Medical Informatics in Healthcare Organizations: externally prior to the study. It consisted of 128. 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 Although clinical information systems are well healthcare organizations and the work roles for established in hospitals, HMOs and regional health informaticists in those organizations. Methods: A systems, little is known about the roles for medical 128-item survey was developed and administered as informaticists in healthcare organizations. a structured interview to thirty-two information * What kinds of informatics work roles are there in managers in eighteen organizations. The survey healthcare organizations? included items about medical informatics training, * What kind of informatics training is most prior work experience, skills for informaticists, and appropriate for people working in healthcare programming proficiency. Results: There was a organizations? strong preference for informaticists with prior * What lkowledge and skills should informatics clinical work experience and an understanding of educators develop in their students to best meet healthcare. Project management and data the needs of hlealthcare organizations? warehousing were highly rated skills. Informaticists This study sought to answer these questions by were expected to know about healthcare processes, interviewing CIOs and other healthcare information clinical guidelines, and outcome management. They managers about the informatics skills needed in their were not expected to be expert programmers. organizations. Conclusion: There is a role in healthcare organizations for interdisciplinary workers who understand clinical medicine, healthcare Methods management, information technology, and who can A survey was developed by one of the authors (JS). communicate and work effectively across these It went through three revisions and was not validated organizational boundaries. externally prior to the study. It consisted of 128 items, including 100 five-point Likert items, ten Introduction yes/no items, nine rank order items, and eight openended items. arly articles about medical infonnatics careers emphasized research training and developing the Survey participants were solicited by and by information system infrastructure in hospitals."5 As phone calls. Many of these and telephone Braude wrote in 1991, the National Library of solicitations for participation were not returned, and Medicine (NLM) "...adopted the approach of many individuals who were contacted declined to training investigators in medical informatics (MI) participate. Managers from eighteen organizationis with the anticipation that these investigators would did agree to participate in the survey, and many of choose careers in academic medicine where they them asked other information managers in their would form a cadre offaculty who could perform organizations to participate as well. A total of thirtyresearch in the applications of MI and teach the two individuals from these eighteen organizations principles ofmi to medical students. "2 were surveyed (Tables 1 and 2). Since no stratification was expected in the analysis, thirty-two The NLM's training programs have been highly was considered a sufficient sample size. The survey successful. There are educational programs in was administered as a structured interview in order to medical informatics in over two-dozen academic encourage participants to express their views about medical centers. Information technology has become related subjects that weren't covered explicitly by the part of the fabric of healthcare in a way that only survey items. Twenty-nine interviews were visionaries could have imagined in 1972 when the conducted on-site and three by telephone between NLM began funding fellowship training programs. August and October of /00/$5.0O AMIA, Inc. 744

2 We sought a broad range of organizations that were skill sets for informaticists in their organizations. involved in the management and analysis of Skill set A emphasized programming skills, set B healthcare information (Tables 1 and 2). Because the emphasized medical informatics research skills, and survey was administered as a structured interview, set C emphasized healthcare management skills most target organizations were located in and around (Table 3). A three-point rank order scale was used. Missouri to minimize travel time and expenses. Skill Set A Number Type of organization C, C++, Java, Visual Basic, HTML, DHTML, JavaScrpt, 5 eqional liealth systems MS ASP, SQL, data modeling, database technologies, 2 Regional healh systems data warehousing, computer modeling and simulation, 2 Large health insurance Qompanies enterprse information systems, and "some related skills." 1 Small rgional HMO I Large group practice Skill Set B F1 l ety m a c Information retrieval, vocabularies, UMLS, natural 1 UDatarcenterymrhealth language processing, term dustering, automated 1 Disateacntgermoealth systemy indexing, decision support, knowledge representation, - Disease manargementcompanyer HL7 and other healthcare information standards, 1 - ClinicalQI softwaredevelopr telemedicine, structured documentation, experimental 1 - State health department and cutting edge information systems, and "some related 1 State hospital association skills." 1 - Large pharmaceutical company Table 1: Types of organizations Skill Set C Project management, healthcare information policy and law, healthcare management and administration, financial Number Title of survey participant management, organizational behavior, healthcare quality 6 Corporate VP (for IS, IT, etc.) improvement and outcome management, program 6 CrDireVtor evaluation, vendor information systems in healthcare, and ISieCIO, "some related skills." 2 Consultant Table 3: Skill sets 2 Director of Medical Informatics 1 Medical Director D. Programming proficiency: Participants were 1 Director of Outcomes Reporting asked to indicate agreement or disagreement with six -1I - Supervisor, Architectre and Planning different statements about programming skills for 1 Chief Technology Development Officer informaticists in their organizations. (See Table 6 for in their as the percent I - Senior Healthcare Analyst mformaticists 1 Team Leader for Prolects and Planning the statements.) Results are reported as the percent I Ql Coordinator / Research Analyst of the sample that agreed with each statement. 1 Manager, Data Analysis 1 Software Applications Manager. Courses for informatics students: Twelve 1 Project Leader for Systems Coordination different courses in a medical informatics curriculum I Director of Product Coordination ffrncoremamdclmomtcsurilm 1 Project Manager for MR Implementaton were listed (Table 7). Participants were asked to rate T 2: Job titles of survey participants the value of these courses for the informatics Table 2: Job titles of survey participants employees in their organizations (five-point Likert Survey content: The survey addressed the question of scale). informatics skills from several points of view: F. Specific skills, knowledge and prior experience: A. Medical informatics training: Informaticists can In Part D, survey participants rated the value of fifty be trained in a variety of educational programs. In items -- skills, knowledge, and prior work Part A ofthe survey, participants were asked to rate experiences -- for informatics employees in their eleven different degrees andeciationsal programs on organizations (five-point Likert scale). The list a five-point Likert scale. included items on technical skills, knowledge of healthcare, quality improvement, management B. Prior work experience: An employee brings both experience, clinical experience, and other items. training and prior work experience to an organization. In Part B, participants rated various Analysis: Data forthelikertscaleitems is reported prior work experiences for the informaticists in their as the average score for each item (sum of the Likert organizations (five-point Likert scale). scores divided by thirty-two). C. Skill sets: Part C was designed to assess Qualitative data: Participants were encouraged to participants' views of the relative importance of three make comments during and after the interviews. 745

3 Their remarks were written down and analyzed. The highest scores were for "Healthcare QI / outcome interviews were not recorded and this written management," "Healthcare management," and qualitative data consisted mostly of paraphrases of "Physician." "Non-healthcare management" had the their remarks. All written comments were labeled, lowest score. such as "project management skills are important," "clinical experience is valuable," "CIOs need a ProrWork xperience Preferred different kind of training than medical informatics," etc. Scores were obtained by counting the number of A individuals who made remarks corresponding to each B of these categories. c Results Medical informatics training: The two most highly H rated educational programs for medical informatics I 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 Figure 2: Prior work experience fourth most desirable were MBA and MHA programs that included additional medical informatics courses. A c D Row Score Priorworkexperience A 3.81 Nurse, midlevel or other clinician Training for lnformatics Workers B 3.73 Healthcare QI / outcome mgmt. c 3.56 Healthcare management II1 D 3.35 Physician 3.05 Computer programming F 0 F 2.72 Information science G 2.68 Academic research and teaching _ H 2.68 Financial management G l I 2.13 ngineering J 1.94 Non-heafthcare management I.A + l ltable 5: Prior work experience K Skill sets: Three different skill sets were ranked, with being the lowest possible score and 1 the highest. Figure 1: Training for informatics employees (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. Row Score Type of training A 3.98 Previous on the job trainina r B 3.92 MS in medical informatics Fil s C 3.44 MBA + extra informatcs courses D 3.27 MHA + extra informatics courses $A 3.06 Self taught in medical informatics PregmIngaadITskllIl F 2.96 Fellowship in medical informatics G 2.92 MS in computer science H 2.85 BS in computer science Md = rca sills 2.62 PhD in medical informatics J 2.34 Information technology training onlyy X c K 2.27 PhD in information science 1 nilhcare maaeenlt skils _ Table 4: Training for informatics employees L _, 25 - Prior work experience: The highest rating went to Figure 3: Skill sets "Nurse, midlevel, or other clinician (excluding physicians)," with a score of 3.81 on a five-point Programmingproiciency: Figure4and Table6show Likert scale (Figure 2 and Table 5). The three next the agreement scores regarding programming proficiency for informaticists. The highest score 746

4 (76%) was for the statement, "Having a general H 3.65 Health information poli and law understanding of the uses and limitations of many I 3.63 I Healthcare management different computer languages is more important for J 3.48 Organizational behavior them than actually being able to program in specific L 1.80 Biopn matics languages." The lowest score (32%) was for the Table 7: Scores for informatics courses statement, "It is important for informatics workers to have an expert level of proficiency in at least one language." Courses for Informatics Students Views on programmh guaes % agr.mt) AC I 0% 209b 109b A B C D F Figure 4: Programming proficiency scores F G ~~~~~~~~~~~~~~~~~~~~~J ~~~~~~~~~~~~~~~~K Figure 5: Scores for informatics courses Specifc skills, knowledge, and experience: Survey Percent Statement participants rated a list of fifty specific items on a agreement five-point Likert scale. Nineteen of these items Having a general understanding of the uses received scores above 3.50 (Table 8). and limitaftons of many different computer A 76% languages is more important for them than actually being able to program in specific Rank Score Item A basic level of proficbncy in. computer Knowledge of healthcare processes B 70% languages is adequate for them Clinical guidelines, outcome mgmt. Medical informaffcs professionals in my Proect management C 66% organization are not expected to function as Datawarehousing programmers, even on projects they initiate. * Healthcare Ql Basic proficiency in many computer Practical decision support methods D 60% languages is more important than an expert T 3 Vocabulaies, UMLS, codin systems level of proficiency in a few languages mplementation of information systems It is important for them to have at least Clinical experience 53% moderate proficiency in some languages Knowledge of ciinical decision making It is important for informatics workers to Quality measurement in healthcare F 32% have an expert level of profidency in at Relational da s data modeling least one language Internet technologies and tools Table 6: Programming proficiency statements H Info retrieval (Medrine, Internet, etc.) SQL, DB development and mgmt. Informatics courses: Table 7 and Figure 5 show the Computerized medical records scores for twelve courses in a medical informatics Visual tools for DB management master's degree program. Survey participants rated Knowledge of IS vendor products the value of these courses for informaticists in their Table 8: Scores for the nineteen top-rated skills organizations. "Research in medical informatics" was ranked 31st with a score of 3.09 and "xpert systems" was ranked Aow 4.02e roject managemen35th, with a score of 3.02 (not shown in Table 8). B IntePrettechnologyandtools The three lowest scores were for "Writing journal *c 3.90 Database technology articles for publication" (2.41), "Bioinformatics" D 3.90 Healthcare vocabularies (2.36), and "Writing grant applications" (2.27) Clinical decision making F 3.83 Healfthcare quality Qualitative data: In their comments and remarks, IG Clinical inforimation systems seventeen of the thirty-two participants said that 747

5 clinical experience was important for informaticists in their organizations. Thirteen said that management experience was important and twelve mentioned the importance of projectf 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 importtnt. 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 itselfwith the cognitive, information processing, and communication tasks of medical practice, education, and research, including the informationr 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."' The FAQ goes on to say, "Informaticists are often also qualified to serve as a liaison between the technical ITpeople 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 trainod in only one discipline. Medical informatics 0ucati 1 programs that have an applied healtb~&re fo s are well equipped to train people for thete roles,- More studies need to%e done in order to more Ailly 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 1 990,65(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;1 l(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 ;1'1(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 H. Medical informatics. An emerging academic discipline and institutional priority. JAMA 1990;263(8): Oregon Health Sciences University. Frequently Asked Questions; Available fronm URL: Acknowledgement: This-work was supported by the National Library of Medicine grant 5 T15 LM