Guide to Health Informatics 2nd Edition
Enrico Coiera
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If physiology literally
means ‘the logic of life’, and pathology is ‘the logic of disease’, then health
informatics is the logic of healthcare. It is the rational study of the way we
think about patients, and the way that treatments are defined, selected and
evolved. It is the study of how clinical knowledge is created, shaped, shared
and applied. Ultimately, it is the study of how we organise ourselves to create
and run healthcare organisations. With such a pivotal role, it is likely that
in the next century, the study of informatics will become as fundamental to the
practice of medicine as anatomy has been to the last.
Health informatics is
thus as much about computers as cardiology is about stethoscopes. Rather than
drugs, X-ray machines or surgical instruments, the tools of informatics are
more likely to be clinical guidelines, formal health languages, information
systems, or communication systems like the Internet. These tools, however, are
only a means to an end, which is the delivery of the best possible healthcare.
Although the name
‘health informatics’ only came into use around 1973 (Protti, 1995), it is a
study that is as old as healthcare itself. It was born the day that a clinician
first wrote down some impressions about a patient’s illness, and used these to
learn how to treat their next patient. Informatics has grown considerably as a
clinical discipline in recent years fuelled, in part no doubt, by the advances
in computer technology. What has fundamentally changed is our ability to
describe and manipulate health knowledge at a highly abstract level, as has our
ability to build up rich communication systems to support the process of
healthcare.
We can formally say
that health informatics is the study of information and communication systems
in healthcare. Health informatics is particularly focused on:
1.
Understanding the
fundamental nature of these information and communication systems, and
describing the principles which shape them,
2.
Developing
interventions which can improve upon existing information and communication
systems,
3.
Developing
methods and principles which allow such interventions to be designed,
4.
Evaluating the
impact of these interventions on the way individuals or organizations work, or
on the outcome of the work.
Specific
subspecialties of health informatics include clinical informatics, which
focuses on the use of information in support of patient care and
bioinformatics, which focuses on the use of genomic and other biological
information.
Perhaps the greatest
change in clinical thinking over the last two centuries has been the ascendancy
of the scientific method. Since its acceptance, it has become the lens through
which we see the world, and governs everything from the way we view disease,
through to the way we battle it. It is
now hard to imagine just how controversial the introduction of theory and
experimental method into medicine once was. Then, it was strongly opposed by
the views of the empiricists, who believed that observation, rather than
theoretical conjecture, was the only basis for the rational practice of
medicine.
With this perspective,
it is almost uncanny to hear again the old empiricists’ argument that
‘healthcare is an art’, and not a place for unnecessary speculation or
formalisation. This time, the empiricists are fighting against those who wish
to develop formal theoretical methods to regulate the communal practice of
healthcare. Words like quality and safety, clinical audit, outcome measures,
healthcare rationing and evidence-based practice now define the new
intellectual battleground.
While the advance of
science pushes clinical knowledge down to a fine-grained molecular and genetic
level, it is events at the other end of the scale are forcing us to change. Firstly,
the enterprise of healthcare has become so large that it now consumes more
national resources than any country is willing to bear. Despite sometimes
heroic efforts to control this growth in consumption, the healthcare budget
continues to expand. There is thus a social and economic imperative to control
healthcare and minimise its drain on social resources.
The structure of
clinical practice is also coming under pressure from within. The scientific
method, long the backbone of medicine, is now in some ways under threat. The
reason for this is not that experimental science is unable to answer our
questions about the nature of disease and its treatment. Rather, it is almost
too good at its job. As clinical research ploughs ahead in laboratories and clinics
across the world, like some great information machine, health practitioners are
being swamped by its results. So much research is now published each week that
it can literally take decades for the results of clinical trials to translate
into changes in clinical practice.
So, healthcare workers
find themselves practising with ever restricting resources and unable, even if
they had the time, to keep abreast of the knowledge of best practice hidden in
the literature. As a consequence, the scientific basis of clinical practice
trails far behind that of clinical research.
Two hundred years ago,
enlightened physicians understood that empiricism needed to be replaced by a
more formal and testable way of characterising disease and its treatment. The
tool they used then was the scientific method. Today we are in analogous
situation. Now the demand is that we replace the organisational processes and
structures that force the arbitrary selection amongst treatments with ones that
can be formalised, tested, and applied rationally.
Modern healthcare has
moved away from seeing disease in isolation, to understanding that illness
occurs at a complex system level. Infection is not simply the result of the
invasion of a pathogenic organism, but the complex interaction of an
individual’s immune system, nutritional status, environmental and genetic
endowments. By seeing things at a system level, we come ever closer to
understanding what it really means to be diseased, and how that state can be
reversed.
We now need to make the
same conceptual leap and begin to see the great systems of knowledge that
enmesh the delivery of healthcare. These systems produce our knowledge, tools,
languages and methods. Thus, a new treatment is never created and tested in
intellectual isolation. It gains significance as part of a greater system of
knowledge, since it occurs in the context of previous treatments and insights,
as well as the context of a society’s resources and needs. Further, the work
does not finish when we scientifically prove a treatment works. We must try to
communicate this new knowledge and help others to understand, apply, and adapt
it.
These then are the
challenges for healthcare. Can we put together rational structures for the way
clinical evidence is pooled, communicated and applied to routine care? Can we
develop organisational processes and structures that minimise the resources we
use and maximise the benefits delivered? And finally, what tools and methods
need to be developed to help achieve these aims in a manner that is
practicable, testable and in keeping with the fundamental goal of healthcare -
the relief from disease? The role of health informatics is to develop a systems
science for healthcare that provides a rational basis to answer these
questions, as well as to create the tools to achieve these goals.
The scope of
informatics is thus enormous. It finds application in the design of clinical
decision support systems for practitioners, in the development of computer
tools for research, and in the study of
the very essence of medicine - its corpus of knowledge. Yet the modern
discipline of health informatics is still relatively young. Many different
groups within healthcare are addressing the issues raised here and not always
in a co-ordinated fashion. Indeed, these groups are not always even aware that
their efforts are connected, nor that their concerns are ones of informatics.
The first goal of this
book is to present a unifying set of basic informatics principles which
influence everything from the delivery of care to an individual patient through
to the design of whole healthcare systems. Its next goal is to present the
breadth of issues which concern informatics, show how they are related, and to
encourage research into understanding the common principles that connect them.
Each area that is
covered has been written with three criteria in mind - its possibility, its practicability,
and its desirability. Possibility
reflects the science of informatics - what in theory can be achieved?
Practicability addresses the potential for successfully engineering a system or
introducing a new process - what can actually be done given the constraints of
the real world? Desirability looks at the fundamental motivation for using a
given process or technology.
These criteria are
suggested in part because we need to evolve a framework to judge the claims
made for new technologies and those who seek to profit from them. Just as there
is a long-standing symbiosis between the pharmaceutical industry and medicine,
there is a newer and consequently less examined relationship between healthcare
and the computing and telecommunication industries. Clinicians should try to
judge the claims of these newcomers in the same cautious way that they would
examine claims about a new drug (Wyatt, 1987) and perhaps more so, given that
clinicians are far more knowledgeable about pharmacology than they are about
informatics and telecommunications.
The book is organised
into a number of parts, all of which revolve around the two distinct strands of
information and communication. While the unique character of each strand is
explored individually, there is also an emphasis on understanding the rich way
in which they can interact and complement each other.
Like healthcare,
informatics has both theoretical and applied aspects to its study. This first
part of the book is focused on developing an intuitive understanding of the
basic theoretical concepts needed to approach informatics practice in a
principled way. Three fundamental ideas underpin the study of informatics - the
notions of what constitutes a model, what one means by information, and what
defines a system. Each of these three ideas is explored to develop an understanding
of the nature of information and communication systems. A recurring theme in
this part will be the need to understand the limitations imposed upon us
whenever we create or use a model of the world. Understanding these limitations
defines the ultimate limits of possibility for informatics, irrespective of
whichever technology one may wish to apply in its service.
Building upon the
concepts in Part one, the second part of the book looks at the practical
lessons that can be drawn from informatics to guide everyday clinical activity.
Every clinical action, every treatment choice and investigation, is shaped by
the available information and how effectively that information is communicated.
Five basic clinical informatics skills are explored, each with their own
individual chapter:
1.
Communicating effectively is based upon understanding cognitive models of
information processing, and is constantly challenged by the limits of human
attention, and the imperfection of models;
2.
Structuring information, with a particular focus on the patient record, is
shown to be dependent upon the task at hand, the channel used to communicate
the message, and the agent who will receive the message;
3.
Questioning
others to find information is essential in clinical practice to fill the ever
present gaps in every individual’s knowledge;
4.
Searching for knowledge describes the broader strategic process of knowing
where to ask questions, evaluating answers, and refining questions in the light
of previous actions, and occurs in many different settings, from when patient’s
are interviewed and examined, through to when treatment options are
canvassed;
5.
Making Decisions occurs when all the available information
needed has been assembled using the other informatics skills, and attempts to
come up with the best alternative to solve a problem like selecting a
treatment, based both upon the evidence from science, as well as the wishes and
needs of individuals.
The chapters in this
part explore the special character of information systems in healthcare. The
clinical record is given many names and is discussed in many different guises
throughout the book, and its role and scope are introduced here. Information
systems like the electronic medical record are shown to manage a wide variety
of activities. Ultimately, the way that these activities are modelled, measured
and then managed is determined by information system design.
Sometimes, leaving
things unsaid or informal is more productive than encoding them in a formal
computer system. Consequently, the important concept of system formality is
also introduced here, since it is not always appropriate to build information
systems. Indeed it can often be counterproductive. Understanding the role of
formality helps principled decisions to be made before information systems are
introduced. The concept of formality also helps us to understand the different
roles that communication and information systems play in healthcare. The final
chapter in this part spends some time describing how one sets out to build such
systems, and some of the design problems that bedevil that process.
Having laid down these
foundational ideas in the first two parts of the book, the next two parts turn
to focus on two information problems that are specific to healthcare -
protocol-based care, and clinical coding.
Clinical guidelines or
protocols have been in limited use for many years. The current emphasis on
evidence-based clinical practice has made it more likely that healthcare
workers will use, and perhaps be involved in the design and maintenance of
protocols. In this part, the various forms and uses of protocols are
introduced. The various roles that computer-based protocol systems can play in
clinical practice are outlined. These cover both traditional ‘passive’ support
where protocols are kept as a reference, and active systems in which the
computer uses the protocol to assist in the delivery of care. For example, protocols
incorporated into the electronic record can generate clinical alerts or make
treatment recommendations. Their characteristic advantages and limitations of
are also discussed and these are then used to formulate a set of protocol
design principles.
If the data contained
in electronic patient record systems is to be analysed, then it needs to be
accessible in some regular way. This is usually thwarted by the variations in
health terminology used by different individuals, institutions and nations. To
remedy the problem, large dictionaries of standardised clinical terms have been
created.
The chapters in this
section introduce the basic ideas of concepts, terms, codes and
classifications, and demonstrate their various uses. The inherent advantages
and limitations of using terms and codes are discussed. The last chapter in
particular looks at some more advanced issues in coding, describing the
theoretical limitations to coding, and outlines practical approaches to
managing these issues, as well as presenting open research questions.
While interpersonal
communication skills are fundamental to patient care, the process of
communication has, for a long time, not been well supported technologically.
Now, with the widespread availability of communication systems supporting
mobility, voice mail, electronic mail and video-conferencing, new possibilities
arise. The chapters in this section introduce the basic types of communication
services and explain the different benefits of each.
Given that much of the
technology is new for many, one chapter is devoted to describing the basics of
the various different communication systems now available. The final chapter in
this part examines clinical communication and the field of telemedicine in the
context of these new technologies. The potential of telemedical systems within
different areas of healthcare is described, but the importance of carefully
choosing the right set of technologies for a given problem is emphasised.
Information systems
are starting to become indistinguishable from communication ones, and this
convergence is perhaps nowhere more apparent than with the Internet. This part
explores in detail the phenomenal rise of the Internet and the World Wide Web,
and examines why its technologies have proven to be so revolutionary. The
complex way that the Web alters the balance of information publishing and
access is explained, along with the consequences of these changes. The full
impact of the Internet on healthcare has yet to be felt. Some of the many
different ways that it will change healthcare are presented here, from the way
communication occurs, through to the change it will have upon the
doctor-patient relationship.
The concluding
chapters of the book look to some of the most complex computer systems created
so far - those based upon the technologies of artificial intelligence (AI). The
early promise of computer programs that could assist clinicians in the process
of diagnosis have come to fruition, and they are now in routine use in many
clinical situations. AI techniques also permit the creation of systems able to
assist with therapy planning, information seeking, and the generation of
alerts.
The final chapters in
this part look in detail at some of the specialised ways that decision
technologies are applied in clinical practice. They find application in
creating intelligent patient monitors, and potentially, autonomous therapeutic
devices like self-adjusting patient ventilators. Along with communication
technologies, they are essential components of biosurveillance systems.
Finally, in the field of bioinformatics, human genome knowledge is harnessed
using computer techniques, and reframes many classes of clinical decision as
questions of genetics as much as pragmatic clinical science.
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ewc@pobox.com ©
Enrico Coiera 1997-2003
updated
10 Oct 03