The VITALS Framework: Empowering Programs to Leverage Health Information Technology for Trainee-Led Health Care Decarbonization and Climate Adaptation

Climate change from greenhouse gas (GHG) emissions is having increasingly devastating effects on global health.¹  Unfortunately, despite providing care for only 4% of the world’s population, the US health care system is responsible for 25% of all global health care emissions, while also accounting for 8.5% of all US carbon emissions.²  The Carbon Accounting for Care Delivery Project, funded by a Stanford Health Care seed grant, focuses on developing electronic health record (EHR) tools to promote and scale sustainable care pathways (SCPs)—clinical care plans that prioritize practices to reduce GHG emissions without compromising quality of care. Examples of SCPs include increasing telehealth utilization and substituting high-carbon inhalers with low-carbon alternatives.³  To advance this aim, we gathered approximately 30 international experts to discuss SCP integration strategies at the Healthcare Sustainability and the EHR Roundtable conference held at Stanford University in September 2023. Our deliberations ultimately underscored the importance of harnessing not only the EHR, but also other tools within the broader health information technology (HIT) landscape to facilitate physician-led uptake of SCPs. Moreover, they emphasized the importance of including trainees in this transformation who can both energize this movement and craft longitudinal careers in this emerging space. To facilitate this process, we developed the VITALS framework—a guide for programs to leverage HIT to improve the integration of SCPs and climate health–related topics into graduate medical education (GME; Figure).

Visualization can be a powerful tool for delineating sustainable choices and equipping trainees with concrete longitudinal representations of their practice patterns. One popular idea from the roundtable event was to use green leaf icons to indicate the relative sustainability of various EHR orders, similar to the relative cost data already depicted within many EHRs (Table). This intuitive “green” visualization could, for example, nudge physicians toward prescribing more environmentally friendly dry-powder inhalers over metered dose inhalers.²²  Additionally, an EHR dashboard depicting the carbon savings of trainees’ decisions could offer insights and contextualize their performance alongside that of other clinicians.³  This approach also naturally lends itself to gamification techniques such as residency-wide challenges to achieve the greatest carbon savings, complete with associated rewards.²³ 

We can embed the consideration of SCPs into trainees’ developing clinical practice through integration of climate-related items within both faculty- and trainee-facing evaluations (Table).²⁴  Existing online evaluation platforms (eg, MedHub, New Innovations) can be used to deliver these assessments across rotations, easily providing higher-level metrics on program-wide progress and more granular faculty- and rotation-specific data to guide additional support and education efforts. Moreover, implementation and regular review of the EHR carbon accounting dashboard can augment these subjective assessments with objective performance data. As programs demonstrate that competencies in climate health can be feasibly assessed, more specialties may incorporate climate health curricula, accompanied by board certification questions and specialty milestones on climate health.

Incorporating education on adaptation (adjusting clinical care for climate-related health threats) and mitigation (reducing health care–associated carbon emissions)²⁵  is often viewed as challenging due to insufficient curriculum space and a perceived lack of high-quality educational content.²⁶  Programs can gradually incorporate climate health teaching points by encouraging lecturers to enhance their existing presentations with relevant considerations or sample cases,²⁷  drawing from existing online curricular content libraries.²⁸  These teaching points can be further reinforced at the point of care through the optimization of EHR tools, such as order sets designating sustainable choices and prewritten patient education materials (Table).

Programs can encourage trainees to lead sustainability-related quality improvement (QI) as a means to demonstrate their QI competence and fulfill the requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME).²⁹  The EHR contains rich data that can facilitate the often onerous task of tracking predefined outcomes, processes, and balancing measures.^30,31  However, trainees frequently cannot harness this data due to unfamiliarity with the relevant reporting tools (eg, Epic Systems’ SlicerDicer) and generally limited research IT staff support.³²  We have found success with educating trainees on using these tools by facilitating access to free vendor-specific online training classes (eg, Epic Systems’ UserWeb courses) and incorporating walkthroughs in didactics taught by clinical informatics experts. Trainees can further their efforts by joining or creating climate health–related working groups within their national specialty societies³³  or conducting research on the effects of climate change on patients within their specialty (online supplementary data).

Programs should tailor their climate health–related education efforts to their unique geographic location, patient population, and practice setting. For example, a pediatrics residency in a wildfire-affected area could incorporate the management of wildfire-related risks into a lecture on asthma.³⁴  They could then sponsor a resident-led QI initiative to enhance an existing EHR-embedded “asthma action plan” tool with a wildfire-specific component,³⁵  followed by a competition among residents to utilize the tool within a clinic. Alternatively, an obstetrics and gynecology program in a region prone to heat waves could incorporate education on the effects of extreme heat exposure on pregnancy.³⁶  Residents in that program could then develop patient education materials to mitigate these risks and incorporate them into the EHR’s after-visit summary feature.³⁷  This localized and multifaceted approach will not only better capture trainees’ attention, but also directly improve patient care.

Once successful educational or operational strategies for climate health are developed, it is essential to proactively ensure their long-term success. Establishing review and monitoring protocols for EHR tools can prevent them from inadvertently becoming outdated, while collaboration between faculty and trainees can help sustain momentum after trainees graduate. Identifying executive sponsors for projects is key for institutional buy-in; trainees can highlight the potential cost savings of sustainability initiatives³⁸  to appeal to hospital administration. Programs can also expand pilot projects to other departments, units, and clinics through multiyear efforts across trainee classes and interspecialty collaboration. EHR-based interventions are particularly advantageous due to their inherent scalability, enabling rapid and reproducible expansion within an institution. Finally, trainees can disseminate their work through conferences and publications, inspiring others and providing evidence to support broader policy changes. Presenting at conferences hosted by EHR vendors (eg, Epic Systems’ User Group Meeting, Cerner Health Conference) can also motivate vendors to incorporate these features into their foundation build, facilitating widespread adoption and reducing local maintenance burdens.

Climate change is a growing global health crisis, exacerbated by health care–associated GHG emissions. The VITALS framework offers a structured guide for programs to leverage HIT to empower trainees to proactively consider climate-related health threats in their clinical care plans and utilize sustainable care pathways when appropriate. The Table highlights documented instances of successful interventions, supporting evidence, and practical suggestions for applying the framework components. By incorporating visualization, standardized evaluation, curriculum integration, specialty-specific initiatives, localized strategies, and sustainable interventions, the framework enables program leadership to cultivate future leaders in sustainable health care.

The authors would like to thank the attendees and presenters from the Healthcare Sustainability and the EHR Roundtable event in September 2023. They would especially like to express gratitude to Cassandra Thiel, Praveen Kalra, Samantha Green, Jyothi Tirumalasetty, Baylis Beard, Kathy Gerwig, Catherine Chen, and Terry Duffina for their phenomenal contributions toward decarbonizing health care.

The online supplementary data contains mitigation- and adaptation-based care examples for quality improvement, research, and education across common medical specialties.

* Denotes co-first authors.