sections have been awarded a section grant from ACEP to write a white paper on the quality and safety implications of ED information system (EDIS) implementation.

Since passage for the HITEC Act in 2009, Hospitals are encouraging, and sometimes mandating, Emergency Department electronic health record (EHR) implementations in their quest to qualify for “meaningful use” funds. EHRs have been touted by some as a panacea, promising decision support, interoperability, prevention of medication errors, and increased efficiency and safety. A few paper have recently questioned the basic assumption that computerization improves quality, but were fairly limited in scope. A comprehensive paper exploring the unintended consequences and impact of EHRs and ED information systems (EDIS) in general on efficiency, safety, and quality of care in the ED does not currently exist in the literature.

The white paper will be written to include:

  • Identification of broad issues that can impact safety and quality
  • Description of major safety issues involved with current EDIS systems and implementation, including data integrity, user error, work flow alteration, and alert fatigue
  • Exploration of the disconnect between implementation goals and actual means of implementation
  • Description and analysis of failure modes
  • Statement of the need for hazard analysis, usability testing, and transparency on the part of industry and regulators 
  • Proposal of solutions and path forward

QIPS/Informatics EDIS Taskforce is being headed by Dr. Heather Farley from Christiana and Dr Kevin Baumlin from Mount Sinai in NYC. Team members have already been drafted and through a series of conference calls, that have already begun, we will work together to gain consensus, and ultimately draft a manuscript suitable for submission to a peer-reviewed journal.

The team includes the following:  Jim McClay, MD Jeff Nielson, MD Jason Shapiro, MD, Nicholas Genes, MD, Adam Landman, MD (from EMI) and Suzanne Stone, RN, Michael Phelan, MD, Jesse Pines, MD,  Terry.Fairbanks, MD Jack Fuller, MD,  Drew Fuller, MD Azita Hamedani.MD (from QIPS). The expert reviewers will be Brian Keaton, MD, Jennifer Wiler, MD, Robert Wears, MD.


Status of ABMS Subspecialty Certification in Clinical Informatics - EM Informatics Section Newsletter, September 2011

Benson Munger, PhD  

benmungerIn 2005 The American Medical Informatics Association (AMIA), with the support of the Robert Wood Johnson Foundation, embarked on a process it hoped would lead to the creation of an American Board of Medical Specialties (ABMS) subspecialty certificate in Clinical Informatics. A Core Content document and Draft Training Requirements were developed by a group of content experts and approved by AMIA in 2009. When the required documents and information were collected, AMIA sought an ABMS member board to sponsor the application. The American Board of Preventive Medicine (ABPM) became that sponsor and the application was submitted in 2010.

Since its submission the application has taken the standard review path within ABMS. A critical step is a two-step review and approval by the Committee on Certification, Subcertification and Maintenance of Certification (COCERT). The second step in this review was accomplished in July of 2011 with a final vote scheduled for ABMS this September. The review has been without major difficulties to date. A significant amount of interest has been expressed by most of the ABMS member boards and in fact two additional boards have indicated a desire to become sponsors.

If as expected the application is approved by ABMS in September, the Training Requirements will be reviewed by the Accreditation Council for Graduate Medical Education (ACGME) and oversight assigned to an existing Residency Review Committee. At that point programs may apply for accreditation. The ABPM will also immediately start the process of developing the examination and approving the final candidate application criteria. It is expected that a practice track will be available with the details available in the next 6 months. It is reasonable to assume that the first examination will be offered 24-30 months after ABMS approval.

Accredited program will have to be affiliated with an accredited core residency program. Institutions interested in starting a program should contact the American Board of Preventive Medicine after September. It is also reasonable to assume that organizations such as AMIA will continue their interest in the subspecialty and may offer education options to assist in the development of accredited programs and to support physicians practicing Clinical Informatics who have an interest in preparing for the examination.


Bath Salt Blues and Federated Alerting - EM Informatics Section Newsletter, September 2011

Jeff Nielson, MD, MS

Over the last month, I’ve been seeing a lot of patients who abused “Bath Salts”.   I saw two cases on my last night shift and I have to say that they aren’t particularly interesting to me. Abusers are loud, confused and always accompanied by a bunch of police. Then, they get to sleep in my ER overnight after getting benzos. I get the idea that abuse hasn’t peaked yet, since my personal experience is that the incidence is still rising.

This got me thinking about how we are alerted of dangerous patient conditions, epidemics, drug shortages, etc. With bath salts, I found out from ACEP news and from my boss—both through email earlier this year. But, how should something like this communicated?  As an informatician I’d think we would want to automate a push notification to all practicing EPs who are likely to see a patient with a pertinent condition. The notification population would depend on a host of factors: severity, frequency, location, population, climate, etc, etc.  Ultimately, it isn’t the kind of thing I want to ask the computer to decide, but we really do need a network for communicating better. We aren’t all ACEP members, we aren’t all in EDs that have good quality and notification mechanisms. We all going to be using EHRs in about 4 years or our hospitals are going out of business, so that would really be the way to communicate things. On the other hand, I don’t want repeated alerts and I don’t want useless alerts. I definitely don’t want drug companies sending me ads through the network. It would need to be controlled by a federated, well intentioned alerting body.

I know I’m not the first to want this. I also know people have tried to institute things like this in the past through ACEP. What is different now?  Fresh blood, new ideas, more friendliness toward technology. I think someone should develop the model and push forward again; EPs have too much to gain! The problem isn’t going away.


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