Category Archives: 2013-2014

Achieving Meaningful Use: Using Standards to Bring Medical Information to Practitioners and Patients

Marc Overhage, MD, PhD, FACMI
Chief Medical Informatics Officer, Siemens Healthcare
Member, Meaningful Use workgroup, U.S. Health IT Policy Committee

  • When you have a pumpkin, it’s not just about having it but using it meaningfully, such as for pumpkin pie
  • Stage 2 anticipated for being pushed back an additional year
  • Meaningful use as an escalator system towards EHRs use
  • 2011-2014 – carrot (financial subsidy); 2015+ – stick (financial penalty, such as for readmissions within 30 days, etc)
  • Nobody’s figured out how providers benefit from EHRs yet, but meaningful use subsidies can cover up to 2/3 cost of EHR implementation for ambulatory settings
  • Improving Quality of Care and Safety mechanisms
    • Stage 1+2
      • Structured data
      • CPOE
      • CDS
      • Progress notes
      • Safety (drug-allergy checks, medication reconciliation)
      • Population management
    • Stage 3
      • CDS
      • Order tracking
      • real-time dynamic dashboards
      • medication adherence
      • patient safety
  • Eligible providers (outpatient) (n=527k)
    • 9% doing nothing
    • 8% signed up with Regional center to help
    • 21% signed up on federal website (yes, this one worked)
    • 15% registered and intend to get EHR
    • 47% have EHR
  • 3-5% of providers last year said they were out due to shifting groups, restructuring/remodeling practice, or just being totally done with EHRs
  • Hospitals
    • 5% not there
    • 2% signed up with Regional center to help
    • 7% signed up on federal website (yes, this one worked)
    • 13% registered and intend to get EHR
    • 73% have EHR
  • medical group ownership has shifted from 69% physician owned in 2005 to 39% in 2010; 26% hospital owned in 2005 has increased to 58% in 2010 – trend due to reimbursement rate primarily, but consolidated EHR systems benefit from the shift; going out-of-business by some EHRs will lead to greater movement of physicians to larger health systems and then impacts pricing negotiations for services
  • CMS now driving EHR adoption, less so than ONCHIT
  • trends in 90 day performance – there’s no major change
  • transitions of care and reportable lab results were least popular feature at hospitals
  • Herfindalh-Hirschman Index Change by HRR 2006-10 – documents evolution of HIT market (doi:10.1136/amiajnl-2011-000769).  Part of the impetus of the HITECH Act was to increase the market, resolve failure to by
  • only 76 EHRs are certified for Stage 2
    • this has led to some physicians who had invested in a system, but gets kicked out, has to start over, or even lose data because of other systems falling out of the market
  • adoption is a massive challenge – Siemens can make the bells and whistles you want, but most adopters are getting systems with all features turned off to complete slow roll out due to training burden
  • interoperability schmoperability
    • certification has helped
    • teaching to the test (bare minimum) but not getting folks to move beyond the most basic expectations
    • while they can create the patient file via HL7, there is no secure method for transmission to other provider(s)
  • Quality measure madness
    • about 10% of measures are designed to support e-initiatives
    • CMS checklist
  • Documentation burden
    • 690k physicians hours per year = cost of EHR adoption (approx. 1 hour per day added)
    • challenge to put data into structured format
    • $19bn of tax payer investment pales to provider costs
  • Patient Engagement or Just Friends
    • more HIPAA violations through this initiative than entire past history of Siemens (patients leaving it behind, throwing it away in regular trashcans, etc)
    • patients like just booking appts online, getting lab results online
    • haven’t found the secret sauce to get patients more engaged
  • 2/3 of things in the meaningful use list aren’t things people want
  • HITECH Act’s HIT education has had little to no effect on improving the foundation of a workforce to help with implementation
  • Stage 3 is being defined now

Public Libraries + the Affordable Care Act

To the general public, the relationship between  public libraries and the Affordable Care Act   seems tenuous.  But for those who work in these environments, helping with tax forms, setting up and learning how to use email, and generally being a wealth of knowledge on every and anything, public libraries  are a central part of lots of communities and are a big connector to the online portal to the health insurance marketplace.  In an attempt to bridge the town and gown relationship, the public library and I have been communicating information and support resources regarding ACA.   In preparation, the public library got a special training session on the new system from the official Shenandoah Valley ACA Navigator, Andrew Bolt, and I got to attend.

Continue reading Public Libraries + the Affordable Care Act

AHEAD webinar: A Clear Standard for Access to Instruction

AHEAD, the Association on Higher Education and Disability, presented an audio conference covering accessible instructional materials, particularly  online items.  A review of different case studies regarding current problems with accessibility compliance, recent legal complaints and resolutions, and updates regarding arenas for exploration were a part of the panel presentation and discussion.

Continue reading AHEAD webinar: A Clear Standard for Access to Instruction

Sloan-C: Unconference Session: eTexts and Open Educational Resources (OER)

For a full listing of materials and questions proposed, you can review the Google Doc at

The audience was a majority of instructional faculty.  Overall, this is a place libraries should be involved and we are 99% not.  Here are some of the conversation highlights.

Questions asked:

  • Are publishers willing to let you take a copy of a chapter from one book and then take another chapter of another book?
    • Why aren’t they working with their Reserves service?
  • Pearson’s offers a My Finance Lab entire portal connected to textbooks – this resource wouldn’t be available if you didn’t use the book
  • the amount of time that an electronic text (they meant books) is available is limited
    • generally they get eText for 6-18 months
    • print still had greater resale value
  • Push to identify the major courses we all teach – the California affordable textbooks
    • this will create tension determining what is a “basic” or “common” course versus something that needs to be more distinctive
  • How do we amass this multimodal materials for use across systems?
  • Classroom Salon is like VoiceThread but better analytics – used in Intro to Chem and Anatomy classes
  • Faculty want to be able to share annotated text so students see the emphasized information or incorporating video lectures at the key points in the text
  • Free adaptive software (possibly this MIT-based open source project
  • For professional organizations like Modern Languages Association, there aren’t typically sessions to consider collaborating on a textbook together on Philosophy, for example –> maybe we should?
  • AAMC+Khan Academy+Robert Wood Johnson Foundation – one example of coordinating the efforts
  • this also sounds like they need a central repository, like PRIMO
  • if you are using a system or text aggregator, use it for what it is intended; don’t try to have discussion outside the LMS since that is what students are most familiar with using and they may hit you on the course reviews
  • unsure of the value of Ginkgotree or if this just duplicates the LMS
  • it would be great to have the analytics about how the class had to read the same paragraph 7 different times, indicating we need to emphasis this concept or explain better
  • health sciences tends to need 5 different books based on content – don’t have enough time to search the periodical literature to find all the information you would need to cover the same material from the books
  • for some topics (like Aristotle), he hasn’t written anything new so publishers are mostly scrambling the content every two years or so as a “new” book
  • how we visually represent this stuff can create visual consistency challenges

Sloan-C: Educational Mixology: Pedagogical Approaches to Faculty Development and Course Redesign in Health Sciences

  • Project based in School of Medicine at George Washington University in DC
  • Other initiatives on campus are in School of Nursing and Writing program

Drivers and needs

  • need more healthcare providers, as Consumer Reports has identified and introduced the different roles
  • expanding curricula
  • emphasis on problem based or case based learning
  • emphasis on improve learning outcomes related to future practice


  • resistance from faculty and students
  • methods of instruction have been highly traditional (lecture–>application)
  • perception of loss of personal contact –> same fear as EHR usage

BL and faculty development

Faculty approach

  • evidence-based using Quality Matters rubric
  • collaborative
  • two initiatives
    • Review, Refresh, Revise class – done before the semester
    • SMART labs
      • software, hardware, peopleware
      • physically located right next to the departments

PA6210: Health, Justice & Society

  • PA is a 2 year, cohort program
  • 2 credit, first semester course to introduce new PA students to social dynamics of health
  • challenges
    • large class size
    • theater style classroom
    • variety in student background
  • focus less on reduction of F2F time, as a reason for BL
  • using multimodal approach: review what did work well in course already and then consider how to reformat
  • goal of more reflection–>journaling
  • Pedagogical goals
    • promote reflective practice (Schon, 1987)
    • increase interaction (Bandura, 1986; Illeris, 2003; McDonald, 2012)
    • support higher level of learning –> challenge since didactic learning in first year and practice in 2nd year so content and use are separated or could be forgotten
    • support communities of inquiry (Garrison & Kanuka, 2004; Garrison & Anderson, 2003)
    • promote teams and teaming
  • push back from students not wanting to watch videos ahead of time because they felt they should just hear it from the expert himself in the class session
  • spot check or follow more interesting discussions, as they choose
  • assignment
    • develop groups and each to explore epidemiological information of each different ward in DC
    • students develop wikis — little specific instruction allowed creativity with information representation
  • things learned
    • never enough structure
    • some initial pushback, perhaps since this is the only course in program like this – had 1 day, in-person orientation
    • must brief guest lecturers on the course structure
    • great reflection, application and synthesis
    • journals recognize individual biases
  • student reactions
    • most value reading responses of peers in online discussion
    • some indicate how online discussion impacts F2F discussion
    • many value thinking about materials prior to class
    • concerns regarding workload compared to course credit — despite student self-reporting that they spent 2-4 hours outside of class, which is not unusual for this course
    • a few see no value in online portion
  • evaluation
    • lots and lots of surveys….
    • selective assignment review
    • focus groups with faculty

Sloan-C: Will It Blend? Technology Use in Student Support Services

The presentation focused on academic advising’s use of technology in blended support.  I’ve added notes on personal JMU practices that are doing this in some way, shape, or form, but definitely these tools have alternate uses and potentials.

  • Google Voice as a means to text with students
  • Examples of use include scheduling advising appointments,
  • Provide easy integration into Outlook email

Tech tools you can invest in

  • Desktop Capturing – Camtasia Relay
    • institutional cost
    • students can download client
    • Jing is free alternative
    • quick voiceover / web demo
    • JMU has Camtasia Relay for faculty, but we should explore this for students
  • Student Lounge – Desire2Learn, Blackboard, Moodle
    • virtually simulate hallway conversation space
    • JMU has 90% of traditional, in-person undergraduates — how might we recreate this for the distance graduate programs?
  • Virtual Desktops – XenDesktop
    • helps work around cost and installation issues for expensive softwares like Photoshop
    • JMU has done some of this through the Business school due to use of Remote Desktop access to specific software loaded on Showker computers
  • Web Conferencing – GoToMeeting
  • Instant messaging for advising
    • yea, idea was “stolen” from library virtual reference support – w00t!
    • emails as formal/easy to delete
    • best practices:
      • be approachable – introduce yourself
      • communicate if you are juggling multiple chats – fosters understanding and patience
      • check back often
      • don’t just give the answers, show them
      • confirm question resolution
    • using Zoho
      • can be friended through any system but you have 1 login
      • people are assigned to one dedicated person each day (office of 5)
      • have to provide name
      • provide direct option for friending on Yahoo, Google, MSN, Yahoo messaging systems
    • JMU Libraries’ use of Libraryh3lp seems easier (no friending necessary) but involves open source setup time; LibAnswers could also be a good solution for this group given FAQ auto-creation, possible reuse of Jing video guides
  • Twitter and TweetDeck
    • 10 commandments for academics
    • more about allowing students to get to know you
    • JMU has no broad initiative, but the Libraries have dabbled a bit – currently, this is mostly individual efforts.  There are some interesting projects from Nursing and Health Sciences faculty with using Twitter to create communal conversations about news updates on course topics.
  • Boundaries
    • student identity/privacy/FERPA
      • most of the research is happening RIGHT NOW, but is a limited pool
    • student behavior online
    • responsibility and effects
  • UWM has dedicated Twitter person to track and tweet
  • efforts have all homegrown/free product adoption but future reviews of other collaborations with library platforms for similar services (LibAnswers, etc) could be a future step

Sloan-C: Scholarship trends in blended learning

Impact – Phase 1

  • determine impact
    • introduced impact factor and described altmetrics but ignored these metrics
    • Publish or Perish – why?
  • Articles
  • Book chapters
    • 2005 is largest collection
    • 14 chapters on chart come from the same book
  • Books
    • only 3 books had 5 or more citations for books published after 2009
  • White papers, reports, non-scholarly
  • Top journals – not generally from the traditional top education journals
    • British Journal of Educational Technology
    • Internet and Higher Education
  • Findings
    • diversity of fields
    • little conversation from core distance education journals
    • seminal works are more focused on definitions and nature, not empirical research
  • Utilized 2013 Drysdale, Graham, Spring, and Halverson coding system to codify articles into categories
  • Research questions focus (ranked in popularity order)
    1. instructional design
      1. models
      2. strategies and best practices
      3. design process
      4. implementation
      5. environment and course structure
    2. disposition
    3. exploration
    4. learner outcomes
      1. Performance outcomes
      2. Satisfaction, Student
      3. Engagement
      4. Independence in Learning
      5. Motivation and Effort
    5. comparison
    6. technology
    7. interaction
    8. demographics
    9. professional development
    10. others
  • 19 articles attempted to develop existing theory, but only 2 used the same theory
  • gaps:
    • lack of research on instructors
    • few EXPLAIN models
    • lack of theoretical cohesiveness
  • huge growth in graduate research (theses/dissertations) over the last 15 years
    • searched ProQuest

Sloan-C: Research in Blended Learning: Where are we now? And what are the future challenges and needs?

  • Overview of some of the topics from Charles Graham’s book related to research in blended learning.  Topics include workload factors, K-12, and more.  If you are interested in more, keep an eye out for Blended Learning: Research Perspectives, Volume 2 in November 2013
  • critical area that need more investigation: professional development
  • we tend to be more practice-oriented, so we need more development regarding research methods to move beyond just the case study since individual case studies are hard to compare to aggregate results for more broadly reusable practices
  • if we have 4,000 universities and each university has 4 sections of Psychology 101, do we really need to treat these as completely unique courses to build?  Even accounting for some unique differences, we probably don’t
  • blended learning makes you think very carefully about what you can do and what someone else could help you do
  • shifts attention appropriately to students
  • online components allow for greater data gathering to track individual student learning and achievement
  • for administrators, cost is a main driver
  • we can’t just be adding adjuncts to save cost
  • blended learning saves money by not using classroom space (long term savings), but we need to navigate new models of collaborative teaching/course development
  • K-12 sector
    • lens of disruptive innovation theory
    • blended learning started as a dropout recovery solution, home schooling solution
    • K-12 has a custodial role, so the daytime components like homeroom or band still exist but a good chunk of content is online
    • modalities needs to be connected
    • 7 main models, such as enriched
    • challenge: get beyond best practices and get to circumstance-based theory (ex: if you have feathers and wings, then you must be able to fly–>however, bats don’t have feathers but they fly and ostriches have feathers and wings but don’t fly–>more sophisticated understanding of drag, gravity, etc adjust the context)
    • for more information, you may want to check out the May 2013 report Is K-12 Blended Learning Disruptive? An Introduction to the Theory of Hybrids
  • European Union perspective – Anders Norberg from Skelleftea Council/Umea University, Sweden
    • don’t use “blended learning” but instead focus on quality enhancements – the concept is not connected to their theories
    • interested in how IT tools enhance educational process
    • education is a science in its own right while here instructional design is more the emphasized science
  • distance learning field struggled to find theories
  • theories are important to give direction to practice
  • we need to move beyond the looking at the physical dimension of blended/online learning to instead address the pedagogical dimensions
  • K-12 taxonomies help us work with at least using the same language
  • we seem to be suffering a bit from innovation fatigue; we also aren’t in a position to be able to fail, so we need to consider the human factors

Sloan-C: Alex Couros – Keynote Speaker

  • Interesting idea – self, auto-tweet during his own presentation
  • helping students and kids prepare for the social networks, identity, and presence online
  • Odd history
    • Relationship of a mixtape and a pencil
    • Microsoft Encarta ’95 – not really the largest amount of knowledge ever accumulated
  • Biggest mistake of our time – not leaving time or space to wonder
  • Google only gives us incomplete knowledge
  • Tools are different than they used to be – instead of being alone in a software or document, now you can share
  • Community
    • how do we develop community?
    • why do we create artificial boundaries of community in short, class-only environments instead of community over a longer term?
  • Networks provide
    • affordances – enable communication, collaboration, and cooperation in new and previously impossible ways
    • ideas/inspiration: connect us to new ideas
  • Relationships
  • Ethics issues: “Girl Rushes the Field at a Baseball Game, Captures a $1,500 Selfie”
  • Power of the Internet: A girl who blogs on her own, 9 years old, about something she cares about
  • we need to be leery of the technologies, as it has some great but also scary potential

What is blended learning?

  • a chore for students to do at home
  • that a blog, online submissions, and digital textbooks exist
  • mix interaction spaces between students and faculty
  • get support when, where, and from who they want
  • personalized learning experience
  • Identity – starts with the students
    • many have lost jobs due to social media
    • we need to prepare students better with the private vs public and open vs closed
    • “you’re not just hiring me, you’re hiring my entire network” – network documented via digital identity on Twitter, Facebook, etc, as well as traditional professional portfolio
    • play with it – ex: who wins in the battle of bird poop versus a SmartCar?
  • MOOC is not a static concept

Things To Read Later