Medical informatics is a growing industry and many physicians are looking to expand their careers and enhance their education by learning more about the use of informatics in health care. Strictly defined, medical informatics investigates the structure and properties of medical information. Medical informatics is the scientific study and practical design, selection, implementation, evaluation, and maturation of systems that underlie the management (acquisition, classification, storage, retrieval, dissemination, and usage) of medical information, with the aim of supporting evidence-based decision making and improved quality in medical education, research, administration, and practice.

Today, the term "Clinical Informatics" is frequently used interchangeably with that of Medical Informatics. By definition, clinical informatics is usually used to refer to that subset of medical informatics that deals with the practice of medicine by healthcare providers--as opposed to those areas of medical informatics that deal with pharmacy operations, billing for medical services, administration of health insurance plans, etc.--although in practice, there is often overlap between "clinical" and "nonclinical" areas of medical informatics.

Information is critical to the practice of medicine. As the volume of clinical information, medical literature and number of individuals involved in a patient's care have risen, the study of healthcare information management issues depends more and more on the medical informaticist to serve as an interface between information system experts and clinical users. A medical informaticist requires skills in the fields of medicine, management and information technology. Medical informatics focuses on the subject matter--information, as well as the tools--the computers. Medical informaticists look at information and how it is captured, used, and stored as well as the equipment and database servers that make it all possible.

What training should a medical informaticist have and how can it be obtained? Experience in the clinical setting is essential. This experience is often gathered through medical, nursing or other healthcare professional training. Informatics training can be obtained in several ways. The most common is fellowship training at an institution with an informatics training program. Some fellowships require formal computer science training at an undergraduate level, while others provide a computer science background during the fellowship years. Fellowships in the United States are often funded by the US National Library of Medicine requiring US citizenship but others are open to non-US citizens. Fellowships typically last two to four years and may include participation in masters or doctoral programs at the host university.

Less formal training is available at some institutions with active medical informatics programs. By participating in the development and operation of active hospital clinical computing systems, a great deal can be learned. Finally, by attending informatics meetings such as Medinfo and those sponsored by the American Medical Informatics Association and reading journals such as the Journal of the American Informatics Association, MD Computing, Computers and Biomedical Research, Methods and Information in Medicine and others, exposure to medical informatics is available to all those with an interest.

There are many career paths medical informaticists can pursue. They can be working in academic medical informatics research, development and educational support. They can be in clinical administrative and educational management within a healthcare system. Physician informaticists may work in information systems (IS) departments and continue to practice clinical medicine part-time. Medical informaticists can also be involved in operational service management within a clinical institution. They can be the hospital's chief information officer or medical director for information technology. There are also opportunities in digital library development and implementation. Medical informaticists are needed in corporate research and development by healthcare institutions. Biotechnology and pharmaceutical companies are hiring them for their research, development and management teams.

The role of a medical informaticist traverses different levels of expertise and crosses different role boundaries but is based on combinations of key skills:

• Strategic planning, management and leadership skills
• Understanding the culture of healthcare organizations
• Business orientation and training
• Knowledge of healthcare financing and management
• Healthcare professional training
• Knowledge of system infrastructure design and networking
• Medical informatics training

Probably the most common role for physicians in an IS department today is that of the physician liaison: a communicator and translator between the department and end users. The physician liaison's primary tasks include frequent contact with practitioners from representative environments across the enterprise to gain a clear understanding of practitioners' information needs, communicate these needs to IS, work with IS staff in developing solutions, and review these solutions to ensure that they address the needs appropriately. A physician liaison also assists IS in presenting new functions to users, helping to explain limitations encountered or why one approach was adopted instead of another. In some organizations, these physicians also participate in the strategic planning process for information systems. A growing number of academic medical centers with large informatics groups employ physicians under IS who actively design and implement clinical systems.

As health care becomes more complex and more health care organizations appreciate the potential for clinical computing to help in monitoring and improving quality and in reducing costs, there will be more demand for expertise in medical informatics. Healthcare organizations should have medical informatics expertise available to them and health professionals should consider this field when planning their careers.

Chronic diseases cost the health care system upwards of $132 billion each year. Health plans and providers are constantly seeking new ways to control these costs, while still delivering quality health care services. Disease management programs have aimed to achieve this goal and many projects across the country are combining traditional programs with technology - and achieving successful results.

The California Healthcare Foundation and GlaxoSmithKline are sponsoring a series of workshops throughout California that help physicians improve their chronic care treatment. The workshops emphasize the use of technology in disease management and are providing physicians with the boost they need to implement technology solutions in their everyday practice.

Another initiative in California will use IT as a metric to benchmark physician groups in six health plans. The Integrated Healthcare Association, which consists of several California health care organizations, will rate each physician group based on a score in three areas. Technology spending accounts for 10% or the total score, which is based on a practice's use of data at the group level or physicians' access to data at the point of care. Patient satisfaction will account for 40% of the score, and a full 50% will be based on the group's treatment of asthma, diabetes, and coronary artery disease, screening for breast and cervical cancer, and childhood immunizations. The health plans, which include Aetna, Blue Cross California, and CIGNA, will then pay bonuses based on the physician group report cards.

Monetary incentives are also being used in a project based in Boston, Cinncinati, and Lexington, Kentucky. A group of large employers, including General Electronic, Ford Motor, Proctor & Gamble, United Parcel Services, and Verizon Communications, have partnered to form Bridges to Excellence - a not-for-profit organization that develops reimbursement models that recognize health care providers for delivering high quality, effective care. One of the programs offers physicians an annual bonus of $55 per patient for buying and using disease management software and electronic medical records for patients with chronic conditions. Bridges to Excellence also promotes Diabetes Care Link, an interactive web site that allows patients to enter key information on medication compliance or blood levels. Physicians who demonstrate that they are managing their diabetes patients well will receive an annual bonus.

Other disease management programs across the country are not necessarily linked to financial rewards, but do measure the effect that technology has on patient care. A web-based disease management pilot project at the Georgetown University Medical Center in Washington, D.C. tracks blood levels for diabetic patients. The six-month project reduced the HbA1c levels of 16 patients by at least two points. The patients who were more frequent users of the Internet-based program dropped their levels by three points. The program has now become part of routine care for approximately 30 to 40 patients at the medical center.

Technology is changing how patients interact with their case managers and physicians. Home monitoring devices, telephone calls and website live chats are all techniques used to communicate patient status from the home. In other programs, when a problem or change occurs with a patient, an "exception report" is sent to the doctor's office, leaving it to the doctor to take appropriate action. The doctor, notified by phone, page, fax or e-mail, can use the information to schedule an appointment, adjust the patient's medication, or take other measures as he or she deems appropriate.

Due to the cost-effectiveness of IT solutions, health plans are keen on using technology for disease management programs. A recent report from the Alliance of Community Health Plans (ACHP) revealed that insurers are increasingly using technology as a tool to supplement preventative services. The CDC-sponsored study included 10 of the ACHP's 11 member plans. All 10 plans used IT to send reminders to physicians of recommended treatments using either clinical or administrative data.

The survey forecasted that health plans will continue to increase their use of the Internet and predictive software modeling for disease management programs in the next three years.

Physician buy-in and support is of paramount importance to ensure the success of the disease management program. Program guidelines must be based on proven medical evidence and then must allow for physician input and education. Guidelines must be developed by extremely credible sources and clinical models must be flexible enough to allow for individual style, while still attempting to limit the variation from best practice.

Some plans emphasize how disease management programs can make physicians' lives easier through moving some of the patient management to case managers who make sure that patients keep their appointments, and keep them out of the ER. Others pay physicians for time spent reviewing care plans and talking to nurses for patients in the program, or for reviewing its patient reports. Nevertheless some physicians are beginning to feel that insurer-sponsored programs add to their paperwork with long lead times to prove effective outcomes. The most obvious problem is with different plans who each have their own disease management program, leaving the physician to ensure that the proper protocol for that payor was followed.

As more and more health plans turn to disease management vendors to cut costs, however, some solutions to those problems may be on the horizon. States like California, for example, are considering legislation that would give physicians some control over disease management. Ultimately, industry observers believe, disease management will gain greater acceptance among doctors as the programs learn to better serve physicians' needs. Those programs that don't serve physicians well won't last long, and the result will be a market with fewer, but stronger, companies.

Acquiring an electronic medical records system requires equal parts technology, psychology and patience. The attraction and promise of the electronic medical record is to capture all the data in the treatment of a patient from all possible sources at any point in time. For physicians to be efficient, accurate and compensated fairly, they must have access to information from every person - clinical or administrative - who dealt with the patient relative to current treatment. But the transition to the electronic medical record (EMR) from paper charts, what with the expense, training, work flow change, potential privacy issues and other side effects, can be difficult, even for practices enthusiastic for the technology. Yet many practices have taken their first steps into the electronic world through proper preparation, training and support before, during and after the electronic transition. This article will profile several practices and their approach in moving toward an EMR system - whether it has included total or partial implementation.

One of the major reasons for purchasing an EMR is to improve any inefficiency in work flow. This means an assessment of your current work flow and then a detailed plan of what you want to change. Look first to see if there is anything that you can standardize in easy-to-fill templates. One solo internist in Columbus, GA, who employs a physician assistant and a staff of fifteen, did just that. He worked with a practice consultant to develop templates that represented processes used to treat his patients' most common problems. These templates cover questions to be asked and include a list of commonly prescribed procedures and drugs. Developing such a system made for a simpler-to-use-EMR and an easier transition from paper. When a patient comes in with one of the "templated" conditions, the patient's notes can be entered by just the "click of the mouse" instead of typing. This helps eliminate costly transcription. The system also coordinates and stores the massive amounts of patient office data much more efficiently and effectively than the old paper system.

A three-physician ENT group in Washington, DC, was looking for an EMR system that would encompass the total integration of the patient encounter-from check-in/check-out through outside services, such as lab tests. It was decided that patients would still fill out the patient questionnaire data on paper but the staff would then enter it into the EMR. The paper form would then be shredded after data entry. The group also found that many records from the outside were still paper-based and needed to be scanned into the EMR. Even with these concessions the group's EMR has shortened patient office stays. The time is automatically entered when a patient signs in and a pop-up message on the wireless computer alerts the appropriate physician in the exam room. The physician can then access quickly all the information related to the patient. Most of the physician's notes on the visit can be entered with a few clicks on pre-set options. The physician then enters instructions and any prescriptions, if needed. By the time the patient checks out, all that information is available at the front desk.

Another medical group in Brewster, NY had its staff spend two months working on paper forms that replicated what the screens on the system would look like before implementing its EMR. This made the transition much easier and decreased actual training time to a few hours. Spreading the training and practice time over several months before actual implementation of the system makes the learning curve less stressful for everyone involved.

A fifty-five-physician multi-specialty group practice in Mount Vernon, WA, is taking a step-by-step approach to implementing an EMR. The first step is to put patient progress notes online. This accomplishes two things. Technologically, it enables providers access to patient information as soon as it is transcribed. Psychologically, online progress notes can pave the way to acceptance of a full-blown EMR by the group. The pilot program, which began in June 2000, enables "view only" access to transcribed notes, including progress reports, letters and radiology reports. The system does not permit users to manipulate data yet. The practice's goal is to get all data online. By last January, the practice was entering patient data from area hospitals into the clinical data repository. A lab system interface that would enable online access to lab reports was under development.

The most clear-cut benefit from this incremental approach to an EMR has come from reduced paper chart "pulls". Clinical staff use the system when responding to patient phone calls or when treating patients in the emergency room. Users access the clinical data repository via PCs located in the respective practices and the central billing office. Additional benefits come from improved patient care. Better patient service includes fewer staff callbacks to answer patients' telephone questions.

Understanding the unique elements that your system may require, especially any specialty-oriented data, is key in planning for your EMR. And if you are implementing in steps, you want to be sure to take these into account early on in the process. Take as an example, Pediatrics, which deals with children and adolescents. A pediatric EMR must have the functions to monitor development, growth and immunization schedules. An August 2001 report by the American Academy of Pediatrics actually identifies three areas in which pediatric EMRs should differ from systems designed for adult care: data representation, data processing and system design. Data representation includes patient growth data, the ability to generate data graphics to give to parents and "special calculations of growth patterns," according to the AAP report. A pediatric EMR should be programmed to understand pediatric lexicon and to determine "normal" ranges of readings based on a child's age, the AAP report says. Among the data-processing issues identified by the academy are pediatric-specific drug dosing, immunization records that can be reported in multiple formats, documentation for parents and reporting "mandated formats," such as for school or camp physicals. On system design, the academy calls for EMRs to address special privacy factors, including adolescent privacy laws that vary by state, genetic information and issues of adopted children, children in foster care and reports of abuse and neglect.

There are both benefits and risks associated to a piecemeal approach toward a complete EMR system. The healthcare organization must have a well-thought out strategy in terms of future integration of all the little parts into one big system. Working with the same EMR vendor from the beginning and working toward implementing that particular vendor's EMR may reduce the risk that the sum of the parts will not come together into an integrated whole EMR system.

Technology now provides the healthcare industry with many tools to collect, analyze, and distribute vast amounts of data, including data on the outcomes of care. Increasingly being summoned by payors and providers, outcomes data is used to identify where quality care is being practiced, which physicians to reward, and what patients need to know to decide on the best providers for their needs.

A growing trend in both government and private insurance sectors is the use of outcomes data to find ways to reward physicians, as well as hospitals, nursing homes and other healthcare providers, based on the quality of the care they give to patients. This "pay for performance" approach is dependent on two evolving criteria. One is that providers demonstrate that they are providing quality of care through using best practices, and the other is that they are publicly identified as having done so. This effort requires developing extensive computerized patient records and a comprehensive process for establishing uniform quality standards.

At the government level, the Center for Medicare & Medicaid Services is starting a three-year demonstration project directed to physicians' groups that have 200 or more members. Those who meet quality benchmarks will receive a bonus and will share in any savings resulting from increased quality of care. And in California, Blue Cross (BCC) has initiated one of the first large-scale efforts in a PPO network to tie physician reimbursement bonuses to the quality of the practice, as judged by clinical quality measures. The National Health Care Purchasing Institute (NHCPI) of the Public Health Service, sponsored by the Robert Wood Johnson Foundation, is also distributing nearly $9 million in grants to study incentive models that can be used to motivate physicians and hospitals, in a program called "Rewarding Results." A component of the program is to enable participating physicians to access Internet data that lets them compare their own performance with other physicians.

The clinical measures used to assess performance are still a work in progress for many of these efforts. However, they generally include such criteria as treatment for chronic illnesses like asthma, depression and diabetes; screening for breast, cervical, and colorectal cancer; preventive care like childhood immunizations; level of patient satisfaction; physician board certification; prescribing generic drugs where appropriate; and most recently, improvements in a group's use of information technology. At the federal government's website, talkingquality.com, consumer advocates, government officials, and benefits managers will find resources to help develop projects and reports on health care quality. The site addresses the concerns of how to implement a quality report, and provides a step-by-step method to collect and analyze data, present and publish information, and support an ongoing reporting project.

For surgeons, quality measures are usually tied to survival rates after surgery and mortality rates are increasingly being collected and widely disseminated. For example, the Pennsylvania Health Care Cost Containment Council, a state agency, publishes a guide to coronary artery bypass graft surgery, with each surgeon's mortality rate listed. The Maryland Health Commission publishes a hospital guide on the Internet, and Healthgrades.com gathers outcome and performance data as well.

Patients are now turning to the Internet to access the data about physicians. Access to this type of information is growing nationwide. In New York, Empire Blue Cross and Blue Shield has initiated an online hospital ratings report service for some of its members, using software from HealthShare Technology. Members can then decide which hospital to go to for a given procedure based on comparisons of length of stay and mortality rates. In Minnesota, HealthPartners was the first plan to put data on the quality of clinical care of its affiliated providers online. Its website posts evaluations of providers in several areas, including heart disease care, preventive health, diabetes, pediatric immunizations and others. HealthPartners uses assessment measures that are drawn from a combination of standardized measures created by the National Committee for Quality Assurance and from its own measurement guidelines. And in California, the Pacific Group on Health, a nonprofit coalition of California Employers, has set up a website called healthscope.org that allows consumers to select a medical group, and click on it to find how patients evaluate the practice based on four criteria: overall rating, treatment and specialty care, communication with patients, and timeliness of care and service.

With the outcomes data generated and distributed through these models directly impacting physicians' practices, physicians need to play a key role in determining which criteria should be used to define quality care and how to support the creation of well-designed assessment models.