Health Information Technology and the Medical School Curriculum

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Supplements and Featured Publications, Special Issue: Health Information Technology — Guest Editors: Sachin H. Jain, MD, MBA; and David B, Volume 16,

There are opportunities for and obstacles to adding core biomedical informatics competencies to medical school curricula.

Medical schools must teach core biomedical informatics competencies that address health information technology (HIT), including explaining electronic medical record systems and computerized provider order entry systems and their role in patient safety; describing the research uses and limitations of a clinical data warehouse; understanding the concepts and importance of information system interoperability; explaining the difference between biomedical informatics and HIT; and explaining the ways clinical information systems can fail. Barriers to including these topics in the curricula include lack of teachers; the perception that informatics competencies are not applicable during preclinical courses and there is no place in the clerkships to teach them; and the legal and policy issues that conflict with students' need to develop skills. However, curricular reform efforts are creating opportunities to teach these topics with new emphasis on patient safety, team-based medical practice, and evidence-based care. Overarching HIT competencies empower our students to be lifelong technology learners.

(Am J Manag Care. 2010;16(12 Spec No.):SP54-SP56)

Perhaps more than any other recent advance, health information technology (HIT) is rapidly becoming a key foundation for all aspects of patient care. As the complexity of healthcare increases, so does the complexity of collaboration needed between different members of the healthcare team. To evaluate the effectiveness of new treatments and the quality of care in specific populations, individual providers or the team as a whole must be able to rapidly and efficiently collect, analyze, and select intervention and performance data. Regardless of their chosen field, all medical students will have to manage vastly increased amounts of biomedical and clinical data.

There is a clear need for medical schools to teach core biomedical informatics competencies that address HIT. The Association of American Medical Colleges (AAMC) and the Howard Hughes Medical Institute (HHMI) recently defined scientific competencies for future medical school graduates. These new skills will enable the student to meet the competency: “Apply quantitative knowledge and reasoning—including integration of data, modeling, computation, and analysis—and informatics tools to diagnostic and therapeutic clinical decision making.”1

The AAMC-HHMI report recommends training our students in critical competencies that are largely absent from most traditional medical curricula. Some of their examples include explaining the difference between an electronic medical record (EMR) system and a computerized provider order entry system, and each one’s role in patient safety; describing the uses and limitations of a clinical data warehouse as a research tool; understanding the concepts and importance of information system interoperability; explaining the difference between biomedical informatics and HIT; and explaining the ways clinical information systems can fail. These topics include not only the use and application of HIT itself but also how HIT will help create new models of clinical practice and affect the provision of care.

The call to include these topics in medical school curricula is not new. More than 10 years ago, reports from the American Medical Informatics Association and AAMC’s Medical School Objectives Project outlined core student competencies, teaching strategies, and required resources.2,3 In 2006, AAMC surveyed medical schools to determine the presence of these topics in curricula.4 Fewer than one-third of medical schools had curricular objectives that addressed computer-based HIT systems. A subsequent survey of internal medicine clerkships found that approximately half of medical schools teach these topics in the preclinical years and only one-third during the clinical clerkships.5 Despite the availability of curricular outlines and suggested teaching strategies, the actual teaching of these competencies has not kept pace with the explosive increase in HIT use and innovation.

Schools will need to overcome many barriers before we see widespread and routine inclusion of these important topics in medical school curricula. There is a shortage of trained informaticians nationwide, and few medical schools are affiliated with institutions that have robust academic informatics departments or centers. It is insufficient to train students without providing faculty development. Both the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education mandate that teachers are versed in the specific competencies that they are assessing.

Medical students receive most of their HIT education from house staff and attendings in the clinical setting. This approach often is limited by a prevalent culture that reinforces the use of the EMR to document and communicate rather than to transform and to improve the way we practice. In order to promote the teaching of these competencies at the highest level, as described by Miller,6 faculty need to be proficient in them and be able to assess the expected level of competence of their students and residents.

Barriers exist at the level of curricular planning. These topics often lack advocates who oversee the education curriculum, and there has been little recognition of competencies beyond the needed technical training and student access policies. Reports like this recent one from the AAMC-HHMI will continue to encourage the presence of these topics in our curricula; however, informatics competencies often are perceived as not being directly applicable to preclinical courses, and there is usually no clear setting in which to teach them during the clinical clerkships.

The “ownership” of HIT at an academic medical center is another challenge. Health information technology often is the domain of the clinical enterprise, which may be completely separate, both organizationally and culturally, from the medical education mission. Even within a single medical center, students may be using EMRs from a private hospital, the Veterans Administration, state- or city-run hospitals, and privately owned clinics. Each of those entities may understand its responsibility to teach students about the technical aspects and use of their systems, but seldom do they address the competencies and concepts that span all of them.

This environment also introduces several legal and policy issues that cause conflict between the skills we want our students to demonstrate and what they actually are permitted to do in various HIT systems. Legal, billing, and Health Insurance Portability and Accountability Act concerns have resulted in situations where students can write notes and orders in some systems and not others. A recent survey of medical schools nationwide found that only 42% had a formal policy defining the level of access for medical students to the EMR. Of those schools, only half permitted fourth-year medical students to write notes within the EMR systems of all of their affiliated hospitals.7

Despite a lack of broad HIT curriculum adoption and the barriers listed above, many medical schools have been innovative at teaching these topics. Vertically integrated curricula have been in place at some schools for years with excellent results.8-12 The Phoenix track of the Arizona State University School of Medicine includes courses on biomedical informatics for all first-year and second-year medical students.13

The time is ripe for HIT curriculum to be taught in all medical schools. Several factors foster this need: increased adoption of HIT, curricular change, and the changing nature of American healthcare.

Federal government support has led to the increased adoption of HIT in both the outpatient and inpatient settings. As a result, academic medical centers have come to recognize the need for meaningful use of these expensive systems by prepared clinicians. Health information technology is an essential element in the missions of academic medical centers, and allows both innovation and education. Yet, for the promise of HIT to be realized, healthcare providers will need to be competent in a sophisticated informatics skill set from a very early point in their medical education.

The curricular reform efforts happening at many medical schools are creating novel opportunities to teach these topics with new emphasis on patient safety, team-based medical practice, and evidence-based care. Many medical schools are introducing integrated curricula that include clinical exposure to patients (and correspondingly their HIT) for first-year and second-year students. This situation heightens the need to teach informatics competencies to these novice learners, because the timing of their new clinical exposures allows for better integration into the preclinical academic schedule.

To teach interprofessional collaboration and newer models of care delivery, an informatics curriculum is required. Topics such as professionalism and patient communication have taken on entirely new meanings with the advent of HIT tools for patients and providers. As many schools implement simulation centers, there is an opportunity to use these HIT tools for integrated technology teaching and assessment. Emerging literature on the unintended consequences of HIT use, both positive and negative, provides further evidence that informatics curricular development for medical students is important.14-16

The changing nature of healthcare itself drives the need for this curriculum. Improved patient safety, performance, and quality are achievable using HIT. Providers are practicing in multiple settings that use different HIT systems. These HIT systems themselves are constantly evolving or being replaced. New sciences such as genomics and personalized medicine generate unique decision making regarding patient care. Overarching HIT competencies empower our students to be lifelong technology learners, rather than experts in a single system or approach that will soon be obsolete.

Now is the perfect time for medical schools to broadly adopt formal curricula addressing HIT and biomedical informatics. Competencies have been well delineated, and teaching strategies have been outlined. Academic medical centers must involve their informatics faculty in the education planning process and provide curricular time for implementation of an HIT curriculum addressing the AAMC-HHMI competencies. The clinical teams also need training in these competencies to provide adequate supervision and formative feedback to students and trainees, creating a cadre of teachers and role models. The legal issues limiting student use of these systems need clarification so that these learners may demonstrate skills and competencies. Effective teaching of these topics will prepare tomorrow’s physicians to deliver better care in their clinical practice, so they can realize the promise of 21st-century healthcare.

Author Affiliations: From the Division of Educational Informatics (MMT), New York University, New York, NY; Department of Medicine (EF), Mount Sinai Medical Center, New York, NY; Division of Educational Informatics (CC), Albert Einstein College of Medicine, Bronx, NY; Biomedical Informatics and Information Science (EMG), Albany Medical College, Albany, NY; Associated Medical Schools of New York (JW, CM), New York, NY.

Funding Source: The authors report no external funding for this work.

Author Disclosures: The authors (MMT, EF, CC, EMG, JW, CM) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (CC, EMG, JW, CM); acquisition of data (EF, EMG, CM); analysis and interpretation of data (EF); drafting of the manuscript (MMT, EF, CC, EMG, JW); critical revision of the manuscript for important intellectual content (MMT, EF, CC); and administrative, technical, or logistic support (JW, CM).

Address correspondence to: Jo Wiederhorn, MSW, President/CEO, Associated Medical Schools of New York, 1270 Ave of the Americas, Ste 606, New York, NY 10020. E-mail:

1. Association of American Medical Colleges and the Howard Hughes Medical Institute. Scientific Foundations for Future Physicians Committee. Report of the AAMC-HHMI Committee. Washington, DC: Association of American Medical Colleges; 2009. grants/pdf/08-209_AAMC-HHMI_report.pdf. Accessed August 2010.

2. Staggers N, Gassert C, Skiba D. Health professionals' views of informatics education: findings from the AMIA 1999 spring conference. J Am Med Inform Assoc. 2000;7(6):550-558.

3. Contemporary issues in medicine-medical informatics and population health: report II of the Medical School Objectives Project. Acad Med. 1999;74(2):130-141.

4. McGowan J, Passiment M, Hoffman H. Educating medical students as competent users of health information technologies: the MSOP data. Medinfo 2007: Proceedings of the 12th World Congress on Health (Medical) Informatics; Building Sustainable Health Systems. Amsterdam, Netherlands: IOS Press; 2007:1414-1418.

5. Aiyer MK, Dorsch JL, Mintz M, et al. Medical informatics in the internal medicine clerkship: results of a national survey. Med Teach. 2009;31(8):e351-e355.

6. Miller GE. The assessment of clinical skills/competence/performance. Acad Med. 1990;65(9 suppl):S63-S67.

7. Friedman E, Fallar R, Sainte M. Taking note of the perceived value and impact of medical student chart documentation on education and patient care. Acad Med. 2010;85(9):1440-1444.

8. Brown JF, Nelson JL. Integration of information literacy into a revised medical school curriculum. Med Ref Serv Q. 2003;22(3):63-74.

9. Fleiszer DM, Posel NH. Development of an undergraduate medical curriculum: the McGill experience. Acad Med. 2003;78(3):265-269.

10. McGlade KJ, McKeveney CJ, Crawford VLS, Brannigan P. Preparing tomorrow's doctors: the impact of a special study module in medical informatics. Med Educ. 2001;35(1):62-67.

11. Speedie SM, Niewoehner C. The Minnesota virtual clinic: using a simulator EMR to teach medical students medical science and clinical concepts. AMIA Annu Symp Proc. 2003:1013.

12.Geyer EM, Irish DE. Isolated to integrated: an evolving medical informatics curriculum. Med Ref Serv Q. 2008;27(4):451-461.

13. Greenes RA, Panchanathan S, Patel V, Silverman H, Shortliffe EH. Biomedical informatics in the desert:a new and unique program at Arizona State University. Yearb Med Inform. 2008:150-156.

14. Ash JS, Sittig DF, Campbell EM, Guappone KP, Dykstra RH. Some unintended consequences of clinical decision support systems. AMIA Annu Symp Proc. 2007:26-30.

15. Ash JS, Sittig DF, Dykstra R, Campbell E, Guappone K. The unintended consequences of computerized provider order entry: findings from a mixed methods exploration. Int J Med Inform. 2009;(78 suppl 1):S69-S76.

16. Bernstam EV, Hersh WR, Sim I, et al. Unintended consequences of health information technology: a need for biomedical informatics. J Biomed Inform. 2010;43(5):828-830.