Medical Informatics in Healthcare Organizations: A Survey of Healthcare Information Managers

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1 Medical Informatics in Healthcare Organizations: A Survey of Healthcare Information Managers Jeremiah H. Sable, MD, MHA, Joseph W. Hales, PhD, Kenneth D. Bopp, PhD Department of Health Management and Informatics University of Missouri-Columbia School of Medicine Columbia, Missouri Objective: To assess the medical informatics needs of healthcare organizations and the work roles for informaticists in those organizations. Methods: A 128-item survey was developed and administered as a structured interview to thirty-two information managers in eighteen organizations. The survey included items about medical informatics training, prior work experience, skills for informaticists, and programming proficiency. Results: There was a strong preference for informaticists with prior clinical work experience and an understanding of healthcare. Project management and data warehousing were highly rated skills. Informaticists were expected to know about healthcare processes, clinical guidelines, and outcome management. They were not expected to be expert programmers. Conclusion: There is a role in healthcare organizations for interdisciplinary workers who understand clinical medicine, healthcare management, information technology, and who can communicate and work effectively across these organizational boundaries. Introduction Early articles about medical informatics careers emphasized research training and developing the information system infrastructure in hospitals. 1-5 As Braude wrote in 1991, the National Library of Medicine (NLM) "...adopted the approach of training investigators in medical informatics (MI) with the anticipation that these investigators would choose careers in academic medicine where they would form a cadre of faculty who could perform research in the applications of MI and teach the principles of MI to medical students." 2 The NLM's training programs have been highly successful. There are educational programs in medical informatics in over two-dozen academic medical centers. Information technology has become part of the fabric of healthcare in a way that only visionaries could have imagined in 1972 when the NLM began funding fellowship training programs. Although clinical information systems are well established in hospitals, HMOs and regional health systems, little is known about the roles for medical informaticists in healthcare organizations. What kinds of informatics work roles are there in healthcare organizations? What kind of informatics training is most appropriate for people working in healthcare organizations? What knowledge and skills should informatics educators develop in their students to best meet the needs of healthcare organizations? This study sought to answer these questions by interviewing CIOs and other healthcare information managers about the informatics skills needed in their organizations. Methods A survey was developed by one of the authors (JS). It went through three revisions and was not validated externally prior to the study. It consisted of 128 items, including 100 five-point Likert items, ten yes/no items, nine rank order items, and eight openended items. Survey participants were solicited by and by phone calls. Many of these and telephone solicitations for participation were not returned, and many individuals who were contacted declined to participate. Managers from eighteen organizations did agree to participate in the survey, and many of them asked other information managers in their organizations to participate as well. A total of thirtytwo individuals from these eighteen organizations were surveyed (Tables 1 and 2). Since no stratification was expected in the analysis, thirty-two was considered a sufficient sample size. The survey was administered as a structured interview in order to encourage participants to express their views about related subjects that weren't covered explicitly by the survey items. Twenty-nine interviews were conducted on-site and three by telephone between August and October of 1999.

2 We sought a broad range of organizations that were involved in the management and analysis of healthcare information (Tables 1 and 2). Because the survey was administered as a structured interview, most target organizations were located in and around Missouri to minimize travel time and expenses. Number Type of organization 5 Regional health systems 2 Consulting firms 2 Large health insurance companies 1 Small regional HMO 1 Large group practice 1 University medical center 1 Data center for health system 1 Disease management company 1 Clinical QI software developer 1 State health department 1 State hospital association 1 Large pharmaceutical company Table 1: Types of organizations Number Title of survey participant 6 Corporate VP (for IS, IT, etc.) 6 IS Director 4 CIO 2 Consultant 2 Director of Medical Informatics 1 Medical Director 1 Director of Outcomes Reporting 1 Supervisor, Architecture and Planning 1 Chief Technology Development Officer 1 Senior Healthcare Analyst 1 Team Leader for Projects and Planning 1 QI Coordinator / Research Analyst 1 Manager, Data Analysis 1 Software Applications Manager 1 Project Leader for Systems Coordination 1 Director of Product Coordination 1 Project Manager for EMR Implementation Table 2: Job titles of survey participants Survey content: The survey addressed the question of informatics skills from several points of view: A. Medical informatics training: Informaticists can be trained in a variety of educational programs. In Part A of the survey, participants were asked to rate eleven different degrees and educational programs on a five-point Likert scale. B. Prior work experience: An employee brings both training and prior work experience to an organization. In Part B, participants rated various prior work experiences for the informaticists in their organizations (five-point Likert scale). C. Skill sets: Part C was designed to assess participants' views of the relative importance of three skill sets for informaticists in their organizations. Skill set A emphasized programming skills, set B emphasized medical informatics research skills, and set C emphasized healthcare management skills (Table 3). A three-point rank order scale was used. Skill Set A C, C++, Java, Visual Basic, HTML, DHTML, JavaScript, MS ASP, SQL, data modeling, database technologies, data warehousing, computer modeling and simulation, enterprise information systems, and "some related skills." Skill Set B Information retrieval, vocabularies, UMLS, natural language processing, term clustering, automated indexing, decision support, knowledge representation, HL7 and other healthcare information standards, telemedicine, structured documentation, experimental and cutting edge information systems, and "some related skills." Skill Set C Project management, healthcare information policy and law, healthcare management and administration, financial management, organizational behavior, healthcare quality improvement and outcome management, program evaluation, vendor information systems in healthcare, and "some related skills." Table 3: Skill sets D. Programming proficiency: Participants were asked to indicate agreement or disagreement with six different statements about programming skills for informaticists in their organizations. (See Table 6 for the statements.) Results are reported as the percent of the sample that agreed with each statement. E. Courses for informatics students: Twelve different courses in a medical informatics curriculum were listed (Table 7). Participants were asked to rate the value of these courses for the informatics employees in their organizations (five-point Likert scale). F. Specific skills, knowledge and prior experience: In Part D, survey participants rated the value of fifty items -- skills, knowledge, and prior work experiences -- for informatics employees in their organizations (five-point Likert scale). The list included items on technical skills, knowledge of healthcare, quality improvement, management experience, clinical experience, and other items. Analysis: Data for the Likert scale items is reported as the average score for each item (sum of the Likert scores divided by thirty-two). Qualitative data: Participants were encouraged to make comments during and after the interviews.

3 Their remarks were written down and analyzed. The interviews were not recorded and this written qualitative data consisted mostly of paraphrases of their remarks. All written comments were labeled, such as "project management skills are important," "clinical experience is valuable," "CIOs need a different kind of training than medical informatics," etc. Scores were obtained by counting the number of individuals who made remarks corresponding to each of these categories. highest scores were for "Healthcare QI / outcome management," "Healthcare management," and "Physician." "Non-healthcare management" had the lowest score. Results Medical informatics training: The two most highly rated educational programs for medical informatics workers were "Previous on the job training" (3.98 on a five-point Likert scale) and "MS in medical informatics." (See Figure 1 and Table 4.) Third and fourth most desirable were MBA and MHA programs that included additional medical informatics courses. Figure 2: Prior work experience Row Score Prior work experience A 3.81 Nurse, midlevel or other clinician B 3.73 Healthcare QI / outcome mgmt. C 3.56 Healthcare management D 3.35 Physician E 3.05 Computer programming F 2.72 Information science G 2.68 Academic research and teaching H 2.68 Financial management I 2.13 Engineering J 1.94 Non-healthcare management Table 5: Prior work experience Figure 1: Training for informatics employees Row Score Type of training A 3.98 Previous on the job training B 3.92 MS in medical informatics C 3.44 MBA + extra informatics courses D 3.27 MHA + extra informatics courses E 3.06 Self taught in medical informatics F 2.96 Fellowship in medical informatics G 2.92 MS in computer science H 2.85 BS in computer science I 2.62 PhD in medical informatics J 2.34 Information technology training only K 2.27 PhD in information science Table 4: Training for informatics employees Prior work experience: The highest rating went to "Nurse, midlevel, or other clinician (excluding physicians)," with a score of 3.81 on a five-point Likert scale (Figure 2 and Table 5). The three next Skill sets: Three different skill sets were ranked, with 3 being the lowest possible score and 1 the highest. (See Table 3 for the skills in each set.) Skill set C was ranked the highest with a score of Skill set B was in the middle with a score of Skill set A, with a score of 2.42, was rated least important. Figure 3: Skill sets Programming proficiency: Figure 4 and Table 6 show the agreement scores regarding programming proficiency for informaticists. The highest score

4 (76%) was for the statement, "Having a general understanding of the uses and limitations of many different computer languages is more important for them than actually being able to program in specific languages." The lowest score (32%) was for the statement, "It is important for informatics workers to have an expert level of proficiency in at least one language." H 3.65 Health information policy and law I 3.63 Healthcare management J 3.48 Organizational behavior K 2.65 Applied AI L 1.80 Bioinformatics Table 7: Scores for informatics courses Figure 4: Programming proficiency scores Percent agreement A 76% B 70% C 66% D 60% E 53% F 32% Statement Having a general understanding of the uses and limitations of many different computer languages is more important for them than actually being able to program in specific languages. A basic level of proficiency in computer languages is adequate for them. Medical informatics professionals in my organization are not expected to function as programmers, even on projects they initiate. Basic proficiency in many computer languages is more important than an expert level of proficiency in a few languages. It is important for them to have at least moderate proficiency in some languages. It is important for informatics workers to have an expert level of proficiency in at least one language. Table 6: Programming proficiency statements Informatics courses: Table 7 and Figure 5 show the scores for twelve courses in a medical informatics master's degree program. Survey participants rated the value of these courses for informaticists in their organizations. Row Score Course A 4.02 Project management B 3.93 Internet technology and tools C 3.90 Database technology D 3.90 Healthcare vocabularies E 3.87 Clinical decision making F 3.83 Healthcare quality G 3.67 Clinical information systems Figure 5: Scores for informatics courses Specific skills, knowledge, and experience: Survey participants rated a list of fifty specific items on a five-point Likert scale. Nineteen of these items received scores above 3.50 (Table 8). Rank Score Item Knowledge of healthcare processes Clinical guidelines, outcome mgmt Project management Data warehousing Healthcare QI Practical decision support methods Vocabularies, UMLS, coding systems Implementation of information systems Clinical experience Knowledge of clinical decision making Quality measurement in healthcare Relational databases / data modeling Internet technologies and tools Healthcare information policy and law Info retrieval (Medline, Internet, etc.) SQL, DB development and mgmt Computerized medical records Visual tools for DB management Knowledge of IS vendor products Table 8: Scores for the nineteen top-rated skills "Research in medical informatics" was ranked 31st with a score of 3.09 and "Expert systems" was ranked 35th, with a score of 3.02 (not shown in Table 8). The three lowest scores were for "Writing journal articles for publication" (2.41), "Bioinformatics" (2.36), and "Writing grant applications" (2.27). Qualitative data: In their comments and remarks, seventeen of the thirty-two participants said that

5 clinical experience was important for informaticists in their organizations. Thirteen said that management experience was important and twelve mentioned the importance of project management skills. Twelve people said that communication skills were important. Discussion The executives and information managers in this study valued a broad mix of knowledge, skills, and experience for the informaticists in their organizations. These included a thorough knowledge of healthcare, management experience, practical skills with data and databases, communication skills, and clinical experience. Many of them viewed project management as particularly important. They did not view expertise in programming -- or technical depth in general -- as important for informaticists. They did not view medical informatics research skills as important. It was surprising that twelve people mentioned the importance of communication skills because it was not mentioned anywhere in the survey. Medical informatics has been defined in many different ways in the literature. Lindberg wrote that "Medical informatics attempts to provide the theoretical and scientific basis for the application of computer and automated information systems to biomedicine and health affairs... Medical informatics studies biomedical information, data, and knowledge -- their storage, retrieval, and optimal use for problem-solving and decision-making." 6 Greenes and Shortliffe defined it as "...the field that concerns itself with the cognitive, information processing, and communication tasks of medical practice, education, and research, including the information science and the technology to support these tasks." 7 The healthcare information managers in this study had a narrower view of medical informatics in their organizations, emphasizing the management and analysis of healthcare information. They expressed a need for highly interdisciplinary workers who understand clinical medicine, health management, information technology, and who can communicate and work effectively across these organizational boundaries. This view is consistent with some newer definitions of medical informatics. The following definition appears on the Frequently Asked Questions page of the Web site of the Oregon Health Sciences University Division of Medical Informatics and Outcomes Research: "The field of medical informatics is concerned with the development, dissemination, and evaluation of information technology (IT) in the health care field." 8 The FAQ goes on to say, "Informaticists are often also qualified to serve as a liaison between the technical IT people and clinicians in the health care industry." The people we surveyed echoed these views. Conclusion Healthcare organizations have complex information management needs that cannot be met by individuals who are trained in only one discipline. Medical informatics educational programs that have an applied healthcare focus are well equipped to train people for these roles. More studies need to be done in order to more fully understand the applied informatics needs of healthcare organizations. References 1. Braude RM. Variables influencing career choices of graduates of informatics programs funded by the National Library of Medicine. Academic Medicine 1990;65(12): Braude RM. A descriptive analysis of National Library of Medicine-funded medical informatics training programs and the career choices of their graduates. Medical Decision Making 1991;11(1): Aronow DB, Payne TH, Pincetl SP. Postdoctoral training in medical informatics: a survey of National Library of Medicine-supported fellows. Medical Decision Making 1991;11(1): Miller PL. Training for a research career in medical information science: how much is enough? Medical Informatics 1984;9(3-4): McDonald CJ. Careers in medical computing [editorial]. MD Computing 1984;1(6): Lindberg DAB. NLM Long Range Plan. Report of the board of Regents. Bethesda, MD: National Library of Medicine; 1987 January Greenes RA, Shortliffe EH. Medical informatics. An emerging academic discipline and institutional priority. JAMA 1990;263(8): Oregon Health Sciences University. Frequently Asked Questions; Available from: URL: Acknowledgement: This work was supported by the National Library of Medicine grant 5 T15 LM07089.