Ehealth education for the clinical health professions: curriculum change in context

Dr Kathleen Gray Health and Biomedical Informatics Centre The University of Melbourne, Australia www.healthinformatics.unimelb.edu.au

Ehealth changes professional practice: Image sources: edtansrant.blogspot.com.au, histalk2.com ,webicina.com

We’re not quite sure how it should, though…

“…there has been little policy or guidance on the best practices to inform standards for the professional conduct of physicians in the digital environment. Areas of specific concern include:

• the use of such media for nonclinical purposes,

• implications for confidentiality,

• the use of social media in patient education, and

• how all of this affects the public's trust in physicians as patient–physician

interactions extend into the digital environment.” (Farnan, 2013).

….. And not only PHYSICIANS, but all sorts of CLINICAL HEALTH PROFESSIONALS….

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… giving rise to some educational research questions:

• How does the education of clinical health professionals address ehealth?

• Why should it?

• How could it?

• What’s the baseline?

• What’s the impact?

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There are lots of underlying concepts to draw on in this research, e.g.

The evolution of a research program

• Gray, Kathleen, and Jenny Sim. "Building ICT capabilities for clinical work in a sustainable healthcare system: approaches to bridging the higher education learning and teaching gap." Medinfo 2007: Proceedings of the 12th World Congress on Health (Medical) Informatics; Building Sustainable Health Systems. IOS Press, 2007.

• Kennedy, Gregor, Kathleen Gray, and Justin Tse. “ ‘Net Generation’ medical students: technological experiences of pre-clinical and clinical students." Medical Teacher 30.1 (2008): 10-16.

• Gray, Kathleen, Lucas Annabell, and Gregor Kennedy. "Medical students' use of Facebook to support learning: Insights from four case studies." Medical Teacher 32.12 (2010): 971-976.

• Gray, Kathleen, and Jenny Sim. "Factors in the development of clinical informatics competence in early career health sciences professionals in Australia: a qualitative study." Advances in Health Sciences Education 16.1 (2011): 31-46.

• Gray, Kathleen et al. Advancing ehealth education for the clinical health professions. Final Report. Sydney, NSW: Department of Education Office for Learning and Teaching. ISBN 9781743613429. (2014).

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Outline –

an ongoing clinical informatics education research project in Australia

1. Context

2. Current practice

3. Challenges for practice

4. Ways forward

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1. Context

• The Australian scene

• Three slides about our project

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Australia’s Local & Global Ehealth Concerns

• Australian national strategy www.nehta.gov.au:

Infrastructure, PCEHR, telehealth, e-prescribing, clinical leads

• State & Territory government strategies:

Public hospitals, public health, some primary and community care

• Mixed public and private systems / investments:

Healthcare + biomedical R&D + ehealth IT industry

• Domestic but also international interests:

Health workforce, student population, globalisation of healthcare/IT

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Context: An Australian national project (1/3)

To initiate and encourage:

– curriculum renewal for ehealth capability

– in clinical health professional degrees

– through a coordinated interprofessional approach

4-university, 4-State team 2010-2013 :

Kathleen Gray & Ambica Dattakumar, University of Melbourne

Anthony Maeder, University of Western Sydney

Kerryn Butler-Henderson, Curtin University, Western Australia

Helen Chenery, University of Queensland

Supported by Australian Government Office of Learning & Teaching; reference group from national and international agencies; clinical education champions.

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(2/3) Our project focus & assumptions

“Future clinicians will be expected to be more effective than is now the case in acquiring, managing, and utilising information for clinical decision making.” (UK National Health Service,

2009)

How does tertiary education in Australian need to respond,

so that it produces a generation of clinicians

with the knowledge, skills and attributes to use ICTs effectively in healthcare?

– Clinicians can’t all build this competence by informal learning alone.

– The disciplinary foundation is health and biomedical informatics.

– Informatics education for clinicians can be formal & comprehensive; more so than EBP / information literacy / computing skills curricula.

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(3/3) A coordinated interprofessional approach

All Australian tertiary degrees for entry into clinical practice:

• ~20 health professions in all, including medicine, nursing, pharmacy, dentistry, allied health, complementary therapies

• Bachelor to Doctorate entry level professional degrees

With reference to others doing related work, e.g.

• Australian work: ACPDHS, AIPPEN, ATHS, HWA, NEHTA, AHIEC & its members (ACHI, ACS, HIMAA, HISA, HL7A)

• International work: UK eICE, US ONCHIT Workforce Development Program, Canada COACH Clinician Forum, IMIA Health and Medical Informatics Education Working Group

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2. Our perspective on current practice in clinical informatics education

comes from these project activities:

• Literature review

• Degree coordinator survey & interviews

• Interprofessional workshops

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What we wanted from the literature

Evidence from peer-reviewed reports of implementing and evaluating

clinical informatics education for future health professionals.

What is known to be good pedagogical practice in clinical informatics education, regarding:

– student diversity, learning needs and learning styles?

– teaching methods and modes of delivery?

– techniques for assessment of student learning?

– attainment of intended learning outcomes?

– standardisation and accreditation of curriculum?

– educational quality improvement processes?

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What we found in the literature

• A shortlist of around 20 papers in the peer-reviewed journal and conference literature published in English between the years 2000-2011 covering university teaching of medical / clinical / health informatics to future clinicians.

• Very few research reports of cases or trials that use externally validated instruments or processes.

• A limited evidence base to support effective approaches to clinical informatics teaching, learning, assessment or evaluation.

Details: Gray, K., Dattakumar, A., Maeder, A., & Chenery, H. (2011). Educating future clinicians about clinical

informatics: A review of implementation and evaluation cases. European Journal of Biomedical Informatics, 7(2), 2011.

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What we wanted to know from educators

2011 snapshot data from degree program directors / coordinators:

40 universities / 400 invitations

Over 100 completed surveys & 35 extended interviews

Representatives of Faculties, Schools and Departments of health sciences in three-quarters of Australian universities

What matters about ehealth to you, as the coordinator of an entry level health profession degree?

What are you doing about ehealth in the degree for which you are responsible?

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Educators are unclear about what is known and what is needed.

Clinical informatics education is not systematic nor widespread.

– 25% - 75% were unable to confirm important aspects of educational quality,

e.g. academic knowledge base; explicit curriculum; formal assessment practices;

quality review processes; student-centredness

– Misconceptions e.g. ehealth = elearning.

– Pockets of good practice e.g. contextualised teaching about EHRs.

Details: Dattakumar, A., Gray, K., Butler-Henderson, K., Maeder, A. & Chenery, H. (2012). We are not educating the future clinical health professional workforce adequately for ehealth competence: Findings of an Australian study. In Maeder, A.J. and Martin-Sanchez, F.J. Health informatics: Building a healthcare future through trusted information, IOS Press BV, Amsterdam, Netherlands, pp. 33-39.

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What we found out from educators

What else we wanted to know from educators

Can educators responsible for different health profession degrees work together to improve basic clinical informatics education?

52 academics from 14 different professions took part in a 2012 workshop held in 4 cities.

Resource documents and expert presentations from healthcare, government and academia were provided.

Individual and small group work was recorded, analysed, reported.

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Workshop outcomes

Some core clinical informatics competencies were recognised:

– Efficiency with electronic information and communication

– Accountability for information ethics and security

– Awareness of digital data and tools for decision support

– Evidence-based adoption of ICTs in healthcare

+ examples of learning, teaching and assessment methods.

Some synergies were sparked:

– single profession collaboration across institutions

– interprofessional cooperation within States

AND

Government and healthcare expert panellists,

who had assumed that there was systematic clinical informatics teaching,

were taken aback by low levels of educational activity and educator awareness.

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3. Challenges for educational practice

Our perspective comes from project investigations into:

• Learning resources

• Scenario building

• Accreditation guidelines

• Employer requirements

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Can we leverage existing learning resources?

• Broad web search for ‘teachable’ materials from government, industry, education and research organisations, not-for-profits

• Inventory of 100 relatively open and reputable resources

What’s missing:

• Core clinical informatics materials with an Australasian orientation

• Generic ehealth software and tools for learning and assessment

• AND widely available convenient CPD for educators

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Can we leverage scenarios of interprofessional practice?

Development of 13 scenarios of ehealth in clinical practice: • Chinese Medicine – Drug interaction database • Chiropractic – Medical image sharing • Dentistry – Tele-diagnosis • Dietetics – Online support groups for health • General Practice – Shared electronic health record • Midwifery – Patient flow management • Nursing – Tablet computers for mobile health • Occupational Therapy – Games for health • Paramedics – Disaster management system • Pharmacy – Prescriptions exchange system • Physiotherapy – Tele-rehabilitation • Psychology – Virtual environments for therapy • Social Work – Health data linkage

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Can we leverage degree accreditation guidelines ?

• Review of 21 health professions’ degree accreditation guidelines

• Search for terms broadly related to ehealth and clinical informatics

The missing link:

• ‘ehealth’ nowhere; ‘telehealth’ once; ‘electronic health records’ once; ‘informatics’ twice

• Informatics as a knowledge domain is inferred from related concepts ‘data’, ‘databases’, ‘evidence’, ‘information’, ‘technology’ –sometimes.

• BUT just as often the inference is to elearning facilities.

• Informatics related terms often are not clearly defined.

• AND guidelines are revised and referred to over long cycles:

– 8 documents last updated in 2010; the oldest 2001

– degree (re)accreditation happens every 3-5 years

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Can we leverage clinicians’ employers’ requirements?

• Monitored Australian clinical job ads weekly for 3 months in 2012

• Analysed 800 ads for any evidence of ehealth and biomedical informatics knowledge, skills, attributes sought by employers

Missing in action:

• The word ‘ehealth’ never appeared.

• Fewer than 10% of ads (just over 60) included any term that could be construed as relevant - most commonly ‘computer literate’.

• Such criteria listed as desirable as often as essential.

• Type of competence required often described narrowly or vaguely.

• BUT one ad with an exceptionally detailed job spec; three other ads seeking ability to use a particular software package.

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4. Ways forward, or where to from here?

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Recent Australian developments

• Australian Commission on Safety and Quality in Health Care 2013-14 recommendations for optimising rollouts of clinical systems, with initial focus on discharge summary and hospital medications management programs – a new driver for clinical education

• Health Workforce Australia’s National Common Health Capability Resource, provisional edition March 2013 - associated ehealth tools promised

• National expert consensus on competencies for HI specialists, Certified Health Informatician Australasia, launched July 2013 - reverse engineering for core clinical informatics competencies?

• A competency-based fully-online ‘Ehealth and Clinical Informatics’ subject open to students in any Australian health profession degree will be trialled in 2015

• Curriculum standards work is going ahead within separate clinical professions – but what are the outcomes for connected care if some do and some don’t?

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Further leadership and collaboration is needed • New learning, teaching and assessment resources are needed to explain and explore ehealth and clinical

informatics in current and future healthcare contexts.

• Up-to-date professional development in ehealth and clinical informatics needs to be made accessible to teachers, tutors and student supervisors in the health professions.

• Revised accreditation and certification frameworks for the clinical health professions need to include clear specifications of ehealth and clinical informatics competencies.

• Human resources management of professional staff in healthcare organisations needs to recognise and reward ehealth and clinical informatics competencies.

• Systematic planning and development of professional practice in the health professions needs to integrate long-term ehealth and clinical informatics goals.

• AND Programs of research are needed to study the design, implementation and outcomes of all of these.

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International research is needed

• A recently published national ehealth strategy toolkit makes a start, by suggesting that levels of educational program participation and completion can be used as ehealth education outcome measures. (World Health Organization and International Telecommunication Union, 2012)

• Experts in educational impact evaluation know that such measures are only a start. What

matters increases in importance and in complexity of assessment as follows: – Participants may or may not actively engage in the program that they choose to take up. – Participants may or may not learn what is intended. – Participants may or may not apply what they learn to what they do in their practice. – The way participants practice may or may not improve the way the system works. (Kirkpatrick & Kirkpatrick, 2006)

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Let’s recognise education as a form of ehealth infrastructure

• Education is often invisible in accounts of ehealth infrastructure. It may be implied but is rarely described within strategic plans. For example, a recent detailed comparison of three nations’ national electronic health record system implementations is entirely silent about education (Morrison, 2011).

• Ehealth policy issues and solutions extracted from 60 articles in peer-reviewed and grey literature 1998-2008 identified 9 themes: networked care, interjurisdictional practice, diffusion of ehealth / digital divide, ehealth integration with existing systems, response to new initiatives, goal-setting for ehealth policy, evaluation and research, investment, and ethics (Khoja, 2012).

• We should not assume that broad and deep ehealth learning and development in the clinical professions will occur without policies or programming.

Details: Hilberts, S., & Gray, K. (2014). Education as ehealth infrastructure: considerations in advancing a national agenda for ehealth. Advances in Health Sciences Education, 19(1), 115-127.

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Thanks for your attention!

Comments / Questions / Follow-up

Project report www.olt.gov.au/system/files/resources/PP10_1806_Gray_report_2014.pdf

Project website

http://clinicalinformaticseducation.pbworks.com

Email: kgray@unimelb.edu.au

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