SGIM Forum

Medical Education: Part III

Clinical Scholars in Informatics: A Resident-driven Applied Informatics Pathway

Dr. Hernandez (smhernan@wakehealth.edu) is a General Internal Medicine faculty member and Clinical Informaticist at the Wake Forest School of Medicine. Dr. Feiereisel (kfeierei@wakehealth.edu) is the section chief for general internal medicine and medical director for ambulatory quality at the Wake Forest School of Medicine. Dr. Dharod (adharod@wakehealth.edu) is the vice chair of informatics and analytics for the Department of General Internal Medicine at Wake Forest School of Medicine.

Information is the currency of high-quality clinical care. To that end, Clinical Informatics (or Clinical Information Science) as a discipline has grown exponentially in relevance as clinical care now requires more reliance on the electronic health record (EHR) and the healthcare delivery systems intertwined with them. Although some studies have noted benefits with EHRs (i.e., decreased costs, fewer medical errors, improved care coordination), other literature suggests increasing burnout attributed to the EHR.1 Strategies for improving EHR satisfaction and thereby reducing burnout have been identified: (1) physician EHR education, (2) personalized EHR modifications, and (3) improved digital health care services delivery design.2 Integrating clinical informatics into resident education highlights for learners the magnitude of impact the field can have on clinical care and empowers early career clinicians to affect incremental net positive changes in the health system.

What are synergies or unique intersections of work in Clinical Informatics and General Internal Medicine?

General Internal Medicine is uniquely positioned for systematic profound impact in the domain of applied clinical informatics. As general internal medicine physicians, we tend to think about the patient as a whole—identifying care coordination challenges along with disease processes both mechanistically and socially that impact the whole patient. In a similar vein, clinical informatics as a specialty attempts to address the entire healthcare system in totality to improve care paradigms through digital health and health information technologies.

What role or value does Clinical Informatics have in residency education?

Clinical Informatics has been used to aid in reflection of self-practices, to directly educate residents about evidence-based practices, and to drive quality improvement in patient care. It organically facilitates the “Knowledge to Practice” arm in the Learning Health Systems Model, allowing for evidence-based knowledge to be disseminated and implemented among practicing clinicians and learners.3, 4

For example, General Internal Medicine and Infectious Diseases collaborated on a workshop guiding Internal Medicine residents on how to use the an EpicTM EHR self-reporting tool called SlicerDicer to assess the volume of patients with the encounter diagnosis of “sinusitis” for whom the residents had prescribed antibiotics (contrary to evidence-based-guidelines).5 Residents were surveyed after the workshop and 88% of residents agreed or strongly agreed that the workshop improved their understanding of when to prescribe antibiotics and how to practice antibiotic stewardship in the outpatient setting.

Another potential value of clinical informatics in residency education is personified by the Clinical Scholars in Informatics program at Wake Forest School of Medicine. This program directly incorporates the central principles of clinical informatics into resident education as a bridge between direct patient care and applied clinical informatics.

What is the Internal Medicine Residency Clinical Scholars in Informatics Pathway?

The Clinical Scholars in Informatics (CSI) Program, established in 2017, is a novel two-year longitudinal mentorship and education pathway available to Internal Medicine residents.6 Through a competitive application process, scholars are selected by a committee (representing expertise in clinical, informatics, implementation science and IT domains) in April/May of the PGY-1 year. Applicants are prompted to submit an applied informatics intervention that can leverage health information technology and clinical process quality improvement. The selected CSI scholars work with a specialty-specific mentor (i.e., General Internal Medicine, Cardiology, Rheumatology, Gastroenterology, etc.), an informatics mentor, and the Department of Internal Medicine informatics & Analytics team (including an EHR analyst and biostatistician) to develop, implement and analyze their projects over the two-year period. Furthermore, scholars are provided specialized EHR training and granted certain EHR privileges after achieving EHR certification to construct their applied informatics interventions more directly.

The pathway also includes an informatics education curriculum involving journal club discussion of landmark informatics articles addressing topics ranging from workflow analysis, clinical decision support, data standards, change management, basic coding concepts, regulatory issues (HIPAA, HITECH, The Joint Commission, etc.), security and privacy. These are foundational topics that also align with progress that the CSI resident should be making on their applied informatics project.

Since inception, the pathway has been successful, with CSI residents presenting more than 10 poster presentations at regional and national conferences, receiving three grants (one externally funded grant and two internally funded), and publishing abstracts and manuscripts in peer-reviewed journals.

How does the CSI Pathway differ from other training pathways for aspiring clinical informaticians?

This is the first program of its kind to offer Internal Medicine residents an opportunity to receive training in targeted clinical informatics topics and to facilitate further EHR certifications with the goal of developing, implementing, and evaluating an EHR quality improvement project. This is a hands-on learning experience guiding Internal Medicine residents how to leverage the EHR to directly affect patient care.

The CSI program is different from a traditional research program with a stipend. The CSI focuses on designing and implementing an intervention to impact direct patient care. These interventions are often pain points in clinical workflows or where evidence that exists in the literature with intermittent or poor adherence in the real world. As previously noted, CSI residents receive EHR certification and privileges to modify the EHR in collaboration with Information Technology Services. A substantial focus on support and maintenance of the interventions is considered early in the process—an often overlooked component of many projects.

How can members at all career and training stages get more engaged in or learn more about informatics work in SGIM and at their own institutions?

As digital health further permeates medicine, it is important for all clinicians at all stages of training to ascertain basic informatics skills (i.e., data literacy). The SGIM Annual Meeting offered several opportunities to learn more about clinical informatics. Posters and presentations under the category of “Clinical Informatics and Health Information Technology” offered a venue for learners to engage with Informatics GIM faculty across the nation. Several institutions have discovered the benefits of training clinicians in their respective EHRs to implement applied informatics interventions and improvements in healthcare delivery services.

How might the future of clinical informatics education change for students, residents, and fellows?

As medicine becomes further entrenched in digital health paradigms, especially since COVID-19, health systems will focus attention to growing informatics expertise and capacity. Robust informatics education and mentorship for students, residents and fellows is of paramount importance to address the current supply-demand mismatch in the EHR, Health Information Technology, and Digital Healthcare space.

To arm the clinical workforce with the tools to efficiently interact within in-person and virtual patient care environments, training pathways and programs like Clinical Scholars in Informatics can help to address the specialty-specific demands. To that end, CSI functions as internal development and recruitment for broad-based informatics expertise.

References

  1. Robertson S, Robinson M, Reid A. Electronic health record effects on work-life balance and burnout within the I3 Population Collaborative. J Grad Med Educ. (2017) 9 (4): 479–484. https://doi.org/10.4300/JGME-D-16-00123.1.

  2. Robinson K, Kersey J. Novel Electronic Health Record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout. Medicine. September 2018; Volume 97; Issue 38; p e12319. doi: 10.1097/MD.0000000000012319.

  3. Menear M, Blanchette M-A, Demers-Payette O, et al. A framework for value-creating learning health systems. Health Research Policy and Systems. 17, no. 1 (August 9, 2019): 79. https://doi.org/10.1186/s12961-019-0477-3.

  4. Kohn M, Topaloglu U, Kirkendall E, et al. Creating learning health systems and the emerging role of biomedical informatics. Learning Health Systems. n/a, no. n/a (n.d.): e10259. https://doi.org/10.1002/lrh2.10259.

  5. Nasim J Ohl C, Hernandez S, et al. A self-reflection stewardship workshop improves resident physician understanding of ambulatory antibiotic stewardship. Infection Control & Hosp Epidem. 2020;41(S1):s103-s103. doi:10.1017/ice.2020.605.

  6. Internal Medicine Residency Clinical Scholars in Informatics Pathway. https://school.wakehealth.edu/Education-and-Training/Residencies-and-Fellowships/Internal-Medicine-Residency/Curriculum-Overview/Clinical-Scholars-in-Informatics-Pathway. Accessed on May 15, 2021


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