Medical Informatics: Improving Health Care Through Information

CONTEMPO UPDATES LINKING EVIDENCE AND EXPERIENCE

Medical Informatics Improving Health Care Through Information 5 William R. Hersh, MD offer educational programs. At some Electronic Medical Records institutions, medical informatics is The core application using patient- EALTH CARE IS AN INFORMATION- viewed as a service (eg, helping clini- specific information is the electronic based science. Much of clinicians implement informatics applica- medical record (EMR). The paper- Hcal practice involves gather- tions), but it is more appropriately con- based medical record has its tradition ing, synthesizing, and acting on sidered a science that addresses how and virtues; however, research has information. Medical informatics is the best to use information to improve shown it can be illegible, incomplete, field concerned with the management health care. The government leader in difficult to access in more than one and use of information in health and funding research and education in place, and insecure from unautho- biomedicine. This article focuses on medical informatics has been the Na- rized uses and users.2 Although the the problems that motivate work in tional Library of Medicine (www.nlm EMR overcomes some of these prob- this field, the emerging solutions, and .nih.gov). lems, there are challenges to imple- the barriers that remain. It also ad- Some have argued that the adjective menting the EMR at the levels of the in- dresses the core themes that underlie medical in front of informatics is inap- dividual and the organization. all applications of medical informatics propriate because it implies the work The main challenge to individual use and unify the scientific approaches of physicians and not the remainder of of the EMR has been its integration into across the field. health care and biomedical science. the busy clinical workflow. The few There is a growing concern that in- However, this name has achieved wide- studies that have been performed show formation is not being used as effec- spread usage. In the article by Kukafka computerized physician order entry tively as possible in health care. Recent et al,6 Shortliffe described medical in- (CPOE) adds time for the clinician, al- reports from the Institute of Medicine formatics as the broad term represent- though other time savings are usually have reviewed research findings related ing the core theories, concepts, and gained elsewhere through error reduc- to information use and expressed con- techniques of information application or the automation brought about cerns about medical errors and patient tions in health and biomedicine, with by other features of the EMR (eg, ac- safety,1 the quality of medical records,2 the other adjectives preceding the word cessing test results).7-9 A related chal- and the protection of patient privacy and informatics denoting the specific appli- lenge is determination of the optimal confidentiality.3 The latest Institute of cation area (BOX). Core themes that computing device for the clinical set- Medicine report on this topic ties all these emerge from informatics science (stan- ting. Handheld computers (also called problems and potential solutions to- dards, terminology, usability, and dem- personal digital assistants) are increas- gether in a vision for a health care sys- onstrated value) are relevant across all ingly popular, as documented by their tem that is safe, patient-centered, and evi- levels of medical informatics, not solely use by internal medicine10 and family dence-based.4 A variety of solutions is clinical informatics. practice physicians.11 While their port- required to address the information- ability is of great value, most usage has related problems in health care; many so- Applications of Clinical Informatics focused on entry and retrieval of simple lutions involve the use of computers and There is a variety of classification types data (eg, prescription writing and drug computer-related technologies. for the different applications of clini- information) and it is unclear whether cal informatics; one approach is by the other usage (eg, image viewing and lit- The Field of Medical Informatics type of information used. There are es- erature access) is amenable to these por- Medical informatics is a heterog- sentially 2 types of information used in eneous field, composed of individuals clinical informatics: patient-specific and Author Affiliation: Division of Medical Informatics and Outcomes Research, School of Medicine, Oregon with diverse backgrounds and levels of knowledge-based. Patient-specific in- Health and Science University, Portland. training. Although virtually all health formation is generated by and used in Corresponding Author and Reprints: William R. Hersh, MD, Division of Medical Informatics and Outcomes science universities have some entity the care of patients in the clinical set- Research, School of Medicine, Oregon Health and Sci- with the word “informatics” in its title, ting, whereas knowledge-based infor- ence University, BICC, 3181 SW Sam Jackson Park Rd, Portland, OR 97201 (e-mail: [email protected]). there are fewer than 25 that carry out mation comprises the scientific basis of Contempo Updates Section Editor: Janet M. Torpy, research in medical informatics and health care. MD, Contributing Editor.

consumers, many of which can be found Box. The 4 Levels of Medical Informatics and Their Respective Foci using the National Library of Medi- From the Cell to the Population* cine’s MedlinePlus database (http:// Bioinformatics—molecular and cellular processes, such as gene sequences and maps medlineplus.gov). One concern about Imaging informatics—tissues and organs, such as radiology imaging systems Web sites is their quality, as peer- Clinical informatics—clinicians and patients, including applications of nursing, review mechanisms that normally con- dentistry, and other clinical specialties trol print literature are often not pres- Public health informatics—populations, such as disease surveillance systems ent, and sites purporting to provide *Adapted from Kukafka et al.6 balanced views may well be promoting a point of view or a product to sell.22 Concomitant with the growth of online information resources has been the table devices or whether larger de- due to the Internet and World Wide emergence of tools to use them more vices might be required. Web. More than 50% of the US popu- effectively. Probably the most impor- At the organizational level, the key lation uses the Web regularly, and of tant of these is evidence-based medi- challenges have been managing com- those who do, more than 50% search cine.23 The original focus of evidence- plex informatics applications and the for personal health information.17 Phy- based medicine was to train clinicians computer networks upon which they sicians have embraced the Web as well, to find and critically appraise indi- run. Although individual computers are with 90% using it on a regular basis.18 vidual studies. Few clinicians have relatively inexpensive, maintaining A large variety of online resources are ready access or the time required to large networks of them and training the now available to both patients and search MEDLINE, read articles, and myriad of health care workers who use physicians. The oldest of these is synthesize their findings in the busy them are not. Berg12 has noted that the MEDLINE, the bibliographic database clinical setting. As a result, the focus has interpersonal challenges to large orga- of journal literature with more than 11 changed toward approaches that pro- nizations in implementing EMRs is million references to approximately vide highly concise information in the much more daunting than managing 4000 journals dating from 1966.19 Pro- context of the specific patient and clini- the technology itself. Research has duced by the US National Library of cal problem.24 This has led to a change shown that involving users in the imple- Medicine, MEDLINE is freely avail- in the emphasis of evidence-based mentation process and providing able to the entire world via the PubMed medicine toward the production of syn- features of benefit to them, such as system on the National Library of Medi- theses of clinical topics and concise syn- time-saving measures like specialty- cine Web site (http://pubmed.gov). Bib- opses of their findings.25 specific order sets, widespread imple- liographic databases only contain titles mentation across the organization, and and abstracts of articles; however, us- Decision Support Systems engaging the clinical leadership, are the ers increasingly want the full text of One clinical informatics application, the most important keys to success.13 journals online. The technical chal- decision support system, crosses the Organizational challenges are not lim- lenge of producing such journals has boundary of patient-specific and knowl- ited to hospitals and other large insti- been supplanted by the economic ques- edge-based information. These appli- tutions. A particular problem in the out- tion of how to increase availability when cations, which apply knowledge to pa- patient setting is that small practices electronic publication is cheaper (ie, less tient data, emerged from artificial usually lack the minimal technical ca- printing and mailing costs) but still has intelligence and expert system re- pabilities and financial resources nec- some cost (due to value added in edit- search in the 1970s and 1980s that at- essary to implement EMRs.14 A final ing and production).20 Another chal- tempted to model the clinical diagnos- challenge to all involved with the EMR lenge is how to improve users’ abili- tician. However, the goal of building an is the protection of patient privacy and ties to use such systems, as a systematic electronic diagnostician never materi- confidentiality, with the Health Insur- review has shown physicians do not al- alized and the resulting systems were ance Portability and Accountability Act ways achieve optimal results with too time-consuming for use in the clini- legislating their protection at substan- them.21 cal setting.26 These applications have re- tial cost and effort.15 In addition to the journal literature, emerged in the form of decision sup- other knowledge-based information is port systems, which are embedded in Information Retrieval available on the Web, including many the EMR and aim to detect critical situ- The field concerned with the organi- of the traditional medical textbooks, ations and errors in care and then no- zation and retrieval of knowledge- clinical practice guidelines (National tify the clinician, provide appropriate based information (not limited to medi- Guidelines Clearinghouse [http:// information accordingly, or both.27 cine) is called information retrieval.16 guideline.gov]), and a growing num- Several systematic reviews have docu- This area has seen tremendous growth ber of Web sites aimed at patients and mented the effectiveness of decision

1956 JAMA, October 23/30, 2002—Vol 288, No. 16 (Reprinted) ©2002 American Medical Association. All rights reserved. MEDICAL INFORMATICS support applications within the EMR. cused on usability found that a CPOE pensive care and demonstrate avoidance A variety of approaches, including re- system that allowed physicians to type of error. They will have to accept CPOE, minders that increase adherence with in orders in free text and mapped them because this is the only place to effec- ordering preventive measures, hospi- to known order sets was faster and more tively apply decision support. Society tal admission order sets and display of acceptable than a standard system based as a whole will need to determine who costs, and interventions to detect medi- on a point-and-click interface.36 Re- will pay the costs of EMRs and CPOE, cation prescribing errors, has been lated to usability is the need to demon- because even if they save money in the found beneficial.28-30 Additional work strate value. One study of CPOE dem- long term, the up-front investment will has demonstrated the value of clinical onstrated that use of guidelines and dose be substantial. The key challenge across practice guidelines to standardize care.31 selection menus resulted in signifi- all applications will be adherence to the One interesting finding of decision sup- cantly increased adherence to prescrib- basic goals of the science of medical in- port systems applications is that their ing regimens known to optimize pa- formatics: developing systems that are benefits do not appear to be educa- tient safety and reduce cost.37 easy to use and provide demonstrable tional (ie, they do not result in clini- benefit. Future Directions cians learning how to provide better Funding/Support: Dr Hersh’s work is supported by care). This is illustrated by the fact that Although considerable challenges grants and contracts from the National Library of Medi- when decision support systems appli- remain, the impact of medical infor- cine and the Agency for Healthcare Research and Quality. cations are removed, the adherence to matics will certainly grow. 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The whole purport of literature...isthenotation of the heart. Style is but the contemptible vessel in which the bitter liquid is recommended to the world. —Thornton Wilder (1897-1975)