Unless you're extremely lucky and lead the ultimate healthy lifestyle, you've had the misfortunate of coming in contact with the American healthcare system. Perhaps you've spent hours waiting in the emergency department to be examined. Or maybe you've had to unravel the complicated web of insurance coverage dos and don'ts. Although U.S. providers have access to a cadre of high-tech equipment, like PET and MRI scanners, we rank 37th in the world for quality care, according to the World Health Organization. This is in spite of the fact that healthcare spending topped the $2 trillion mark last year—more than four times the figure spent on national defense—and is anticipated to reach $3 trillion by 2012. Let's face it, the American healthcare system is on life support and the prognosis is critical. Even the political diagnosticians can't agree on what's the best treatment plan to follow.
The good news is the situation doesn't have to be terminal. Indeed, with some intensive rehabilitation, the healthcare industry can rebound, but not without the expertise of engineers and information technology (IT) professionals specializing in medical informatics.
On the Record
For months, the Washington, D.C., politicos have been rallying for what they believe healthcare reform should entail: The president proposes one version and the two political parties each counters with its renditions. Most of the contention centers around who will pay for the care people receive. That, however, is only one symptom to what's ailing the healthcare system. Believe it or not, there's a technology void in many modern facilities that impedes quality care delivery. In some instances doctors still handwrite their orders or nurses have to manually input data into computer medical charting programs. Additionally, each hospital, clinic, and private physician's office is an island unto itself meaning that whatever happens within its walls remains there. There's no interconnectedness that allows one provider to share patient information with others. Oftentimes, it's patients' responsibilities to make sure all members of their care team know what drugs have been prescribed, tests ordered, or diagnoses made. Generally speaking, the healthcare system is disjointed and inefficient, adding to the overall cost of doing business.
Industry watchers believe the answer to this aspect of reform dwells within technology. More specifically, medical informatics, which is the "effective organization, analysis, management, and use of information in healthcare," according to the American Medical Informatics Association (AMIA).
One of the more prevalent examples of informatics is the electronic health record (EHR). This is pretty self-explanatory: Patients' ongoing medical histories are stored digitally. Although one might assume hospitals would've tackled this topic decades ago when other industries took similar steps to electronically store information, as a whole, healthcare has lagged behind. With a few exceptions—such as the Veterans Health Administration—there's a whole slew of facilities that have yet to adopt EHRs. In fact, research indicates only 8% of the nation's 5,000 hospitals currently employ computerized charting. That doesn't even take into consideration the hundreds of clinics or private practices that have yet to go completely electronic.
Installing these expansive programs is not cheap. They easily run into the millions. Granted most hospitals have integrated computers with Internet access and internal communication programs (think email), but historically, the industry has been underfunded in terms of IT services and infrastructure. Studies reveal that IT accounts for less than 2% of total budget outlays.
Photo by mcnevin81
"In Europe where the healthcare system is nationalized, governments have put money into IT. In this country, we have not had that motivation or leadership," states Don Detmer, MD, MA, AMIA president and CEO as well as professor of medical education at the University of Virginia in Charlottesville.
The argument for EHRs is that they streamline services. According to a study published in the New England Journal of Medicine this spring, more than 75% of hospitals that have computerized lab results acknowledged noticeable time savings because providers can pull up the data from any inhouse terminal without having to wait for hand delivery or phone calls from busy lab technicians. Additionally, proponents assert EHR technology can aid healthcare professionals in delivering better care by reducing the chances of medical errors. For example, electronic prescriptions can help reduce the 7,000 deaths each year linked to medication errors because software can be designed to search for misdosings or drug interactions.
Candidate Barak Obama campaigned on the fiscal and technological benefits of EHRs. Upon taking the oath of office, he stepped up his promise by setting a 2014 deadline for all hospitals to fall in line with EHRs. Then in February, the government bankrolled the idea, allocating more than $19 billion for health information technology (HIT) under the American Reinvestment and Recovery Act of 2009.
"Money is the greatest motivator. Now there is the opportunity to get financial support from the federal government," notes Mike Sauk, vice president of IT and CIO for the University of Wisconsin Hospital & Clinic in Madison. He oversees the organization's transition to EHRs. "We're in year three of the installation and hope to finish next year," he says. "The toughest part of installing the system in a large academic medical center is keeping an organized focus. The medical procedures performed here tend to be more complex and the patients are sicker. Plus, there's so much changing in healthcare delivery that it's hard to keep a focus."
Establishing an EHR system is far more intricate than simply creating and maintaining a database. For one thing, each patient represents a unique set of data that is constantly evolving. "It's challenging because there's so much to know. Drugs are new every year. Therapies are new every year. Also, people in the hospital by definition are 'broken' and you can't standardize one person. It's hard to plan for anything," comments Stephanie Guerlain, PhD, an associate professor of systems and informatics engineering at the University of Virginia.
There's also concern over people's right to privacy. Federal laws prevent providers from sharing medical records with unauthorized persons. This poses security issues for informaticians and HIT experts when constructing EHR systems. However, there are individuals who appreciate being able to tap into their own records—Microsoft and Google offer such services now.
"When we talk about informatics, consumers have to be part of that, and that's an exciting development," offers Detmer. "There are tremendous opportunities for both physicians and patients to make their care more efficient."
Another challenge comes from the intermingling of different equipment and technologies produced by a multitude of manufacturers. Throughout any hospital unit you're bound to find an assortment of monitors measuring heart rates, blood-oxygen saturation levels, and other vital signs. Elsewhere you might observe respirators, IV pumps, or anesthesia machines. What they all have in common is some degree of automation that can track a patient's condition and alert staff to any sudden changes. A comprehensive EHR system would compile all the various data from the many inputs in the patient's file and direct it to the appropriate designations, such as the pharmacy, nurses' station, or billing office. On the surface that may not seem like a difficult task, but complications arise due to compatibility issues.
"Right now there are silo systems that don't talk to each other," says Guerlain.
"It's more about how you use IT for the information and not the technology itself," adds Detmer. "If we don't make sure systems talk to each other well enough, we're going to face real challenges."
Part of the problem is that the medical informatics industry currently lacks national standards. Without agreed-upon expectations, vendors are free to write software to answer specific functions, but not necessarily accounting for other informatics. "A typical system has to have two to three dozen interfaces, but that doesn't cover everything. There are separate ones for lab results, cardiac monitoring, and I could go on," says Sauk. "Getting systems to talk with each other [is difficult]."
Industry representatives are joining forces to begin the process of writing standards for vendors and informaticians to follow. "A lot of the problems we have today is that we don't have policies and procedures in place," asserts Detmer. "AMIA has at least four members appointed to the National Advisory Committee, which is charged with setting policy and establish standards."
"There's a continuity of care that comes from documenting standards," adds Guerlain. "Part of [the stimulus spending] is slated to create resource centers where doctors and hospitals can go for technical assistance and ensure they have the ability to transfer data from offices to hospitals. That doesn't have to require everyone using the same vendors, but with system-wide standards."
Whether you're designing hardware, writing software, or managing applications, it's always important to keep the user in mind. If your product doesn't fill a need, then it's extraneous and chances are it won't be endorsed by your customers. That's what previously happened in informatics in some cases. For example, in 2002, Cedars-Sinai Medical Center in Los Angeles invested millions for a computerized physician order system that included functions for medications, lab results, and procedures. After using it for just a few months, doctors declared it was too slow and complained it limited their ability to make judgment calls. The system was scrapped.
A Closer Look
The American Medical Informatics Association (AMIA) divides medical informatics into five major blocks.
- Clinical Informatics is working with electronic health records and networking to move data securely and reliably as well as prompting decision-making support.
- The public health arena uses medical informatics for bio-surveillance and global infections monitoring and predicting, which could involve bio-terrorism.
- Research informatics involves building databases of clinical records that can be mined for trends. Informaticians address security, confidentiality, and procedures. It could also include post-market surveillance, such as gathering feedback from patients when a new drug is released. Much of this work is conducted within the realm of molecular and genome medicine.
- Bio informatics looks at how to move medicine from thinking about the body as a collection of organs and systems to referencing it as molecular medicine, which is based on one's own genetic makeup.
- The final block encompasses the array of technology used in healthcare delivery and education, such as imaging, simulation and visualization. For example, surgery simulation is becoming an integral educational tool.
Since then, user-friendliness has made inroads. "What has significantly changed in the past 10 years is the migration of systems to being faster and easier to use from clinicians' perspective. To place an order for lab tests, it might have taken 25 to 30 clicks," says Sauk. "Now it's designed to speed up providers' ability to enter information and interact with the technology."
"It shouldn't be complicated. What I focus on is how people can navigate and manipulate information in order to make decisions quickly," says Guerlain. "An example could be calculating nutrition for low-birth rate babies who have to be fed intravenously. This can be a complex calculation. Providers use the infant's weight, age, and medications to determine appropriate food levels. When they plug that information into smart informatics systems, the application can help with decision support because it might prompt other considerations or factors that may affect the final calculation."
To ensure users' needs are truly fulfilled, the informatics team must reflect a multi-disciplinary approach, including engineers, IT experts, and a variety of providers. "We use physician champions in our department," notes Sauk. "We've selected people who have the respect and confidence of the medical team. Their interaction with the staff is meant to motivate others to train on the system."
While some facilities have used EHRs and informatics for years and others are just stepping up, all hospitals have to review what role wireless technology will play for future sustainability and user friendliness. Already some physicians have opted to convert their private practice offices into wi-fi zones. Instead of using paper charts for each patient, the doctor pulls up individual records on laptops they carry from one appointment to the next. Medical centers soon could follow suit.
"Mobile technology is the main way of communicating today, and it will be impacting how we do things in the [medical arena]," says Detmer.
Caring for Your Career
As interesting as all this may sound, the bottom line is job possibilities. And as one might conclude with hospitals of all sizes, clinics, and private offices striving to meet the president's EHR deadline a mere five years from now, the demand for engineers and IT professionals well-versed in medical informatics and HIT will be unprecedented. "There is such a need right now for those professionals who have the knowledge," says Detmer. "However, it's not necessarily just IT skills required now, but more about medical informatics as a specialty."
This type of work isn't something you can walk into cold and expect to pick up everything you need to know immediately. For one thing, many aspects are geared more toward medical providers who have an intense interest in computer technology (see "A Closer Look"). Even for those professionals coming at the situation from a technical point of view, a working knowledge of medicine is invaluable.
"It's a challenge to get the right people in the door. Having various clinical experiences can make a big difference," says Dan Sodemann, senior staffing consultant for human resources at the University of Wisconsin Hospital & Clinic.
"AMIA is in the process of building clinical medical informatics certifications that will advance the inter-professional information. The certification will show that you do know how to do IT in the clinical environment," adds Detmer.
"Also having a systems engineering background can be extremely helpful. Database design is good, too, as is simulation and human factors or domain knowledge," advises Guerlain.
So great is the need that more and more universities offer specific tracks in the discipline. Others can find training through organizations like AMIA. Detmer explains, "We've developed the '10x10 Partner Programs' with universities. It's our goal to train 10,000 medical informaticians by 2010. About 15-20% of those who take the courses are IT professionals or engineers, and about 20% of those will get a master's degree in the field."
Employers also appreciate candidates who can function with a variety of professionals who possess different degrees of computer competency. "Customer service is important. The stereotypical IT employee is staring at a computer screen and not involved with other folks in the organization. The opposite is actually true," asserts Sodemann. "We're looking for someone who can not only excel on the technical side, but who has a personality that fits in with a team, both as a member and leader."
There are plenty of interesting opportunities for entry-level hires. At acute care hospitals, chances are you'll help with EHR installation or training staff. Then there are positions with equipment manufacturers or software developers to produce the next generation of products. More experienced informaticians may assist researchers by maintaining and cross-referencing complex databases.
That, at least, is what's in store for the short-term. As more and more facilities and providers embrace technology—and as lawmakers iron out healthcare reform wrinkles—the realm of what medical informatics entail is sure to morph and evolve, creating even more opportunities.
"Regardless, you'll be working with interesting, bright, people who are obviously doing important work and having a lot of fun at the same time," Detmer summarizes. "We're in a wonderful situation in that as other industries shrink, medical informatics is growing, and not just by a little. It's a chance to make your mark on a burgeoning field."