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Clinical Informatics for Dummies - Trying to make the most of health information systems Print E-mail
The Quarterly 2011


This article first appeared in The Health Advocate, the magazine of the Australian Healthcare and Hospitals Association (Issue 9, June 2011).

I have been doing "clinical informatics" for more than 10 years, but was forced to re-evaluate just what it is that I do, and the context in which I do so, following the request to write this article. I used to give lectures to Masters students, some 5 years ago, about "Introductory Health Informatics", so went back to those slides to see how little, or how much, the landscape had changed.

The principles are the same - health informatics is about providing better care to patients using technology. It sits at the intersection of computer science, information science, health care and health care management.

The definitions all congregate around the notion of the art and science of providing better health care using IT. But what are the driving forces behind health informatics? Firstly, there has to be a "desire to take better care of patients", deep and right at the core. Others include the increasing power of technology and the internet, an increasingly stronger need to demonstrate public accountability in the context of errors becoming more public (eg the Bristol Royal Infirmary 1), the information explosion, and also the need to provide more care, in the context of the greying of the population, higher costs, increasing expectations, increasing cost of technology, but a reducing workforce.

Essentially, the need is to provide demonstrably better care to more patients with constrained resources and proportionally fewer staff.

How does health informatics expect to achieve these aims?

Let's follow the patient journey to analyse where health informatics can assist. The patient presents and is registered - have we uniquely identified the person to ensure we have the right person and the right information held against them? If we have a robust unique person identification system and process then we have made a good start.

Do we have relevant history available from past encounters with our practice and others? Immunisation status? Medications? Important lab and imaging results? Alerts and allergies? Again, an encounter summary with unique person identification will help the process of care.

Can we compare the images from the past to those captured today? A Research Information System (RIS) or Picture Archiving and Communication System (PACS) program will do this, assuming it is fed by the unique identity system already in place. Perhaps the symptoms and signs are not diagnostic - decision support listing differential diagnoses will assist.

The condition found is unusual ñ what is the best care? Access to the internet will quickly determine what is Evidence Based Medicine (EBM).

The prescription process, one of the four main sources of errors in health, should be monitored by clinical decision support software which applies expert rules devised by senior clinicians along with graded drug or drug interaction alerts. The process of clinical care on the ward should be monitored for unusual observations, again by expert IT systems.

When the care pathway is over, the transfer of care should be electronic and seamless. The monitoring of the processes of care in the facility should be able to be supervised by the clinicians, by both analysis of the triggering of the rules engine noted above, but more importantly as to outcomes of care, by disease, by patient group, by ward, by operation, and by clinician.

Lastly, the monitoring of the processes and outcomes of care should be able to be applied to the population as a whole by the aggregation of de-identified patient data. An interesting example of the latter was the analysis by Kaiser Permanente of its large data store that identified that Vioxx contributed to an excess rate of myocardial ischaemia 2.

The various academic definitions have not changed in a real sense over the last decades - so what has changed? The focus of clinical informatics has narrowed in during the last years onto the use of information in IT systems in health care by clinicians.

What has also changed has been the increasing pervasiveness of technology. Google, similarly, has made significant changes to the way we work and study. Some of this article was sourced from Google, the depth and reach of which was unthinkable when I started this job.

Who are Clinical Informaticians?

They are doctors, or nurses, or health information managers, who know enough about health and health care, and its work processes, and have learnt enough about information and computer sciences, that they can assist both their clinical colleagues and the IT groups to achieve common aims.

Bill Gates said it fairly succinctly in 1999 in his book Business at the Speed of Thought as follows: "It's impossible to properly re-engineer a process using technology in an area without oversight of someone who can bridge [the different] teams."

The technologists just donít understand health care processes; and clinicians, without further training or experience, donít understand the technology. It has become the solid perceived wisdom that it is easier to train a doctor or a nurse to have enough understanding of the broad brush strokes and some of the detail of technology that they can effectively bridge the teams.

In fact in the USA in 2009, there arose the clinical sub-specialty of clinical informatics. 3, 4

So, what do clinical informaticians do and what do they use?

They use their knowledge of health care processes, of informatics principles and processes, and health informatics tools 5. Clinical processes need no introduction ñ but what are the latter two? Informatics principles are about IT technology, privacy and health law, data base concepts, project management, change management, statistics, health and IT standards, messaging, person identification, and so on. Health informatics tools are things like clinical guidelines, pathways, order sets, and staff education processes, to name a few.

So, what does the clinical informatician seek to do? (S)he seeks to:

  • Assess and inform the information needs of clinicians, managers and patients
  • Characterise, evaluate and improve clinical processes

How does the clinical informatician seek to do this?

In essence, they achieve these goals by bridging the different teams. Specifically, this means to develop, implement, and refine clinical decision support systems, understanding both the clinical processes in depth and the technology in a broad way. As well, it means to lead or participate in the procurement, customisation, development, implementation, management, evaluation, and continuous improvement of clinical information systems, again understanding both the clinical world and the IT world 5.

It would be understood that clinical informaticians, then, would do this work from before the inception of a clinical project or system, to well after the (nominal) project had finished - it is a truism that health information systems projects are never finished until the data and information have been passed onto the next system and the original system has been turned off.

The last of the queries is where, and the answer is fairly intuitive - wherever clinical care is delivered, and close to the point of care.

The state of play for clinical informatics in Australia is not optimum - there are a handful of doctors who do it full-time, and a much larger number who do so part-time. There are no training positions, and few tertiary courses.

What I find the most gratifying as a doctor in this field, is the capacity to improve the care that large numbers of patients receive, and from a "life satisfaction" perspective, problem-solve with my colleagues how we will practice medicine tomorrow.

Dr Tony Sara

1Treasure T Lessons from the Bristol case BMJ 1998; 316: 1685-1686
2http://www.fda.gov/NewsEvents/Testimony/ucm113235.htm, accessed 15 March 2011
3Gardner RM, Overhage JM, Steen EB, et al. (2009). "Core content for the subspecialty of clinical informatics". Journal of the American Medical Informatics Association 16 (2): 153-7. doi:10.1197/jamia.M3045
4Safran C, Shabot MM, Munger BS, et al. (2009). "Program requirements for fellowship education in the subspecialty of clinical informatics". Journal of the American Medical Informatics Association/i> 16 (2): 158-66. doi:10.1197/jamia.M3046
5http://en.wikipedia.org/wiki/Health_informatics, accessed 14 March, 2011

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