formal informatics courses for medical students are some- times available. ... cal computing tools in our academic medical centers, and current research continues to .... Stanford we offer M.S. and Ph.D. degrees in this field, with many of our ... 1991;11:S2-S14. 8 Teach R, Shortliffe E. An analysis of physician attitudes regard-.
MEDICAL TECHNOLOGY
Medical Informatics Meets Medical Education
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By Edward H. Shortliffe, M.D., Ph.D.
B
ecause the expanding influence of computers on society is being felt in medicine as well, it is appropriate that we ask how medical education should evolve to reflect these changes. Essentially all hospitals and outpatient practices depend on computers for administrative functions, especially for financial management, but the machines are increasingly playing a clinical role as well. It is natural that physicians and other health workers increasingly feel the need to understand computing and communications technology and to have an informed view of how advances in these areas are affecting the practice of medicine.1 Interest in computing topics has grown even stronger in recent months with the explosive growth in the Internet, extensive attention in the mass media, and increasing recognition of the global network’s potential role in bringing health information both to patients and to practitioners.2,3 The discipline that involves itself with computers and communication, and their use in biomedicine, is known as medical informatics. Academic programs in the field have begun to emerge at several medical schools, and formal informatics courses for medical students are sometimes available. In our introductory textbook, we defined medical informatics as: “the rapidly developing scientific field that deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for problem solving and decision making. It accordingly touches on all basic and applied fields in biomedical science and is closely tied to modern information technologies, notably in the areas of computing and communications. The emergence of medical informatics as a new discipline is due in large part to advances in computing and communications technology, to an increasing awareness that the knowledge base of medicine is essentially unmanageable by traditional paper-based methods, and to a growing conviction that the process of informed decision making is as important to modern biomedicine as is the collection of facts on which clinical decisions or research plans are based.”4 Workers in medical informatics have developed many of the information systems that now provide us with clini-
cal computing tools in our academic medical centers, and current research continues to anticipate both the needs of our evolving health care system and the remarkable new technologies that regularly appear. Figure 1 summarizes the core themes in medical informatics research, including the focused attention on biomedical data and knowledge and their proper use. Essentially all medical schools in the United States are making use of computers to assist with portions of their standard curriculum,5 and many have defined formal requirements for assuring that all medical students are “computer literate.” The emphasis of such requirements is typically on familiarity with the machine itself, with word processing, databases, and electronic mail, and with bibliographic searching. However, although computers are commonly seen in or near the classrooms, in the library, and on the hospital wards, and although students increasingly use the machines in their traditional studies and for access to the literature and to clinical data, it is rare for medical informatics to be a subject of required study by students in the health sciences. Many of us who work in the field, and who also care for patients and know the clinical world well, strongly believe that medical education should expose students to key concepts in medical informatics in order better to prepare them for the practice settings and responsibilities that they will encounter in their future careers. Health professionals obviously need to understand the proper use of biomedical knowledge and data-the core topics in medical informatics. Furthermore, they need to understand the capabilities and limitations of information technologies when applied in medicine, an inevitable element in the practice environments of the future. The National Library of Medicine has been especially active in urging an enhanced appreciation of how computing and communications technology can plan a central role in enhancing information access and dissemination.6 In urging exposure to medical informatics, it is important to emphasize that studying this field is not the same as becoming computer literate. In fact, incoming medical students increasingly already demonstrate strong computer skills while they understandably lack familiarity with the issues or lessons reflected in Figure 1. Post-doctoral
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fellows who take the informatics courses offered at our institution frequently express amazement that they had never been taught these concepts before, including the decision sciences, despite their relevance to clinical practice.7
perspective” on a hospital committee that is evaluating information system products are often poorly prepared to provide knowledgeable advice because they are unfamiliar with the potential limitations and recurring problems that have threatened the success of past systems. • What are the integrated functionalities that I should expect in the desktop workstations of the future, and what local, regional, and national impediments are preventing me from having them today? Unrealistic expectations, and an inability to function as an informed consumer, often result in physicians making poor purchase decisions for their own practices. • Why have many clinical computing systems failed, and what is the role of the health professional in helping assure that they succeed? Physicians can contribute to the effective solution of information system problems if they have an understanding of the reasons for past failures and can communicate effectively with those who are charged with system implementation or maintenance.
Figure 1: The core issues in the field of medical informatics are those related to the nature of biomedical data and knowledge and their representation and use in computer systems (red). From these recurring themes arise a number of research topics in the field (black). One benefit of informatics education will be a more informed set of attitudes and expectations regarding computing technology among clinicians.8,9 The most widely available use of computers in medical schools is bibliographic searching, essentially eliminating the use of the Index Medicus, formerly the sole means for finding pertinent literature. The popularity of such searching is not surprising in light of the well documented need for improved information access in practice settings,10 although MEDLINE alone will not meet all the information needs that arise.11 In the past few years we have also seen the introduction of computer-based tools that are designed to assist with difficult diagnoses, although such programs do not yet integrate well with the available clinical data systems and they are best viewed as memory joggers rather than as replacements for one’s own diagnostic skills.12 The following items illustrate some of the questions that graduating medical students should be able to answer and that draw on lessons that could be derived from courses in medical informatics:
• How can I achieve the most efficient and cost-effective evaluation of a complicated patient for whom many diagnostic and management options exist? The basic decision sciences (predictive values of tests, cost effectiveness, technology assessment issues) are increasingly being taught in medical schools and will help future physicians deal more effectively with the need to provide cost-effective care.13 • Why do my teammates, attending, and subspecialty consultants disagree on the management of this case, even though we have all read the same articles? This common phenomenon can be dealt with more effectively if physicians understand better the role of preferences, as well as probabilities, in determining the preferred approach to a patient’s management. • What are the common reasoning biases that can confound an optimal approach to diagnosis or treatment? 14 There is a wealth of knowledge in this area, but few physicians are familiar with the work or with its relevance to clinical practice.
• What are the tradeoffs among search strategies that I might use when doing bibliographic retrieval? Despite basic exposures to MEDLINE searching, most students never become expert searchers and have limited knowledge of methods for narrowing or expanding searches in response to initial retrievals.
• What are the characteristics of information management and flow in the modern health-care institution, and what are the major explanations, and potential solutions, for inefficiencies in these areas? Physicians who are frustrated with inefficiencies that they see around them can often benefit, and contribute to solutions, if they have familiarity with systems analysis methods and organizational theory as it applies to medical institutions. In academic medical centers, much has been learned about the way that integrated information systems can streamline information access and data sharing among practitioners.15
• How can I adequately represent the clinician’s perspective in helping my institution choose a hospital information system? Physicians asked to provide the “doctor’s
If we are to offer medical informatics courses in medical school, there is of course a need for faculty who can effectively teach the topics. Formal degree programs and
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fellowships in medical informatics are now offered at several schools, many of which have been created with support from the National Library of Medicine. 6 At Stanford we offer M.S. and Ph.D. degrees in this field, with many of our trainees entering graduate school after completing medical school or residencies.16 A variety of career paths are available for individuals with such training.17 In order to offer appropriate educational opportunities in informatics for medical students, schools must develop or recruit expertise in academic computing and must tie those people in closely with curriculum planners and reformers. School leaders must also convey to students the importance of informatics topics as fundamental to high-quality practice of medicine. Schools need to look beyond computer literacy concerns to develop formal informatics curricula that meet the needs of future practitioners who will function as users and creators of data and information. Therefore, academic units must be developed and nurtured and schools must develop a computing and communications infrastructure that meets the needs for coordination of academic, clinical, and administrative computing across the entire institution (including the teaching hospitals and clinics). At this time of rapid change in our health care system, and hence in medical education, recognition of the strategic role of informatics education is dependent on visionary leadership and institutional commitment; those institutions making the greatest strides in this area have made broad commitments to integrated information technologies. __________
Edward H. Shortliffe is Professor of Medicine and Computer Science at Stanford University School of Medicine. He is also Director of the Medical Information Sciences Training Program at Stanford. Reprinted with permission from Journal of American Medical Association, 1995, Volume 273, page 1061. Copyright 1995, American Medical Association.
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