1 Informatics In Medical Education 1 Frank Naeymi-Rad, Ph.D. 1, David Trace, M.D. 1, Khalid Moidu, M.D., Ph.D. 2, Lowell Carmony, PhD 3, and Theodore Booden, Ph.D. 1 1 Finch University of Health Sciences/The Chicago Medical School, North Chicago, IL Center for Health Informatics, Section for Pulmonary Medicine, Norwalk Hospital, Norwalk, CT Lake Forest College, Lake Forest, IL Abstract The importance of informatics training within a health sciences program is well recognized and is being implemented on an increasing scale. At Chicago Medical School, the Informatics program incorporates information technology at every stage of medical education. First year students are offerred an elective in computer topics that concentrate on basic computerliteracy. Second year students learn information management such as entry and information retrieval skills. For example, during the Introduction to Clinical Medicine course, the student is exposed to a computerized patient record program developed at The Chicago Medical School. This program, IMR-E (Intelligent Medical Record-Entry), allows the student to enter and organize information gathered from patient encounters. In the third year, students attending the Internal Medicine rotation at Norwalk Hospital are equipped with Macintosh power books to enter and manage their patients. Patient data gathered by the student is stored in a local server in Norwalk Hospital. This server is in communication with the server at Chicago Medical School. The link enables the staff to provide educational information for the students at Norwalk to review, in essence implementing informatics tools as a learning resource. This also enables the faculty to monitor the students' clinical experience at a distant site. In the final year, we teach students the role of informatics in clinical decision making. The present senior class at CMS has been exposed to the power of Medical Informatics tools for several years. The use of these informatics tools at the point of care is stressed. Introduction A physician in a dilemma is either taking a chance or making a choice and the difference lies in the data content of the information available to support the decision making process at that time. Computers, as tools for information management, can assist the practicing clinician to access all available information. Therefore, future physicians need to be trained to exploit the full potential of these informatics tools. It was in 1984, that the "General Professional Education of the Physician" (GPEP) report recommended, among other things, that medical curricula be revised to rely less on lectures and more on independent study and problem solving . In order to prepare physicians for the information age, a strong recommendation was made that informatics training be incorporated and institutions designate departments for this role . Institutions responded to the recommendations and some have described the elaborate steps taken to plan and develop a curriculum . Health informatics continues to gain recognition as a discipline in the United States and abroad, and professional societies are encouraging medical educators to include informatics in their curricula. Other health professions are also developing courses and requirements in informatics . Educators have reported the different approaches they have adopted in developing Medical Informatics curricula [5,6,7]. Most medical informatics curricula incorporate education about medical data, clinical decision making, information systems, use of communication networks, and knowledge processing. The introduction of informatics within a overloaded curriculm has not been easy and two common approaches are either to offer it as an elective or to integrate it into the main curriculum. In this paper, the Informatics plan of The University of Health Sciences/ Chicago Medical School is described to present a scenario of Applied Informatics in Medical Education. It is based on a mixed philosophy, at first
2 introducing the informatics technology as an elective, and later it's concepts and tools are integrated to support the traditional curriculum, with a program specifically developed for the purpose. First Year: Introductory Course (Elective) More and more students are entering medical school with computer skills obtained at the undergraduate level. Therefore, at CMS, the Introduction to Computer Science and Medical Informatics course is offered as an elective to those students who need to become computer literate. The course is offerred to the first year medical students and to graduate students in Applied Physiology program. The primary objective of this course is to teach basic computer literacy. That is: To understand the impact of technology and to learn to prepare for it. To learn to use popular, off-the-shelf software (such as EXCEL, LOTUS 123, WordPerfect, Microsoft WORD), To experience simple programming exercises in information management using DBASE, HYPERCARD, or ORACLE SQL. To learn to work in teams to design and implement applications in information management, such as the design of an interactive course in microbiology. The course has been very popular and has been oversubscribed in each semester that it has been offerred. Because the students have a basic level of computer literacy, the faculty has been able to incoprorate several computer-aided instruction programs to support the learning process in the basic sciences. Second and Third Year: Information Retrieval and Biostatistics The Introduction to Clinical Medicine (ICM) course is the students' first introduction to hands-on clinical medicine. During this course, students are trained in the techniques of collecting and documenting clinical data, essentially to collect a comprehensive history of present illness (HPI) and perform a complete physical exam. Understanding the value of clinical data and how it is organized and retrieved is critically important to medical students. IMR-E, the Intelligent Medical Record Entry system, was developed at the Chicago Medical School to computerize the collection and generation of a medical encounter case report . The students in the ICM course are exposed to IMR-E to enhance their data collection capabilities. In the History of Present Illness (HPI), there are many pertinent questions that need to be asked in context. IMR-E provides a reminder vehicle insuring that the students do not forget to ask important questions. We believe that training with such tools will inculcate in the students methods that will enhance their clinical performance. Examples of IMR-E screens for collection of chief complaints and physical exams follow. 2
3 Figure 1: An IMR-E Chief Complaint Screen 3 Figure 2: An IMR-E Physical Exam Screen The Biostatistics and Epidemiology course is an applied course. One of the objectives of the course is to teach students to critically analyze and understand Statistical Methods used in the medical literature. The course includes four classic designs used in modern clinical and health-services research: Cross-Sectional, Retrospective Case-Control, Prospective Cohort, and Randomized Trials. Inferential statistics for comparing outcomes among two or three independent samples of patients is also covered. The emphasis of the course is on concepts and real situations with the computer doing the tedious calculations. Third Year: Informatics in the Internal Medicine Clinical Clerkship At Remote Sites A health sciences campus should not be confined by walls or limited by geographic distances Medical students need to receive training at multiplr sites, some of which are not the traditional Academic Medical Center. At the Chicago Medical School, we have developed informatics tools to enable the educators based at the main campus to manage and communicate with students at remote sites. Currently we have been managing students at Norwalk Hospital in Norwalk, Connecticut from our primary Chicago site. Since the fall of 1992, third-year, students attending the Internal Medicine rotation at Norwalk Hospital have been equipped with Macintosh power books to enter and manage their patients data using IMR-E. IMR-E enables the student to store patient data gathered on the local server in Norwalk Hospital in a timeseries data representation. Students in Norwalk are now able to manage multi-encounter patient records on this one network. The hardware platform includes an Apple Macintosh Server 95 as the file server, running AUX (the Apple version of UNIX). The database management software is Oracle 7 and the communication protocol is AppleShare. As clients, we have IMR-E running on IBM compatibles using Windows 3.1, on Macintosh desktop machines, and on Macintosh DUO 230s connected to the server through docking stations. The server at Norwalk Hospital is also in communication with the server at the Chicago Medical School. The link enables the staff to provide documents for the students at the sites to review, implementing informatics tools as learning resources. This also enables the faculty to monitor the students' clinical experience at the distant sites, checking each student's workload and providing real time assistance to each as needed. Fourth Year: Applied Informatics in Clinical Decision Support The final year of the program introduces the student to state-of-the-art decision support software: We call this complete electronic workup on a patient an "Informatics Workup". An Informatics Workup consists of the following:
4 An electronic medical record for the patient, especially a complete history of present illness (HPI). The result of decision support programs, based on this patient's medical data. Searches of electronic knowledge sources, including MEDLINE and electronic books for papers specific to this patient's medical problems. Organization of the information contained in the informatics workup into a final report suitable for presentation to other medical staff. The Program used for the first section is IMR-Entry (Intelligent Medical Record Entry system). IMR-Entry produces a comprehensive history and physical exam. It runs under the Macintosh, and PC-Windows and allows the user with minimal typing to generate a complete HPI. The decision support programs selected for the workup were MEDAS , QMR , Dxplain , Iliad , PKC , and Drug Advisor [Clinical Reference, Inc.]. These programs provide the students with unique opportunities to explore rich knowledge bases and state-of-the-art decisionsupport systems. Each student is required to use all of the programs. Searching the electronic knowledge sources is the most rewarding exercise CMS students undertake. The concept of an electronic library and the value of searching the medical knowledge at the bed side is stressed. Programs used for these sessions are Scientific American Medicine Consult, Aries System Knowledge Finder, and the Stat-ref. electronic publishing library. Finally the students are given access to document managing tools to organize the result of the workup into reports suitable for presentation. The primary tools used are MS-word, IMR-E, and Wordperfect. Discussion Greenes and Shortliffe describe medical informatics as the field that concerns itself with the cognitive, information processing, and communication tasks of medical practice, education, and research, including the information science and the technology to support these tasks . An intrinsically interdisciplinary field, medical informatics has a highly applied focus, but also addresses a number of fundamental research problems as well as planning and policy issues. Medical informatics is now emerging as a distinct academic entity . The early efforts in medical informatics were largely directed towards developing systems for application in health care settings. Now, as part of health care reform, all health care institutions and organizations are in the process of making large-scale commitments to information systems and services. True benefit from these implementations will only be derived if there is a end-user base able to exploit the potential that these systems offer. Möhr reviewed several different approaches to medical informatics education . One is described as the "specialist approach" with training in medical informatics taught like the established disciplines of medicine, computer science, nursing, and engineering. Another approach is the "generalistic approach" whereby medical informatics is taught as an integrated discipline incorporating essential traits of the aforementioned disciplines . Training in Health Informatics at the undergraduate level has offered electives with an emphasis to promote understanding of the technology. In the integrated approach, active learning experiences are part of the traditional medical school curriculum. In light of the undergraduate medical curriculum being overloaded, the introduction of informatics has evoked global interest . A recent report by Burrows et al. described the experiences gained from a course offerred as an elective that required the students to learn the effective use of health information tools in seeking information from both printed sources and computerized bibliographic databases . 4
5 Grëmy, drawing on his long years of experience as a medical educator, emphatically states that present medical education does not prepare students to deal with human needs, neither their own nor those of their patients . This is due, in his opinion, to the almost exclusive devotion to hard sciences, contaminated by unscientific ideological drift, which tends to negate subjectivity and to suppress any significance of human destiny. However, medical informatics, if properly used as a complement and not as a competitor to human intelligence would help to renovate medical education, introduce true humanistic dimensions, and restore the element of human subjectivity. An objective of the CMS program on Informatics has been to emphasize the applied approach. The Informatics tools are placed to complement the human elements of teacher and student, ensuring the lacunae of personal supervision and learning at one's own pace. This has been the experience gained from the Informatics program during the third year clinical rotation in Medicine at Norwalk Hospital. Another major benefit is to help the students recognize through their own experiences that the patient is the most important knowledge source. Analysis of the database of cases entered using IMR-E and discussions stimulated by these results have enabled the students to distinguish what is meant by statistically relevant as opposed to clinically relevant. The introduction of technology has in no way affected the humanistic values so essential to the art of medical practice. The present discussions in health care reform are limited to the macro issues of economics, quality, and access. Modern health care systems, both at the policy as well as the delivery level, are becoming increasingly data-dependent. Developments in Applied Medical Informatics have led to the establishment of gate-keepers who will effectively control the use of medical data. . This position, in turn, places special ethical obligations not only on the medical profession as a whole but in the development of applied informatics tools. IMR-E is extremely alert to security considerations and uses passwords to protect patient confidentiality. Conclusion The early experiences in Applied Informatics at UHS/CMS have been positive both at the pre-clinical and clinical levels of the medical curriculum. This may be attributed to the pace and collaborative approach we have adopted, especially as we have, at each step, pondered to ensure that the training focus remained on health sciences complemented with an added skill in informatics. It has, at all times, been our objective to enable the physicians of the future to access all available data and to make all their clinical decisions as choices and not take chances. References 1. Association of American Medical Colleges. Physicians for the Twenty-First Century: The GPEP report: Report of the Panel on the general professional education of the physician and college preparation for medicine. Washington, D.C., Association of American Medical Colleges Association of American Medical Colleges. Medical Informatics in the Information Age. Proc. of Symposium on Medical Informatics, Washington, D.C.; Association of American Medical Colleges Ball MJ, Douglas JV. Informatics in professional education. Methods Inf Med 1989; 28: Ball MJ, Douglas JV. Informatics programs in the United States and abroad. MD Comput 1990; 7: Frisse ME. Medical informatics in academic health science centers. Acad Med 1992; 67: Hasman A. Description of a blockcourse in medical informatics. Methods Inf Med 1989; 28: Jennett PA, Edworthy SM, Rosenal TW, Maes WR, Yee N, Jardine PG. Preparing doctors for tomorrow: information management as a theme in undergraduate medical education. Med Educ 1991; 25: Nayemi-Rad F, Trace D, Carmony L, Evens M, et. al. Steps in implementing a multi-user integrated electronic medical record. In: Lun KC, Degoulet P, Piemme T, Rienhoff O (eds). Proceedings of Seventh World Conference on Medical Informatics MEDINFO 92. North-Holland, Amsterdam. 1992; 1: Greenes RA, Shortliffe EH. Medical informatics. An emerging academic discipline and institutional priority. JAMA 1990; 263: Möhr JR. Teaching medical informatics: teaching on the seams of disciplines, cultures, traditions. Methods Inf Med 1989; 28:
6 6 11. Jones R. Health informatics in the undergraduate curriculum [letter; comment]. BMJ 1991; 303: Burrows S, Ginn DS, Love N, Williams TL. A strategy for curriculum integration of information skills instruction. Bull Med Libr Assoc 1989; 77: Grëmy F. Crisis of meaning and medical informatics education: a burden and/or a relief? Methods Inf Med 1989; 28: Kluge EH. Medical informatics and education: the profession as gate-keeper. Methods Inf Med 1989; 28: Ben-Bassat, M., Carlson, R.W., Puri VK., Davenport MD., Schrivwe JA, Latif M., Mith R., Portigal LD., Lipnick EH., Weil MH. Pattern-Based Interactive Diagnosis of Multiple Disorders: The MEDAS System. IEEE Transactions on Pattern Analysis and Machine Intelligence. PAMI- 1,2, Miller, R.A.., Masarie Jr, FE: Use of the Quick Medical Reference (QMR) Program as a Tool for Medical Education. Methods of Information in Medicine 1989; Barnett, G. Octo, Cimino, J.J., Hupp, J.A., Hoffer, E.P.: DXplain-An Evolving Diagnostic Decision-Support System. JAMA 1987; Warner, H.R., Haug, P. Bouhaddou, O., Lincoln, M. Warner Jr, H. Sorenson, D., Williamson, J. W., Fan, C. Iliad As An Expert Consultant to Teach Different Diagnosis. Department of Medical Informatics, University of Utah School of Medicine; Weed, L. Problem-Knowledge Couplers: Philosophy, Use and Interpretation: PKC Corporation.