An Informatics Primer

John S. Luo, MD

Dr. Luo is assistant clinical professor in the Department of Psychiatry and Biobehavioral Sciences at the University of California in Los Angeles.

Information and technology have long been integral to the practice of medicine. In the early days of medicine, information and understanding about various diseases grew with keen observation and intellectual curiosity. Technology, such as computerized tomography, gene sequencing, and insulin pumps, has shaped the practice of medicine with even more disease information as well as treatment implications. Today, the practice of modern medicine continues to be both a fine art and science that requires a tremendous amount of information. Physicians now require new tools to assist them in the management of information in the many tasks of patient care. Gone are the days of literature searches using Index Medicus, which involved perusing through many large volumes of books. Medical records are voluminous with laboratory tests and imaging reports, and encounter documentation. This demand for information management in its various forms in the practice of medicine has led to a new discipline of information technology called medical informatics.

Edward H. Shortliffe, MD, PhD, director of medical informatics at Columbia University in New York City, has defined medical informatics as “the scientific field that deals with biomedical information, data, and knowledge—their storage, retrieval, and optimal use for problem-solving and decision-making”. 1 This term is defined to be inclusive of basic and applied fields in biomedical science as well as modern information technologies in areas of computing and communication. Medical informatics has emerged as a new discipline because of rapid advances in computing and communication technology as well as the increasing amount of medical knowledge that is simply no longer manageable with traditional paper-based methods. Some examples of specific technologies in the domain of this field include artificial intelligence, clinical-decision support systems, patient-monitoring systems, computerized patient record systems, and information retrieval systems. Medical informatics encompasses both the “basic science” of neural networks and artificial intelligence as well the “clinical practice” of implementing these technological advances in patient care.

Computers have become the primary information tool of the modern physician, but there is a significant difference between computer literacy and knowledge and understanding of the role that computers play in health care. Computer literacy involves the mastery of basic skills that enable the user to input, access, and retrieve information from the computer. Over 15 years ago, computer literacy was challenging to many physicians faced with entering commands at a DOS (disk operating system) prompt and using keys with predefined functions. Today, computing power has improved dramatically to enable graphical interfaces such as the Windows and Mac OS operating systems to serve as intermediaries and shield users from the unintuitive command line. The technology behind the World Wide Web has made the Internet into a growing information space for health and other information, but its magnitude can be overwhelming. Fortunately, search engines such as Google have enabled users to find relevant information on the Internet. These developments have made computing a far more user friendly, instinctive, and efficient way to manipulate information, enabling the user and reducing the barrier to computer literacy.

However, the use of computers in health care is not a simple matter of computer literacy, but a more involved process involving a myriad of factors. For example, the use of a computer to generate a progress note is commonplace, but how does doing so during a patient visit impact the patient-physician relationship? Given the sensitive nature of psychiatric information, how secure is that information once it is entered into the computer? What is the balance between security and availability? These questions are answered with a greater understanding of how computers impact communication and information access in the healthcare setting. The development of such distinct knowledge in this interface between health care and computer science is one of the many domains of medical informatics.

Novel and innovative technology alone is not sufficient enough to drive adoption and usage of computer hardware and software. Healthcare organizations are one of many complex organizational systems in society, described often as having even their own culture. Human factors play a significant role in determining which computer systems succeed as well as the ultimate responsibility in deciding which systems fail. Process engineering, change management, diffusion of innovation theory, and workflow analysis are some of the non-technical considerations that are also important in medical informatics. Silverstein 2 chronicles many of these issues on his clinical computing Web site. Understanding human behavior and cognition, as well as recognizing workplace culture, are important informatics principles.

Given the many different nuances to consider in using computer technology in the practice of medicine, it may appear that this specialty is limited only to those with dual training in computer science and medicine. However, medical informatics includes domains such as public health, nursing, veterinary medicine, bioinformatics, imaging, and dentistry. It differs from medical computer science in that it draws upon decision sciences, cognitive sciences, information sciences, and management sciences. It is closely related to biomedical engineering, but differs in that biomedical engineering focuses more on research and development of instrumentation, monitoring systems, and medical devices. With its rather broad range of domains, professionals in medical informatics have a rich diversity of backgrounds and expertise.

Training in medical informatics traditionally involves either a masters or doctorate degree in informatics or via a National Library of Medicine (NLM)-sponsored postdoctoral fellowship. 3 Degree-based programs are typical of most graduate programs, requiring several years of study and generating a thesis. Most professionals choose the postdoctoral research fellowship route. These NLM sponsored fellowships are available for both physicians and computer science PhD’s who wish to receive postdoctoral training in medical informatics. Many programs have NLM-funded center grants that provide training and salary support. Alternatively, postgraduates may also apply for an NLM fellowship as an individual at his or her home institution under the guidance of a mentor.

Although training in medical informatics may be intriguing to physicians already actively in practice, taking a hiatus for a year or longer for training is a daunting and somewhat impractical idea. A viable alternative includes taking a short course or online training available at the many training sites listed on the American Medical Informatics Association (AMIA; http://www.amia.org) Web site. Many physicians involved with medical informatics have no formal training, but are extensively involved in various computing projects with telemedicine, personal digital assistants, treatment algorithms, computerized therapy, e-therapy, etc. These projects and technologies are often presented at the AMIA annual meeting and at the annual meeting of the Association for Technology in Psychiatry (http://www.techpsych.org). These associations are open to all professionals regardless of computing expertise, and they serve as a fertile ground for exchange of expertise and ideas.

The goal of the “Tech Advisor” column is to distill many of the topics in medical informatics into executive summaries for the busy clinician. Each column will review the historical background, explain the technology basics, and highlight the clinical implications of various topics such as electronic medical records, virtual therapy, telemedicine, and computer-based therapy. Medical informatics is a relatively new, but important specialty that functions at the crossroads of clinical medicine and computer science. With new computer hardware and software available on a daily basis, the impact on the practice of medicine is more than just an “upgrade.” Applying informatics principles and knowledge will help physicians to recognize the benefit and limitations of new computing and communication technologies to enhance their ability to deliver quality and efficient medical care.

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