Each month, Arlene Chung, MD, MHA, MMCi, assistant professor of medicine and pediatrics at UNC, and one of the inaugural School of Medicine clinical informatics faculty hires, organizes a health informatics research collaborative on the fifth floor of the Health Sciences Library. The gathering gives clinician investigators and research faculty from across the university a platform to discuss their informatics research and share information about current trends in clinical and health informatics research.
“The informatics train has arrived,” says Chung, whose research explores how patient-generated health data including patient-reported outcomes and mobile health tools could improve health and health outcomes. “If you don’t get on now, you’ll be left behind. So hopefully everyone will get on board.”
Today, UNC is undergoing a campus-wide informatics renaissance. Advances in health information technology, an increased university commitment to health informatics, as demonstrated by the launching of the Carolina Health Informatics Program (CHIP) and the development of two advanced training and research degrees in health informatics, and excitement about the role of informatics in the future of health care have all contributed to a thriving informatics culture. Look no further than the number of health IT researchers and scholars who call UNC home for evidence of UNC’s informatics revitalization.
Carlton Moore, MD, MS, associate professor of medicine, is one of three board-certified physicians in clinical informatics at UNC – and one of approximately 400 in the world. His work in developing natural-language processing software that identifies abnormal results in free-text clinical reports (e.g., mammograms) stored in electronic health records promises to improve quality of care and patient safety.
“UNC is a huge institution,” says Moore. “In the past, with informatics research and projects, people have been more siloed than we’d like. With the help of CHIP and with simple ideas like meeting monthly, researchers are talking to each other, getting to know each other, and collaborating more than ever in clinical informatics research.”
Although the push in informatics is reaching schools and departments across campus, Carolina isn’t a newcomer to the field. UNC Hospitals was a pioneer in developing an electronic health record (EHR) data standard through the creation of WebCIS, and the university has many large and continuously updated electronic health data repositories, including the Carolina Data Warehouse for Health in partnership with IBM, the Lineberger Cancer Data Warehouse, and the Integration Cancer Information and Surveillance System (ICISS).
The long history of interest in informatics has, in fact, aided UNC Health Care’s transition from WebCIS to Epic, one of the most widely used advanced EHRs.
“Informatics isn’t something we’re just jumping into now,” says Don Spencer, MD, MBA, professor of family medicine and chief medical informatics officer for UNC Health Care, and also one of UNC’s three board-certified clinical informaticians. “This energy is part of a developmental history with goals and direction, and it’s not only helped our Epic implementation, but when you look at it more broadly, it’s helped the care of our patients.”
Merging the collective informatics brain power at UNC with existing data repositories and skilled physicians is certain to open doors for healthcare improvements.
“We have so much data at our fingertips,” says CHIP director, Javed Mostafa, PhD. “Connecting with one another and talking about the innovative ways we might use data to produce better health outcomes is invaluable as we work to integrate data and engender a way to think about health care that is collaborative, cooperative, and proactive.”
Ongoing informatics research at UNC includes mobile and wearable tech in the form of activity-tracking devices and calorie-counting smartphone applications; text-messaging and social media interventions for behavioral changes; analysis of genomic data; development of innovative data visualization and machine learning techniques to process “big” data in health care; syndromic surveillance to improve early detection of disease outbreaks; patient-powered research networks built upon health information technology tools; and much more. Eventually, Epic@UNC and its implications for informatics, clinical, and health services research will also advance treatment of individual patients and patient populations in North Carolina and beyond.
“We’re beginning to capture people’s imagination with what’s possible with health information technologies,” says Chung. “What’s great about UNC are the multi-disciplinary informatics collaborations across campus. From basic science to software development, investigators from different schools and departments all work together sharing their respective expertise to conduct cutting-edge informatics research.”
ImproveCareNow, a national Learning Health System comprising more than 60 hospitals and practices treating children and young adults with Inflammatory Bowel Disease (IBD), is a leading example of leveraging state-of-the-art informatics to measure and improve the quality of care, conduct research, and translate this research into practice – all in the context of routine clinical care.
The N.C. Children’s Hospital and Associate Professor of Pediatrics, Michael Kappelman, MD, MPH, are founding members of this national network. Kappelman also serves as the network’s Director of Data Management and is a member of the network’s Executive Committee. For patients with IBD, including, Crohn’s disease and ulcerative colitis, the network approach has proven that data collection and integration across populations of patients leads to changes in care delivery that result in improved outcomes (remission).
Although we have a long history in the field and CHIP is home to very exciting research, we’ve only just begun building what we believe will be the premier university informatics culture in the country. –Javed Mostafa, CHIP director
“Our findings suggest that collaborative quality improvement methods focused on improving chronic illness care can lead to improved process and outcome measures in children with IBD,” says Kappelman. “Furthermore, the very same data can be effectively repurposed to generate new knowledge through comparative effectiveness research.”
According to Mostafa, ImproveCareNow serves as an example of much of what Carolina informatics hopes to accomplish.
“The more information you have, the more generalizable your predictions can become,” Mostafa says. “You’ll be able to focus on specific areas – an urban hospital or a rural hospital, for example – compare them, and find one consistent solution that seems to be a robust treatment that works across different groups and populations. That’s the type of informatics we want to build. That’s where we want to take health care….The collection of data is not just good for looking back at what happened, but more importantly, it’s helpful for looking forward. It leads us to ask ourselves, ‘What can we do differently?’”
From the Stethoscope to the Computer
Sam Cykert, MD, professor of internal medicine and director of the School of Medicine Program on Health and Clinical Informatics, sees two types of people in informatics: those who focus on the nuts and bolts of computing and who imagine how systems can physically interact, and those who are innovators.
“Either way, informatics requires imagination and being unafraid of failure,” says Cykert. “When you try new things and you attempt to be innovative, not all of your ideas are going to work, and so you have to go into it with the attitude that you’ll move on to the next idea.”
Bringing people who have nuts-and-bolts computing expertise together with those with clinical and research expertise is one of the challenges of informatics, says Rich Medlin, MD, MSIS, assistant professor of emergency medicine, a lead informatics physician at UNC, and one of the three board-certified clinical informaticians at Carolina.
“Informatics requires three sets of skills: technical skills, medical knowledge or health care skills, and administrative skills,” says Medlin, who is the first UNC physician to receive a Master of Science in Information Science (MSIS) from UNC’s School for Library and Information Science (SILS). “The people who are managers in IT and medicine rarely have all three of those. You don’t need to give physicians additional information about the health care system. But they need information about management and possibly about the technical side of informatics.”
Medlin’s research includes how reference information can be supplied at the point of care to physicians in terse, relevant documents generated by a computer search based on patient characteristics found in the EHR. He believes that the data that can be obtained using EHRs can tell physicians in the ED how care is utilized and advise them about can be done to best serve patients.
“Similar to business intelligence, we’re able to use data analytics to give patients what they need,” he says. “In the way that Google is serving you ads that may interest you, we’re learning to serve patients better, targeted health care.”
Medlin points out that doctors interested in the operational side of informatics, as he is, have a passion not only for computers, but also for improving care for patients. He has been working alongside the Epic@UNC team to make operational informatics in the ED and elsewhere at UNC Hospitals function for physicians.
“Most of us involved in the operational side feel that to get improved clinical utility from computers, clinicians have to be involved in the development of our electronic systems,” he says.
But for some physicians, the computer is an obstruction that gets in the way of caring for patients.
“People are often afraid of the computer coming between the physician and the patient,” says Don Spencer. “They shouldn’t be any more afraid than when the stethoscope was first introduced more than a century ago.”
In his role as chief medical informatics officer, Spencer has been chairing the Epic@UNC Physicians Informatics Committee during the Epic@UNC implementation. He received his graduate certificate in biomedical informatics from Oregon Health & Science University, and his experience implementing health information technology projects, including the Carolina Data Warehouse for Health, has shaped his view of the use of computers in medical care.
For Spencer, the computer, like any other device available to the physician, is a tool that physicians must learn how to use.
“Physicians used to have a hard time listening to breathing sounds without putting their ear directly on the patient’s back,” he says. “When the stethoscope was introduced, patient care improved. An electronic medical record is a tool that can help with direct patient care.”
A Hot-Bed of Innovation
Early in his career, Sam Cykert was an attending for an electronic intensive care unit in a small, rural hospital in North Carolina. There were no intensivists on staff. From off-site locations, attendings used cameras and sensors to follow changes in patient conditions by zooming in on IV drips, viewing ventilators, and even examining a patient’s eyes.
Cykert recalls an instance in which he noticed an irregularity in a patient’s pupils. He ordered a head CT. The results of the scan revealed a subdural bleed that required evacuation.
The moment showed Cykert how electronics can be used to perform remote interventional treatment – similar to the possibilities he sees with computers and biomedical informatics. Computers, like electronics, he says, can shape how we provide care.
“Many people think only of electronic health records when they think about the relationship between computers and medicine,” Cykert says. “EHRs are part of informatics, but there are many more ways informatics can improve health.”
UNC is in a great position. As one of the bigger health systems in North Carolina, and with an amazing cohort of people across the university who are doing exciting work in clinical informatics, we have all the pieces of the puzzle. When everyone is under one umbrella and people are working in synergy, UNC will become not only a leader in the field, but a powerhouse. –Carlton Moore, MD, MS
Through commitment to data management, increased educational opportunities, and the implementation of Epic, among other informatics advancements, UNC is poised to become a hot-bed of health IT innovation.
“UNC is in a great position,” says Carlton Moore. “As one of the bigger health systems in North Carolina, and with an amazing cohort of people across the university who are doing exciting work in clinical informatics, we have all the pieces of the puzzle. When everyone is under one umbrella and people are working in synergy, UNC will become not only a leader in the field, but a powerhouse.”
As director of CHIP, Javed Mostafa has been working to build the informatics infrastructure at UNC while also developing relationships with private-sector companies in the RTP and nonprofits such as RTI International. Mostafa agrees that UNC informatics is entering a new era.
“Although we have a long history in the field and CHIP is home to very exciting research, we’ve only just begun building what we believe will be the premier university informatics culture in the country,” says Mostafa.
The culture already extends beyond Chapel Hill. As clinical director of the Regional Extension Center for Health Information Technology, Cykert is helping to implement EHR systems in practices across the state and teaching the doctors how to use them to drive quality and improve care, particularly for chronic diseases.
“When you’re working with doctors who are my generation and ten years younger, you really have to be a salesman, and you have to get hard buy-in from them,” he says. “But with the younger generation, that’s how they live and breathe, so when I talk about a program in which you send a text reminder to a patient to take their medicine, it’s intuitive, and the idea of using computers to make their work easier is intuitive, so there is a generational advantage, and we’re beginning to see the changes around the state….New concepts in community-based research and modern clinical systems demand cutting-edge informatics tools for clinical support, patient support, and robust data acquisition, and that’s where we’re heading.”
Arlene Chung, who obtained her graduate degree in clinical informatics from the Fuqua School of Business at Duke University during her research fellowship and plans to seek board certification in clinical informatics, is pursuing innovative research in patient-centered health information technologies. She believes that taking good care of patients is inherently linked to clinical informatics.
“The majority of a patient’s life is spent outside of the walls of our clinics and hospitals, so harnessing the potential insights from patient-generated health data has incredible promise,” she says. “Once we can capture this for populations of patients, we will be able to conduct comparative effectiveness research and hopefully gain important insights into health and wellness.”
Like many of her UNC colleagues, she says that patients are the motivating force behind why she pursues clinical informatics research. It is her hope that clinical informatics research at UNC will push the boundaries and transform the way clinical care and research is conducted.
The School of Medicine’s Program on Health and Clinical Informatics is supported by the NC TraCS Institute, home of the NIH Clinical and Translational Science Awards (CTSA) Program at UNC-Chapel Hill.