How Clinical Informatics is Gaining Traction at Stanford Children's Health

Clinical informaticists have a deeper understanding of the opportunities and the limitations of information science, says Stanford Children's Health's chief medical information officer.

This is part two of a conversation with Natalie M. Pageler, MD, chief medical information officer at Stanford Children's Health about some of the clinical decision support tools that the hospital is developing. Read part one.

She is also clinical associate professor of pediatric critical care and Stanford University.

This conversation covers development costs, the evolution of clinical informatics as a subspecialty, and what the Stanford Children's team is working on now. The transcript below has been lightly edited.

HLM: Can you talk a little bit about cost for developing these tools? Where does it come from?

Pageler: The answer is often that it depends. We have a very active clinical informatics program here. We started one of the first clinical informatics fellowships in the country, where we have physicians from all different backgrounds who then come for a two-year fellowship and are working to develop these types of tools.

Many of the tools that I've been talking about are outputs of some of the scholarly work from our clinical informatics fellows or from partnerships with our biomedical informatics programs. It's part of our academic mission.

Once they are available online and in this web-based format, it is very easy and low cost to integrate with them.

For example, the GluVue tool that I mentioned earlier is available online to anybody who wants to use it, and there have even been individual patients who have accessed that tool. The real development costs are upfront.

Our organization supports the clinical informatics fellowship because it understands the value of these types of developments, so there is some funding there.

Our informaticists have also applied for and received small internal grants. They've also partnered with masters and PhD students in the biomedical informatics program who have larger grant funding.

We also, at times, collaborate with local companies, like the example I gave earlier with InsightRX, where the company is funding a lot of that development cost.

HLM: How typical is it for a hospital to work with an outside company?

Pageler: For Stanford this is not unusual. It's definitely in line with Stanford's innovative stance.

HLM: Up until now, clinical informatics has kind of been its own subspecialty, is that right?

Pageler: It's a relatively new subspecialty. Clinical informatics was just recognized as a board certified subspecialty in 2013. Stanford Children's and three other sites started the first ACGME-accredited fellowships during the summer of 2014. Now there are 26 across the nation and more coming.

[The fellowships are] designed for people who are already trained as physicians. You have to complete a residency in any clinical subspecialty, so they could be a pediatrician, an internal medicine doc, an ER doc, or a pathologist, for example. And then they would do this subspecialty after completing their primary specialty.

Our third class of fellows is coming in this summer. We've had a pediatrician, an emergency doctor, three internal medicine doctors, and we have an obstetrician coming in this summer.

After completing their primary residency, they come and do a two-year fellowship with us specifically focusing on clinical informatics.

HLM: Is there an argument for making clinical informatics just part of being an MD?

Pageler: There definitely is, and I think we are seeing more and more integration of clinical informatics concepts, both in medical school and in residency.

We run a residency elective here in clinical informatics, and we also work with some of the core pediatric residency content to incorporate bits of clinical informatics and I think we'll see more and more of that.

I actually partnered a couple years ago to write an article about the increasing role of clinical informatics in medical training. I think you'll see more and more clinical informatics content in medical school training and residency training.

[But] I still think there is a role for having a fellowship where you get a higher level of informatics core content. There is a huge evolving body of literature about the best ways to incorporate information systems in the practice of medicine.

So there's some baseline knowledge that you need to know just to practice medicine, but there's also an advanced level of knowledge that you need to know in order to continue to develop these information systems.

HLM: Are there some fundamental ways that people who are trained in clinical informatics approach medicine differently?

Pageler: I definitely think so. I think they have a much better understanding of the opportunities and the limitations of information science. I think they take a much more systematic approach to the practice of medicine.

When faced with a specific issue about a specific patient, they're much more likely to think how could the system be changed or augmented to improve this on a more general or global level.

When you really dig into the literature and see it on the systemic end, you understand a little bit more about some of the unintended consequences, such as alert fatigue, or automation bias, and automation complacency.

I think understanding how clinical decision support is created and what the limitations are helps you use it in a more responsible fashion. That's something that the clinical informatics fellows learn inherently.

That's something we try to get them (as well and other faculty) to go back and to teach our trainees and our practitioners so that people are using clinical decision support responsibly and to its best effect.

HLM: And they understand that it's a combination of the two. I was just reminded of a HealthLeaders story about electronic alerts combining with physician huddles to reduce missed sepsis diagnoses.

Pageler: Exactly. The implementation of any technology effectively also requires the implementation of a process change along with it.

Whenever we're thinking about any new tool, we're thinking about the people, the processes and the technology—and so I think clinical informatics fellows, like you said, really understand the importance of both the technology pieces and the process pieces for using that technology effectively.

HLM: What's next in terms of what you're working on now and what's in development?

Pageler: There are lots of different things going on. In terms of clinical decision support, getting to more and more of that precise clinical decision support and looking at ways to partner again with researchers, with students on the biomedical informatics side.

We're looking at more and more advanced machine learning or computerized models that will help us to get to better clinical decision support.

The other thing I think it's really important to highlight in clinical decision support work is the importance of the involvement of the frontline staff. I think the importance of the physician informaticists is that they understand both the clinical side and the technology side, as well as the process pieces in between.

We also have a very active "Nursing Informatics Council" where we have frontline nurses involved in the development of our information systems and clinical decision support.

Involving the frontline clinicians in the development of these tools is incredibly important in making sure the tools are optimally designed and utilized in the healthcare system.

We're also trying to look at how we use the technology available today to reshape the practice of medicine.

For our diabetes patients, I talked about some of the technology we're using in terms of the GluVue decision support tool and the continuous glucose monitoring being uploaded via HealthKit.

But what we're looking at now is how you create a comprehensive program that utilizes all of that technology to really support pediatric diabetic patients in their home, in their daily lives on a continual basis, instead of interrupting their lives and making them come to us only when they're having a decompensation.

We're in the process of creating a comprehensive diabetes digital health program that will use that technology, use our telehealth technology, and look at keeping those patients in their home communities, their homes, and supporting them on a continual basis.