Clinical Informatics Explained, Part 2: the ‘Who’ and the ‘How’

This is the second in a two-part series focusing on the critical role of clinical informatics in improving user experience. While the first part centered on the ‘what’ and the ‘why’ when it comes to informatics (including how it can specifically help improve workflow), this piece will delve into various roles that exist within the space, the challenges these individuals face, and how they can be addressed.

Where are the Clinical Informaticists?

It can be difficult to identify the clinical informatics professionals on many EMR implementations, because there are often challenges in separating them out from other common Health IT roles – few of which require clinical backgrounds. While these roles commonly overlap, and many people fill more than one role, here are some gross generalizations:

• Clinical analysts. Generally, they work with end-users to analyze, build, test, and implement clinical content in an EMR. While analysts are the backbone and workhorses of configuration for most EMRs — they generally focus mainly on the tools inside the EMR, and often do not have time or expertise to manage additional workflow tools that may be necessary outside the EMR.
• Application Support Professionals. These are often the ‘second-tier help desk’ or ‘second-tier support’ professionals who work with the help desk to respond to more detailed user questions, troubleshoot issues, and provide elbow-to-elbow support for end-users.
• Clinical/credentialed trainers. These are experts at studying clinical workflows, studying application features, developing training materials and curricula, and delivering training in classroom and online settings. They also sometimes assist application support professionals in direct elbow-to-elbow settings.
• Project Managers. These individuals (many with PMP certificates) who are experienced at planning, budgeting, scoping, and leading projects. Their tasks include meeting frequently with stakeholders, developing detailed project plans, timelines, and deliverables, and keeping the team on schedule and on budget.
• Analytics professionals/report writers. They are focused on getting data out of the system, validating it, interpreting it, and displaying it in a meaningful way, to help advance clinical care and research needs.
• Process Improvement Specialists (E.g. Lean or Six Sigma). These are trained professionals who typically report to quality to study clinical processes, study outcomes, and improve upon them. They may or may not have clinical experience.

While clinical informaticists may work with all of the above, or fill some of all of these roles, the informatics role is unique in their ownership of implementing clinical workflows, change management, standards, clinical terminology and translation, information design, indexing, archetype analysis, usability, and clinical outcomes. Clinical informaticists are skilled at critically evaluating details of workflows and configuration, and adjusting them if needed. While it is not always necessary, most come from clinical backgrounds, which is very helpful when trying to navigate clinical terminology, roles, or processes.

Despite their important role, there are other things that may make it more difficult to identify a clinical informatics professional:

1. For many years, clinical informatics was a poorly-understood, poorly-controlled term. Since clinical analysts, application support professionals, clinical/credentialed trainers, project managers, analytics professionals/report writers, and process improvement specialists are all involved in information design and EMR support, some of them might refer to themselves as ‘Informaticists’ or ‘Informatics professionals.’ Unfortunately this loose association clouded the role for the new generation of clinical informaticists who come prepared with formal informatics training and certification.
2. Clinical informatics often reports to IT departments, where there can be a competition for resources.
3. Software vendors, seeking to lower the cost barriers-to-entry for their products, sometimes minimize the importance of having clinical informatics professionals available on projects to help support the clinical analysts, clinical trainers, report writers, application support professionals and process improvement specialists who help develop content and support end-users.
4. Some organizations believe they can save significant time by replacing clinical workflow evaluations and operational discussions with ‘sample content’ that has already been developed by another organization. Unfortunately, these workflow evaluations and clinical discussions are still necessary to validate and align configuration with end-user needs, expectations, and training, which doesn’t allow for much saved time.
5. Many workers fulfill the role of clinical informatics, but through other vague job titles like ‘solutions engineer’ or ‘clinical workflow analyst’ or ‘EMR implementation specialist.’

This somewhat-ironic ‘Informatics terminology issue’ was recently highlighted in this humorous segment from the November 2018 AMIA conference in San Francisco, featuring  President and CEO Doug Fridsma.

Given these terminology, budget, and support challenges, many health IT projects and EMR implementations occur with little or no significant informatics support.

The Cost of No Informatics

Making great clinical configuration, workflows, and outcomes is a lot of work. Many organizations struggle to have the time or resources to fully complete all steps, and so, to meet project deadlines, they often have to make compromises — while still trying to fulfill as many of the steps as possible.

Without well-trained, well-defined clinical informaticists there to support the project team, a few things become clear:

• It is usually difficult to manage all of the steps of a ‘best-practice’ change control and project management process. This can result in user dissatisfaction, lack of engagement, and unplanned outcomes.
• Terminology and naming conventions may be difficult to manage. This can result in reporting challenges, and difficult validation of data.
• Other roles (clinical analysts, application support professionals, clinical/credentialed trainers, project managers, analytics professionals/report writers, and Performance Improvement specialists) may have translational challenges when trying to engage with clinical staff.
• Prioritization of projects may be difficult, without an accurate assessment of needs, and proper scoping and prioritization.
• Without adequate analysis, scoping, prioritization, and design pre-work, analysts may spend time rebuilding workflows that require frequent adjustments.

In my experience, organizations that support the role of clinical informatics to augment their project team generally see better use of their technology, improved user satisfaction, better staff engagement, and improved outcomes.

Improving physician satisfaction

To help clinical staff in Dr. Gawande’s organization better utilize their technology, it’s important to critically assess the configuration and workflows that the providers and their teams are working in every day, and ask some of these questions:

1. Have all of the steps of this workflow been properly organized, designed, and budgeted?
2. What is the clinical governance like? Is it shared or siloed? And how does it interact with administrative governance?
3. Healthcare is a team sport; do the physician, nursing, and pharmacy leaders need to meet to critically assess and re-evaluate their shared clinical goals and needs?
4. Have the current-state and future-state workflows in all service lines been well-documented?
5. Are there templates for common operational tools and documents found both inside and outside the EMR?
6. Do directors and clinical chiefs have adequate support for their participation in EMR discussions (analysis, design, and testing)?
7. What is the request intake, prioritization, and project management process like?
8. How many ways can users find solutions? Is end-user education easily available on the organizational intranet?
9. How is clinical terminology managed and harmonized?
10. How many clinical staff have been trained in workflow development, project management, or document writing (e.g. policies, orders, order sets, protocols, guidelines, clinical documentation, clinical decision support, etc.)?

And, are there trained clinical informatics professionals available to help educate, evaluate, and oversee all of the above?

Finally, I want to thank Dr. Gawande for writing such a great, real, and thought-provoking piece. Burnout is a real issue, and we need to work together to combat it. I hope my discussion helps shed light on how clinical informatics can help change the environment for both providers and patients.

This piece, authored by Dirk Stanley, MD, a board-certified hospitalist, informaticist, workflow designer, and CMIO based, on his blog, CMIO Perspective. To follow him on Twitter, click here.