Medical, Biomedical, Clinical Informatics; Tomorrow's Healthcare

Mar 02, 2016 at 05:29 pm by Staff

U.S. healthcare professionals have been given the option of continuing to deliver care in a costly, unsustainable and inequitable system (which will eventually disappear) or develop sustainable alternative(s) for the future, and continue leading. We have pockets that deliver exceptional care, however, quality-care is not evenly distributed across regions or populations. Even before 1991, when the Institute of Medicine published The Computer Based Patient Record: An Essential Technology for Health Care, there's been a correlation between organizations that have a real grip on their clinical data -which they manage electronically to the extent possible - and those that provide exceptional care. Evidence suggests that electronically managing holistic health data improves healthcare as it has equivalently done for other sectors such as banking, air travel and others; albeit, health data is far more complex than that of the ones managed by other sectors as well as how we use and process our data into information.

Before the 70's pioneer-physicians saw that computers had uses in handling health data and began combining their medical expertise with available computer technology and created the field known as medical informatics (MI). The history of medical informatics doesn't fit a short article, so I'll refer you to a 1995 book by Morris F. Cohen, MD, called A History of Medical Informatics in the United States: 1950 to 1990; he summarized early-day use of computers to manage clinical data to improve care, adhere to evidence-based care, control costs and more. Consecutively Lawrence Weed, MD, was inventing in those early days the SOAP-format (i.e. subjective, objective, assessment, plan) so physicians could keep their patient records organized while computer technology evolved enough so patient records could be completely managed through these. By the early 1990's, electronic records where showing promise by improving care coordination, adherence to evidence, while most where staring at the stars.

So medical informatics is a half a century multidisciplinary field that scientifically and methodically evaluates, designs, develops and adopts, implements and applies computer-based tools to improve the four cornerstones of healthcare abbreviated by the acronym C.A.R.E.; meaning Clinical, Administrative, Research and Education. Another view is the convergence between distinct philosophies on how to manage data to improve health and care, including the body of knowledge of medicine, computer science, engineering, etc. Regardless of "definition," the primary aim of MI is to make all attainable health-data and information available at the Point-of-Care with minimum impact on the provider-patient relationship alert about options and preventable errors. Between the 1980's and 90's MI training was attained through one of a few National Institutes of Health (NIH) sponsored on-hands fellowships in a handful of U.S. medical education institutions. By the end of 2011, the American Board of Medical Specialties (ABMS) approved Clinical Informatics as a medical sub-specialty.

We can't predict what the future of healthcare in the U.S. will look like, but one thing is unquestionable, data will be captured, maintained, managed and shared electronically. On the one side, MI's decades-old track record, inevitable growth, influence and recent recognition as a medical sub-specialty dictates that it will be an informatics-supported healthcare future. No matter that our entry into the electronic health data paradigm has been less than stellar ever since the announcement by President George W. Bush in 2004 of a U.S. Federal Government initiative, "...whose aim was that the majority of Americans would have their health records managed electronically within ten (10) years..." the problem has been the "solution (i.e. vendors) feeding frenzy" has taken over everyone's practice and emotional stability.

Things posing as Electronic Health Records (EHR) have risen like cicadas but causing harm in the form of billions of dollars misspent, reduced productivity, vendor lock-in, amongst other nasty verrucae. Concurrently, the most dreaded and feared outcome also materialized and will continue take deeper root unless physicians act fast; that is, "we've become slaves of new masters" as exemplified by the way EHR system vendors, to whom we've provided our data, hold us hostages to their systems. For example, once data is inserted into any EHR it cannot be migrated completely to another EHR in the very likely event that we need to change our "chosen" EHR.

Additionally, the U.S. federal government implemented an incentives program to honor providers who where using EHRs and demonstrated that they used them meaningfully with their patients - meaningful use. Now, the riddle of meaningful use, Medicare's electronic prescribing, patient quality reporting system (PQRS), hospital inpatient and outpatient quality reporting, health employer data information set (HEDIS) and other "metrics" have been conjoined into Medicare's Value-Based Payments via the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA.) Accountable Care Organizations (ACO), merit-based incentive program (MIPS) and alternative payment models (APM) all use "metrics" to demonstrate "quality" and "value"; ambiguous terms that merit that I direct you to a NEJM article available at

Most providers, managers, administrators or CEO's have never heard the computer-technology sector practice that colloquially is referred to as "Wine, Dine and Sign"; I urge you pay close attention to this "offerings approach." EHRs are here and the landscape will evolve rapidly and continuously; some systems will stay in the market, some will be absorbed and a sizeable number will disappear. In such a turbulent environment, physicians need to take back what they unknowingly gave-up, that is, full-access to the raw health data that we as physicians, not the EHR-vendors, are liable for, with no strings attached. Concurrently we also need to embrace health data exchange so we can reap the real benefit that computer technology promised for healthcare: the ability to construct more complete patient medical records at the Point-of-Care.

Those who've chosen medical, biomedical or clinical informatics as a specialty, practice or career are specially trained to select and implement cost-effective Health Information Technology - of which EHR's are just one part - as required by each organization. Like pathologists and radiologists, medical informaticists are healthcare professionals that at times may not have time for direct patient contact, but are still members of the workforce with knowledge to find actionable information in data and improve sustainable care - before non-healthcare-actors take the rest of healthcare away from healthcare professionals.

Jose Piovanetti, MD, is a physician with over thirty years of formal training and real-world expertise in the new medical specialty of clinical informatics. He has attained unique hands-on medical informatics knowledge and experience through completing medical informatics fellowship training as well as developing and managing electronic health records (EHR) since 1984.

He uses his acquired knowledge and expertise to assist hospitals, outpatient practices and other care facilities to expand and improve their informatics systems and operations. He can be reached at