Using Informatics to Help Improve Clinical Care.

Clinical informatics, the science of how to use data, information, and knowledge to improve human health and the delivery of health care services, plays an integral role at Children’s and Emory. Dr. Evan Orenstein’s passion to use electronic health record design to help improve clinical care started during his residency. He says he became interested in clinical informatics because of the likable features in the electronic health record he was using, but he felt some frustration with it at the same time.

“There were several areas where I felt the electronic health record helped me take better care of patients. Guidelines and order sets had been built out in ways that mapped very well to how I was thinking of patients. As an example, it would help me think of complications for certain diseases. It became routine for me to order certain sets of antibiotics for certain diseases, and it helped me tailor my treatments. On the other hand, I had some frustrations where I felt like I was double documenting many pieces of information. I felt this electronic health record had a surprisingly large influence on the care we provided and how we thought clinically about the patients, so I want to make it better for those reasons.”

Dr. Orenstein’s research process in clinical informatics starts when a clinical stakeholder notices a quality or safety issue. Dr. Orenstein and his team work to address these issues by using a combination of analytics and qualitative work, observing the workflows where these problems happen, and gathering data. Let’s look at flu vaccine distribution as an example. These are questions a hospital may want to know: How many eligible kids are we seeing? What proportion of them are getting the flu vaccine? Where does the ball get dropped? Dr. Orenstein wants to help design a system that automatically shows who the eligible patients are and present that in the workflow, so physicians and nurses will remember to give the flu vaccine to eligible patients and have all the information they need to make good decisions about their patient’s health.

Clinical informatics has grown significantly in particular through electronic health records. Dr. Orenstein says over 90% of health systems with more than 100 beds use electronic health records. Most organizations are moving towards greater investment in clinical informatics to ensure clinical experts are involved in electronic health record design.

These are some of the projects involving informatics that have been completed by Dr. Orenstein and his team and are currently being used: Increasing influenza vaccination rates, reducing medication errors in ketogenic diet patients, improving antibiotic stewardship in the neonatal intensive care unit, improving the use of guidelines for common pediatric diseases (e.g. asthma, musculoskeletal infections), and identifying patients who have metabolic diseases when they show up to the Emergency Department looking healthy, but are at risk for decompensating quickly.

On average, it takes three to six months to really understand each process, develop a plan, and implement it. It generally takes another three to six months to determine if the electronic health record design really leads to the intended improvements. Since Dr. Orenstein started this research in 2018, there are around ten projects in production that demonstrate improved outcomes, two publications, and five manuscripts in progress. This work is funded by Children’s, National Library of Medicine ($225,000 grant), Agency for Healthcare Research and Quality (R03 for $100,000), and the National Blood Foundation ($75,000).


What’s next for this research? On the internal side, Dr. Orenstein would like to scale it up at Children’s. Whenever there’s quality and safety problems, the team tries getting human factor engineering into their design process. Another goal is to do more scientific implementations. Dr. Orenstein says, “we are blessed with hospitals that are similar to each other, but also different… one goal is to move to a model where we pull data automatically in all the areas where we might implement a change, but we actually implement in stages. By implementing in stages, we can compare our performance in places where we intervened to places we haven’t intervened or within the place we intervened before and after.”

On the external side, Dr. Orenstein hopes to develop innovative designs with partners at Children’s, identify what works and what does not, and then scale up by involving colleagues at other institutions to have a larger impact on patient outcomes.

Beyond the research, Dr. Orenstein says he’s excited that trainees get to learn about informatics. “I’m most excited about the education side. Clinical informatics is a route for fellows and residents to be more effective in their clinical research and quality improvement work. I’m proud we developed an elective in clinical informatics. We’ve had 16 participants in our first year and a half. We also now have a physician builder program where physicians are learning how to build new things in electronic health records and they get to learn about analytics. I want to expand the number of people with these skills who can go on to have a greater impact on children’s health.”