Data visualization for truth maintenance in clinical decision support systems.

BACKGROUND AND OBJECTIVES: The goal is to inform proactive initiatives to expand the knowledge base of clinical decision support systems. DESIGN AND SETTING: We describe an initiative in which research informationists and health services researchers employ visualization tools to map logic models for clinical decision support within an electronic health record. MATERIALS AND METHODS: We mapped relationships using software for social network analysis: NodeXL and CMAP. We defined relationships by shared observations, such as two Arden rules within medical logic modules that consider the same clinical observation, or by the presence of common keywords that were used to label rules according to standardized vocabularies. RESULTS: We studied the Child Health Improvement through Computer Automation (CHICA) system, an electronic medical record that contains 170 unique variables representing discrete clinical observations. These variables were used in 300 medical logic modules (MLM's) that prompted health care providers to deliver preventive counseling or otherwise served as clinical decision support. Using data visualization tools, we generated maps that illustrate connections, or lack thereof, between clinical topics within CHICA's MLMs. CONCLUSIONS: The development of such maps may allow multiple disciplines commonly interacting over EMR platforms, and various perspectives (clinicians, programmers, informationists) to work more effectively as teams to refine the EMR by programming logic routines to address co-morbidities or other instances where domains of medical knowledge should be connected.

When Informationists Get Involved: the CHICA-GIS Project.

Child Health Improvement through Computer Automation (CHICA) is a computer decision support system (CDSS) that interfaces with existing electronic medical record systems (EMRS) and delivers "just-in-time" patient-relevant guidelines to physicians during the clinical encounter and accurately captures structured data from all who interact with the system. "Delivering Geospatial Intelligence to Health Care Professionals (CHICA-GIS)" (1R01LM010923-01) expands the medical application of Geographic Information Systems (GIS) by integrating a geographic information system with CHICA. To provide knowledge management support for CHICA-GIS, three informationists at the Indiana University School of Medicine were awarded a supplement from the National Library Medicine. The informationists will enhance CHICA-GIS by: improving the accuracy and accessibility of information, managing and mapping the knowledge which undergirds the CHICA-GIS decision support tool, supporting community engagement and consumer health information outreach, and facilitating the dissemination of new CHICA-GIS research results and services.

Giving patients granular control of personal health information: using an ethics 'Points to Consider' to inform informatics system designers.

OBJECTIVE: There are benefits and risks of giving patients more granular control of their personal health information in electronic health record (EHR) systems. When designing EHR systems and policies, informaticists and system developers must balance these benefits and risks. Ethical considerations should be an explicit part of this balancing. Our objective was to develop a structured ethics framework to accomplish this. METHODS: We reviewed existing literature on the ethical and policy issues, developed an ethics framework called a "Points to Consider" (P2C) document, and convened a national expert panel to review and critique the P2C. RESULTS: We developed the P2C to aid informaticists designing an advanced query tool for an electronic health record (EHR) system in Indianapolis. The P2C consists of six questions ("Points") that frame important ethical issues, apply accepted principles of bioethics and Fair Information Practices, comment on how questions might be answered, and address implications for patient care. DISCUSSION: The P2C is intended to clarify what is at stake when designers try to accommodate potentially competing ethical commitments and logistical realities. The P2C was developed to guide informaticists who were designing a query tool in an existing EHR that would permit patient granular control. While consideration of ethical issues is coming to the forefront of medical informatics design and development practices, more reflection is needed to facilitate optimal collaboration between designers and ethicists. This report contributes to that discussion.

Promotion and tenure for community-engaged research: an examination of promotion and tenure support for community-engaged research at three universities collaborating through a Clinical and Translational Science Award.

INTRODUCTION: Community-engaged health research, an approach to research which includes the participation of communities, promotes the translation of research to address and improve social determinants of health. As a way to encourage community-engaged research, the National Institutes of Health required applicants to the Clinical and Translational Science Award (CTSA) to include a community engagement component. Although grant-funding may support an increase in community-engaged research, faculties also respond to the rewards and demands of university promotion and tenure standards. This paper measures faculty perception of how three institutions funded by a CTSA support community-engaged research in the promotion and tenure process. METHODS: At three institutions funded by a CTSA, tenure track and nontenure track faculty responded to a survey regarding perceptions of how promotion and tenure committees value community-engaged research. RESULTS: Faculty view support for community-engaged research with some reserve. Only 36% agree that community-engaged research is valued in the promotion and tenure process. DISCUSSION: Encouraging community-engaged scholarship requires changing the culture and values behind promotion and tenure decisions. Institutions will increase community-engaged research and more faculty will adopt its principles, when it is rewarded by promotion and tenure committees.

Perspective: is it time for advocacy training in medical education?

As the modern medical system becomes increasingly complex, a debate has arisen over the place of advocacy efforts within the medical profession. The authors argue that advocacy can help physicians fulfill their social contract. For physicians to become competent in patient-centered, clinical, administrative, or legislative advocacy, they require professional training. Many professional organizations have called for curricular reform to meet society's health needs during the past 30 years, and the inclusion of advocacy training in undergraduate, graduate, and continuing medical education is supported on both pragmatic and ethical grounds. Undergraduate medical education, especially, is an ideal time for this training because a standard competency can be instilled across all specialties. Although the Accreditation Council for Graduate Medical Education includes advocacy training in curricula for residency programs, few medical schools or residency programs have advocacy electives. By understanding the challenges of the health care system and how to change it for the better, physicians can experience increased professional satisfaction and effectiveness in improving patient care, systems-based practice, and public health.