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Home , Informationist, Library science, Medical library, National library

Medical : an alternative pathway for training informationists

By William Hersh, M.D. [email protected] Professor and Head

Division of Medical Informatics and Outcomes Research Oregon Health & Science University 3181 Southwest Sam Jackson Park Road Portland, Oregon 97201-3098

Recognition of the growing complexity of health needs has led to a call for the creation of a new health care professional, the . Controversy exists as to the role of such individuals and what their training should be. A science degree, augmented with clinical background or experience, is one pathway. Another to consider is training in medical informatics. With the right coursework, individuals trained in medical informatics should be equally well qualified to assume the role of informationists.

INTRODUCTION ing prudent fiscal for their institutions’ information resources are part of the overall role of The call for creating new health care professionals de- , but may not be required of all information- voted to the information needs of the clinical team has ists. On the other hand, some of the unique aspects of created a stir in the community. With medical informatics do address their specialized roles. the growth of end-user searching tools, relatively in- While medical informatics and are not experienced users can now obtain access to essentially mutually exclusive (indeed our medical informatics all the clinical information previously available only to training program at Oregon Health & Science Univer- those who worked in . Furthermore, as it be- sity [4] has funding from the of Med- comes clear that have frequent information icine to provide fellowships for librarians), the major- needs (on the order of two questions per three pa- ity of individuals who seek medical informatics train- tients) [1], economics alone clearly dictate that librar- ing are not librarians. Not only is medical informatics ians will be unable to take part in most clinical infor- training an alternative pathway for the required skills mation seeking. of informationists, but, in fact, individuals do not have There will be instances, of course, when the services to be librarians to become informationists. of information professionals will emerge as an impor- tant part of the clinical team, particularly in critically BACKGROUND ON MEDICAL INFORMATICS ill . For these instances, Davidoff and TRAINING Flornace have argued that a new professional, the in- formationist, must emerge [2]. The medical library Medical informatics is the field concerned with ac- community has responded by touting the virtue of quiring, storing, and using information in health care, clinical librarianship and affirming the value of library usually (but not always) involving the application of science training [3]. [5]. It is a broad, multidisci- While the value of librarians to the information mi- plinary field, covering electronic medical records, ac- lieu of medical centers is unquestioned, it is not clear cess to knowledge-based information and digital li- that clinical librarianship represents the only path to braries, digital imaging systems, telemedicine, clinical training informationists. Another path to consider for decision support, and more. Closely related to medical training such individuals is through education in med- informatics (or perhaps a part of medical informatics) ical informatics. Librarians’ responsibilities and skills is evidence-based (EBM), which focuses on cover a broader range of institutional functions than creating tools to access and apply the best evidence for the needs that would be met by informationists. Build- making decisions about care [6]. ing and managing collections, supporting broad rang- The boundaries of medical informatics are fuzzy. es of user services to diverse populations, and provid- Are individuals who work in information technology

76 J Med Libr Assoc 90(1) January 2002 Medical informatics education departments of medical centers medical informati- stitutes of Health. Bioinformatics focuses on informat- cians? Are librarians informaticians? Are individuals ics issues related to molecular biology and genomics. who do research, performing complex analyses of the A brief discussion of the master’s of science in med- output of gene microarrays, informaticians? ical informatics program at OHSU indicates why such Because of these fuzzy boundaries, there is no com- training can suitably prepare individuals to become mon medical informatics curriculum, nor any common informationists.§ The OHSU program traces its lineage job that anyone with training in the field could hold. to the early trail blazers in the field, particularly Stan- (There probably is a core curriculum in medical infor- ford University and the University of Utah. One di- matics, but that is the topic of a different paper.) The vergence from these leaders is more emphasis on pre- lack of a common skill set and curriculum is different paring professionals (as opposed to researchers), al- from librarianship or medicine, where there are basic though the OHSU program is flexible enough to allow skills that all with library science or medical degrees, those interested in research careers to pursue them, respectively, can be expected to have. particularly if they already have doctoral training in Most training in medical informatics is provided by another field. the dozen programs funded by the National Library The OHSU program has courses in four major areas: of Medicine (NLM).* A majority of trainees in these medical informatics, health and medicine, computer programs are postdoctoral, who often, but not always, science, and quantitative methods. The medical infor- have medical doctor degrees. A growing number of matics courses cover the core of the field. An intro- programs also offer academic degrees, either at the ductory survey course broadly covers the main areas master’s or doctoral level, in medical informatics or a of information and information technology applica- related field, such as computer science, intelligent sys- tions in health care. A following course, ‘‘Clinical Sys- tems, or systems science. In most postdoctoral pro- tems,’’ covers the issues surrounding patient-based in- grams, the degree is optional. formation in health care, with particular focus on the There are additional routes for medical informatics electronic medical record. A third core course, ‘‘Infor- training that do not require residence at an NLM- mation Retrieval,’’ focuses on knowledge-based infor- funded program. There are also a growing number of mation, including the use of resources likely to be of great use by the informationist, such as MEDLINE and institutions without NLM funding that offer degree evidence-based compendia. The OHSU program may programs in medical informatics. Another pathway to be somewhat anomalous in having an entire course on training in medical informatics is the short course, , but most programs cover at least with the offerings by NLM and Stanford University the basics of this area. the best-known programs. Some institutions also offer There are additional required courses in the medical more clinically focused training, such as the continu- informatics area. Courses in organizational behavior ing medical course for clinicians at Oregon Health & and management and project management teach stu- Science University (OHSU), ‘‘Using Computers to dents how to function in organizations and work as Solve Clinical Problems.’’† A more recent phenomenon teams. A scientific writing course ensures that stu- is the development of distance-learning programs in dents are capable of written communication. There are medical informatics, such as the graduate certificate also electives in other medical informatics areas, such program offered by OHSU.‡ as security and confidentiality, implementation of clin- There are also programs that offer training in infor- ical systems, and individual research or practicum ex- matics that substitute other adjectives in place of periences arranged by the students. ‘‘medical’’ in front of ‘‘informatics.’’ There is a long The health and medicine area of the curriculum cov- tradition, for example, of informatics pro- ers clinical medicine topics for those without clinical grams that focus on information issues for nurses. backgrounds. Students take part in portions of the There are likewise programs in dental informatics that principles of clinical medicine offered to OHSU med- focus on issues for . More recent is the growth ical students in their preclinical training [7]. This area of bioinformatics, poised to expand dramatically due of the curriculum also includes a course in ethical, le- to recent infusions of funding from the National In- gal, and social issues in informatics required of all stu- dents. As with most medical informatics training pro- * Information about the National Library of Medicine (NLM) pro- grams, computer science is a required element of the grams may be viewed at http://www.nlm.nih.gov/ep/ curriculum. OHSU faculty believe that, while few of curr࿞inst࿞grantees.html. † The Website for the Oregon Health & Science University (OHSU) the graduates will become programmers (unless they course, ‘‘Using Computers to Solve Clinical Problems,’’ may be viewed at http://www.ohsu.edu/bicc-informatics/cme/. ‡ The Website for the OHSU distance-learning program may be § The Website for the OHSU medical informatics program may be viewed at http://www.ohsu.edu/bicc-informatics/distance/. viewed at http://www.ohsu.edu/bicc-informatics/ms/.

J Med Libr Assoc 90(1) January 2002 77 Hersh had programming skills prior to entering the pro- ministration of their institutions to obtain access to gram), all of them should have a fundamental under- them. They must also have expertise in searching these standing of the computer science issues most relevant resources, from effectively using the Medical Subject to medical informatics. They should also be able to Headings (MeSH) vocabulary to skillfully querying converse as colleagues with programmers and other full-text resources that are not manually indexed. technicians who work with information technology. The skills in the previous paragraph are what would The OHSU computer science sequence focuses on basic be expected from any well-trained . But in- computer programming, organization and formationists require more skills. They must also have querying, and computer network operations. A recent some familiarity with the clinical setting. Background survey of graduates, few of whom do significant com- in a clinical area (e.g., medicine or nursing) is very puter programming, confirmed the value of this por- helpful but not essential. However, some basic under- tion of their education [8]. Students seeking more ad- standing of human health and disease, along with a vanced courses in computer science can take courses perspective on how the health care system and the offered by the Department of Computer Science and professionals within it function, are paramount. Also Engineering in OHSU’s School of Science and Engi- required is an understanding of EBM, including the neering. ability to phrase an answerable question, locate and The final area of the curriculum is quantitative retrieve the best evidence, and critically appraise and methods. The goal of this portion of the curriculum is apply it. to provide skills in and understanding of carrying out Graduates of the OHSU medical informatics pro- research and analyzing clinical data. After a first gram, and likely graduates of most any other medical course in biostatistics, a second course covers the fun- informatics program with the proper coursework, damentals of research design. A third course is devot- would be capable of performing all of the tasks in the ed to outcomes research, surveying the variety of ways prior two paragraphs. OHSU’s ‘‘Information Retriev- that the outcomes of clinical care are analyzed and al’’ course teaches the skills of being able to identify compared. An additional elective covers medical de- and search appropriate resources. The clinical back- cision making. ground is present by virtue either of past clinical train- While other medical informatics programs organize ing or the ‘‘Principles of Clinical Medicine’’ course. their courses and subject areas differently, it is likely Training in EBM is received in the introductory med- that most follow, or at least allow, a similar course of ical informatics course as well as throughout the quan- learning. Such training should allow individuals to titative methods sequence. The ability to function as pursue careers as informationists. part of a team is grounded in the ‘‘Organizational Be- MEDICAL INFORMATICS TRAINING AND THE havior & Management’’ course. INFORMATIONIST This author can speak to the skills required of in- formationists not only as the head of a medical infor- Medical informatics trainees are not uniquely qualified matics training program, but also as an employer of to serve as informationists. However, medical infor- an informationist. My institution has recently estab- matics training can serve as another pathway to train- lished a Web-based, asynchronous clinical consultation ing the informationist. Individuals so trained are as service that allows physicians in rural areas of Oregon well qualified to serve as informationists as those with to ask questions of specialists at OHSU, aiming for a library science training. turnaround time of one business day. Funded in part Is informatics training sufficient for informationists? by the Eugene Garfield Foundation, the goal of this To answer this, the skills required of informationists project is to determine whether such a service is valu- must first be examined. Clearly, such individuals must able and cost effective without placing an undue bur- be aware of the vast array of information resources and den on the specialists, who must take time from their the ways to access them. They must be familiar with already busy days to answer the questions. Another medical journals, literature , medical text- goal of the system is to reduce the cost and burden of books, practice guidelines, and the growing number of the current phone-based consultation system, whose ‘‘synthesized’’ evidence-based resources, such as the synchronous nature is an obstacle for both users of the Cochrane Database of Systematic Reviews** and Clin- service and the specialists who answer the questions. ical Evidence.†† Informationists must know not only The informationist plays a key role in this project. The what these resources are but also work with the ad- informationist triages the question to the appropriate specialists, interacts with them to obtain the answer, ** The Website for the Cochrane Database of Systematic Reviews and provides assistance in designating appropriate re- may be viewed at http://www.cochrane.org. sources (journal literature or otherwise) to back up the †† The Website for Clinical Evidence may be viewed at http:// answers to the questions. This position requires a va- www.evidence.org. riety of technical, clinical, and organizational skills.

78 J Med Libr Assoc 90(1) January 2002 Medical informatics education

CONCLUSIONS related, they operate in independent spheres, both of which are relevant to the problem of getting the right As stated in the introductory article to this series, the information to busy clinicians at the point of need. We need to provide information to clinicians and patients now have an opportunity for the two fields to work has never been stronger [9]. With growing concerns together to identify the appropriate skills for infor- about the quality of health care as well as the patient mationists and ensure that individuals of either train- experience when receiving that care, the ability to ac- ing experience can apply and teach them effectively. cess the best information in a timely manner is para- mount. One way to facilitate this process is through REFERENCES the training of informationists, individuals who have the skills to find appropriate information, extract the 1. GORMAN PN. Information needs of physicians. J Am Soc best evidence, and assist clinicians and patients in ap- Inform Sci 1995 Dec;46(10):729–36. plying it to make the best decisions. 2. DAVIDOFF F, F LORANCE V. The informationist: a new health ? Ann Intern Med 2000 Jun 20;132(12):996–8. Clearly one pathway for training informationists is 3. SCHACHER LF. Clinical librarianship: its value in medical to augment the skills of traditional library science care. Ann Intern Med 2001 Apr 17;134(8):717–20. training with additional material in EBM, as well as 4. HERSH WR. Oregon Health & Science University’s 2-for-1 the basics of clinical medicine and health care orga- proposition: the fusion of medical informatics and outcomes nization. A growing number of library science pro- research. M D Comput 1999 Sep–Oct;16(5):35–7. grams are already doing this. But another pathway to 5. SHORTLIFFE EH, PERREAULT LE, EDS. Medical informatics: training informationists is via training in medical in- computer applications in health care and biomedicine. 2d ed. formatics. As long as there has been adequate instruc- New York, NY: Springer-Verlag, 2001. tion in information retrieval and EBM, along with ei- 6. SACKETT DL, STRAUS SE, RICHARDSON WS, ROSENBERG W, HAYNES RB. Evidence-based medicine: how to practice and ther a background or additional training in clinical teach EBM. 2d ed. New York, NY: Churchhill Livingstone, medicine and health care organization, individuals 2000. with training in medical informatics are equally well 7. FIELDS SA, TOFFLER WL, ELLIOTT D, CHAPPELLE K. Prin- qualified to be informationists. ciples of clinical medicine: Oregon Health & Science Univer- In light of the fact that the need for individuals with sity School of Medicine. Acad Med 1998 Jan;73(1):25–31. the skills of informationists will only increase as the 8. PRICE SR, LOGAN JL, HERSH WR. The role of computer volume of medical knowledge grows and as more ed- science and computing skills in a medical informatics cur- ucated patients demand a voice in their care, it is im- riculum. Proceedings of the 2001 Annual American Medical Informatics Association Fall Symposium. Washington, DC: in portant to go beyond arguing whether or not a library press. science or a medical informatics background is the 9. SHEARER BS, SEYMOUR A, CAPITANI C. Bringing the best ‘‘best’’ training. Library science and medical informat- of medical librarianship to the patient team. J Med Libr As- ics have developed as intersecting fields with similar soc 2001 Jan;90(1):22–31. interests but significant divergences in scope and ac- tivity. While the problems they seek to address are Received June 2001; accepted August 2001

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