State of the Art/Best Practice Paper 261

A Model for Clinical Informatics Education for

Residents: Addressing an Unmet Need
Mark V. Mai1,2 Brooke T. Luo1 Evan W. Orenstein1,2 Anthony A. Luberti1,2

1 Department of Pediatrics, Children’s Hospital of Philadelphia, Address for correspondence Mark V. Mai, MD, Children’s Hospital of
Philadelphia, Pennsylvania, United States Philadelphia, 2716 South Street, Ste 15-194, Philadelphia, PA 19146,
2 Department of Biomedical and Health Informatics, Children’s United States (e-mail: [email protected]).
Hospital of Philadelphia, Philadelphia, Pennsylvania, United States

Appl Clin Inform 2018;9:261–267.

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Abstract Opportunities for education in clinical informatics exist throughout the spectrum of
formal education extending from high school to postgraduate training. However,
physicians in residency represent an underdeveloped source of potential informati-
cians. Despite the rapid growth of accredited fellowship programs since clinical
informatics became a board-eligible subspecialty in 2011, few resident physicians
are aware of their role at the intersection of clinical medicine and health information
technology or associated opportunities. In an effort to educate and engage residents in
clinical informatics, Children’s Hospital of Philadelphia has developed a three-pronged
model: (1) an elective rotation with hands-on project experience; (2) a longitudinal
experience that offers increased exposure and mentorship; and (3) a resident founded
Keywords and led working group in clinical informatics. We describe resident participation in
► medical informatics these initiatives and lessons learned, as well as resident perceptions of how these
► medical education components have positively influenced informatics knowledge and career choices.
► internship and Since inception of this model, five residents have pursued the clinical informatics
residency fellowship. This educational model supports resident involvement in hospital-wide
► strategies for health informatics efforts with tangible projects and promotes wider engagement through
IT training educational opportunities commensurate with the resident’s level of interest.

Background and Significance and pathology informatics through an 8-week summer

course since 2009 in anticipation of the escalated demand
The demands and challenges facing biomedical and clinical for informaticians.2 Increasingly, college courses are incor-
informatics highlight the need for the development of a porating a discussion of information sciences into biological
pipeline of future informaticians who can bridge the com- and health care-related topics.3–5 With support from the
plex issues of clinical medicine with the innovative solutions National Library of Medicine, Masters and PhD-level gradu-
of information technology. Already, opportunities for educa- ate school programs in biomedical informatics have been
tion in clinical informatics are becoming more prevalent particularly well developed.6–8 Many medical school curri-
throughout the spectrum of medical training. The American cula include a discussion of the role of information technol-
Medical Informatics Association (AMIA) High School Scholars ogy in medicine.5,9–11 Following residency, physicians have
Program pairs accepted high school students with a mentor the opportunity to engage in further informatics training
to work on a biomedical informatics project and present at through the clinical informatics fellowship or the practice
the AMIA Annual Symposium.1 At the University of Pitts- pathway.12–15 However, there exists a gap of clinical infor-
burgh, high school students have been exposed to biomedical matics training at the residency level.

received Copyright © 2018 Schattauer DOI https://doi.org/

December 19, 2017 10.1055/s-0038-1641735.
accepted after revision ISSN 1869-0327.
March 10, 2018
262 A Model for Clinical Informatics Education for Residents Mai et al.

While tapping into this group can be fraught with chal- approach required substantial resources, including monthly
lenges due to residents’ intense clinical obligations, residents lectures, an application acceptance program, and a monetary
are uniquely positioned to be receptive to and contribute to project stipend after completion of the program. Scaling up
the field of informatics. As front-line clinicians, residents are these educational initiatives in this critical period may be
a key demographic of electronic health record (EHR) users difficult without such resources.
whose daily workflow is directly impacted by the structure In this article, we present a model of a clinical informatics
of the EHR. Residents are intimately aware of a system’s curriculum that has been in place at Children’s Hospital of
strengths and have a vested interest in fixing shortcomings at Philadelphia, a large urban academic pediatrics hospital,
the sharp end of care delivery. They represent a potential since 2012. The pediatrics residency program consists of
source of collaborative solutions and practical feedback. 163 residents. The Department of Biomedical and Health
Because of the nature of their training, residents are also Informatics supports a clinical informatics fellowship with 4
well acquainted with the intricacies of various workflows fellows and 10 board-certified faculty educators. This model
including people and processes in a given institution. Resi- for resident education in clinical informatics includes
dents represent a large proportion of the workforce at many options such as an introductory elective, a longitudinal

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hospitals, increasing the points of contact for collaboration. experience, and a resident working group. We also present
Furthermore, as a result of the opportunities prior to resi- residents’ perceptions of the impact of different curricular
dency, as previously described, recent generations of resi- elements, as well as their career trajectories after elective
dents are increasingly adept with the technologies used in participation.
clinical informatics, although their familiarity with the prin-
ciples may be lacking. Engagement of resident physicians in
Key Components of Informatics Educational
hospital informatics efforts can accelerate implementation of
Model
meaningful improvements, while preparing residents to
become proficient physicians in the electronic era. During the 3-year pediatric residency training program,
Based on traditional models of clinical subspecialty fel- residents have exposure to informatics education at multiple
lowships, the majority of applicants to clinical informatics levels. These range from required experiences for all resi-
fellowships are likely to come directly from residency train- dents to optional, short- and long-term informatics educa-
ing. To provide a glimpse into potential fellowships, pro- tional opportunities (►Table 1). The central pillars of the
grams require several clinical rotations that provide in-depth model include a health informatics elective, a longitudinal
contact with core principles, daily activities, and potential experience, and a resident working group.
mentors in the field. A rotational correlate does not exist at
most training institutions for clinical informatics, although Short-Term Experience—Health Informatics Elective
some have successfully established medical student and The health informatics elective combines structured didac-
resident electives.16–18 Until recently, little had been pub- tics with skill-building online EHR training modules. The
lished on the education of residents in the field of medical elective is 2 to 4 weeks in duration and offered throughout
informatics since 1999.19 In 2017, the University of Califor- the year. Participants in the elective meet with the course
nia, Los Angeles (UCLA) Health Informatics program shared director prior to or at the start of the elective to assess the
their approach consisting of a longitudinal program where participant’s knowledge and proficiency in health infor-
accepted residents and fellows follow a yearlong curriculum matics to personalize their goals and objectives for the
covering major topics in clinical informatics, learn to develop rotation. This approach aims to provide a foundation of
new tools in the EHR, and partner with a mentor to develop informatics knowledge, but emphasizes exploration within
and implement an informatics project.20 Comprehensive the individual resident’s interest area. Activities include
programs like these improve the visibility of clinical infor- viewing online recorded lectures, reading select textbook
matics as a potential career option for trainees. However, this chapters and journal articles, and participating in various

Table 1 Resident experiences in clinical informatics

Curricular Extracurricular
Required • EHR case simulations23 • EHR efficiency workshops
• Introductory informatics lecture
• Knowledge management lecture
Optional (short-term) • Elective rotation • Mentorship by informatics faculty, fellows, staff, and peers
• Informatics committee meetings
• Invited lecturers
• Regional and national informatics conferences
Optional (long-term) • Longitudinal experience • Resident informatics working group
• Independent project

Abbreviation: EHR, electronic health record.

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 A Model for Clinical Informatics Education for Residents Mai et al. 263

informatics-related meetings and conferences (see sample Resident Informatics Working Group
objectives and activities in ►Appendix Tables A1–A4). In Following the establishment of the formal educational cur-
addition to meeting with other faculty, participants riculum, a group of residents interested in workflow
continue to meet weekly with the course director to improvement started a resident informatics working group
follow-up on progress and to adjust their activities to in 2013. This group, also known as the New EHR Resident
meet their individualized objectives. For each resident in Development (NERD) Squad, meets in the evenings every 1 to
the elective, this structure requires approximately 2 hours 2 months to discuss resident workflow issues with potential
per week of time commitment from the course director as EHR solutions. As part of the NERD Squad, residents are
well as approximately 2 hours per week of ad hoc meetings encouraged to pursue the elective in health informatics and
with other faculty members or Information Services (IS) offered a wide array of opportunities to be involved in
staff with expertise in the resident’s area of interest. hospital initiatives. Faculty and fellows within clinical infor-
During the elective, residents are encouraged to complete matics also routinely attend meetings, providing mentorship
projects, providing hands-on experience where they apply and guidance on core informatics principles. These meetings
newfound informatics knowledge to clinically relevant sce- often take place in the evening following resident shifts with

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narios. The course director and the participant specify a funding for meals provided by the clinical informatics
project that will be feasible within their time commitment, department.
that will be appropriately mentored, and that will align with The NERD Squad serves as a forum for nontechnically
their personalized goals and objectives. Depending on the oriented residents to voice their concerns. As a result, it
resident’s interest, their contribution to the project may be creates an informal space for crowdsourcing, accelerating the
limited to the duration of the rotation or continue to evolve incorporation of user input in the design process of resident-
after the elective. Of note, nearly all successful projects were led projects. Example projects resulting from collaborations
started during the elective and then benefitted from crowd- of residents with informatics faculty are detailed in ►Table 2.
sourcing through the resident working group described The majority of resident efforts has involved enhancing
below. documentation support and peer education. All content
As part of their projects, elective participants may be given created by residents requires a faculty mentor to review
access to an EHR sandbox development environment, which before presentation at an EHR operational meeting. Follow-
does not migrate to the production environment. This envir- ing approval, the content is incorporated into standard
onment exists as a space to test new functionality without change control processes.
disrupting operational processes. Residents are required to
complete a set of training modules hosted by the EHR vendor Example Resident Project
(►Appendix Table A3) in addition to a 1-hour review of best The following example of a resident-led project serves to
practices with the informatics course director. The course highlight the interplay between the informatics elective,
director subsequently works with our IS department to pro- longitudinal experience, mentors, and resident working
vide the resident with sandbox development environment group. Previously, residents were required to free-text all
access. Residents are expected to use this access to augment discharge instructions once a patient was ready for discharge
their skills in other core competencies, like performing work- contributing to documentation burden and variation in
flow analyses, understanding the impact of EHR build on discharge care for common diagnoses. During the clinical
patient care, and aligning user needs with EHR capabilities. informatics elective, one pediatric intern proposed
Residents have the option of presenting their work to a
hospital committee, who may then decide to migrate their
Table 2 Examples of resident projects
work to production. Aside from time invested by the course
director and that of IS, there is no additional cost associated
Project
with providing residents with this access.
Handoff templates for common admission diagnoses
Longitudinal Experience Discharge summary templates for common diagnoses
All pediatric residents at Children’s Hospital of Philadelphia Standardized inpatient discharge instructions for common
have the option of applying to participate in a longitudinal diagnoses
track, which allows residents to increase their exposure to Documentation template for medically complex foster
academic domains outside of traditional clinical experi- childrena
ences. Examples include bioethics, health care disparities, Templated list of common contingency plans
as well as clinical informatics. Residents in this informatics
EHR simulation curriculum for interns
track engage in advanced didactics (both directed and self-
guided), meet with faculty mentors throughout the remain- EHR training sessions
der of their training, attend committee meetings, and work Health hackathon
on a long-term project with goal of completion prior to
Abbreviation: EHR, electronic health record.
graduation from residency. At graduation, this advanced skill a
Initiated and completed within a 4-week elective; all other projects
participation is acknowledged on their diploma along with were initiated during an elective but completed in conjunction with the
the participant’s training in pediatrics. resident working group.

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264 A Model for Clinical Informatics Education for Residents Mai et al.

reviewing the top 20 admission diagnoses to prioritize Resident Perceptions

creation of standard templates. In conjunction with faculty
mentorship from clinical informatics, she drafted several We contacted all 23 prior participants of the health infor-
templates and incorporated feedback from the resident matics elective for feedback on how components of the
working group and clinical faculty. After implementation educational model influenced their informatics knowledge
into the EHR production environment, she presented this and career choices (►Fig. 1). Although this was not a formal
work to the resident working group, and other interested evaluation of the model, many elective participants also
residents began adding content. These contributions interacted with other components of the educational model
expanded the number of discharge diagnoses and grew including the longitudinal experience, the resident working
into a longitudinal project for the original resident. This group, as well as mentorship activities and a clinical infor-
experience allowed the resident to learn key informatics matics project. Among the 19 respondents, 79% (15/19)
principles in workflow analysis, change management, and found the elective to be very or extremely influential on
stakeholder engagement. their knowledge base and 60% (6/10) who had completed
residency and were still involved in informatics felt simi-

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larly about the elective’s impact on their career choice. In
Participation
addition to the elective, the majority of respondents high-
Pediatrics residents have one elective block during their lighted that participation in a clinical informatics project,
first year, two during their second year, and four during mentorship activities, and the resident working group were
their third year. The incoming resident cohort ranges from 48 similarly influential on their knowledge base and career
to 54 residents. Since the resident health informatics elective choices.
was established in 2012, 23 residents have completed the
elective, of whom 4 (17%) pursued further education through
Career Trajectories
the longitudinal experience, and 10 (43%) participated in the
resident working group. From each residency class, on Following residency, five elective participants went on to
average, 5% of residents participated in the elective. An pursue additional training through the clinical informatics
additional 33 residents have participated in the resident fellowship. From those who provided feedback, all 14 post-
working group without engaging in other informatics residency participants indicated some continued involvement
opportunities. in clinical informatics or related activities, with 4 of 14 (29%)

Fig. 1 Factors influencing residents’ knowledge of clinical informatics and residency graduates’ career choices.

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 A Model for Clinical Informatics Education for Residents Mai et al. 265

acting as an “EHR clinical champion,” 3 of 14 (21%) participat- informatics initiatives. Additionally, while we anticipate
ing in a clinical decision support committee, 8 of 14 (57%) that this model would be generalizable to other settings,
participating in informatics related research, 8 of 14 (57%) our institution benefits from facilitators such as a large
incorporating informatics into quality improvement work, and number of clinical informatics faculty and clinical cham-
6 of 14 (43%) acting as informatics educators. pions, a department focused on informatics and education,
and a fellowship program.
To our knowledge, the only other published informatics
Discussion
curriculum focused on residents is the UCLA Health Resident
Using a model focused on resident education, project Informatics Program, where moderate investments in an
experience, and a grassroots community, we have improved application process, didactic training, a project stipend,
resident engagement in clinical informatics at our institu- and faculty mentorship have led to impressive accomplish-
tion. This approach has led to organizational benefits in the ments and resident engagement.20 In contrast, our model
form of tangible projects and increased front-line provider requires fewer funding resources to support the resident
participation in clinical informatics efforts. Additionally, working group, although faculty time for mentorship and

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residents have noted that these educational opportunities meetings remains critical. Nonetheless, we have seen grow-
influenced their knowledge in clinical informatics and ing interest in resident-led activities through the working
career choices, with all participants incorporating infor- group despite concerns about resident workload and train-
matics training into their careers in some capacity and a ing gaps.22
growing number of residents choosing to specialize in
clinical informatics.
Conclusion
Residency training represents a critical window of oppor-
tunity for the education and recruitment of future physicians Clinical informatics is increasingly permeating into the
into the field of clinical informatics. However, residents have practice of medicine. Residency is a vital time to educate
very little free time outside of clinical duties, limiting physicians about the field of clinical informatics to support
chances for exposure to clinical informatics without a prior their clinical work and to inspire the next generation of
interest. One of the key lessons learned as we have developed leaders. Our institution has created a combination of short-
this educational model is that wider engagement can be term and longitudinal opportunities to expose residents to
achieved through educational opportunities commensurate the field. This exposure has in turn led to a cultural shift,
with the resident’s level of interest. For residents without resulting in the dissemination and spread of informatics
previous experience, the resident working group offers knowledge within the residency program and has generated
exposure to clinical informatics in a social setting without a pipeline of informatics fellowship applicants. Even among
necessitating the commitment of an elective. For those who residents who did not pursue an advanced degree in clinical
want to learn more, the health informatics elective provides informatics, all postgraduate residents now incorporate clin-
residents an opportunity to increase their knowledge base, ical informatics in their careers in some capacity. While we
to meet mentors, and to lead a project. As residents gain a cannot distinguish the impact of this educational model from
deeper interest, the longitudinal experience offers a chance increasing familiarity with technology, elective participants
for advanced skill development throughout residency. This indicate that these educational experiences influenced their
approach meets the individualized educational needs of knowledge and career choices. We have also seen tangible
residents with varying levels of interest. Since inception of organizational benefits from projects initiated during elec-
this educational model, five participants are pursuing clin- tives, supported by a resident working group, and incorpo-
ical informatics fellowship training, suggesting that this rated into longitudinal experiences. Expansion of this and
investment may grow the applicant pool to fill an unmet similar models to promote resident engagement in clinical
clinical need.21 informatics across training programs has the potential to
The descriptive discussion was not intended to prove accelerate healthcare improvements and develop the clinical
that the organizational benefits and increased resident informaticians of the future.
engagement were caused by the educational model pre-
sented here. The feedback solicited from previous elective
Clinical Relevance Statement
participants was not gathered from a validated scientific
instrument, but rather was intended to inform whether Opportunities for clinical informatics education extend from
residents perceived the components of the educational high school to beyond clinical fellowship training, but a gap
model as influential on their clinical informatics knowledge exists during residency. We describe a low-resource, but
and career trajectories. We also did not assess this model potentially high-impact educational support structure that
compared with alternatives. Nonetheless, in the setting of appears to have influenced not only participants’ knowledge
these educational opportunities, we have seen a sharp of clinical informatics, but also their future career activities.
increase in awareness of clinical informatics within the Similar models to promote resident engagement in clinical
residency program, the number of interested residents informatics have the potential to accelerate health care
pursuing additional training, the impact of resident-led improvements and develop the clinical informaticians of
projects, and the participation of residents in operational the future.

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266 A Model for Clinical Informatics Education for Residents Mai et al.

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high school students with a mentor to work on a biomedical
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accredited clinical informatics fellowships. J Am Med Inform
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13 Detmer DE, Munger BS, Lehmann CU. Clinical informatics board
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Collection of resident feedback and perceptions was
15 Baldwin K, Bell DS. ACGME Clinical Informatics Fellowships –
deemed exempt by the Institutional Review Board at Lessons Learned. In: AMIA 2016 InSpire Conference Proceedings;
Children’s Hospital of Philadelphia. 2016
16 Partners Clinical Informatics Elective. Available at: http://infor-
Conflict of Interest matics.partners.org/elective-rotation/. Accessed December 19,
None. 2017
17 Harvard Medical School Medical Student Clinical Informatics
Elective. Available at: http://www.medcatalog.harvard.edu/cour-
Acknowledgments sedetails.aspx?cl¼&id¼19532. Accessed December 19, 2017
We would like to thank the faculty of Children’s Hospital 18 Stanford medical student elective. Available at: http://bmi.stan-
of Philadelphia for contributing their time and mentor- ford.edu/biomedical-informatics-students/electives.html.
ship of our residents. We would also like to thank Naveen Accessed December 19, 2017
Muthu for providing feedback on early versions of the 19 Jerant AF. Training residents in medical informatics. Fam Med
1999;31(07):465–472
manuscript. Finally, we would like to acknowledge mem-
20 Singer JS, Cheng EM, Baldwin K, Pfeffer MA; UCLA Health Physi-
bers of the NERD Squad for their continuing support, cian Informaticist Committee. The UCLA Health Resident Infor-
feedback, and friendship. maticist Program - a novel clinical informatics training program.
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the biomedical informatics field: the AMIA High School Scholars tion: The Benefits of an Informatics Curriculum that Provides EHR
Program. J Am Med Inform Assoc 2016;23(04):819–823 Build Experience to Empower Residents. In: AMIA 2017 InSpire
2 Dutta-Moscato J, Gopalakrishnan V, Lotze MT, Becich MJ. Creating Conference Proceedings; 2017
a pipeline of talent for informatics: STEM initiative for high school 23 Orenstein E, Rasooly I, Phillips W, et al. The Impact of Simulation on
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 A Model for Clinical Informatics Education for Residents Mai et al. 267

Appendix Appendix Table A3 EHR build modules

An Example of an Individualized Curriculum for the Health Topic Number of Duration

Informatics Elective for a Resident Interested in Usability videos
Building note templates 3 videos 25 min
Building order sets 3 videos 42 min
Appendix Table A1 Sample learning objectives
Building alerts 2 videos 28 min
1. State and understand how the discipline of clinical infor-
Abbreviation: EHR, electronic health record.
matics intersects with and influences the three domains of
clinical care, local and national health care systems, and
Appendix Table A4 Sample activities during elective
information and communications technologies
2. Describe and understand the role of a clinician in applying Participation in EHR operational meetings
the principles of health informatics in the daily practice of • Clinical champions meeting (1 h biweekly)
pediatrics • Clinical decision support workgroup (1 h biweekly)
• Clinical IT advisory committee (2 h monthly)

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3. Participate in simple usability projects with faculty men-
tors in health informatics focused on optimization of elec- Faculty lecture series
tronic health record systems • DBHI visiting faculty series (1 h monthly)
• Penn Institute for Biomedical Informatics Forum (1 h
4. Facilitate discussions related to the ongoing improve- monthly)
ments of clinical information systems as a “clinician cham- • DBHI section meeting (1 h monthly)
pion” or liaison between the clinical informatics team and Meeting with faculty and fellows
your clinical peers • Course director (1 h weekly)
• Cognitive informatics expert (2 h)
• Usability expert (2 h)
• EHR outcomes measurement expert (1 h)
• Clinical informatics fellows (2 h)

Abbreviations: DBHI, Department of Biomedical and Health Informatics;

EHR, electronic health record; IT, information technology.

Appendix Table A2 Didactic materials

Selected readings for all elective participants

• Selected chapters from: Shortliffe EH and Cimino JJ. Biomedical Informatics: Computer Applications in Health Care and
Biomedicine, 2006
• Ash JS, Stavri PZ, Dykstra R, Fournier L. Implementing computerized physician order entry: the importance of special people.
Int J Med Inform. 2003;69(2–3):235–250
• Weed LL. Medical records that guide and teach. N Engl J Med. 1968 Mar 14;278(11):593–600
• Bates DW, Kuperman GJ, Wang S, Gandhi T, Kittler A, Volk L, et al. Ten commandments for effective clinical decision support:
making the practice of evidence-based medicine a reality. J Am Med Inform Assoc. 2003;10(6):523–530
• Han YY, Carcillo JA, Venkataraman ST, Clark RSB, Watson RS, Nguyen TC, et al. Unexpected increased mortality after
implementation of a commercially sold computerized physician order entry system. Pediatrics. 2005 Dec;116(6):1506–
1512
For an example resident interested in usability
• Selected chapters from: Zhang J, Walji M. Better EHR, Usability, workflow and cognitive support in electronic health records.
2014
• Selected chapters from: Patel VL, Kannampallil TG, Kaufman DR, editors. Cognitive Informatics for Biomedicine: Human
Computer Interaction in Healthcare. 2015
• Zhang J, Walji MF. TURF: Toward a unified framework of EHR usability. J Biomed Inform. 2011 Dec;44(6):1056–1067
• Hettinger AZ, Roth EM, Bisantz AM. Cognitive engineering and health informatics: applications and intersections. J Biomed
Inform. 2017;67:21–33
Recorded lectures
• Larry Weed’s 1971 Internal Medicine Grand Rounds (https://www.youtube.com/watch?v¼qMsPXSMTpFI)
• Selected lectures from the CHOP Department of Biomedical and Health Informatics YouTube channel (https://www.
youtube.com/user/chopcbmi1/)
• Selected videos from Workforce Development Programs: Health IT Curriculum Resources for Educators Module 15 (Usability
and Human Factors) from the Office of the National Coordinator for Health Information Technology (https://www.healthit.
gov/providers-professionals/health-it-curriculum-resources-educators)

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