Where to in the next ten years of health informatics education?

OBJECTIVES: To explore whether education in health/medical informatics should continue to evolve along the lines pursued since the early seventies, or whether a change is advisable. METHODS: Roots and key resulting characteristics for European and US American approaches HI education are identified. In Europe holistic approaches based on a synthesis of medicine and informatics (= computer science) with programs ranging from vocational training through university programs to doctoral and postdoctoral programs were characteristic. The US American approaches emphasized the higher levels of education and a diverse selection of specialized subjects. Changes in health and health informatics are summarized. RESULTS: Two types of changes are identified: high-tech applications arising at the interface of imaging, robotics, and the -omics (genomics, proteomics, metabolomics), and invasive applications centering on consumer health informatics and a move from curative to prospective health care. CONCLUSIONS: It is proposed that curative medicine is adequately served by current educational approaches, but that the move towards prospective health care requires a move towards education and change management for health professionals and health informatics professionals.

Lest formalisms impede insight and success: evaluation in health informatics--a case study.

OBJECTIVES: To illustrate the advantages of an open-ended formative evaluation approach using a project-specific selection of methods over the controlled trial approach in the evaluation of health information systems. To illustrate factors leading to success and others impeding it in a telehealth project. METHODS: The methods and results of an evaluation of the BC Telehealth Program are summarized. RESULTS: The evaluation gave a comprehensive picture of the project, including assessment of the effects of an array of telehealth applications, and their economic impact. Factors leading to success and others preventing it are identified from the level of overall program management to the project specifics. The results include unanticipated effects and explanations for their reasons of occurrence. Neither the comprehensiveness of information nor the timeliness was achieved in a related project using a controlled trial approach. CONCLUSIONS: Not all types of health information system projects can be evaluated using the controlled trial approach. This approach may impede important insights. It is also usually much less efficient. Funding agencies and journal editors have to take this into account when selecting projects for funding and submissions for publication.

Success factors for telehealth--a case study.

PURPOSE: To present the lessons learned from an evaluation of a comprehensive telehealth project regarding success factors and evaluation methodology for such projects. METHODS: A recent experience with the evaluation of new telehealth services in BC, Canada, is summarized. Two domains of clinical applications, as well as educational and administrative uses, and the project environment were evaluated. In order to contribute to the success of the project, the evaluation included formative and summative approaches employing qualitative and quantitative methods with data collection from telehealth events, participants and existing databases. The evaluation had to be carried out under severe budgetary and time constraints. We therefore deliberately chose a broad ranging exploratory approach within a framework provided, and generated questions to be answered on the basis of initial observations and participant driven interviews with progressively more focused and detailed data gathering, including perusal of a variety of existing data sources. A unique feature was an economic evaluation using static simulation models. RESULTS: The evaluation yielded rich and detailed data, which were able to explain a number of unanticipated findings. One clinical application domain was cancelled after 6 months, the other continues. The factors contributing to success include: Focus on chronic conditions which require visual information for proper management. Involvement of established teams in regular scheduled visits or in sessions scheduled well in advance. Problems arose with: Ad hoc applications, in particular under emergency conditions. Applications that disregard established referral patterns. Applications that support only part of a unit's services. The latter leads to the service mismatch dilemma (SMMD) with the end result that even those e-health services provided are not used. The problems encountered were compounded by issues arising from the manner in which the telehealth services had been introduced, in particular the lack of time for preparation and establishment of routine use. Educational applications had significant clinical benefits. Administrative applications generated savings which exceeded the substantial capital investment and made educational and clinical applications available at variable cost. CONCLUSION: Evaluation under severe constraints can yield rich information. The identified success factors, including provision of an overarching architecture and infrastructure, strong program management, thorough needs analysis and detailing applications to match the identified needs should improve the sustainability of e-health projects. Insights gained: Existing assumptions before the study was conducted: Evaluation has to proceed from identified questions according to a rigorous experimental design. Emergency and trauma services in remote regions can and should be supported via telehealth based on video-conferencing. Educational applications of telehealth directed at providers are beneficial for recruitment and retention of providers in remote areas. Insights gained by the study: An exploratory approach to evaluation using a multiplicity of methods can yield rich and detailed information even under severe constraints. Ad hoc and emergency clinical applications of telehealth can present problems unless they are based on thorough, detailed analyses of environment and need, conform to established practice patterns and rely on established trusting collaborative relationships. Less difficult applications should be introduced before attempting to support use under emergency conditions. Educational applications are of interest beyond the provider community to patients, family and community members, and have clinical value. In large, sparsely populated areas with difficult travel conditions administrative applications by themselves generate savings that compensate for the substantial capital investment for telehealth required for clinical applications.

Video conferencing-based telehealth--its implications for health promotion and health care.

PURPOSE: To review the experience with a province-wide telehealth system in Canada, and its implications for health care and health promotion. To explore whether group support systems (GSS) based on networked computers can substitute for video conferencing technology. METHODS: Key results of the evaluation of the BC Telehealth Program are summarized. The potential of extending the successful principles through use of GSS is explored based on literature review, demonstrations, and trial use for educational applications. RESULTS: The BC Telehealth Program was designed to support health professionals at secondary care facilities, such as regional and district hospitals in two application domains: children's and women's health (C&W) and emergency room and trauma care (ER-Trauma). Successful applications extended beyond health professionals and focused on chronic conditions, the management of which is contingent on visual information, and involves established teams in regular scheduled visits or in sessions scheduled well in advance. Ad hoc applications, in particular applications under emergency conditions proved problematic. Administrative applications in support of telehealth implementation, e.g., through facilitation of management and provider education, are essential for clinical success. Savings from support of administrative applications exceeded the substantial capital investment and made educational and clinical applications available at variable cost. Educational applications were shown to have significant clinical benefits. Exploration of GSS technology showed that it may not be mature enough to substitute for video conferencing technology in support of sophisticated training and education aiming at clinical impact. CONCLUSION: The substantial clinical and efficiency gains provided by video conferencing-based telehealth may for now continue to depend on mature video-conferencing technology.

A new look at information retrieval evaluation: proposal for solutions.

This is the fourth and the final in the series of the papers on an application of the systems analytic approach to evaluation of information retrieval (IR). In the previous papers terminological and evaluation problems associated with IR were identified and discussed, and it was proposed that the systems analytic approach could provide solutions to these problems. A review of existing systems analytic approaches in IR was given, and a conceptual framework and two models of IR were presented. This paper discusses how the proposed conceptual framework and the models can be used to improve terminology of IR, to analyze the relevance-based method of recall and precision, and to propose new approaches to evaluate relevance relationships and search engines. The proposed evaluation approaches are compared amongst each other and with the existing methods. The paper is concluded by a summary of the contributions of the research and an identification of the directions for a future research in IR evaluation.

Reflections on an arranged marriage between bioinformatics and health informatics.

OBJECTIVE: To compare the discussions of two workshops held during 2001 by two Canadian organisations, HEALNet, a Network of Centres of Excellence for research in health information applications, and Genome Canada, a national research funding agency for genomics and proteomics, in collaboration with the Institute of Genetics of the Canadian Institutes of Health Research, to examine strategic research development in Health Informatics and Bioinformatics respectively. METHODS: Invited workshops with structured debate. Concept analysis of preparative material and debates. RESULTS: A predominantly common set of concepts was discerned from both workshops. Analysis of published definitions showed an inability to distinguish a definition that would suggest that health informatics and bioinformatics are separate disciplines. In both workshops there was evidence of deep concerns of identity, the lack of clear structures to support research funding as well as uncertainty in distinguishing between service and research. CONCLUSIONS: Many deep issues currently inhibit the recognition and funding of research in health and bioinformatics in Canada and elsewhere. Some of these issues are common to both health and bioinformatics. The overlap in prevailing definitions, research concerns and methodological content in the respective domains suggest that common research needs should be better identified and reinforced for the benefit of both.

Guidelines, the Internet, and personal health: insights from the Canadian HEALNet experience.

OBJECTIVES: To summarize the insights gained in collaborative research in a Canadian Network of Centres of Excellence, devoted to the promotion of evidence-based practice, and to relate this experience to Internet support of health promotion and consumer health informatics. METHODS: A subjective review of insights is undertaken. RESULTS: Work directed the development of systems incorporating guidelines, care maps, etc., for use by professionals met with limited acceptance. Evidence-based tools for health care consumers are a desirable complement but require radically different content and delivery modes. In addition to evidence-based material offered by professionals, a wide array of Internet-based products and services provided by consumers for consumers emerged and proved a beneficial complement. CONCLUSION: The consumer-driven products and services provided via the Internet are a potentially important and beneficial complement of traditional health services. They affect the health consumer-provider roles and require changes in healthcare practices.

Project-based teaching in health informatics: a course on health care quality improvement.

Teaching the skills and knowledge required in health informatics [1] is a challenge because the skill of applying knowledge in real life requires practice. We relate the experience with introducing a practice component to a course in "Health Care Quality Improvement". Working health care professionals were invited to bring an actual quality problem from their place of work and to work alongside students in running the problem through a quality improvement project lifecycle. Multiple technological and process oriented teaching innovations were employed including project sessions in observation rooms, video recording of these sessions, generation of demonstration examples and distance education components. Both students and their collaborators from the work place developed proficiency in applying quality improvement methods as well as in experiencing the realities of group processes, information gaps and organizational constraints. The principles used to achieve high involvement of the whole class, the employed resources and technical support are described. The resulting academic and practical achievements are discussed in relation to the alternative instructional modalities, and with respect to didactic implications for similar endeavors and beyond to other fields such as systems engineering.

Medical informatics and medical education in Canada in the 21st century.

The advances of health informatics over the last 50 years are briefly sketched to reveal the pervasiveness of their applications in health and health care. The relations to research in health informatics and health are pointed out. From this perspective it is argued that the evolution of consumer health informatics in the last decade has had a profound impact on the practice of medicine, on patient-physician relations and, hence, on the requirements for medical education. The different access to information and how it is used in educational environments will also dramatically affect how curricula are structured both at undergraduate and postgraduate levels. The impact of health informatics on medical education is further elaborated, and the requirements on infrastructure in support of this education are detailed. This infrastructure goes beyond instructional laboratories and includes academic units for medical informatics and, most importantly perhaps, funding resources and adjudication capacity for health informatics research and their integration into the Canadian research organization and the new Canadian Institutes of Health Research.

Macro allocation in health: an ethically based model.

We propose an approach to macro allocation of health care resources that is compatible with the principles of the Canada Health Act. The approach is equitable and just and takes public support into account. It hinges on the provision of data on disease prevalence and incidence, on data on the effectiveness of intervention measures and of their cost. It is therefore a proposal that may be important as a direction for ongoing research even if it is not immediately feasible. The approach is analyzed with respect to selected related approaches.

Adoption of security and confidentiality features in an operational community health information network: the Comox Valley experience--case example.

Since 1993, a budding community health information network (CHIN) has been in operation in the Comox Valley in Canada. A general hospital and three multi-doctor clinics are linked electronically. The clinics operate without paper charts using a comprehensive clinic information system. The link is provided by RSALink, a commercial message exchange service, based on Health Link, a system developed at the University of Victoria (McDaniel et al., Can. Med. Inform. 1 (1994) 40-41; McDaniel, Dissertation, University of Victoria, Canada, 1994). Health Link is a highly adaptable message exchange service with rich functionality. Despite this, the system is used exclusively to receive laboratory results transmitted by the hospital's laboratory system (RSAStat). The results are deposited in the patient data base of a commercial clinic information system (CliniCare). This case is instructive because the users' selection of services available through Health Link allows us to observe the preferences in this informational sophisticated environment. Laboratory data transmission is appreciated as highly beneficial. The reliability, security and ample privacy protection and authentication features of Health Link, in contrast, are used in a black box mode and are not consciously exploited. This is consistent with our experience of the use of other systems which have operated for a substantial time, essentially without serious protection features. Our experience suggests that security and confidentiality features are exploited only to the extent that they do not require additional effort or conscientious intervention. This puts the system provider in the difficult position of either offering interactive systems that nobody will use, or providing automated features that nobody is aware of and that are therefore not used to full advantage--if at all.

Informatics in the service of health, a look to the future.

The paper attempts a balanced look at the directions of health informatics required in the future. In a high level review of impediments to health and health care a number of issues are identified that may be amenable to improvement by contributions from health informatics. Attention is drawn to the improvement of the collection and dissemination of knowledge in addition to the analysis of morbid conditions as a focus for health informatics. On this basis a review of the current state of health information systems is undertaken. The importance of adaptable user interfaces for end users and systems personnel, privacy and confidentiality protection, and linkage among clinical support systems and knowledge repositories is stressed. These improvements hinge on advancements in medical concept representation. Canadian contributions to these developments, particularly the instigation of Evidence Based Medicine (EBM) are briefly reviewed.

Organizational models: from institutional to supra-national responsibility for health information systems.

Internationally as well as within a given national environment, there are many variations in the organization of health care, hospitals and hospital information systems. This paper attempts to structure the diversity by examining determinants of organizational models. These show an increasing need for inter-institutional coordination and cooperation. An examination of organizational components shows that those at the institutional level are increasingly complemented by components at the national, international and global levels. Hence, organizational models do not only have to be dynamically responsive to changing requirements arising from changes in determinants, but more importantly, inter-institutional and supra-institutional organizational structures gain in importance.

Internet for teaching and learning introductory health informatics.

Internet resources seem attractive for teaching and learning. But are they usable and useful in their present form? We explored Internet, in particular its World Wide Web (WWW) resources, in a course on "Medical Methodology" (HINF270) for students of health information science. This course offers a systematic overview of the methodological principles of clinical care. Its broad scope and low depth makes this course a reasonable model to explore the limits of WWW resources. During the course, students wrote summaries of individual lectures. After critiquing and appropriate corrections, the texts were edited with Hypertext Mark-up Language (HTML) and augmented with links to WWW resources. Grading based on the papers, on their improvements through HTML and WWW, and on the provision of information on the search experience were incentives to use WWW. A formal questionnaire, administered on-line on a voluntary basis, concluded the investigation. Results show: 1) Even under considerable pressure to use WWW, libraries remain the reference source of choice for research; 2) Internet provides entertainment appeal even though practical utility is currently limited; 3) Technological proficiency with HTML and search engines is perceived as an asset; 4) Varying availability of Internet resources, uncertain and varying quality of sources, and limited specificity of research results are the major disadvantages of WWW. The teaching implications of these findings are discussed.

Advanced patient information systems and medical concept representation.

With ubiquitous networked computer based patient information systems, the conventional technology reaches a sound barrier: problems of recall and precision curtail the efficiency gains in data retrieval as the number of data sources and the amount of data in them increases; concerns for privacy protection meet the limits of conventional means as the entropy of the data collections and the number of persons implicated by them increases. We propose that these shortcomings will require additional features for advanced patient information systems, and that medical concept representation has a key role in overcoming these deficiencies. After substantiating the evidence for the need, we outline a means for improvement through medical concept representation. We conclude by discussing the current state of alternatives for medical concept representation and propose that the methodology for resolution of the identified impediments is available.