After 25 years of service to the American Medical Informatics Association (AMIA), Ms Karen Greenwood, the Executive Vice President and Chief Operating Officer, is leaving the organization. In this perspective, we reflect on her accomplishments and her effect on the organization and the field of informatics nationally and globally. We also express our appreciation and gratitude for Ms Greenwood's role at AMIA.

OBJECTIVE: The study sought to provide physicians, informaticians, and institutional policymakers with an introductory tutorial about the history of medical documentation, sources of clinician burnout, and opportunities to improve electronic health records (EHRs). We now have unprecedented opportunities in health care, with the promise of new cures, improved equity, greater sensitivity to social and behavioral determinants of health, and data-driven precision medicine all on the horizon. EHRs have succeeded in making many aspects of care safer and more reliable. Unfortunately, current limitations in EHR usability and problems with clinician burnout distract from these successes. A complex interplay of technology, policy, and healthcare delivery has contributed to our current frustrations with EHRs. Fortunately, there are opportunities to improve the EHR and health system. A stronger emphasis on improving the clinician's experience through close collaboration by informaticians, clinicians, and vendors can combine with specific policy changes to address the causes of burnout. TARGET AUDIENCE: This tutorial is intended for clinicians, informaticians, policymakers, and regulators, who are essential participants in discussions focused on improving clinician burnout. Learners in biomedicine, regardless of clinical discipline, also may benefit from this primer and review. SCOPE: We include (1) an overview of medical documentation from a historical perspective; (2) a summary of the forces converging over the past 20 years to develop and disseminate the modern EHR; and (3) future opportunities to improve EHR structure, function, user base, and time required to collect and extract information.

Clinicians often attribute much of their burnout experience to use of the electronic health record, the adoption of which was greatly accelerated by the Health Information Technology for Economic and Clinical Health Act of 2009. That same year, AMIA's Policy Meeting focused on possible unintended consequences associated with rapid implementation of electronic health records, generating 17 potential consequences and 15 recommendations to address them. At the 2020 annual meeting of the American College of Medical Informatics (ACMI), ACMI fellows participated in a modified Delphi process to assess the accuracy of the 2009 predictions and the response to the recommendations. Among the findings, the fellows concluded that the degree of clinician burnout and its contributing factors, such as increased documentation requirements, were significantly underestimated. Conversely, problems related to identify theft and fraud were overestimated. Only 3 of the 15 recommendations were adjudged more than half-addressed.

The COVID-19 pandemic has once again highlighted the ubiquity and persistence of health inequities along with our inability to respond to them in a timely and effective manner. There is an opportunity to address the limitations of our current approaches through new models of informatics-enabled research and clinical practice that shift the norm from small- to large-scale patient engagement. We propose augmenting our approach to address health inequities through informatics-enabled citizen science, challenging the types of questions being asked, prioritized, and acted upon. We envision this democratization of informatics that builds upon the inclusive tradition of community-based participatory research (CBPR) as a logical and transformative step toward improving individual, community, and population health in a way that deeply reflects the needs of historically marginalized populations.

The biomedical research and healthcare delivery communities have increasingly come to focus their attention on the role of data and computation in order to improve the quality, safety, costs, and outcomes of both wellness promotion and care delivery. Depending on the scale of such efforts, and the environments in which they are situated, they are referred to variably as personalized or precision medicine, population health, clinical transformation, value-driven care, or value-based transformation. Despite the original intent of many efforts and publications that have sought to define personalized, precision, or data-driven approaches to improving health and wellness, the use of such terminology in current practice often treats said activities as discrete areas of endeavor within minimal cross-linkage across or between scales of inquiry. We believe that this current state creates numerous barriers that are preventing the advancement of relevant science, practice, and policy. As such, we believe that it is necessary to amplify and reaffirm our collective understanding that these fields share common means of inquiry, differentiated only by the units of measure being utilized, their sources of data, and the manner in which they are executed. Therefore, in this perspective, we explore and focus attention on such commonalities and then present a conceptual framework that links constituent activities into an integrated model that we refer to as a precision healthcare system. The presentation of this framework is intended to provide the basis for the types of shared, broad-based, and descriptive language needed to reference and realize such a framework.

Large amounts of personal health data are being collected and made available through existing and emerging technological media and tools. While use of these data has significant potential to facilitate research, improve quality of care for individuals and populations, and reduce healthcare costs, many policy-related issues must be addressed before their full value can be realized. These include the need for widely agreed-on data stewardship principles and effective approaches to reduce or eliminate data silos and protect patient privacy. AMIA's 2012 Health Policy Meeting brought together healthcare academics, policy makers, and system stakeholders (including representatives of patient groups) to consider these topics and formulate recommendations. A review of a set of Proposed Principles of Health Data Use led to a set of findings and recommendations, including the assertions that the use of health data should be viewed as a public good and that achieving the broad benefits of this use will require understanding and support from patients.

Tourism as well as international business travel creates health risks for individuals and populations both in host societies and home countries. One strategy to reduce health-related risks to travelers is to provide travelers and relevant caregivers timely, ongoing access to their own health information. Many websites offer health advice for travelers. For example, the WHO and US Department of State offer up-to-date health information about countries relevant to travel. However, little has been done to assure travelers that their medical information is available at the right place and time when the need might arise. Applications of Information and Communication Technology (ICT) utilizing mobile phones for health management are promising tools both for the delivery of healthcare services and the promotion of personal health. This paper describes the project developed by international informaticians under the umbrella of the International Medical Informatics Association. A template capable of becoming an international standard is proposed. This application is available free to anyone who is interested. Furthermore, its source code is made open.

Over the last four decades, the UK has made large investments in healthcare information technology. The authors conducted interviews and reviewed published and unpublished documents to describe national-scale clinical information exchange in England, how it was achieved, and the problems experienced that the USA might avoid. Clinical information exchange in the UK was accomplished by establishing a foundation of policy, infrastructure, and systems of care, by creating and acquiring clinical computing applications and with strong use of financial and clinical incentives. Many software and hardware vendors played a part in this effort; they participated in a national framework created by the NHS in which standards for exchange are specified and their applications designed to make clinical information exchange part of normal practice. Great potential exists for cost reduction, increased safety, and greater patient involvement as a result of clinical information exchange.

There is an increased level of activity in the biomedical and health informatics world (e-prescribing, electronic health records, personal health records) that, in the near future, will yield a wealth of available data that we can exploit meaningfully to strengthen knowledge building and evidence creation, and ultimately improve clinical and preventive care. The American Medical Informatics Association (AMIA) 2008 Health Policy Conference was convened to focus and propel discussions about informatics-enabled evidence-based care, clinical research, and knowledge management. Conference participants explored the potential of informatics tools and technologies to improve the evidence base on which providers and patients can draw to diagnose and treat health problems. The paper presents a model of an evidence continuum that is dynamic, collaborative, and powered by health informatics technologies. The conference's findings are described, and recommendations on terminology harmonization, facilitation of the evidence continuum in a "wired" world, development and dissemination of clinical practice guidelines and other knowledge support strategies, and the role of diverse stakeholders in the generation and adoption of evidence are presented.

In the current issue of JAMIA, Friedman and Parrish have crafted an insightful and provocative call for the Population Health Record writ large.1 This paper contributes in an important way to the literature and appears at a propitious time in our nation's health policy history. Furthermore, it is appropriate for JAMIA in that the AMIA Board first called for such a development in 1997.2 The authors present a compelling case, with sufficient details to make clear exactly what is needed. I will therefore not seek to elaborate upon the paper's content except to say that I support it wholeheartedly. Rather, I offer some added thoughts related to overcoming critical policy barriers. My comments will deal with understanding our civilization culturally, and touch on the role and importance that health can yet play in our nation's priorities. Before engaging in these weighty matters, I note that the reason that it took 13 years for this proposal to be so ‘timely’ now has both technical and governmental components. The long delay in addressing the population health record—the final one-third of the data architecture that encompasses patient, personal, and population records—relates to the state of information and communications technology at the time that AMIA initially called for PopER. Bill Wolf, until recently President of the National Academy of Engineering, reminds us that even the Apollo moon missions in 1969 only had as much computer ‘memory’ to work with as one can now buy in an ordinary greeting card to sing ‘Happy Birthday’ to you. While our minds might have been willing to dream of crunching gigabytes of data on populations in 1997, most of us were at the time forced to live and work in megabytes, still using 3 1/2 inch ‘floppy’ disks. Electronic health records (EHRs) were largely hospital-based clinical records. Personal health records were just a gleam in a few people's eyes. On the policy side, it was at that time that the Department of Health and Human Services under Secretary Donna Shalala decided that the government needed advice not only on vital statistics but on all aspects of health information policy. This led to a reformulation of the mission and goals of the National Committee on Vital and Health Statistics, the creation of a National Health Information Infrastructure Working Group, and the ultimate release of two relevant policy documents on National Health Information Infrastructure.3,4 While both documents mention population health records, the vision for the population health record as proposed by Friedman and Parrish mostly resembled the old saw about unicorns… ‘Yeah, I've heard of them but I haven't seen one’. Now over a decade later, the US is into our third or fourth National Coordinator for Health IT, depending on how one chooses to count; the country is about to spend billions of dollars on electronic health records and information exchanges to achieve meaningful use; and, regulators and care providers now prepare for a second iteration of the Health Insurance Portability and Accountability Act (HIPAA) that was included in the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act of 2009.5 For both better and worse, the bulk of policy attention has circulated far more heavily around protection of personal health data as opposed to responsible ways to share it for improving health and healthcare through EHRs—whether or not the data contains a patient, personal, or population focus. Two additional momentous policy developments now part of the picture potentially bode well for Friedman and Parrish's vision. The Patient Protection and Affordable Care Act of 2010 guarantees citizens lifetime access to health insurance; this development removes the risk and the fear associated with it that inappropriate access to personal health data will render a citizen forever uninsurable.6 With this historic law plus the added safeguards for person specific health data included in the American Recovery and Reinvestment Act (ARRA) law, including stiffer penalties for those who willfully ignore these mandates, the nation can now call for better evidence of what works in healthcare and how well it works compared to other treatments based upon data derived from electronic health records. And, it has done just this with ‘comparative effectiveness' in ARRA.7 The Secretary of Health and Human Services, Kathleen Sebelius, stated that she hopes to make evidence-based decisions based upon data and research.8 All these recent policy developments offer potential hope and support for the population health record. With the US now having the policy infrastructure for security and privacy that it needs, including a privacy officer within the Office of the National Coordinator, data management and exchange mechanisms can consider greater and more trustworthy data sharing for those citizens who are open to sharing their data. The question is whether or not we will press to balance all the current protections of data by facilitating access to data as proposed in the UK with its 2007 Research Capability Program in the Department of Health.9 Twenty-one NHS data-sets will become available to approved researchers with ‘safe havens' for population-based research—read population health record. On the home front, the recent development that touches on a part of the PopER vision is the Community Health Data initiative that seeks to help Americans understand health and healthcare performance in their communities, as well as spark and facilitate action to improve performance—population health records are indeed on the Government's agenda.10 America needs broader legislation for two reasons. The first reason is philosophical, while the second is practical. Social science research recently has shown “that modern prosociality is not solely the product of an innate psychology, but also reflects norms and institutions that have emerged over the course of history”.11 Hoff points out that a society is not just a random group of people with a shared territory—it is a group that shares cognitive frames and social norms.12 Recent fear of invasion of personal privacy in the absence of lifelong insurability led to attendant legislation that erected more and more barriers to data access. While well-intended, left to themselves without opportunity for altruistic expressions favoring ‘managed’ community data sharing (as per the UK initiative), the privacy advocates will continue to erode our capacity to have a learning society and a learning healthcare system in particular. As the Institute of Medicine has stated, a learning healthcare system is essential to going forward.13 More importantly, without counter-veiling attention at the federal level to balance the continuing restrictions in the name of privacy, we will inexorably transform ourselves from a nation with great historic investment in the common good into a fearful, self-interested set of individuals without positive ‘cognitive frames and social norms’. Much public good has come from responsible access to health-related data, and greater good can yet be achieved. To accomplish the PopER, a new kind of health policy reform must enable access to personal health data for worthy public uses, including population health records and legitimate biomedical and health related research. The US has spent over a decade focused heavily on privacy and security at the expense of equally important social ends such as the uses of data for supporting better public policy, public health and legitimate research. What I propose is neither trivial nor politically palatable to many of the more strident privacy advocates. Unfortunately, too many practicing health professionals undervalue their own stake in preserving a robust learning environment. And, many in the science community know how difficult it is to rouse busy researchers to see that their research depends on more than simply the National Institutes of Health, the National Science Foundation, and Agency for Healthcare Research and Quality budgets. The 2008 AMIA policy conference got it right when it concluded that the US must refocus public policy with respect to data access if the country is to improve data integrity, continue to secure privacy and security, and facilitate research.14 The US should pass a ‘Health Research and Safe Care Act of 2011’. Through the Department of Health and Human Services, the law would create an opportunity for individual citizens to do the following: ‘Opt-out’ of having a unique personal health identifier assigned for use in research databases, for example PopER, with an additional option to opt-out for using the same identifier for their own routine healthcare purposes as well. Opt-out of an otherwise automatic consent to share their personal health data for IRB approved research which complies fully with HIPAA security regulations, with the additional opportunity to opt-out of any IRB or national requirements for data anonymization of their individual records. Opt-out of an otherwise automatic consent to share their personal genetic data, if it is available, for IRB-approved research that complies fully with HIPAA security regulations, with the additional opportunity to opt-out of any IRB or national requirements for data anonymization of their personal genetic data. In addition, through the law: Use of anonymized data would be available without explicit personal consent. A public-private partnership would be encouraged that would allow citizens to ‘opt-in’ by submitting their preferred email address onto a well maintained website to take part in IRB-approved clinical trials for which further consent would be required by the researchers. This last feature as well as the personal identifier for healthcare purposes could be managed as part of the regional data exchanges being developed through the HITECH provisions. Applying human behavior research findings to energy policy, Allcott and Mullainathan argue for policy structures that acknowledge that human behavior is more complex and less idealized than traditional economic models of rational choice.15 Similarly, since the Secretary as the top official seeks greater evidence and research for better decision making and since default ‘no-action’ options strongly influence choices and are far less expensive to implement and maintain, ‘opt-out’ is totally defensible. I agree with Thaler and Sunstein that such ‘nudges' are valuable ways to improve public decision-making for better health, wealth, and happiness.16 Whether or not others will take up the proposed legislation, the US must clearly refocus on the future of population health records. Health is a complex admixture of cultural behaviors, habits, workplace factors, nutrition, and the influence of healthcare delivery services. Friedman and Parrish have done a great service by moving our thinking forward. With ‘friendly’ public policy and continued efforts, PopER can gain its rightful place alongside the Patient and Personal health record. And, none too soon. None. Commissioned; not externally peer reviewed.

In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. This article assesses progress toward the short-term goals within the roadmap, and recommends activities to continue to improve CDS adoption throughout the United States. The report finds that considerable progress has been made in the past four years, although significant work remains. Healthcare quality organizations are increasingly recognizing the role of health information technology in improving care, multi-site CDS demonstration projects are under way, and there are growing incentives for adoption. Specific recommendations include: (1) designating a national entity to coordinate CDS work and collaboration; (2) developing approaches to monitor and track CDS adoption and use; (3) defining and funding a CDS research agenda; and (4) updating the CDS 'critical path'.

As the professional home for biomedical and health informaticians, AMIA is actively working to support high quality relevant professional education and research opportunities. This issue of JAMIA presents two key documents that provide tangible evidence of progress on this front. In this editorial, we describe the context and specific purpose of the two documents, how they were developed, and AMIA's plans to build upon the documents.

The Core Content for Clinical Informatics defines the boundaries of the discipline and informs the Program Requirements for Fellowship Education in Clinical Informatics. The Core Content includes four major categories: fundamentals, clinical decision making and care process improvement, health information systems, and leadership and management of change. The AMIA Board of Directors approved the Core Content for Clinical Informatics in November 2008.

The Program Requirements for Fellowship Education identify the knowledge and skills that physicians must master through the course of a training program to be certified in the subspecialty of clinical informatics. They also specify accreditation requirements for clinical informatics training programs. The AMIA Board of Directors approved this document in November 2008.

The fields of health informatics and biomedical research increasingly depend on the availability of aggregated health data. Yet, despite over fifteen years of policy work on health data issues, the United States (U.S.) lacks coherent policy to guide users striving to navigate the ethical, political, technical, and economic challenges associated with health data use. In 2007, building on more than a decade of previous work, the American Medical Informatics Association (AMIA) convened a panel of experts to stimulate discussion about and action on a national framework for health data use. This initiative is being carried out in the context of rapidly accelerating advances in the fields of health informatics and biomedical research, many of which are dependent on the availability of aggregated health data. Use of these data poses complex challenges that must be addressed by public policy. This paper highlights the results of the meeting, presents data stewardship as a key building block in the national framework, and outlines stewardship principles for the management of health information. The authors also introduce a taxonomy developed to focus definitions and terminology in the evolving field of health data applications. Finally, they identify areas for further policy analysis and recommend that public and private sector organizations elevate consideration of a national framework on the uses of health data to a top priority.

This document comprises an AMIA Board of Directors approved White Paper that presents a roadmap for national action on clinical decision support. It is published in JAMIA for archival and dissemination purposes. The full text of this material has been previously published on the AMIA Web site (www.amia.org/inside/initiatives/cds). AMIA is the copyright holder.

Secondary use of health data applies personal health information (PHI) for uses outside of direct health care delivery. It includes such activities as analysis, research, quality and safety measurement, public health, payment, provider certification or accreditation, marketing, and other business applications, including strictly commercial activities. Secondary use of health data can enhance health care experiences for individuals, expand knowledge about disease and appropriate treatments, strengthen understanding about effectiveness and efficiency of health care systems, support public health and security goals, and aid businesses in meeting customers' needs. Yet, complex ethical, political, technical, and social issues surround the secondary use of health data. While not new, these issues play increasingly critical and complex roles given current public and private sector activities not only expanding health data volume, but also improving access to data. Lack of coherent policies and standard "good practices" for secondary use of health data impedes efforts to strengthen the U.S. health care system. The nation requires a framework for the secondary use of health data with a robust infrastructure of policies, standards, and best practices. Such a framework can guide and facilitate widespread collection, storage, aggregation, linkage, and transmission of health data. The framework will provide appropriate protections for legitimate secondary use.

For over thirty years, there have been predictions that the widespread clinical use of computers was imminent. Yet the "wave" has never broken. In this article, two broad time periods are examined: the 1960's to the 1980's and the 1980's to the present. Technology immaturity, health administrator focus on financial systems, application "unfriendliness," and physician resistance were all barriers to acceptance during the early time period. Although these factors persist, changes in clinicians' economics, more computer literacy in the general population, and, most importantly, changes in government policies and increased support for clinical computing suggest that the wave may break in the next decade.

In order to accelerate and support technological advancement and to provide timely resources for developers and users of technology, AMIA and its College seek to develop sound policies and to disseminate them through a series of formal statements. This new initiative complements earlier policy reports and position statements from the organization. The first paper in the new series appearing in this issue, “Clinical Decision Support in Electronic Prescribing: Recommendations and an Action Plan,” was developed by Jonathan M. Teich, MD, PhD, and Jerome A. Osheroff, MD, and coauthored by Eric A. Pifer, MD, Dean F. Sittig, PhD, and Robert A. Jenders, MD, MS, with the support of the CDS Expert Review Panel. The Agency for Health Care Research and Quality (AHRQ) and AMIA fostered its creation through support for the time of those involved in the Expert Panel and the reviewers. The report will immediately benefit policy deliberations related to the National Health Information Infrastructure, especially the Commission on Systemic Interoperability. We commend this report to JAMIA readers for both serious study and enjoyment. It charts a course for future activity in this arena and focuses on what is arguably the most potent advantage of computer-based health records systems—their increasing capacity to offer expert advice to busy clinicians at the time and point of decision making with regard to their patient's needs.1 Indeed, we anticipate the time when such decision support will assist members of the general population (with and without disease) and public health experts in a similar fashion. We will not discuss further the report itself here but rather describe how AMIA and its College intend to create additional reports to move the national agenda forward. We are fortunate to have access to the best minds in the field, and, happily, these members are willing to commit a substantial amount of time and effort to produce reports that will become foci for discussion and indeed argumentation, future study, and understanding—all with the expectation that better health policy and practice will result. Over the next two years, AHRQ plans to support a series of additional reports on other dimensions of informatics. We believe that those reports will prove equally relevant to our discipline and our country. Russell Altman is currently preparing a brief paper on policy issues of immediate relevance to development of pharmacogenomics and pharmacogenetics. A separate paper on genetic data and personal health records is under way, and others are on the drawing board. Those having the support of AHRQ will include a panel of experts to support development of findings and recommendations; others may be less extensive. AMIA's President and Board have developed a rigorous review process, and publication in JAMIA may occur under two formats. The first option is for the report to be approved by the AMIA Board and published under this guise since JAMIA is the official journal of the organization. The second option would be to submit reports for additional peer review through the standard submission and publication processes of JAMIA, supervised as usual by the Editor and Editorial Board. We commend these important forthcoming papers to you. AMIA is seeking sources of financial support to augment that provided by AHRQ in order to increase the number and frequency of these offerings and to broaden the range of topics. To move forward in the transformation of health care through the use of IT-supported clinical systems, the United States (and, indeed, other nations) will benefit from targeted, timely advice. Such advice must focus on how to create care systems that are safe, equitable, efficient, effective, and both patient-centered and capable of managing the health of populations.

BACKGROUND: Improving the safety, quality, and efficiency of health care will require immediate and ubiquitous access to complete patient information and decision support provided through a National Health Information Infrastructure (NHII). METHODS: To help define the action steps needed to achieve an NHII, the U.S. Department of Health and Human Services sponsored a national consensus conference in July 2003. RESULTS: Attendees favored a public-private coordination group to guide NHII activities, provide education, share resources, and monitor relevant metrics to mark progress. They identified financial incentives, health information standards, and overcoming a few important legal obstacles as key NHII enablers. Community and regional implementation projects, including consumer access to a personal health record, were seen as necessary to demonstrate comprehensive functional systems that can serve as models for the entire nation. Finally, the participants identified the need for increased funding for research on the impact of health information technology on patient safety and quality of care. Individuals, organizations, and federal agencies are using these consensus recommendations to guide NHII efforts.