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106 Biomedical and Health and agency. At its core, biological citizenship Biomedical and poses the question of how people should balance the necessity of having to rely on the technical expertise of others to lead their lives, against the possibility of exerting a hitherto unprecedented Biomedical and health informatics (BMHI) is level of autonomous biological agency made pos- the field that is concerned with the acquisition sible by the biotechnological changes of the last of data, information, and knowledge to improve few decades. On the one hand, the complexity of health, , , and research. knowledge and technology—biological, medical, BMHI is playing a growing role in health-related and otherwise—with which people interface daily fields. On the clinical side, it is increasingly rec- requires a reliance on specialized expertise; on the ognized for developing methods and tools to other hand, these same complexities make avail- improve the quality and safety while reducing the able to everyone new ways of about and cost of health care. For patients and consumers, controlling biological characteristics and their it is seen as providing empowerment to use data impact on people’s future. and information to improve health. BMHI also The relative newness of the biotechnologies makes contributions to research, especially in most closely linked to biological citizenship, areas such as genomics, in which basic biological coupled with their pace of growth and develop- findings are translated to improved diagnosis and ment and the lack of established social norms treatment of disease. and legislative regulations governing them, make biological citizenship an important concept to Basic Terminology of the Field understand, inquire, and use. Concepts related Before exploring the details of BMHI, the word to biological citizenship—Philip Frankenfeld, for informatics needs to be defined. This word has example, proposed a model for “technological been around for several decades and its usage is citizenship,” which defines belonging to a group not limited to biomedical and health disciplines. based on boundaries created by the usage of cer- But certainly in the , the most promi- tain specific technologies, or of technology gener- nent usage of it comes from the biomedical and ally—provide additional perspectives on the kinds health disciplines. William Hersh has defined of questions, problems, and situations related to informatics as the field concerned with optimal biological citizenship. use of information, often aided by the use of tech- nology, to improve individual health, health care, Zoltan P. Majdik public health, and biomedical research. North Dakota State University Informatics is more about information than technology, with the latter being a tool, albeit an See Also: Genetically Modified Organisms, Media important one, to enable better use of informa- Coverage of; Genetics; Risk Society; Scientific tion. The former School of Informatics at the State Complexity, of. University of New York at Buffalo defined infor- matics as the Venn diagram showing the intersec- Further Readings tion of people, information, and technology. C. P. Petryna, Adriana. Life Exposed: Biological Citizens Friedman has defined a “fundamental theorem” After Chernobyl. Princeton, NJ: Princeton of informatics, which states that informatics is University Press, 2002. more about using technology to help people do Rabinow, Paul. Artificiality and Enlightenment: cognitive tasks better than about building sys- From Sociobiology to Biosociality. Princeton, NJ: tems to mimic or replace human expertise. He Princeton University Press, 1996. has also defined informatics as “cross-training,” Rose, Nikolas and Carlos Novas. “Biological bridging an application domain (such as public Citizenship.” In Global Assemblages: Technology, health or ) with basic information sci- Politics and Ethics as Anthropological Problems, ences. Friedman has also defined informatics by Aihwa Ong and Stephen J. Collier, eds. Oxford: what it is not, including analyzing large data Blackwell, 2005. sets, employment in circumscribed information Biomedical and Health Informatics 107 technology (IT) roles, or anything done using a which is often housed academically in engineer- . ing schools. However, IT professionals come from Within BMHI are myriad subdisciplines, all other backgrounds, including fields such as man- of which apply the same fundamental agement information systems (MIS), whose pro- and methods, but are focused on particular sub- grams are usually in business schools. Within IT ject domains. Edward H. Shortliffe has proposed and are a heterogeneous array that informatics proceeds along a continuum of people with varying skills, including develop- from the cellular and molecular () ers, programmers, software engineers, informa- to the person (medical or clinical informatics) to tion architects, and support personnel. the population (public health informatics). The Another source of diverse terminology con- application of informatics is focused on specific cerns the health record of the individual. When health care disciplines such as (nursing these records were first computerized, the term informatics), (dental informatics), and electronic (EMR) was most com- (pathology informatics), as well as monly used. However, this has mostly been sup- among consumers and patients (consumer health planted by the term informatics) (see Figure 1). There are also disci- (EHR), which implies a broader and more longitu- plines in informatics that apply across the cell- dinal collection of information about the patient. person-population spectrum, as follows: There is increasing interest in the (PHR), which usually refers to the patient- • : informatics with a controlled aspect of the health record, which may focus on imaging, including the use of or may not be tethered to one or more EHRs from picture archiving and communication health care delivery organizations. systems (PACS) to store and retrieve There has been a major investment in EHRs images in health care settings. in the United States since 2009, when the Health • Research informatics: the use of infor- for Clinical and Eco- matics to facilitate biomedical and health nomic Health (HITECH) Act was included as research, including a focus on clinical part of the American Recovery and Reinvest- and translational research that aims to ment Act (ARRA, also known as the economic accelerate research findings into health care.

Related Terminology of Informatics Imaging informatics Research informatics There are a number of other terms that are impor- tant for one to understand in the context of BMHI. {Clinical field} Consumer health The term health information management (HIM) informatics informatics is the discipline that has historically focused on the management of medical records. As medi- cal records have become electronic, this field has Bioinformatics Medical Public health been in transition and increasingly overlaps with (cellular and or clinical informatics molecular) informatics. One major difference between HIM informatics (population) and informatics is the educational path of practi- (person) tioners. HIM professionals have historically been educated at the associate or baccalaureate level, Biomedical whereas informaticians often come from clini- Legal Chemo‑ informatics and health informatics cal backgrounds, including those with doctoral informatics degrees such as M.D. or Pharm.D. Information technology (IT) is the term gener- Informatics = People + Information + Technology ally used to describe and related tech- nologies in operational settings. The academic Figure 1 An overview of biomedical and health informatics discipline that underlies IT is computer science, and its subdisciplines 108 Biomedical and Health Informatics stimulus bill). HITECH allocates up to $29 bil- for other applications such as quality assurance, lion in incentives for the adoption of EHRs by , and public health. and other professionals as well as hos- Another broad set of terms important to BMHI pitals in the United States. The HITECH program are the “tele-” terms. The two most widely used is administered by the Office of National Coor- terms are “telemedicine,” which refers to the dinator for Health Information Technology, an delivery of health care when the participants are agency within the U.S. Department of Health and separated by time or distance, and “,” Human Services. which has more of a focus on direct interaction Related to EHR growth is interest in health with health on information and communication information exchange (HIE), which is the exchange technology (ICT). As with informatics, the “tele-” of health information for patient care across tradi- terms sometimes reflect medical specialties in tional business boundaries in health care and was which they are applied, for example, teleradiol- also funded through the HITECH Act. Even many ogy and . health care organizations that have exemplary A somewhat related term is e-Health, which is health IT systems have difficulty providing their sometimes defined as the application of ICT to patient information to other entities where the health and health care. A variant of this term is patient may receive care. An increasingly mobile m-Health, which focuses on applications of ICT population also needs to have “data following the using mobile devices connected wirelessly to net- patient.” HIE is actually but one example of what works such as smartphones and tablets. is sometimes called secondary use or re-use of clin- Another area important to BMHI is evidence- ical data, where data from clinical settings is used based medicine (EBM). Some use the term

A doctor scrutinizes digitized medical images on his computer. Images are an essential chapter in a patient’s health history, and health care professionals rely on them to diagnose or monitor illnesses and plan a patient’s care. For patients and consumers, biomedics— the use of data and information to improve health—is viewed as a means of providing empowerment. Biomedical and Health Informatics 109 evidence-based practice (EBP), which advocates criteria. This review found benefits from EHRs that health care decisions be made using the and health IT systems designed to run indepen- best available scientific evidence by those who dently from EHRs, but little formal evaluation of receive care, informed by the knowledge of those other types of applications. There were somewhat who provide care, and within the context of fewer relevant studies from the health IT leader available resources for that care. A new term to organizations. emerge related to EBM is “comparative effective- These reviews were updated using the same ness research” (CER), which has been defined as methodology in 2011. The authors reviewed the research studies that compare one or more diag- literature similar to the previous reviews and nostic or treatment options to evaluate effective- found that 92 percent of the recent articles on ness, safety or outcomes. health IT reached conclusions that were positive overall. The authors also found that the benefits The Value of Informatics of health IT were beginning to emerge in smaller All of these nuanced definitions of informatics practices and organizations, as well as in large and its subdisciplines would be moot if infor- organizations that had been early adopters. How- matics did not provide value to health. A great ever, they also noted that dissatisfaction with deal of research does show that informatics when EHRs among some providers was still high and properly applied can contribute to the “triple a barrier to achieving value. They concluded that aim” of improved health, improved health care, studies documenting the challenging aspects of and reduced health care costs. Most studies of implementing health IT and how those challenges the value of informatics have come from the might be addressed were critically needed. health care setting, making a challenge to public health informatics (PHI) and other subdisciplines Conclusion to demonstrate value scientifically in their set- It is critical that an understanding of PHI include tings. A good deal of the evidence for the value of the perspective of the larger BMHI as well as BMHI is summarized in three successive system- where subdisciplines such as PHI fit in. The value atic reviews. of BMHI has been demonstrated in studies and The first systematic review to critically analyze summarized in systematic reviews as well as all informatics evaluation studies to date was developed via educational programs. published in 2006. A total of 257 studies met the inclusion criteria. Most studies addressed William Hersh decision support systems or EHRs. One concern Oregon Health and Science University was that approximately 25 percent of the stud- ies were from four academic institutions that See Also: Digital Personal Health Records; Evidence: had implemented internally developed systems; Role in Campaigns; Health Information Channels; only nine studies evaluated multifunctional, Medical Records, Electronic; Oral Health and commercially developed systems. The review Dentistry; Secondary Data Analysis; Severe Acute concluded that evidence for the value of BMHI Respiratory Syndrome; Telemedicine. was demonstrated most prominently in three areas: increased adherence to guideline-based Further Readings care, enhanced surveillance and , and Berwick, D. M., et al. “The Triple Aim: Care, Health, decreased medication errors. The primary clini- and Cost.” Health Affairs, v.27 (2008). cal domain of these improvements was preven- Buntin, M. B., et al. “The Benefits of Health tive health. The major efficiency benefit shown Information Technology: A Review of the Recent in the studies was decreased utilization of care. Literature Shows Predominantly Positive Results.” Data on another efficiency measure, time utili- Health Affairs, v.30 (2011). zation, were mixed, while empirical cost data Chaudhry, B., et al. “Systematic Review: Impact were limited. of Health Information Technology on Quality, A second systematic review was published in Efficiency, and Costs of Medical Care.” Annals of 2009. In this review, 179 studies met the inclusion , v.144 (2006). 110 Biopower and Biopolitics

Friedman, C. P. “A ‘Fundamental Theorem’ of Health care systems and practices respond to Biomedical Informatics.” Journal of the American changing values, economies, and illness pat- Medical Informatics Association, v.16 (2009). terns. Take, for instance, emergent policies, edu- Friedman, C. P. “What Informatics Is and Isn’t.” cational efforts, and drug markets generated by Journal of the American Medical Informatics emergent forms of knowledge about depression, Association, v.20 (2012). deficit hyperactivity disorder (ADHD, Goldzweig, C. L. et al. “Costs and Benefits of Health diabetes, and obesity. As suggested by anthro- Information Technology: New Trends From the pologist Paul Rabinow and sociologist Nikolas Literature.” Health Affairs, v.28 (2009). Rose, genomic medicine might enable new tests, Hersh, W. “A Stimulus to Define Informatics and , values, other mechanisms around the Health Information Technology.” BMC Medical commercial-medical mapping and of Informatics and Decision Making, v.9 (2009). life and health. http://www.biomedcentral.com/1472-6947/9/24 In line with Foucault’s theorizing of power more (Accessed March 2013). generally, biopower differs from some more tradi- Shortliffe, E. H. and J. J. Cimino, eds. Biomedical tional notions of power in the following ways: Informatics: Computer Applications in Health Care and Biomedicine 4th ed. New York: Springer, • It is not wholly or necessarily oppres- 2013. sive, negative, or harmful, but can impact people in various ways (therefore it must be judged based on its effects). • It is not repressive but productive, creat- ing various strategies, procedures, and Biopower and Biopolitics techniques for managing people (as indi- viduals, groups, populations) and knowl- Biopower is a concept originated by French phi- edge about them. losopher Michel Foucault and adapted by schol- • It produces and is, in turn, shaped by ars in health communication and the rhetoric of specific forms of knowledge (e.g., from health (among others) to analyze and critique clinical medicine, public health, medi- the power relations involved in health-related cal research, health marketing, personal discourses and practices. The relational nature health care management) about life and of biopower—that it comes out of and works health. through sociocultural, political, economic, inter- • It is not centralized in sites or authori- personal, and other relationships—is especially ties but dispersed over a wide range of important. Foucault developed the concept from health-related practices and discourses, studying how new forms of knowledge, institu- including the small, everyday ones of tions, and techniques, including those involved ordinary people. in clinical medicine and public health, emerged • Although it is driven by specific values in the 18th century to regulate people’s health and goals, it is not fixed but dynamic and and lives. therefore able to be adapted or revised. Like the studies from which it was derived, biopower is always historically specific; as health Regarding the last two items, biopower works care systems, institutions, and practices change, not in a top-down direction on people but by so do the ways they operate and function to enlisting them, often through communication, shape people, their actions, and knowledge to participate in their self-management. Thus, about them. One might observe, for example, people are not the passive objects of biopower, how health knowledge and management systems but are shaped by and participate in its processes, have become increasingly privatized and market though they can be variously constrained or even driven, generating new forms of health regula- oppressed in their actions. People’s responses tion around personal health care management, have the potential to reshape the mechanisms and evidence-based medicine, and other strategies. effects of power relationships, but they are also