Essential Electronic Health Record Reforms for This Decade.

This Viewpoint posits suggestions to reform electronic health records (EHRs), including use of unique personal safety identifiers, reduction of administrative and regulatory content from clinical time, inclusion of patient-entered information into the EHR, and reinvention of the clinical note.

EFMI initiatives for inter-regional cooperation: the TrEHRT project.

The paper refers to EFMI's initiatives to develop an international cooperation with different regional groups of IMIA. More details are presented about the successful project "TrEHRT - Traveler's Electronic Health Record Template". Its potential applicability, compact structure and functional simplicity turned this product into a template capable to become an international standard, using mobile phones.

The International Academy of Health Sciences Informatics: 2021 Update.

OBJECTIVES: To summarize the activities of the International Academy of Health Sciences Informatics (IAHSI) in 2021 and welcome its 2021 Class of Fellows. METHODS: Report on governance, strategic directions, newly elected fellows, plenary meetings, and other activities of the Academy. RESULTS: As in 2020, all of the Academy's activities were carried out virtually due to the COVID-19 pandemic. In 2021, new Board members were elected. Strategic activities in data standards and interoperability and in mentorship moved forward. A new class of 26 Fellows was elected, bringing the total membership of the Academy to 204 Fellows from all regions of the world. In addition, a virtual plenary meeting was held. CONCLUSIONS: The Academy has continued to pursue its role as the honorific society globally for biomedical and health informatics. Expansion of strategic activities and membership will continue moving forward.

A tribute to Karen Greenwood and her contributions to the American Medical Informatics Association.

After 25 years of service to the American Medical Informatics Association (AMIA), Ms Karen Greenwood, the Executive Vice President and Chief Operating Officer, is leaving the organization. In this perspective, we reflect on her accomplishments and her effect on the organization and the field of informatics nationally and globally. We also express our appreciation and gratitude for Ms Greenwood's role at AMIA.

25 × 5 Symposium to Reduce Documentation Burden: Report-out and Call for Action.

BACKGROUND: The widespread adoption of electronic health records and a simultaneous increase in regulatory demands have led to an acceleration of documentation requirements among clinicians. The corresponding burden from documentation requirements is a central contributor to clinician burnout and can lead to an increased risk of suboptimal patient care. OBJECTIVE: To address the problem of documentation burden, the 25 by 5: Symposium to Reduce Documentation Burden on United States Clinicians by 75% by 2025 (Symposium) was organized to provide a forum for experts to discuss the current state of documentation burden and to identify specific actions aimed at dramatically reducing documentation burden for clinicians. METHODS: The Symposium consisted of six weekly sessions with 33 presentations. The first four sessions included panel presentations discussing the challenges related to documentation burden. The final two sessions consisted of breakout groups aimed at engaging attendees in establishing interventions for reducing clinical documentation burden. Steering Committee members analyzed notes from each breakout group to develop a list of action items. RESULTS: The Steering Committee synthesized and prioritized 82 action items into Calls to Action among three stakeholder groups: Providers and Health Systems, Vendors, and Policy and Advocacy Groups. Action items were then categorized into as short-, medium-, or long-term goals. Themes that emerged from the breakout groups' notes include the following: accountability, evidence is critical, education and training, innovation of technology, and other miscellaneous goals (e.g., vendors will improve shared knowledge databases). CONCLUSION: The Symposium successfully generated a list of interventions for short-, medium-, and long-term timeframes as a launching point to address documentation burden in explicit action-oriented ways. Addressing interventions to reduce undue documentation burden placed on clinicians will necessitate collaboration among all stakeholders.

Electronic health records and clinician burnout: A story of three eras.

OBJECTIVE: The study sought to provide physicians, informaticians, and institutional policymakers with an introductory tutorial about the history of medical documentation, sources of clinician burnout, and opportunities to improve electronic health records (EHRs). We now have unprecedented opportunities in health care, with the promise of new cures, improved equity, greater sensitivity to social and behavioral determinants of health, and data-driven precision medicine all on the horizon. EHRs have succeeded in making many aspects of care safer and more reliable. Unfortunately, current limitations in EHR usability and problems with clinician burnout distract from these successes. A complex interplay of technology, policy, and healthcare delivery has contributed to our current frustrations with EHRs. Fortunately, there are opportunities to improve the EHR and health system. A stronger emphasis on improving the clinician's experience through close collaboration by informaticians, clinicians, and vendors can combine with specific policy changes to address the causes of burnout. TARGET AUDIENCE: This tutorial is intended for clinicians, informaticians, policymakers, and regulators, who are essential participants in discussions focused on improving clinician burnout. Learners in biomedicine, regardless of clinical discipline, also may benefit from this primer and review. SCOPE: We include (1) an overview of medical documentation from a historical perspective; (2) a summary of the forces converging over the past 20 years to develop and disseminate the modern EHR; and (3) future opportunities to improve EHR structure, function, user base, and time required to collect and extract information.

Informatics-enabled citizen science to advance health equity.

The COVID-19 pandemic has once again highlighted the ubiquity and persistence of health inequities along with our inability to respond to them in a timely and effective manner. There is an opportunity to address the limitations of our current approaches through new models of informatics-enabled research and clinical practice that shift the norm from small- to large-scale patient engagement. We propose augmenting our approach to address health inequities through informatics-enabled citizen science, challenging the types of questions being asked, prioritized, and acted upon. We envision this democratization of informatics that builds upon the inclusive tradition of community-based participatory research (CBPR) as a logical and transformative step toward improving individual, community, and population health in a way that deeply reflects the needs of historically marginalized populations.

A retrospective look at the predictions and recommendations from the 2009 AMIA policy meeting: did we see EHR-related clinician burnout coming?

Clinicians often attribute much of their burnout experience to use of the electronic health record, the adoption of which was greatly accelerated by the Health Information Technology for Economic and Clinical Health Act of 2009. That same year, AMIA's Policy Meeting focused on possible unintended consequences associated with rapid implementation of electronic health records, generating 17 potential consequences and 15 recommendations to address them. At the 2020 annual meeting of the American College of Medical Informatics (ACMI), ACMI fellows participated in a modified Delphi process to assess the accuracy of the 2009 predictions and the response to the recommendations. Among the findings, the fellows concluded that the degree of clinician burnout and its contributing factors, such as increased documentation requirements, were significantly underestimated. Conversely, problems related to identify theft and fraud were overestimated. Only 3 of the 15 recommendations were adjudged more than half-addressed.

Clinician and Health Care Leaders' Experiences with-and Perceptions of-COVID-19 Documentation Reduction Policies and Practices.

BACKGROUND: Substantial strategies to reduce clinical documentation were implemented by health care systems throughout the coronavirus disease-2019 (COVID-19) pandemic at national and local levels. This natural experiment provides an opportunity to study the impact of documentation reduction strategies on documentation burden among clinicians and other health professionals in the United States. OBJECTIVES: The aim of this study was to assess clinicians' and other health care leaders' experiences with and perceptions of COVID-19 documentation reduction strategies and identify which implemented strategies should be prioritized and remain permanent post-pandemic. METHODS: We conducted a national survey of clinicians and health care leaders to understand COVID-19 documentation reduction strategies implemented during the pandemic using snowball sampling through professional networks, listservs, and social media. We developed and validated a 19-item survey leveraging existing post-COVID-19 policy and practice recommendations proposed by Sinsky and Linzer. Participants rated reduction strategies for impact on documentation burden on a scale of 0 to 100. Free-text responses were thematically analyzed. RESULTS: Of the 351 surveys initiated, 193 (55%) were complete. Most participants were informaticians and/or clinicians and worked for a health system or in academia. A majority experienced telehealth expansion (81.9%) during the pandemic, which participants also rated as highly impactful (60.1-61.5) and preferred that it remain (90.5%). Implemented at lower proportions, documenting only pertinent positives to reduce note bloat (66.1 ± 28.3), changing compliance rules and performance metrics to eliminate those without evidence of net benefit (65.7 ± 26.3), and electronic health record (EHR) optimization sprints (64.3 ± 26.9) received the highest impact scores compared with other strategies presented; support for these strategies widely ranged (49.7-63.7%). CONCLUSION: The results of this survey suggest there are many perceived sources of and solutions for documentation burden. Within strategies, we found considerable support for telehealth, documenting pertinent positives, and changing compliance rules. We also found substantial variation in the experience of documentation burden among participants.

Engineering information technology for actionable information and better health - balancing social values through desired outcomes, complementary standards and decision-support.

Information technology in health care (HIT) is getting a major boost in the United States through the passage of the American Recovery and Reinvestment Act (ARRA) of 2009. The portion of the Act that relates to health information technology (HITECH) seeks to achieve widespread implementation of electronic health records (EHRs) across the land and assure that these EHRs achieve sufficient levels of 'meaningful use' to improve care, reduce costs, and result in better outcomes. This chapter sets the stage for the other chapters that follow in this section. The chapter will review current thinking about how HIT will facilitate collection, dissemination, and evaluation of information throughout the system. Further, it will discuss the role and potential for HIT to support a learning organization [7,8]. Finally, it will outline the current widely identified barriers to progress, e.g., standards development, lack of interoperability and connectivity, and limited decision support that uses evidence-based guidelines created and maintained explicitly to be actionable through computer-based records and systems. Further, with the passage of HITECH, there is a continued attention given to privacy policy at the expense of access to person-specific health information for legitimate social purposes including research and community health. More will be said about this near the end of the chapter. Finally, the chapter will end with a discussion of the difference between information and communication and it will advocate for greater attention to the use of technology as a tool for improve communications and not simply storage and transmission of information.

Language matters: precision health as a cross-cutting care, research and policy agenda.

The biomedical research and healthcare delivery communities have increasingly come to focus their attention on the role of data and computation in order to improve the quality, safety, costs, and outcomes of both wellness promotion and care delivery. Depending on the scale of such efforts, and the environments in which they are situated, they are referred to variably as personalized or precision medicine, population health, clinical transformation, value-driven care, or value-based transformation. Despite the original intent of many efforts and publications that have sought to define personalized, precision, or data-driven approaches to improving health and wellness, the use of such terminology in current practice often treats said activities as discrete areas of endeavor within minimal cross-linkage across or between scales of inquiry. We believe that this current state creates numerous barriers that are preventing the advancement of relevant science, practice, and policy. As such, we believe that it is necessary to amplify and reaffirm our collective understanding that these fields share common means of inquiry, differentiated only by the units of measure being utilized, their sources of data, and the manner in which they are executed. Therefore, in this perspective, we explore and focus attention on such commonalities and then present a conceptual framework that links constituent activities into an integrated model that we refer to as a precision healthcare system. The presentation of this framework is intended to provide the basis for the types of shared, broad-based, and descriptive language needed to reference and realize such a framework.

Defining the medical subspecialty of clinical informatics.

As the professional home for biomedical and health informaticians, AMIA is actively working to support high quality relevant professional education and research opportunities. This issue of JAMIA presents two key documents that provide tangible evidence of progress on this front. In this editorial, we describe the context and specific purpose of the two documents, how they were developed, and AMIA's plans to build upon the documents.

Program requirements for fellowship education in the subspecialty of clinical informatics.

The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.

Core content for the subspecialty of clinical informatics.

The Core Content for Clinical Informatics defines the boundaries of the discipline and informs the Program Requirements for Fellowship Education in Clinical Informatics. The Core Content includes four major categories: fundamentals, clinical decision making and care process improvement, health information systems, and leadership and management of change. The AMIA Board of Directors approved the Core Content for Clinical Informatics in November 2008.

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.

Advancing the framework: use of health data--a report of a working conference of the American Medical Informatics Association.

The fields of health informatics and biomedical research increasingly depend on the availability of aggregated health data. Yet, despite over fifteen years of policy work on health data issues, the United States (U.S.) lacks coherent policy to guide users striving to navigate the ethical, political, technical, and economic challenges associated with health data use. In 2007, building on more than a decade of previous work, the American Medical Informatics Association (AMIA) convened a panel of experts to stimulate discussion about and action on a national framework for health data use. This initiative is being carried out in the context of rapidly accelerating advances in the fields of health informatics and biomedical research, many of which are dependent on the availability of aggregated health data. Use of these data poses complex challenges that must be addressed by public policy. This paper highlights the results of the meeting, presents data stewardship as a key building block in the national framework, and outlines stewardship principles for the management of health information. The authors also introduce a taxonomy developed to focus definitions and terminology in the evolving field of health data applications. Finally, they identify areas for further policy analysis and recommend that public and private sector organizations elevate consideration of a national framework on the uses of health data to a top priority.

Integrated personal health records: transformative tools for consumer-centric care.

BACKGROUND: Integrated personal health records (PHRs) offer significant potential to stimulate transformational changes in health care delivery and self-care by patients. In 2006, an invitational roundtable sponsored by Kaiser Permanente Institute, the American Medical Informatics Association, and the Agency for Healthcare Research and Quality was held to identify the transformative potential of PHRs, as well as barriers to realizing this potential and a framework for action to move them closer to the health care mainstream. This paper highlights and builds on the insights shared during the roundtable. DISCUSSION: While there is a spectrum of dominant PHR models, (standalone, tethered, integrated), the authors state that only the integrated model has true transformative potential to strengthen consumers' ability to manage their own health care. Integrated PHRs improve the quality, completeness, depth, and accessibility of health information provided by patients; enable facile communication between patients and providers; provide access to health knowledge for patients; ensure portability of medical records and other personal health information; and incorporate auto-population of content. Numerous factors impede widespread adoption of integrated PHRs: obstacles in the health care system/culture; issues of consumer confidence and trust; lack of technical standards for interoperability; lack of HIT infrastructure; the digital divide; uncertain value realization/ROI; and uncertain market demand. Recent efforts have led to progress on standards for integrated PHRs, and government agencies and private companies are offering different models to consumers, but substantial obstacles remain to be addressed. Immediate steps to advance integrated PHRs should include sharing existing knowledge and expanding knowledge about them, building on existing efforts, and continuing dialogue among public and private sector stakeholders. SUMMARY: Integrated PHRs promote active, ongoing patient collaboration in care delivery and decision making. With some exceptions, however, the integrated PHR model is still a theoretical framework for consumer-centric health care. The authors pose questions that need to be answered so that the field can move forward to realize the potential of integrated PHRs. How can integrated PHRs be moved from concept to practical application? Would a coordinating body expedite this progress? How can existing initiatives and policy levers serve as catalysts to advance integrated PHRs?

Sharing innovation: the case for technology standards in health professions education.

Information technologies have provided fertile ground for innovation in healthcare education, but too often these innovations have been limited in scope and impact. One way of addressing these limitations is the development of common and open technology standards to scale innovation across organizational boundaries. Research on the diffusion of standards indicates that environmental forces, such as regulatory changes, top-down management support, and feasibility are key determinants of standards adoption. This paper describes the perspective and work of MedBiquitous, the only internationally recognized standards body in healthcare education. Many innovators are implementing MedBiquitous healthcare education standards to effect change within and across organizations. In a resource-constrained and knowledge intensive domain such as healthcare education, collaboration is an imperative. Technology standards are essential to raise the quality of healthcare education and assessment in a cost-effective manner.