NLM and the IAIMS initiative: Cross-institutional academic/advanced systems contributing to the evolution of networked information and resources.

The Integrated Academic/Advanced Information Systems (IAIMS) program began in 1983 and was based on a study by the Association of American Medical Colleges (AAMC). Donald A.B. Lindberg M.D. was a member of the AAMC Advisory Committee. The U.S. National Library of Medicine (NLM) grants for IAIMS were initiated in 1984 the same year Dr. Lindberg became Director of the NLM. This chapter presents an overview of IAIMS and its progression through three stages with Dr. Lindberg's leadership.

Recommendations for the design, implementation and evaluation of social support in online communities, networks, and groups.

A new model of health care is emerging in which individuals can take charge of their health by connecting to online communities and social networks for personalized support and collective knowledge. Web 2.0 technologies expand the traditional notion of online support groups into a broad and evolving range of informational, emotional, as well as community-based concepts of support. In order to apply these technologies to patient-centered care, it is necessary to incorporate more inclusive conceptual frameworks of social support and community-based research methodologies. This paper introduces a conceptualization of online social support, reviews current challenges in online support research, and outlines six recommendations for the design, evaluation, and implementation of social support in online communities, networks, and groups. The six recommendations are illustrated by CanConnect, an online community for cancer survivors in middle Tennessee. These recommendations address the interdependencies between online and real-world support and emphasize an inclusive framework of interpersonal and community-based support. The applications of these six recommendations are illustrated through a discussion of online support for cancer survivors.

Registries and evidence-based medicine in craniofacial and plastic surgery.

Evidence-based medicine is a vital process for maintaining and improving quality and value in health care. However, evidence-based practice is most limited by the availability of research and outcomes data. Although randomized controlled trials (RCTs) have been identified by numerous research organizations as the criterion standard for research methodology (eg, "level I evidence"), the execution of well-designed RCTs has proved either challenging or impossible in many surgical fields and with rare disease conditions. In particular, craniofacial and plastic surgery has been noted to be lacking in both the number and quality of RCTs. Many reasons are discussed for this dearth of research including inadequate sample size and challenges in randomization, blinding, and clinical equipoise. Yet, data for outcomes assessment are highly valued by surgeons and by consumers and payers. Therefore, alternative and more practical means for research and data collection must be sought. Observational studies of clinical practice are particularly useful for outcomes assessment despite relegation to a lower tier of evidence (eg, "level II evidence"). Functional databases with well-defined processes for data collection, called medical data registries, are an essential informatics tool to collect and store outcomes data and produce high-quality observational, practice-based research studies. A properly designed and implemented registry can provide surgeons with an abundance of data to perform research and quality improvement projects. In fact, registries may be superior in many ways to RCTs for craniofacial and plastic surgeons both pragmatically and functionally. In this commentary, we discuss the production of such registries in the framework of evidence-based practice and the relevant studies in craniofacial surgery.

Effective strategies for implementation and evaluation of public e-health innovations.

The creation of a new public e-health product is no guarantee that it will be used. Developing an implementation strategy is crucial for success. This paper presents a model for both an implementation and an evaluation process. It offers strategies for the multiple phases of an implementation process (foundational concepts, actual implementation, and the on-going use process). It also offers evaluation considerations that parallel each of the implementation phases.

NLM and the IAIMS Initiative: Cross-Institutional Academic/Advanced Systems Contributing to the Evolution of Networked Information and Resources.

The Integrated Academic/Advanced Information Systems (IAIMS) program began in 1983 and was based on a study by the Association of American Medical Colleges (AAMC). Donald A.B. Lindberg M.D. was a member of the AAMC Advisory Committee. The U.S. National Library of Medicine (NLM) grants for IAIMS were initiated in 1984 the same year Dr. Lindberg became Director of the NLM. This chapter presents an overview of IAIMS and its progression through three stages with Dr. Lindberg's leadership.

Supporting the pursuit of professionalism during a crisis.

BACKGROUND: Crisis plans for healthcare organisations most often focus on operational needs including staffing, supplies and physical plant needs. Less attention is focused on how leaders can support and encourage individual clinical team members to conduct themselves as professionals during a crisis. METHODS: This qualitative study analysed observations from 79 leaders at 160 hospitals that participate in two national professionalism programmes who shared their observations in focus group discussions about what they believed were the essential elements of leading and addressing professional accountability during a crisis. RESULTS: Analysis of focus group responses identified six leadership practices adopted by healthcare organisations, which were felt to be essential for organisations to navigate the crisis successfully. Unique aspects of maintaining professionalism during each phase of the pandemic were identified and described. CONCLUSIONS: Leaders need a plan to support an organiation's pursuit of professionalism during a crisis. Leaders participating in this study identified practices that should be carefully woven into efforts to support the ongoing safety and quality of the care delivered by healthcare organisations before, during and after a crisis. The lessons learnt from the COVID-19 pandemic may be useful during subsequent crises and challenges that a healthcare organisation might experience.

Accelerating the deployment of a health information technology and informatics workforce through education, training, research, and evaluation.

Supported by stronger and more coordinated US federal funding and policies, driven by goals to deliver care more efficiently, and motivated to provide high quality care for an aging and more diverse population, public-private-sector organisations are redoubling efforts to implement information systems. Thus, there is a critical need to increase and broaden the pool of workers who can help organizations maximise the effectiveness of their investments in technology. There are in the US various current health informatics education and training initiatives and ongoing efforts to accelerate Health IT workforce development.

A proposed vision: the transatlantic observatory for meeting global health policy challenges through information and communications technology-enabled solutions (ARGOS).

In 2010 the ARGOS project was funded by the EC (DG RELEX) to contribute to the establishement of a "Transatlantic Observatory for meeting Global Health Policy Challenges through Information and Communication Technology-enabled solutions" to develop and promote common methods for responding to global eHealth challenges in the EU and the US. The European Institute for Health Records (EuroRec) was coordinating the project. The vision is that the Transatlantic Observatory will act as an international platform for dialogue and collaboration on health policy issues and will 1. build international consensus about how to improve the access, efficiency and quality of health services through ICT, 2. promote the importance of interoperability in eHealth, 3. help to define approaches to ensure that health data are easily available where it is needed, 4. identify optimal development paths.

Policy brief on the current status of certification of electronic Health Records in the US and Europe.

If Electronic Health Record systems are to provide an effective contribution to healthcare, a set of benchmarks need to be set to ensure quality control and interoperability of systems. This paper outlines the prevailing status of EHR certification in the US and the EU, compares and contrasts established schemes and poses opportunities for convergence of activity in the domain designed to advance certification endeavours generally. Several EU Member States have in the past proceeded with EHR systems quality labeling and/or certification, but these differ in scope, in legal framework under which they operate, in policies (legislation and financial incentives), in organization, and perhaps most importantly in the quality criteria used for benchmarking. Harmonization, therefore, became a must. Now, through EuroRec (with approaches ranging from self-assessment to third party certification depending on the level of confidence needed) and its Seals, the possibility to achieve this for EHR systems has started in the whole of Europe. The US HITECH Act also attempts to create incentives for all hospitals and eligible providers to adopt and use electronic information. A centerpiece of the Act is to put in place strong financial incentives to adopt and meaningfully use EHRs. The HHS/EHR Certification Programme makes use of ISO/IEC 170XX standards for accreditation, testing and certification. The approved test method addresses the functional and the interoperability requirements defined in the Final Rule criteria and standards. To date six Authorized Testing and Certification Bodies (ATCBs) are testing and certifying products in the US.

Enabling adoption and use of new health information technology during implementation: Roles and strategies for internal and external support personnel.

OBJECTIVE: Successful technological implementations frequently involve individuals who serve as mediators between end users, management, and technology developers. The goal for this project was to evaluate the structure and activities of such mediators in a large-scale electronic health record implementation. MATERIALS AND METHODS: Field notes from observations taken during implementation beginning in November 2017 were analyzed qualitatively using a thematic analysis framework to examine the relationship between specific types of mediators and the type and level of support to end users. RESULTS: We found that support personnel possessing both contextual knowledge of the institution's workflow and training in the new technology were the most successful in mediation of adoption and use. Those that lacked context of either technology or institutional workflow often displayed barriers in communication, trust, and active problem solving. CONCLUSIONS: These findings suggest that institutional investment in technology training and explicit programs to foster skills in mediation, including roles for professionals with career development opportunities, prior to implementation can be beneficial in easing the pain of system transition.

Mining tasks and task characteristics from electronic health record audit logs with unsupervised machine learning.

OBJECTIVE: The characteristics of clinician activities while interacting with electronic health record (EHR) systems can influence the time spent in EHRs and workload. This study aims to characterize EHR activities as tasks and define novel, data-driven metrics. MATERIALS AND METHODS: We leveraged unsupervised learning approaches to learn tasks from sequences of events in EHR audit logs. We developed metrics characterizing the prevalence of unique events and event repetition and applied them to categorize tasks into 4 complexity profiles. Between these profiles, Mann-Whitney U tests were applied to measure the differences in performance time, event type, and clinician prevalence, or the number of unique clinicians who were observed performing these tasks. In addition, we apply process mining frameworks paired with clinical annotations to support the validity of a sample of our identified tasks. We apply our approaches to learn tasks performed by nurses in the Vanderbilt University Medical Center neonatal intensive care unit. RESULTS: We examined EHR audit logs generated by 33 neonatal intensive care unit nurses resulting in 57 234 sessions and 81 tasks. Our results indicated significant differences in performance time for each observed task complexity profile. There were no significant differences in clinician prevalence or in the frequency of viewing and modifying event types between tasks of different complexities. We presented a sample of expert-reviewed, annotated task workflows supporting the interpretation of their clinical meaningfulness. CONCLUSIONS: The use of the audit log provides an opportunity to assist hospitals in further investigating clinician activities to optimize EHR workflows.

Informatics and evidence-based medicine: prescription for success.

This article reports on the experience of one organization between 2004 and 2009 to develop an effective people-process-technology system to better manage the quality of health care. The creation of this system started with creating a strategic plan for quality and then establishing a structure to implement the plan. The next phase consisted of establishing a number of simultaneous steps that ranged from identifying and leveraging the appropriate informatics tools to the oversight process, and from the implementation team to strategies for working with clinical groups. The outcome as of 2009 is a well established evidence-based quality process and team in place. There are over 450 evidence-based medicine quality sets. More than 52% of all patients are admitted on quality evidence-based medicine pathways and protocols. This article reflects a successful prescription for combining informatics and evidence-based medicine to improve the quality of health care.

Organizational diagnostics: a systematic approach to identifying technology and workflow issues in clinical settings.

OBJECTIVES: Healthcare organizations need to rapidly adapt to new technology, policy changes, evolving payment strategies, and other environmental changes. We report on the development and application of a structured methodology to support technology and process improvement in healthcare organizations, Systematic Iterative Organizational Diagnostics (SIOD). SIOD was designed to evaluate clinical work practices, diagnose technology and workflow issues, and recommend potential solutions. MATERIALS AND METHODS: SIOD consists of five stages: (1) Background Scan, (2) Engagement Building, (3) Data Acquisition, (4) Data Analysis, and (5) Reporting and Debriefing. Our team applied the SIOD approach in two ambulatory clinics and an integrated ambulatory care center and used SIOD components during an evaluation of a large-scale health information technology transition. RESULTS: During the initial SIOD application in two ambulatory clinics, five major analysis themes were identified, grounded in the data: putting patients first, reducing the chaos, matching space to function, technology making work harder, and staffing is more than numbers. Additional themes were identified based on SIOD application to a multidisciplinary clinical center. The team also developed contextually grounded recommendations to address issues identified through applying SIOD. DISCUSSION: The SIOD methodology fills a problem identification gap in existing process improvement systems through an emphasis on issue discovery, holistic clinic functionality, and inclusion of diverse perspectives. SIOD can diagnose issues where approaches as Lean, Six Sigma, and other organizational interventions can be applied. CONCLUSION: The complex structure of work and technology in healthcare requires specialized diagnostic strategies to identify and resolve issues, and SIOD fills this need.

How to successfully select and implement electronic health records (EHR) in small ambulatory practice settings.

BACKGROUND: Adoption of EHRs by U.S. ambulatory practices has been slow despite the perceived benefits of their use. Most evaluations of EHR implementations in the literature apply to large practice settings. While there are similarities relating to EHR implementation in large and small practice settings, the authors argue that scale is an important differentiator. Focusing on small ambulatory practices, this paper outlines the benefits and barriers to EHR use in this setting, and provides a "field guide" for these practices to facilitate successful EHR implementation. DISCUSSION: The benefits of EHRs in ambulatory practices include improved patient care and office efficiency, and potential financial benefits. Barriers to EHRs include costs; lack of standardization of EHR products and the design of vendor systems for large practice environments; resistance to change; initial difficulty of system use leading to productivity reduction; and perceived accrual of benefits to society and payers rather than providers. The authors stress the need for developing a flexible change management strategy when introducing EHRs that is relevant to the small practice environment; the strategy should acknowledge the importance of relationship management and the role of individual staff members in helping the entire staff to manage change. Practice staff must create an actionable vision outlining realistic goals for the implementation, and all staff must buy into the project. The authors detail the process of implementing EHRs through several stages: decision, selection, pre-implementation, implementation, and post-implementation. They stress the importance of identifying a champion to serve as an advocate of the value of EHRs and provide direction and encouragement for the project. Other key activities include assessing and redesigning workflow; understanding financial issues; conducting training that is well-timed and meets the needs of practice staff; and evaluating the implementation process. SUMMARY: The EHR implementation experience depends on a variety of factors including the technology, training, leadership, the change management process, and the individual character of each ambulatory practice environment. Sound processes must support both technical and personnel-related organizational components. Additional research is needed to further refine recommendations for the small physician practice and the nuances of specific medical specialties.

Physician Perspectives on Training for an EHR Implementation.

In 2017, a US academic medical center switched to a commercial EHR system using the "specialist training the specialist" model, which combines peer-to-peer training, classroom based training, and web-based training. We conducted semi-structured interviews with physicians at multiple training levels to investigate the impact of this EHR switch and to explore the training experience of physicians and their perception of the training quality pre and post Go-Live. Our team used Grounded Theory methodology to classify the interview information. Themes that emerged from the interviews included stress and anxiety, the desire for more realistic training environments tailored to specialty needs, and concerns about the duration of time between training and implementation. In future implementations, we recommend more data-rich test patients and the demonstration of real-world workflows during training.

Crossing the implementation chasm: a proposal for bold action.

As health care organizations dramatically increase investment in information technology (IT) and the scope of their IT projects, implementation failures become critical events. Implementation failures cause stress on clinical units, increase risk to patients, and result in massive costs that are often not recoverable. At an estimated 28% success rate, the current level of investment defies management logic. This paper asserts that there are "chasms" in IT implementations that represent risky stages in the process. Contributors to the chasms are classified into four categories: design, management, organization, and assessment. The American College of Medical Informatics symposium participants recommend bold action to better understand problems and challenges in implementation and to improve the ability of organizations to bridge these implementation chasms. The bold action includes the creation of a Team Science for Implementation strategy that allows for participation from multiple institutions to address the long standing and costly implementation issues. The outcomes of this endeavor will include a new focus on interdisciplinary research and an inter-organizational knowledge base of strategies and methods to optimize implementations and subsequent achievement of organizational objectives.

US and Scottish health professionals' attitudes toward DNA biobanking.

BACKGROUND: The authors define a DNA biobank as a repository of genetic information correlated with patient medical records. DNA biobanks may assist in the research and identification of genetic factors influencing disease and drug interactions, but may raise ethical issues. How healthcare providers perceive DNA biobanks is unknown. OBJECTIVES: To determine how useful healthcare professionals believe DNA biobanks will be and whether these attitudes differ between private and socialized healthcare systems. DESIGN: The authors surveyed 200 healthcare professionals, including research and non-research focused doctors, nurses and other staff from medical centers and independent practice in both the United States and Scotland. The survey included fifteen items evaluated for general receptiveness toward biobanks, presumed usefulness of biobanks and perceived attitudes in recruiting patients for a biobank. MEASUREMENTS: A total of 81 (45%) of 179 eligible participants responded: 41 from the U.S. and 40 from Scotland. Of these respondents, most (70%) were from academic centers. RESULTS: Results indicate that there is a broadly favorable attitude in both locations toward the creation of a DNA biobank (83%) and its perceived benefit (75%). This enthusiasm is tempered in Scotland when respondents evaluated their comfort in consenting patients for entry into a biobank; 16 of 40 respondents (40%) were uncomfortable doing so, representing a significant difference from those in the U.S. (p=0.001). CONCLUSIONS: Despite systematic differences in healthcare practice between the U.S. and Scotland, health care professionals in both nations believe DNA biobanks will be useful in curing disease. This finding appears to support further development of such a research tool.

Estelle Brodman: educator extraordinaire.

OBJECTIVE: The purpose of this article is to describe the educational contributions of Estelle Brodman PhD, to medical librarianship. METHODS: The article is based on a comprehensive search of Dr. Brodman's articles, a review of her two Medical Library Association oral history interviews, and personal recollections. FINDINGS: This article documents the educational contributions of Dr. Brodman, a librarian, researcher, and educator who had a significant and lasting impact on the education of medical librarians through more than fifty years of concentrated effort.

eHealth and IMIA's Strategic Planning Process - IMIA conference introductory address.

The International Medical Informatics Association (IMIA) is the only organization in health and biomedical informatics which is fully international in scope, bridging the academic, health practice, education, and health industry worlds through conferences, working groups, special interest groups and publications. Authored by the IMIA Interim Vice President for Strategic Planning Implementation and co-authored by the current IMIA President and the IMIA Past-President, the intention of this paper is to introduce IMIA's current strategic planning process and to set this process in relation to 'eHealth: Combining Health Telematics, Telemedicine, Biomedical Engineering and Bioinformatics to the Edge', the theme of this conference. From the viewpoint of an international organization such as IMIA, an eHealth strategy needs to be considered in a comprehensive way, including broadly stimulating high-quality health and biomedical informatics research and education, as well as providing support to bridging outcomes towards a new practice of health care in a changing world.