CLIIR is...

  • A collaborative research center that believes in the importance of research to maximize the impact of digital health on health system performance.

  • A center that leverages data from UCSF and UC Health to serve as a learning lab and top-tier academic research and policy hub in digital health.


CLIIR's Cornerstone Initiative

Audit-log data captures moment to moment clinical care processes within the electronic health record (EHR). Data on who is doing what and when opens a window into how individual providers and care teams are using the EHR and the resulting clinical work processes. Prior to having access to audit-log data, such information would have to be manually sourced, requiring many hours of observation that is prone to human interpretation and error. Audit-log data makes these labor intensive approaches obsolete, providing more comprehensive data faster and with more accuracy. Taking this audit-log data and combining it with clinical data enables us to research the impact of provider workflows, behaviors and interactions with the EHR on patient outcomes.

National Research Network for EHR Audit-log
CLIIR-led Initiative 

CLIIR is establishing a national research network focused on advancing digital health via use of EHR audit-log data. The main topics that the network addresses are as follows: 

  1. Research Topics and Funding (e.g., types of research questions well suited to audit-log data, funding sources for audit-log research)
  2. Data Quality and Creating Meaningful Measures (e.g., accuracy, usefulness of data documentation, various levels of granularity, strategies for reducing noise/errors)
  3. Research Methodologies and Skillsets (e.g., methodological/modeling approaches well suited to audit-log data, skillsets of research team)


Image Viewing among Cardiologists and the Resulting Impact on Patient Outcomes
CLIIR Pilot Project

Traditionally, a radiologist interprets the image and generates a text-based imaging report with their interpretation of the findings.  However, human interpretation and synthesis of primary imaging data into text reports is a process with inherent imprecision and inaccuracy. As a result, a cardiologist may choose to rely on the imaging report, the primary image, or both when making diagnostic and treatment decisions, and they also may choose to consult with a radiologist when doing so.  We hypothesize that primary review of imaging (ideally with an imaging expert) improves care – and that by reviewing reports alone, information is missed that can help patient care. Our goal is to study the effect on inpatient outcomes of cardiologists viewing imaging reports compared to viewing images themselves (with or without an imaging expert – i.e., radiologist).


The University of California Behavioral Economics and Access Log Research Collaborative (UCBEAR)
CLIIR Pilot Project

The University of California Behavioral Economics and Access Log Research Collaborative (UCBEAR) is a joint venture between CLIIR and faculty in the Haas School of Business and the Department of Economics at UC Berkeley.  The goal of this collaborative is to develop a rich dataset describing EHR users at UCSF, their day to day actions and the outcomes of their actions.  These data will help researchers create a body of work that addresses questions about the impact of clinical training on note writing efficiency, the extent of cognitive biases in diagnostic processes and other explorations at the intersection of behavioral economics, medicine and clinical informatics.


The Impact of Transitioning from Availability of Outside Records within EHR to Integration of Local and Outside Records within EHR
CLIIR Pilot Project

Substantial effort over the past decade has resulted in greater electronic availability of outside records for frontline clinicians.  However, most approaches to enabling such availability require clinicians to go outside of their local EHR (e.g., by logging in to a community longitudinal record) or to go to a separate tab in their local EHR that houses outside records. Under either approach, clinician workflow is interrupted and cognitive effort is required to marry local EHR data with data available in outside records. Newer approaches seek to comingle local EHR data with data from outside records, such that clinicians stay within their workflow and are presented with an integrated list of encounters, lab results, problems, medications, etc. Given the substantial work required to achieve this “last mile” step of integrating data from local and outside records, it is critical to assess the impact of such integration.  We therefore undertook the first-ever study to specifically investigate whether the frequency of outside record viewing increases after such integration as well as characterize for which types of encounters, viewers, and patients any increases accrued.


Association between Objective Measures of EHR Use and Primary Care Clinician Burnout (STEP-PEP)
CLIIR Pilot Project

The Association between Objective Measures of EHR Use and Primary Care Clinician Burnout (STEP-PEP) study aims to explore the relationship between provider burnout and objective measures of EHR use. This study combines self-reported measures from Maslach Burnout Inventory survey of primary care clinicians across UCSF with objective EHR use measures - related to time, volume of work, and proficiency from EHR log files. As organizations increasingly rely on objective EHR measures to design and evaluate interventions to reduce burnout, our findings will point to the measures that should be targeted.    


Clinical Social Informatics
CLIIR Pilot Project

Social determinants of health are increasingly recognized as a major contributor to clinical outcomes, but they are not always represented consistently in the electronic health record.  In collaboration with the Social Interventions Research & Evaluation Network (SIREN), this project seeks to comprehensively characterize what types of social data is captured by the EHR and how that data is consumed by users of the EHR.   



The Market Transparency Project for Health IT Interoperability Services Cooperative Agreement Program 
Sponsor: Office of the National Coordinator for Health IT (ONC)

The 2009 HITECH Act sought to promote nationwide adoption and effective use of interoperable electronic health records (EHRs). While EHR adoption has substantially increased, particularly among hospitals, the ability to move data across EHRs to support frontline clinical care and the ability to move data between EHRs and other systems and applications that support patient engagement, public health, research, and a wide variety of other health-related purposes has been substantially more limited. This project focuses on increasing transparency of interoperability functionality/services. The final result of our project will be an independent, open, online resource. 


National Survey of Health Information Exchange Organizations (HIO)
Sponsor: Office of the National Coordinator for Health IT (ONC)

Electronic health information exchange (HIE) is one of three goals specified by Congress in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act to ensure that the $30 billion federal investment in electronic health records (EHRs) results in higher-quality, lower-cost care. The ability of providers to share data electronically is a core goal of HITECH and a central feature of a high-performing healthcare delivery system. Gaining insights into information blocking practices undertaken by provider organizations and health IT developers, the implementation of and use of standards to enable interoperability, the role of HIOs in supporting information exchange, and the sustainability and governance of HIOs is essential in supporting efforts to enable interoperability and exchange. Over the past eight years, our team has conducted five nationwide surveys of organizations working to promote HIE to determine the state of current efforts, scope of activities, and financing. The most recent findings were published in the March 2016 issue of Health Affairs and offered an independent, comprehensive evaluation of HIE progress.The nationwide survey of HIOs will enable us to focus on new achievements and identify challenges to create a current and accurate picture of HIE efforts. 


Synergies and Sequencing in Delivery and Payment Reform: Understanding What Works 
Sponsor: Agency for Healthcare Research and Quality (AHRQ) 

The Medicare Access and CHIP Reauthorization Act (MACRA) is an unprecedented expansion of value-based payment reform for physicians. Physicians will choose one of two tracks in which to participate. Alternative payment models (APMs) is the track that is widely considered to be the future of healthcare. The future impact of MACRA is unknown. However, recent experience can help to inform how physicians are likely to engage with APMs and the impact of these choices on the quality and cost of care. Our overall objective is to understand the effects of delivery and payment reforms on healthcare quality and spending in the United States. The objective of the project is to identify participation patterns and near-term effects of Meaningful Use and PCMH programs in the context of ACO efforts because these are key components of APMs. 


Advancing Our Understanding of the IT-Enabled Consumer
Sponsor: The Commonwealth Fund

Substantial public- and private-sector investment has sought to digitize health information with a key goal of engaging patients in becoming IT-enabled to manage their health. Yet in practice, these efforts have largely failed to scale and transform healthcare from an episodic, provider-centric model to a continuous, patient-centric model that empowers patients and caregivers by supporting them in complex health and care decisions. This project will generate new knowledge to reveal why efforts to-date have yet to usher in the era of the IT-enabled consumer – using consumer profiles as the foundation.


An Early Look at Patient-Facing APIs
Sponsor: The Commonwealth Fund

Healthcare is entering the next phase of patient-centered care as healthcare delivery systems start to “turn on” patient-facing application programming interfaces (APIs). As health systems begin this process, it is crucial to capture early successes and best practices so that this transition is safe, secure, and has the intended impact of accelerating patient access and use of their electronic health data and digital health development. Our project will distill these best practices by conducting semi-structured interviews with the health systems that are patient-facing API “early adopters.” The themes that emerge from synthesizing responses across interviews will allow us not only to identify best practices but also to characterize early challenges and pitfalls that may require intervention at the policy level.


The Project to Advance Interoperability and Data Access
Sponsor: The Healthcare Leadership Council and the Bipartisan Policy Center  

Advancing interoperability of systems and electronic information sharing in the U.S. is critical to support: 1. Better health outcomes for individuals in the U.S.; and 2. Higher quality, safer, more cost-effective care for individuals and populations. This project will help inform health information sharing priorities for those who deliver, receive, and pay for care, a vision or desired future state, key measures to help us determine whether we’ve made national progress against our vision and key legislative or regulatory policy actions that are needed – by the private sector and by government. 


Using EHR Audit Logs to Capture Contextual Contributors to Diagnostic Excellence
Sponsor: Gordon and Betty Moore Foundation 

The digitization of health records and the metadata captured by these systems create a novel and exciting opportunity to rapidly advance our understanding of the diagnostic process and diagnostic excellence. Specifically, the ability to truly understand how frontline clinicians interact with clinical information when making diagnostic decisions, and how these interactions impact diagnostic quality, may be greatly improved by analysis of a largely-unused, highly-granular level of electronic health record (EHR) data (referred to as “audit log” data) that are captured primarily for administrative compliance purposes today. This grant to the University of California, San Francisco Office of Sponsored Research (UCSF) will leverage the use of audit log data to capture contextual dimensions of diagnostic assessment (including clinical decision-making, clinical team structure and clinical processes) from three health systems (UCSF, Stanford and Kaiser Permanente Northern California). By identifying key contextual factors that contribute to diagnostic performance, this work may ultimately improve the efficiency of diagnostic processes and reduce errors


Developing Measures of HIE in the State of California
Sponsor: Blue Shield of California Foundation 

The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was created to stimulate the adoption of electronic health records (EHRs) and supporting technology, including health information exchange organizations (HIOs). With the HITECH funding available until 2021, California Department of Healthcare Services (DHCS) is applying to CMS for funding to subsidize providers’ cost of implementing HIOs and expects roughly $50 Million in federal and state funds to support improvements in health information exchange by promoting the meaningful use of EHR. This project will generate knowledge of the health information exchange landscape in California and help inform the development of a measurement framework to measure HIE progress in California.


Health Information Exchange to Improve Outcomes in Complex Older Patients
Sponsor: National Institute on Aging

It is critical to ensure that prior health information follows patients across care delivery settings in order to avoid poor outcomes from missing information. Older adults, particularly those with dementia and multimorbidity, are at disproportionate risk of poor outcomes from missing information and therefore should disproportionately benefit from efforts to increase electronic health information exchange. Our project will generate evidence that speaks to whether the nation is pursuing electronic health information exchange in ways that improve clinical outcomes for these populations and will thereby inform ongoing policy and practice-based efforts to help healthcare providers coordinate their services to older adults to optimize health status.


One to One Versus Team-Based Communication Among Care Providers in UCSF’s Intensive Care Nursery
Sponsor: Voalte

Collaborating with the UCSF Center for Digital Health Innovation and clinical care team members, this project evaluates the impact of Voalte Story, a care team based communications and messaging platform used by care providers in the Intensive Care Nursery (ICN) of Benioff Children’s Hospital. The goal of this collaboration is to understand whether a team-based messaging system improves communications and efficiencies in care settings where multiple disciplines and provider types are involved in patient care. This pragmatic evaluation will help researchers understand communications preferences among ICN care providers, and will help clinical leaders determine the optimal tools for internal clinical communications.