Medical informatics is as much about computers as cardiology is about stethoscopes. For those who have studied the application of information technologies in medicine, the past decade has delivered one unassailable lesson. Any attempt to use information technology will fail dramatically when the motivation is the application of technology for its own sake rather than the solution of clinical problems.1
The role of the information sciences in medicine continues to grow, and the past few years have seen informatics begin to move into the mainstream of clinical practice. The scope of this field is, however, enormous. Informatics finds application in the design of decision support systems for practitioners,2 in the development of computer tools for research,3 and in the study of the very essence of medicine—its corpus of knowledge.4 The study of informatics in the next century will probably be as fundamental to the practice of medicine as the study of anatomy has been this century.
I will consider recent advances in medical informatics with two seemingly contradictory themes in mind—apparently unbridled technological promise against less than satisfying practical achievement—and against three criteria —possibility, practicability, and desirability. Possibility reflects the science of information —what in theory can be achieved? Practicability addresses the potential for successfully engineering a system—what can be built given the constraints of the real world? Desirability looks at the fundamental motivation for using a given technology.
These criteria are suggested because a framework is necessary to judge the claims made for these new technologies by those who seek to profit from them. Just as there is a longstanding symbiosis between pharmaceutical industry and medicine, there is a newer and consequently less examined relation between medicine and the computing and telecommunication industries. Clinicians should try to judge the claims of these newcomers in the same cautious way that they would examine claims about a new drug.5 Perhaps more so, given that clinicians are far more knowledgeable about pharmacology than they are about informatics and telecommunications.
In this article I will first review recent activities in telemedicine. Since this is a new subject, research themes are only just becoming apparent. Then I will discuss protocol-based decision support systems, which may be the first substantive clinical information system to appear in routine clinical practice. Finally, I will examine the current state of clinical coding. The terminology and coding enterprise is a concerted attempt to describe uniformly the structure, content, and nature of medical knowledge.
Definitions of telemedicine abound. The essence of telemedicine is the exchange of information at a distance, whether that information is voice, an image, elements of a medical record, or commands to a surgical robot. It seems reasonable to think of telemedicine as the communication of information to facilitate clinical care. And it is not a new enterprise—Einthoven experimented with telephone transmissions using his new invention, the electrocardiograph, at the beginning of the century.6
At its inception telemedicine was essentially about providing communication links between medical experts in remote locations. The health care system, however, is clearly inefficient because of its poor communication infrastructure and telemedicine is now seen as a critical way of reducing that cost. One estimate suggests that the health system in the United States could save $30 billion a year with improved telecommunications.7 Consequently, telemedicine has now become an important subject for research and development. As might be expected, the renewed interest in telemedicine also has much to do with the excitement of new technologies. Currently, the press is flooded with articles about the information superhighway, the Internet, and the rapid growth in the use of mobile telephones. Telemedicine is often presented in the guise of sophisticated new communications technology for specialist activities such as teleradiology and telepathology. These are championed by telecommunication companies because they have the potential to become highly profitable businesses for them.8 Perhaps influenced by these forces, much of the research in telemedicine is driven by the possibilities of technology rather than the needs of clinicians and patients. Yet the communications infrastructure used by health care will not need to be special. The telecommunications market is competitive and the evolving options are numerous. Health care providers will be able to use the services of cable television, mobile cellular carriers, and telecommunication companies. Furthermore, communications technology does not need to be sophisticated to deliver benefit. Appropriate use of today’s telephone can make significant improvements to the delivery of care. For example, follow-up of patients is often possible on the telephone.9 Rapid communication of hospital discharge information using existing electronic data transfer mechanisms is beneficial for general practitioners.10 The combined use of mobile telephones and paging systems can reduce the 5-10 minutes out of every hour many clinicians spend answering pagers.11
Perhaps more interestingly, inexpensive voice messaging systems can deliver simple but powerful services over existing telephone networks. Voice mail for example, has significant potential for improving the process of care.12 Leirer et al. used a voice mail system to phone reminders about drug treatment automatically to elderly people at home, and they showed that it reduced both tardiness and complete forgetting.13 As more patients get access to electronic mail, this will offer further avenues for innovative health services. Already in some populations, access to electronic mail is high. Fridsma et al. in California found that 46 percent of their patients at clinic already used e-mail, 89 percent of which was through their place of work.14
All these points suggest that the potential for the clinical application of communication technologies is indeed great, but equally that there is much still to learn. In particular, the relation between telemedicine and informatics needs to be explored in greater detail. Informatics focuses on the use of information, and telemedicine on its communication. Although seemingly disparate endeavours, they are intimately linked since the goals of communicating information and deciding on its content cannot be separated.15 Furthermore, there is little clinical value in information systems built simply to gather data for administrators without remembering that the essence of delivering health care is the communication of information between members of the clinical team. Together, the technologies of information and communication can enhance access to information, whether it is stored electronically or is in the possession of a colleague.
Several key research questions are apparent. Firstly, clinical practice already revolves around communication, often by telephone, and important information exchanged in this way is often lost because it is not documented.16 Capturing the informal information currently lost in health care’s communication channels may soon become an important issue for those developing the formal electronic patient record. Deciding what information is important and how that information is made available will require the resolution of issues of confidentiality and security, as well as the technology of storage and retrieval of voice recordings.
Secondly, people’s understanding of the effects of technology on communication is still in its infancy. Researchers in human-computer interaction believe that before these technologies can be successfully introduced, the way in which people communicate needs to be understood.17 In one recent study the presence of a computer during doctor-patient consultations had detectable negative effects on the way doctors communicated.18 While they were at the computer, doctors gave short responses to patients’ questions, delayed responding, glanced at the screen rather than looking at the patient, or structured the interview around the computer rather than the patient. On the positive side, recent experiences in Norway have identified benefits to remote telemedical consultation. Services that provided isolated general practitioners with access to specialist skills had an unexpected side effect. The skills of the general practitioners were increased by repeated interactions with specialists during the management of cases that were previously referred.19 This may arise through the dynamics of the relationship between a remote general practitioner and a specialist. Unlike in most educational settings, both are motivated to form a coach and apprentice relationship for the immediate management of a patient.
Finally, along with new communication possibilities, come new medicolegal implications. In the United States the courts have decided that radiologists are negligent if they fail to inform clinicians personally of a diagnosis. "Communication of an unusual finding in an x-ray, so that it may be beneficially utilised, is as important as the finding itself."20 Furthermore, leaving a message with an intermediary is not enough —"certain medical emergencies may require the most direct and immediate response involving personal consultation and exchange."21 The fact that such communication requirements are beginning to be mandated reflects the community’s changing perceptions of best medical practice.
The rapid arrival of telemedicine suggests that the health care community is beginning to identify the benefits of good clinical communications practice and to realise the costs of poor communication. The next few years should see the research in telemedicine mature. The main focus will become the application of communication technologies rather than their development. This represents the same shift in focus that was required of medical informatics, in which initially much effort was spent in developing technologies specifically for medicine.
Many see the development of protocol-based medicine as the essential cultural change in clinical practice that will permit the design of useful clinical information systems.22 It was rightly seen as inappropriate for early computer system designers to try to regularise clinical practice to suit the nature of their systems. The move to evidence-based medicine now begins to make it acceptable for clinicians to follow standard assessment and treatment protocols.23 In this case it is quite appropriate for clinicians to use information systems to help them.
The ultimate goal of a protocol-based decision support system is to provide a set of tools that allows a clinician to access up-to-date guidelines and then apply them to the management of their patients. Simple protocol systems will probably appear in clinical practice by the end of the decade.24 In some sense, first-generation systems have already appeared as treatment guidelines and clinical trial data can now be accessed on the Internet.25
Evidence suggests, however, that even when guidelines are available, clinicians forget to follow them or deviate from them without clear cause.26 Forgetting preplanned management tasks seems to be especially likely when making clinical decisions in high stress situations.27 Yet enforcing uniform adherence to guidelines is probably unacceptable, given the complexity of individual cases. It should be possible, however, to make it as easy as possible for clinicians to access guidelines during routine care, making it less likely that steps will be inadvertently forgotten or altered.
This will require the design of more complex systems that will be integrated into the electronic patient record such that protocols can be stored and manipulated by clinicians. For example, best practice recommendations may need to be customised for local conditions or for individual patients. Furthermore, guidelines may be incorporated directly into patient records. As elements of the guideline are completed, they could be automatically noted. The records of care generated in this manner might ultimately be used for population based outcomes analysis...
Medical coding systems such as versions of the International Classification of Diseases (ICD), the systematised nomenclature of medicine (SNOMED(30a)), and the Read system(30b) are becoming increasingly familiar to clinicians. Their rationale is as follows. Once captured electronically, clinical data should be available for subsequent aggregation and analysis. However, the words used to describe conditions vary so much that simple analysis is often not possible. Furthermore, the meanings attached to terms may vary. If there was an agreed set of terms to describe the process of care then data analysis would be simplified.28 The goal of research into medical terminologies is to arrive at a consensus on the most appropriate set of terms and the way they should be structured.
The fundamental advance in terminological research over the past year or so is the realisation that the goal of constructing a complete and universal thesaurus of medical terms is ill posed. Terminology evolves in a context of use, and attempting to define context-independent terminologies is ultimately implausible. Coupled with this view comes the pragmatic understanding that a more robust scientific approach needs to be brought to the enterprise of terminology construction...
The ideal terminological system would be a complete, formal, and universal language that allowed all medical concepts to be described and reasoned about. Some researchers have explicitly asserted that building such a singular and "correct" medical language is their goal.29 This task emphasises two clear requirements: the ability for the terminological language to cover all the concepts that need to be reasoned about and the independence of the terminology from any particular reasoning task. A further requirement occasionally discussed is that when alternative terminologies exist, they must be logically related such that one can be translated into the other.
Despite the enormous health care investment currently devoted to achieving these goals, current evidence indicates that they are not possible. No set of codes or terms can be universally applied in medicine. There are two fundamental and related obstacles to devising a universal terminological system. The first is the problem that model construction-terminologies are simply a way of modelling the world, and the world is always richer and more complex than any model that humans can devise. The second is the problem of symbol grounding. The words we use to label objects do not necessarily reflect the way we think about the objects, nor do they necessarily reflect defined objects in the real world. The cumulative evidence from recent thinking in cognitive science, computer science, and artificial intelligence provides a formidable set of supporting arguments...
In the short term, administration agencies keen to obtain aggregate clinical data are driven to adopt existing systems, even if they are imperfect. This has led to much debate among those supporting particular systems of their merits over competing ones.30
Doctors in the United Kingdom have been asked to adopt the version 3 Read codes for use not only in personal clinical systems but also in audit, research, outcomes, and guidelines.31 Such a decision can now be seen to be necessarily interim. What is really needed to help rational choices in the longer term is impartial empirical research, comparing the cost and efficacy of different systems in support of well-defined tasks and contexts. For example, in a recent study comparing the utility of different coding schemes in classifying problem lists from medical records, none of the major systems was found to be comprehensive. The unified medical language system (UMLS) and the systematised nomenclature of medicine were found to be superior to Read and ICD-9 clinical modifications.32
In contrast with the British approach, however, the Board of Directors of the American Medical Informatics Association has suggested that it is not necessary or desirable to have all codes coming from a single master system. It suggests that several existing and tested approaches should be embraced, despite their imperfections, in order to progress quickly. A first phase system could be created by borrowing from the different existing code systems, each created for and therefore better suited to different subject domains.33
The longer term need will be to introduce more maintainable and extensible systems as the cost of supporting existing systems becomes insupportable. A solution based in part on multiple compositional systems would seem to be most desirable. Since any general medical terminology will cover only a small part of the specific vocabulary of any medical specialty, separate systems may need to be developed for use between and within specialties—"vocabularies need to be constructed in a manner that preserves the context of each discipline and ensures translation between disciplines."34 Indeed over a century ago, when Farr constructed the classification system ultimately resulting in the ICD, he noted that "several classifications may, therefore, be used with advantage; and the physician, the pathologist, or the jurist, each from his own point of view, may legitimately classify the diseases and the causes of death in the way that he thinks best adapted to facilitate his enquiries."35
Specialised compositional systems will thus need to be constructed that agree on a restricted subset of terms necessary for the passage of information between specialties—a kind of Esperanto between different cultures. Work on such communication standards is at present still in its infancy,36 and more substantive work should be expected in the future. Currently, terms are created without explicit tasks in mind, in the hope that all unseen eventualities will be served. Interspecialty systems would probably need to be tightly task based to ensure maximum utility.
I have reviewed three apparently quite separate areas—telemedicine, protocol-based decision support systems, and terminologies. They can now be seen to be inextricably entwined since the goals of communicating information and deciding on the content of information cannot be separated. Human communication entails information exchange in a context.37 What is said depends on the intended message, the method used to convey the message, who is speaking, and who is being spoken to. The development of protocol-based systems and their supporting terminological systems is a perfect example of that symbiosis.
Recent advances in medical informatics leave the following conclusions:
1. E. Coiera, "Question the Assumptions," in P. Barahona and J.P. Christensen (eds.), Knowledge and Decisions in Health Telematics (Amsterdam: IOS Press, 1994), pp. 61-6; J. Wyatt, "Promoting Use of Medical Knowledge Systems: Lessons from Computerised ECG Interpreters," in Barahona and Christensen, pp. 73-80; and J. Van der Lei, "Computer-Based Decision Support: The Unfulfilled Promise," in Barahona and Christensen, pp. 67-72.
2. R.A. Miller, "Medical Diagnostic Decision Support Systems—Past, Present, and Future: A Threaded Bibliography and Brief Commentary," Journal of the American Medical Association (1994;1), pp. 8-27.
3. L. Hunter (ed.), Artificial Intelligence and Molecular Biology (Menlo Park, CA: AAAI Press/MIT Press, 1993).
4. E. Keravnou (ed.), Deep Models for Medical Knowledge Engineering (Amsterdam: Elsevier Science, 1992).
5. J. Wyatt, "The Evaluation of Clinical Decision Support Systems: A Discussion of the Methodology Used in the ACORN Project," Proceedings of AIME 87: Lecture Notes in Medical Informatics (Berlin: Springer, 1987), pp. 15-24.
6. B.J. Nymo, "Telemedicine," Telektronikk (1993;89,1) pp. 4-11.
7. A.D. Little, Telecommunications: Can It Help America’s Health Care Problems? (Cambridge, MA: Arthur D Little, 1992).
8. R.A. Bowles and R. Teale, "Communications Services in Support of Collaborative Health Care," BT Technology Journal (1994;12,3), pp. 29-44.
9. J.N. Rao, "Follow Up by Telephone," British Medical Journal (hereafter BMJ), (1994;309), pp. 1527-8.
10. P.J. Branger, J.C. van der Wouden, B.R. Schudel, E. Verboog, J.S. Duisterhout, et al., "Electronic Communication Between Providers of Primary and Secondary Care," BMJ (1992;309), pp. 1068-70.
11. K. Fitzpatrick and E. Vineski, "The Role of Cordless Phones in Improving Patient Care," Physician Assistance (June 1993), pp. 87-92.
12. J. Constable, "Active Voice," BJ Healthcare Computing and Information Management (1994;11), pp. 30-1.
13. V.O. Leirer, D.G. Morrow, E.D. Tanke, and G.M. Pariante, "Elders’ Nonadherence: Its Assessment and Medication Reminding by Voice Mail," Gerontologist (1991;31), pp. 514-20.
14. D.B. Fridsma, P. Ford, and R. Altman, "A Survey of Patient Access to Electronic Mail: Attitudes, Barriers and Opportunities," Proceedings of the Symposium on Computer Applications in Medicine (Journal of the American Medical Informatics Association 1994; symposium supplement), pp. 15-19.
15. J.C. McCarthy and F. Monk, "Channels, Conversation, Co-operation and Relevance: All You Wanted to Know about Communication but were Afraid to Ask," Collaborative Computing (1994;1), pp. 35-60.
16. R. Stoupa and J. Campbell, "Documentation of Ambulatory Care Rendered by Telephone: Use of a Computerized Nursing Module, in R. Miller (ed.), Proceedings of the Symposium on Computer Applications in Medicine (Los Alamitos, CA: IEEE Computer Society Press, 1990), pp. 890-3.
17. J.C. McCarthy and F. Monk, pp. 35-60.
18. D. Greatbach, P. Luff, C. Heath, and P. Campion, "Interpersonal Communication and Human-Computer Interaction: An Examination of the Use of Computers in Medical Consultations," Interacting with Computers (1993;5), pp. 193-216.
19. S. Akelsen and S. Lillehaug, "Teaching and Learning Aspects of Remote Medical Consultation," Telekronikk (1993;89), pp. 42-7.
20. T.J. Kline and T.S. Kline, "Radiologists, Communication and Resolution," VA Medicolegal Issue. Radiology (1992;184), pp. 131-4.
21. Ibid.
22. J. Durinck, E. Coiera, R. Baud, et al., "The Role of Knowledge Based Systems in Clinical Practice," in: Barahona and Christenen, pp. 199- 203.
23. C.D. Mulrow, "Rationale for Systematic Reviews," BMJ (1994;309), pp. 597-9.
24. J.L. Renaud-Salis, "Distributed Clinical Management-Information Systems: An Enabling Technology for Future Health Care Programmes," in Barahona and Christensen, pp. 139-46.
25. F. Goodlee, "The Cochrane Collaboration," BMJ (1994;309), pp. 969-70.
26. Renaud-Salis, pp. 139-46.
27. E. Coiera, V. Tombs, G. Higgins, and T.H. Clutton-Brock, "Real-time Clinical Decision Making," HP Laboratories Technical Report 1994; No 79 (HFL-94-59).
28. M. Ackerman, M. Bail, P.D. Clayton, M.E. Frisse, R.M. Gardner, et al., "Standards for Medical Identifiers, Codes and Messages Needed to Create an Efficient Computer-Stored Medical Record," Journal of the American Medical Informatics Association (1994;1), pp. 1-7.
29. J.J. Cimino, "Controlled Medical Vocabulary Construction: Methods from the CANON Group," Journal of the American Medical Informatics Association (1994;1), pp. 296-7; and D. Evans, J.J. Cimino, W.R. Hersh, S.M. Huff, and D.S. Bell, "Toward a Medical-Concept Representational Language," Journal of the American Medical Informatics Association (1994;1), pp. 207-17.
30. S. Tuttle and S.J. Nelson, "The Role of the UMLS in 'Storing' and 'Sharing' Across Systems," International Journal of Biomededical Computing (1994;34), pp. 207-37.
31. K.C. Calman, "New National Thesaurus," CMO’s Update (1994;4), p. 1.
32. J.R. Campbell and T.H. Payne, "A Comparison of Four Schemes for Radification of Problem Lists," Proceedings of the Symposium on Computer Applications in Medicine (Journal of the American Medical Informatics Association 1994; symposium supplement), pp. 201-4.
33. M. Ackerman, M. Bail, P.D. Clayton, M.E. Frisse, R.M. Gardner, et al., pp. 1-7.
34. F. Brennan, "On the Relevance of Discipline in Informatics," Journal of the American Medical Informatics Association (1994;1), pp. 200-1.
35. World Health Organisation, Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death (Geneva: WHO, 1977).
36. H. Ma, "Mapping Clause of Arden Syntax with the HL7 and ASTM E 1238-88 Standard," International Journal of Biomedical Computing (1995;38), pp. 9-21.
37. J.C. McCarthy and F. Monk, pp. 35-60.
* Reprinted by permission of the author and the BMJ Publishing Group from British Medical Journal (May 1995).
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