If you are involved in electronic medical record (EMR) implementations, or healthcare technology in general, someone probably forwarded you the recent New Yorker article (Why Doctors Hate Their Computers) by surgeon and innovative healthcare thinker Atul Gawande, MD.
In the style of Dr. Gawande’s excellent narrative and analysis, this is a well-written, thoughtful piece about the common challenges of EMR implementation, as told from the front lines of medicine: The surgeon who feels the EMR is controlling him, instead of vice-versa. The Internal Medicine Primary Care Physician (PCP) who spends hours after her shift documenting her notes and managing problem lists. The rigidity of EMRs, compared with the fluidity of paper. The use of physician scribes, with questionable improvement in outcomes. And the patients who lose when their provider no longer focuses solely on them during a clinic visit. These are all real — but there is more to the story.
Dr. Gawande very eloquently describes these very real and common scenarios, why they happen, and their impacts on providers and patient care, both for good and for bad. I appreciate his storytelling, and how it educates people about some very real usability issues. And so this is not a rebuttal, but more of a commentary on his piece. As a clinical informatics professional, I was somewhat disappointed that nowhere in his essay did he share the term “clinical informatics,” the discipline that works to implement emerging technology in the safest, most sensible, and cost-effective manner possible.
Given the wide audience for this piece, it could have been a great opportunity to educate the general public about this underrated, poorly-understood, but very important clinical discipline.
What is Clinical Informatics?
For those of us who work hard to implement these technologies, we often to struggle to explain this (still!) emerging discipline of information engineering, and how/why it impacts clinical workflows, safety, efficiency, and provider satisfaction.
Here’s a good place to start. Informatics is a branch of the academic field of information engineering, According to Wikipedia:
“It involves the practice of information processing and the engineering of information systems, and as an academic field it is an applied form of information science. The field considers the interaction between humans and information alongside the construction of interfaces, organizations, technologies and systems. As such, the field of informatics has great breadth and encompasses many subspecialties, including disciplines of computer science, information systems, information technology and statistics. Since the advent of computers, individuals and organizations increasingly process information digitally. This has led to the study of informatics with computational, mathematical, biological, cognitive and social aspects, including study of the social impact of information technologies.”
Informatics is a branch of information science, not information technology, that sits right in the intersection between healthcare (clinical medicine), our health system (clinical operations), and information technology and communication.
If IT professionals need to focus on supporting the technology that will store and route all of this clinical information, then informatics professionals are more focused on what information will be stored, and how it will be used for clinical purposes.
To do this, clinical informatics professionals (‘Informaticians’) need to focus on what care is being delivered, and how exactly clinical staff is using (or planning to use) the information and new technology to improve outcomes:
- How will the technology impact the delivery of patient care?
- In which workflow(s) will clinical staff use the technology?
- Is the technology safe, efficient, and well-configured?
- Are any technical, process, or terminology standards needed to support the technology in a harmonious way?
- Does the technology make it easier to deliver good patient care within the planned workflow(s)?
- What kind of training will clinical users need to correctly use the technology?
- What other things might be needed to achieve a successful implementation of the technology?
- What research opportunities will the technology make possible?
So to accomplish their mission, clinical informaticists have to care about both data in and data out, as well as the breadth of workflows that clinical staff will use to deliver quality care. This means studying a wide variety of disciplines, including:
- Clinical medicine, terminology, roles, and operations
- Cognitive and behavioral science
- Evidence-based design principles
- Interface design, usability and interoperability
- Data structure design (e.g. data indexing, archetypes, hierarchies, and logical functioning)
- Process analysis and engineering
- Linguistics and terminology management
- Project management
- Legal/compliance environmental analysis
It’s this kind of detailed analysis and workflow ownership that is necessary to convert turbulent workflows into laminar workflows:
I know this because I am one of the many physicians who is now board-certified in Clinical Informatics by the American Board of Preventive Medicine (ABPM), a program supported by the American Medical Informatics Association (AMIA). With over 12 years of practical, applied clinical informatics experience, I have seen the problems created by turbulent clinical workflows, and worked hard to make them laminar again. And I’ve seen the improved outcomes and provider satisfaction that informatics can offer.
Why Clinical Informatics?
Clinical Informatics professionals are especially helpful when implementing EMRs because, as Dr. Gawande points out, EMRs enforce a certain sense of operational rigidity and role accountability that is difficult to identify (or enforce) in a paper-based clinical environment. If operational standards are not strictly enforced prior to EMR go-live, then these roles will be re-aligned after go-live:
Given this realignment of roles and responsibilities, a significant amount of workflow analysis and engineering must occur for EMR configurations to align with user needs and expectations. Clinical informaticists are particularly adept at this sort of workflow analysis and design, translating the needs between the clinical and IT realms, and providing design and project management support.
In the next part of this series, we’ll break down the various clinical informatics roles, illustrate their importance in establishing effective workflows, and examine the key questions that leaders need to be asking.