On Medical Informatics, MIS, and Leadership of Clinical Computing


Scot Silverstein, MD, Asst. Professor of Healthcare Informatics and Information Technology
Drexel University, College of Information Science & Technology, Philadelphia, PA

Comments to: InformaticsMD@aol.com


1. Background and introductory information
2. On Medical Informatics
3. Definitions of Medical Informatics
4. Medical Informatics vs. MIS training curriculum
5. The importance of Medical Informatics to healthcare IT success
6. What Medical Informatics is not
7. Conclusion

Case examples of costly healthcare information technology failure, collected and edited by this author. Several are based on the author's personal experiences as a hospital-based Director of Medical Informatics.




1. Background and introductory information

Clinical information technology systems such as electronic medical records (EMR), computerized physician order-entry (CPOE), clinical decision support systems (CDSS), and clinical data repositories (CDR) are seen as the key to "revolutionizing healthcare." Values attributed to clinical IT include improvement in quality of care, reduction in medical errors, standardization of geographic practice variations, improved healthcare operational efficiency and reduced healthcare costs, and improved availability of healthcare data for clinical trials, public health studies, healthcare resource allocation, and outcomes research.

The U.S. National Library of Medicine (NLM) of the National Institutes of Health believes that clinical care, biomedical research and education, and public health administration can be improved by the inclusion of in-context information specialists (informaticists) into work and decision settings. Informaticists are information specialists who have received graduate training and practical experience that provides them with cross-disciplinary background both in medical or biological sciences and in information sciences/informatics. Their cross training provides informaticists with a unique perspective on the acquisition, synthesis and application of information to problem solving and program development in clinical and biomedical areas. Unfortunately, as seen below and in this collection of healthcare IT failure cases, the NIH vision is far from being realized. Effective leadership in clinical IT by cross-disciplinary personnel is lacking.

As explored in this essay, leadership of clinical IT is largely represented by those of a business-computing background, based primarily on the customs and traditions handed down from the mainframe-based data processing culture of past decades. Along with those customs and traditions come some questionable assumptions, e.g., that knowledge of computers and data processing implies knowledge about information science in multiple, complex domains. Such an assumption, rarely examined critically yet prevalent in scientific domains where specialty education, testing and credentials are of paramount importance for leadership roles, is quite surprising.

For example, in a recent Wall St. Journal article, "Doctors Say Office Technology Is Costly and Cumbersome", clinicians pointed to a simple reason why they resist clinical IT: The technology "isn't very good." A significant issue that needs to be addressed is why clinical IT is so cumbersome. One major factor is that the clinical IT industry is dominated by "MIS" personnel (Management Information Systems, i.e., business-computing personnel in the ubiquitous "Information Services" departments) who apply business IT thinking, processes, and methodologies to clinical IT, not cognizant that clinical computing has evolved into a very different subspecialty of computing compared to its business counterpart.

A press release about research at OHSU (one of numerous NIH-funded centers for Medical Informatics research and training) entitled "Most hospitals don't use latest ordering technology" is particularly illuminating:

Computers programmed to screen out errors and standardize physicians' orders for prescriptions, tests and other care have been a source of hope in reducing medical errors and improving patient safety. The problem is that most hospitals aren't using this technology, known as computerized physician order entry (CPOE) ... Reducing medical errors gained a sense of urgency in 2000 when the Institute of Medicine reported on the issue. The institute found that medical errors may be responsible for up to 98,000 deaths in hospitals and cost the U.S. health care system approximately $38 billion per year.

Despite a wide array of quality, policy and financial incentives to use CPOE, fewer than 10 percent of American hospitals make it completely available to their physicians. This was among the findings of a study conducted by researchers in the Oregon Health & Science University School of Medicine and recently published in online edition of the Journal of the American Medical Information Association (JAMIA).

[Use of CPOE] is not yet widespread because it has a reputation for being difficult to implement successfully. Patient care information systems like CPOE ... can create unintended or "silent" errors, according to a separate study conducted by the same author in the Netherlands and Australia.

The study's authors divide these silent errors into two main types: errors during data entry and retrieval, and errors in the communication and coordination process. Both types of errors occur because the systems simply don't take into account the work atmosphere most health care professionals experience, according to Ash, also lead author of this study.

"Many information systems simply don't reflect the health care professional's hectic work environment with its all too frequent interruptions from phone calls, pages, colleagues and patients," Ash said. "Instead these are designed for people who work in calm and solitary environments. This design disconnect is the source of both types of silent errors."

The screen itself can cause errors. Choices that appear too close together result in ordering the wrong tests or sending orders for the wrong person. If a system is rigidly structured, it causes users to focus closely on entering details and switching from screen to screen to enter information.

"Some patient care information systems require data entry that is so elaborate that time spent recording patient data is significantly greater than it was with its paper predecessors," the authors wrote. "What is worse, on several occasions during our studies, overly structured data entry led to a loss of cognitive focus by the clinician."

Calm and solitary environments, indeed.

How are systems that ignore the healthcare workplace's realities finding their way into real products? How is this possible? While the workflow of the National Security Agency might be secretive, the realities of the medical work environment are certainly not. Who are the CPOE designers, exactly, and what are their backgrounds? How could investor dollars have been spent in such a fashion as to ignore the fundamental realities of clinical settings? How could IT companies have designed and implemented systems that "led to a loss of cognitive focus by the clinician" and created error?

Unfortunately, the answer to these questions is that design and implementation of CPOE systems and other clinical IT are being led by Management Information Systems business-computing personnel, who generally design and implement systems for "calm and solitary" business office environments, instead of those with both IT and clinical expertise such as Medical Informatics specialists.

The IT model of "If it's information, we do it" starts to fall apart and impede progress in such organizationally and sociologically-complex environments as medicine. Leaders in clinical IT must be experienced in the complex social and organizational issues of healthcare, such as the need for multiple, contextual levels of confidentiality, the politics and psychology of medical practice, referral, malpractice, and "grading", the complex medical workflow and the need to rapidly improvise due to the unexpected ("there are no committees in cardiac arrest situations"), and societal and personal sensitivities towards the physician-patient interaction.

In this essay, the problems with the arrangement of leadership of clinical IT by business-computing personnel are explored.


2. On Medical Informatics


After a decade of working in medical informatics, it has become apparent that significant confusion and misconceptions exist in hospitals and healthcare, in the biomedical industry, and in the scientific literature about what medical informatics is, and what experts in medical informatics do (and are able to do if given the opportunity). On a related note, there is significant confusion about what medical informatics is not. Finally, there is profound confusion regarding the differences between medical informatics and today's IT (information technology) groups that evolved from the "data processing department" and "management information systems" cultures of the mainframe era. In this essay I attempt to explain and clarify these issues, which are of strategic importance to evolving electronic medical records development and implementation initiatives.

The available quantity of information in most subject areas ("domains") has grown rapidly in recent decades. Issues about information and its use have become quite complex, and the issues themselves have undergone scientific study. Informatics is information science. In other words, informatics is a scientific discipline that studies information and its use.

Both theoretical and practical issues are studied. Examples of theoretical issues include terminology, semantics (term meaning), term relationships, and information mapping (translation). Practical issues include information capture, indexing, retrieval, interpretation, and dissemination. Medical informatics, an informatics subspecialty, is the scholarly study of these information issues in the domain of biomedicine. (Detailed definitions of medical informatics appear in the next section of this article.)

While computers make excellent tools or vehicles for medical informatics work, they do not define the field, nor are they required in medical informatics. This helps to clarify a common misconception. Medical informatics is not the equivalent of "computers in medicine." Using a computer in some medical way, such as by publishing a web site on some medical topic or running a hospital MIS (management information services or "I.S.") department, does not necessarily make an individual a "medical informaticist."

On the other hand, most formally-educated medical informaticists have both clinical knowledge and significant computer science expertise. This is an ideal background for leadership of computing projects in clinical settings, such as electronic medical records, physician order-entry, and medical alert and reminder ("decision support") systems.

Unfortunately, there are significant difficulties within the healthcare information technology (IT) field that arose with the emergence of medical informatics as a clinical computing specialty. The emergence of medical informatics specialists as computing experts in clinical settings has created territorial issues with an unexpected group within healthcare, the MIS departments. Those who had been traditionally in control of healthcare IT, the business-computing personnel in hospital and vendor MIS shops, often resist involvement of medical informatics specialists in clinical computing initiatives.

As pointed out in literature on healthcare computing sociology such as Organizational Aspects of Health Informatics: Managing Technological Change, by Nancy M. Lorenzi and Robert T. Riley (Springer-Verlag, 1995), computers, networks and the control of the information traveling on them are extremely territorial. The territoriality and control issues of the mainframe era did not diminish with the appearance of the PC.

As one manifestation of this territoriality, MIS business-computing personnel, usually not trained in any clinical specialty nor in informatics, represent themselves as the clinical computing leaders. A large amount of healthcare MIS periodical literature, and organizations such as the Healthcare Information and Management Systems Society (HIMSS) and healthcare IT recruiters, support this view. Paradoxically, MIS and other healthcare executives often will not recognize medical informatics as important or allow its experts significant decision-making authority in healthcare settings. These territorial and control issues are creating significant obstacles to medical informatics specialists and the leveraging of their expertise.

For example, a mid-1999 debate between Baltimore radiology IT experts Eliot Siegel, MD and Bruce Reiner, MD and a non-medical CIO over who should control radiology PACS (picture archiving and communications systems that replace photographic film) illustrates these territorial and control issues quite well.

Even when medical informatics is recognized as an important specialty, misconceptions about the field may cause healthcare executives to view such personnel as "clinical consultants who know a little about computers", as opposed to leaders in clinical computing. Applied informatics positions in hospitals and other healthcare organizations may thus be structured according to a medical-consultant paradigm, leading to a mismatch between informaticist temperament (often oriented towards leadership) and organizational expectations and empowerment. This mismatch may cause considerable informaticist dissatisfaction, poor utilization of expertise, and lost opportunities for the organization.

The above issues need to be understood and overcome, as the potential benefits of good clinical information systems and networks are clear. Such benefits are well-described in excellent documents such as "Benefits of a Health Information Network" by A. Tonnesen, MD, University of Texas Health Science Center, and many other studies and sources.

In the United States, the benefits of good healthcare IT are becoming more widely recognized. A report from the U.S. Public Health Service's Data Policy Coordinating Committee (The Health of the Public and the National Information Infrastructure, July 6, 1995) identified health as one of the key sectors that can benefit from advanced computer technology and telecommunications:

"From the outset, health has been identified as one of the key sectors that can benefit from National Information Infrastructure (NII) technology ... Only about 10 percent of all early deaths in this country can be prevented [once disease occurs] by medical treatment. Population-based approaches, on the other hand, have the potential to prevent 70 percent of premature deaths through measures that target underlying risks, such as tobacco, drug, and alcohol use; diet and sedentary lifestyles; and environmental, occupational, and infectious risk factors.

The extent to which population-based public health can achieve its mission depends, in large part, on the effective collection, analysis, use, and communication of health-related information ... Since those with important roles to play in population health are so diverse -- encompassing public health agencies at various levels, health professionals and institutions, managed-care plans, public and private organizations, policymakers, and consumers -- information systems technology is also needed to educate and empower different groups about public health problems and to link them together to take effective action."
An April, 2000 report from Patricia Neighmond of the U.S. National Public Radio network (NPR) stated:
"On reducing medical errors, the great hope remains with computers: new information systems designed to be fail-safe. These systems are expensive and many hospitals are reluctant or unable to make the investment. But in the long run, there is the promise of savings. At hospitals where these new systems are already in place, officials estimate savings in the millions. Fewer mistakes mean less money spent on unexpected patient care, things like extra days in the hospital, additional tests, and new medications."

Medical specialty organizations in the U.S. such as the National Cancer Institute (NCI) are undertaking comprehensive medical informatics initiatives. The NCI's Cancer Informatics Infrastructure (CII) project will help improve the care and prevention of cancer. A 1999 government excerpt about the CII project is illuminating:

"The current national cancer clinical trials program is fraught with redundancies, excessive amounts of paperwork, and fragmentation. With multiple sets of information in many disparate locations, it is nearly impossible to capture an accurate assessment of clinical trials activity in one institution, let alone across the nation. Perhaps more importantly, in the current system there is no way to seamlessly advance the progress made in clinical research to the clinical arena...Learning from the world of commerce and building on advances in information technology and the explosive growth of the worldwide web, the National Cancer Institute is creating a new Cancer Informatics Infrastructure (CII). By replacing today's paper processes, the CII will speed the translation of exciting basic research discoveries to the practice of medicine at the patient's side. Once in place, this new infrastructure will bring profound changes in the practice and art of cancer care...not unlike the promise of advances brought about by the Human Genome Project."

Several European countries including the United Kingdom have also accepted these benefits and announced aggressive positions on healthcare information technology, investing large amounts of capital in national healthcare information initiatives. The purpose of the national strategy in the U.K. is to help their National Health Service (NHS) exploit the full power of clinical IT, ensuring that patients receive the best possible care. The NHS is to invest 1 billion over the next few years in order to modernize how the service collects, stores and uses healthcare information (see the NHS information strategy summary and full plan). Smaller statewide initiatives in the United States are starting to appear, such as the Delaware Health Information Network (DHIN) effort in which this author is participating.

What is not clear at this point in healthcare information technology expansion is who are the optimal personnel to provide leadership in design, selection, implementation, maturation, and evaluation of clinical IT. As pointed out in the report "A New Path for Health-Care Leadership: Clinical Systems Management" by the Clinical Systems Management Task Force of the Clinical Laboratory Management Association:

"[Clinical systems integration] is an inherently difficult process because it involves reorganization of the medical profession and of relationships among physicians, nurses, and other health-care professionals; reinvention of the American hospital; incorporation of new technologies and treatment practices; and ongoing adaptation to new payment arrangements and patient preferences. The challenge is to integrate across time, place, profession, and technology...we may be observing a realignment of clinical management jobs with the emerging demands of integrated delivery systems."
Medical informatics has come into being as the healthcare subspecialty specifically designed to provide leadership in these areas.


3. Definitions of Medical Informatics


Offered here are several definitions of medical informatics. First, my own: "Medical Informatics is the science and art of modeling and recording real-world clinical concepts and events into computable data used to derive actionable information, based on expertise in medicine, information science, information technology, and the scholarly study of issues that impact upon the productive use of information systems by clinical personnel."

Another definition from a pioneer in the field at the University of Utah describes medical informatics as "The study, invention and implementation of structures and algorithms to improve communication, understanding and management of medical information." [Homer Warner].

Another definition from Stanford: "Medical information science is the science of using system-analytic tools . . . to develop procedures (algorithms) for management, process control, decision making and scientific analysis of medical knowledge." [Ted Shortliffe]: The science of biomedical computing. Med Inform 1984;9:185-93.

A more in-depth definition from Columbia addresses the critical non-technologic, social-science and self-evaluation aspects of medical informatics: "Medical Informatics studies the organization of medical information, the effective management of information using computer technology, and the impact of such technology on medical research, education, and patient care. The field explores techniques for assessing current information practices, determining the information needs of health care providers and patients, developing interventions using computer technology, and evaluating the impact of those interventions. This research seeks to optimize the use of information in order to improve the quality of health care, reduce cost, provide better education for providers and patients, and to conduct medical research more effectively." [Stephen B. Johnson], Columbia University.

Dr. Johnson further points out that Medical Informatics, in addition to its technologic base, needs to provide scientific methods to study information needs, not just assume a particular technology is the answer, and must show true impact of systems, not just develop applications or assume that things work. He related that the field is more a social science than a technologic one. An informatician needs to have a strong knowledge of ergonomics, organizational theory, a little economics, and some political and social skills. I strongly agree. In fact, rather than having a technical focus, this site addresses sociological and organizational issues in healthcare information technology.

A view on Medical Informatics from the British Medical Journal points out the importance of improved organization and communication of health information, and the role of medical informatics at the center of these objectives. Medical informatics links such areas as knowledge management, guidance on best practice, education of professionals and the public, and the use of new communication and computer technologies. The article describes medical informatics by analogy: "In the same way that surgeons use scalpel and needle, those involved in medical informatics use tools such as clinical guidelines, medical languages, and information and communication systems to assist the study and dissemination of medical knowledge."

One of the most comprehensive definitions of medical informatics available comes from the "Handbook of Medical Informatics" [Editors: J.H. van Bemmel, Erasmus University, Rotterdam, and M.A. Musen, Stanford Univerity, Stanford, CA]: "Medical informatics is located at the intersection of information technology and the different disciplines of medicine and health care ... We shall also use the term health informatics without entering into a fundamental discussion of the possible differences between medical informatics and health informatics.

Medical informatics has both distinctly applied features and more fundamental characteristics. Just as medicine itself is multidisciplinary, so is medical informatics. The main reason for this convergence of disciplines is that, in principle, medical informatics deals with the whole field of medicine and health care. Blois summarized the heterogeneity of medical science quite eloquently and related the multidisciplinary nature of medicine directly to the basis of medical informatics: In medical informatics we develop and assess methods and systems for the acquisition, processing, and interpretation of patient data with the help of knowledge that is obtained in scientific research.

Computers are the vehicles used to realize these goals. In medical informatics, we deal with the entire domain of medicine and health care, from computer-based patient records to image processing and from primary care practices to hospitals and regions of health care. Some areas of the field are relatively fundamental; others have an applied character. The challenge in developing methods and systems in medical informatics is that once the systems have been made operational for one medical specialty, they can also be transferred to some other specialty."


4. Medical Informatics vs. MIS training curriculum


The curriculum in a medical informatics training program reflects the above definitions, as shown in this link to a detailed example from Columbia University. It should be noted that the curriculum is specialized and markedly different from the MIS training curriculum in particular. These topics are not intuitive, and one does not generally become an expert in these areas through informal or hobbyist-level activities. The medical informatics curriculum covers topics critical to the understanding and proper implementation of clinical IT in healthcare settings, including (but not limited to):

Fundamental of computer science
Medical language and terminology systems
Modeling of medical observations and data
Medical coding systems
Medical knowledge structures
Information organization and flows in medical practice
Quantitative models for medical decision making
Clinical decision support
Medical image processing
User interfaces and ergonomics in healthcare
Health information systems architecture
Security and confidentiality
Ethical and legal issues in electronic medical records
Organizational and sociological issues
Metrics and methods for evaluating healthcare information systems
Cost and investment issues in healthcare IT

The MIS curriculum, as shown in this link to several examples, lacks coverage of most of these topics, particularly the biomedical-related ones. It is almost entirely business-oriented. MIS training is also weak in basic computer science and engineering. This assumes an MIS employee has had formal MIS training. This may not be the case. Unlike clinical medicine, there are no formal requirements or accreditation required for work in healthcare information technology.

This web site in large part originated from my personal observations of MIS personnel leading clinical computing projects and wielding considerable authority over clinicians on decisions affecting medical environments and resources. I also observed difficulties among MIS personnel in functioning as true team members and collaborators on clinical teams, due to a rigid focus on "business process" and questionable management fads over the clinician goal of "getting results." These observations led to the questions "who are these personnel, and what is their expertise? What metrics are applied to ensure such personnel are competent?"

In raising these questions, I've leveraged many years of rigorous clinical and informatics training, and significant experience performing occupational medicine exams on public transportation and law enforcement personnel (where detection and analysis of inadequate medical experience, competence, or specious reasoning by others was often crucial to ensuring both worker and public safety). Application of the same analytical approach raised many questions about healthcare MIS leadership. These questions were found to leave much room for contemplation.

These concerns were only amplified as Informatics faculty at the Yale-New Haven Medical Center and as Director of Informatics at another large medical center, the Christiana Care Health System in Delaware. I had the opportunity to observe a wide variety of attitudes about medical informatics expertise, and interact with colleagues holding similar positions in hospitals, pharmaceuticals, insurance, and other healthcare-related organizations. The attitudes towards medical informatics in such organizations ranged from extremely positive (by most executives and staff) to quite negative (predominantly by MIS leadership personnel and the senior management they reported to).

It should be noted that a lack of executive consensus augurs poorly for an applied informatics position's enjoyability, due to the progress-inhibiting "bureaucratic infighting" that often results. that often result from such issues.


5. The importance of Medical Informatics to healthcare IT success


Informatics professionals such as Medical Informaticists, Nursing informaticists, Information nurse specialists (INS's), dental informaticists, etc. are usually clinicians or other scholars (e.g., MPH, PhD) with expertise in medical information science, information technology, and clinical computing in a healthcare specialty area. They may also have varied degrees of experience in other fields, such as management, business, and academia. They tend to be very "high-ability", often able to apply knowledge in one field to parallel issues in another, and to master new ideas and material quickly to solve multidisciplinary problems and issues. There are several taxonomies of skill levels in informatics, although the most-skilled personnel will have attended a formal training program sponsored by an organization such as the National Library of Medicine in the United States.

It should be remembered that MIS personnel, on the other hand, are computer personnel supporting healthcare, not medical professionals delivering healthcare, an important distinction. There seems to be an unfortunate increase in the indiscriminate use of the "healthcare professional" and "medical professional" labels. This semantic blur contributes to the unclear thinking about healthcare IT leadership.

Implementation of clinical IT is highly knowledge-intensive, where the relevant knowledge includes basic medical sciences, clinical sciences, technological theory, common-sense heuristics, excellent problem-solving abilities, and above all, mastery of operational principles in a clinical setting. The informaticist is a cognitive being who searches freely and associatively in his or her knowledge body, and, being opportunistic, applies whatever knowledge token that appears relevant to the goal of the moment (as paraphrased from "Technology and Creativity", S. Dasgupta, Oxford Univ. Press, 1996). Deprived of such knowledge and experience, this process becomes far less effective.

Therefore, it is clear that the path to clinical computing success is not one of dedication or effort alone. Healthcare computing is distinctly an endeavor where not having enough experience in each focus of the "information architect triad" - that is, medicine, management, and IT - can seriously impair efforts despite the best of intentions. Medical informaticists bring exactly these three skills to the table, in a cross-disciplinary, synergistic manner. The classic article "The Clinical Information Architect as a Member of the Healthcare Team" (Sittig, Proc Annu Symp Comput Appl Med Care, 1995:756-60) discusses these three areas and concludes with the following wise advice about medical informatics:

"There are many different constituencies, and hence views, which must be considered when attempting to develop an integrated clinical information management system in any large medical center. While the costs associated with the hiring of such a highly qualified individual [a medical informaticist] are admittedly high, we believe that without a full-time, on-site person, who is capable of fulfilling the role of the Information Architect described, the difficulty of the task increases to the point of becoming nearly impossible."
Lack of understanding of participatory design principles is another serious issue impairing clinical computing initiatives. Significant strides are made when a medical informaticist brings strategic insights from collaborative clinical and scientific research environments to the healthcare IT table. (See Participatory Design of Information Systems in Healthcare, Sjoberg C, Timpka T: Journal of the Amer. Medical Informatics Assoc. 1998;2:177-183.)

A letter I had written, "Broken Chord" published in the journal Healthcare Informatics, further amplifies the skills and experience issue. The letter addressed issues of skills, insights, and roles of MIS personnel in healthcare settings. I described a Microsoft Healthcare Users Group conference attended predominantly by healthcare MIS staff and vendors, where I observed a panel discussion moderated by the (former) CEO of HBOC and composed of several other industry CEO's. The panel was discussing how they would revolutionize healthcare through their leadership in information technology.

During the Q&A period I asked the audience how many really felt they would revolutionize medicine through their leadership in IT. Several hundred--almost all in the audience--raised their hands. I then asked how many had ever taken care of patients or examined any textbook of medicine, such as Harrison's Textbook of Internal Medicine or the Merck Manual. A minority of hands went up. This suggested, in my view, a striking deficiency of knowledge, experience and insight on the part of the de facto clinical information technology leadership, complicated by cavalier attitudes regarding the essential role of clinical expertise.

The pretension of non-medical computer support personnel in offering profound thoughts on complicated medical matters that they understand, at best, at the level of popularizations, is troublesome. Often, CIO writings in journals of healthcare computing on subjects such as Electronic Medical Records remind me of this. A metaphor to describe the results might be that of a submariner presenting "expert" views on flying a B-52 jet plane. While both are military transporation, in technology specifics do matter.

This deficiency may create substantial information technology issues. In a commentary on a New England Journal of Medicine article "The American health care system--the movement for improved quality in health care" by Thomas Bodenheimer (N Engl J Med 1999 Feb 11;340(6):488-92), informaticist Dr. Gil Kuperman observed that the quality improvement 'crusade' in healthcare has increased the expectations of healthcare consumers and the healthcare industry about information systems. The reviewer also observed that conventional healthcare industry thinking, which tends towards a belief that quality improvement data can simply "fall out" or be extracted from existing healthcare information systems (such as financial systems), is false. The information systems must be properly designed for quality measurement and improvement purposes, their datasets properly modeled, and they must be properly installed, evaluated, and continuously improved by those who understand medicine and medical information science.

Medical Informatics applies the rigor of clinical training, critical thinking, problem-solving, and scientific method to healthcare information technology issues. I sometimes express this idea colloquially in presentations to non-medical audiences, explaining that "Data Doctors" in informatics use the same approaches to "healthcare's data pain" that people demand when they're ill to establish diagnoses, plan therapy, and monitor treatment progress, approaches developed and refined over centuries. Business information technology often seems mired in an older approach of empiricism. "Data doctors" help convert what health care organizations are experiencing today as technology-centered "pain" into welcome opportunities for improved organizational health. I've found this to be a readily-understandible and useful metaphor.

Another metaphor I've used, for example in a presentation Computers and Cultural Change: How do Physicians Benefit? states that medical informaticists specialize in leveraging computers (binary "oil") in medicine (murky waters) by acting as surfactant, allowing the other ingredients to mix properly.


6. What medical informatics is not


In understanding the role of informaticists, it is important to be aware of another common semantic blur that results in overuse of the term "medical informatics" to refer to any activity involving medicine and computers. It's become a very "desirable" term in recent years, resulting in eager adoption by anyone using computers for any purpose in medicine. I label this the "medical instamatics" phenomenon.

The increasingly common use of awkward expressions like "informatics technology" to refer to clinical information systems is another example of that blur. Medical informatics is a formal field of study and a scientific discipline. Computers in medicine is not the equivalent of medical informatics. Yet, position descriptions such as in these employments ads, with requirements for neither clinical nor medical informatics training or experience, are increasingly seen. From the Philadelphia Inquirer:

Medical informatics analyst. [Company name] seeks a Medical Informatics Analyst to support resource management and medical affairs in their data analysis needs. Through downloading of MCS database, PC-based analysis of clinical and clinically-relevant financial data will be performed. Qualifications: BA/BS in computer science or related discipline, 3-5 years experience in PC-based data analysis of health care information, knowledge of SAS or similar analysis software, knowledge of mainframe DB2 database architectures, working knowledge of CPT-4 and ICD-9-CM coding."
From an Internet biomedical employment service, Medzilla.com:
[Company name] seeks a Director of Clinical Informatics. Overall coordination of design specifications, implementation and support for all internet/browser based systems. Assurance of continued, reliable and consistent resources and applications to all corporate personnel and external users who may rely upon these systems. Documentation and control of said software systems including package systems and license control if necessary. Provide ongoing maintenance oversight and management support for said systems. Organize and train personnel, both internal and external, who will be using said products. Client contact and development and assist Sales and Marketing as necessary in client presentations. Minimum of a BA. MBA preferred.
Further, I've noted a number of large vendors and even national medical organizations whose so-called "Medical Informatics Directors" had neither clinical backgrounds nor training in medical informatics (nor in information science of any kind). MIS managers, social workers, and clinicians with no more experience than some tinkering with a home Macintosh can be found as "Directors of Medical Informatics" in the (unfortunately) unregulated healthcare IT industry.

Sometimes the term is used as a sales slogan. General Electric displayed a huge banner over their booth proclaiming themselves "the world leader in Radiology Informatics" at the 1999 Radiological Society of North America (RSNA) conference in Chicago. Unfortunately, nobody present, including sales, management, and engineering representatives, could explain to me what that term meant. They actually said they did not know. I had only identified myself as a physician at that point, not as a medical informatics professional, and expressed incredulity on nobody being able to explain the banner to me. Under pressure, one GE engineer offered the statement "I think it has something to do with computers attached to our x-ray machines."

As an aside, I find blur in usage of the term "medical informatics" highly ironic. One major area of study in medical informatics research is language and data modeling. In applied efforts in that area, exhaustive attention to lexical and semantic issues and intense thinking about precision and imprecision in language have led to excellent tools such as the National Library of Medicine's Unified Medical Language System. Now, it seems the medical informatics field is often finding its own name used in an imprecise way.

The same observation is being made in other areas of clinical informatics, such as nursing informatics. Carol Slone, RN C (cslone@phoenixhealth.com), president of the Midwest Alliance for Nursing Informatics, has defined what nursing informatics is not:

Nursing Informatics is NOT:
The Nurse who likes computers.
The Nurse who hates computers.
The Nurse who "knows" computers.
The Nurse who is now a Network Analyst.
The Programmer who is now a Nurse.

These points apply to all of the informatics subspecialties. She then defined what nursing informatics is:

"Nursing informatics is a specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research and the expansion of nursing knowledge" (Scope of Practice for Nursing Informatics, ANA 1994).

Most importantly, medical informaticists are concerned with creating usable healthcare information. For instance, the invasive cardiology section of a large medical center where I provided medical informatics leadership felt that the dataset, workflows, and reporting facilities of a commercial product (Apollo by Seattle Systems, Inc.) did not meet their specific needs optimally. Apollo had been developed as a "generic" system attempting to satisfy the needs of many different invasive cardiology environments with a "release" in a more traditional business IT model.

Medical informaticists understand that medical environments may differ significantly from one setting to another, and that customization of such applications is not just important, but essential to the proper utilization of such technology by clinicians. Yet, business-oriented information services departments do not have the biomedical and medical informatics expertise required for such customizations, and commonly don't understand that such customization is the key to success in rapid-paced, dynamic clinical environments.

In this case, I discarded and completely redeveloped the internal dataset of the Apollo database and reporting system, via optimized utilization of cardiology domain knowledge (my own and that of the cardiologists) under medical informatics leadership. The model was kept compatible with national reporting standards, but surpassed the existing standards by a wide margin. The information generated by the customized application allowed a significant reduction of operational costs in the invasive cardiology section, and allows for rapid, creative and flexible data analyses significantly beyond generic national standards. Other informaticists have found this to be a familiar situation.

Management guru Peter F. Drucker himself, one of the most respected names in modern management thinking, offers some highly relevant insights about information issues in his book Management Challenges for the 21st Century (HarperBusiness, 1999). These insights amplify the importance of medical information specialists (medical informaticists) taking leadership roles in healthcare organizations, and the problems with allowing MIS to predominate on medical information issues and clinical information tool development and evaluation.

Drucker writes that "the information revolution...is not happening in IT or MIS, and is not led by CIO's...what has triggered the [real] information revolutions and is driving them is the failure of the 'information industry' - the IT people, the MIS people, the CIO's - to provide information. For 50 years, information technology has centered on data...and technology [not useful information]."

He continues, "The data available in business enterprises are still largely based on early 19th century accounting theorem. MIS has taken the data based on this theorem and computerized it. They are the data of the traditional accounting system. IT...collected the [accounting system's] data, manipulated them, analyzed them and presented them. On this rested, in large measure, the tremendous impact the new technology had on what cost accounting data were designed for: operations. But it also explains IT's near-zero impact on the management of business itself."

Medical Informatics and its teachings can thus be seen as a means to an end: the creation and dissemination of useful information that advances the management and science of healthcare, not just facets of its operations.


7. In Conclusion

If medicine is to become a true information-driven enterprise and achieve the highest quality possible, the people who "revolutionize" it must have expertise in both medicine and management of information.

It should be remembered that a license to practice medicine is a privilege earned as a result of intensive study and abdication of the rights of leisure. Becoming a physician requires intelligence, high ability and extreme discipline. Basic training in the Marines is far easier than the year of medical internship, which is only a small part of the medical education process. Basic training in the Marines lasts only eight to sixteen weeks and has fairly regular hours reserved for sleep. The internship year alone is a physical and emotional marathon that runs 24 hours a day. Specialty training after internship, such as the residency (most U.S. physicians now take a residency) and fellowship, is often even more demanding.

This medical background, or the training background of other clinical specialties, supplemented with healthcare IT expertise through medical informatics training, provides the ideal leadership qualities and abilities for meeting the challenges of clinical computing.




Website copyright (c) InformaticsMD@aol.com . All rights reserved. This site is a private undertaking and receives no outside funding. Contents may be used for educational, non-profit purposes only. Author should be informed of such uses and accredited for the material. The author assumes no liability for any use of information herein, medical or otherwise.