1. Five Informatics Issues in Clinical Practice Topics in Clinical Management Course February 5, 2007
Daniel R. Masys, M.D.
Professor and Chair
Department of Biomedical Informatics
Professor of Medicine
Vanderbilt University School of Medicine

2. Biomedical Informatics
Discipline that addresses “...the cognitive, information processing, and communications tasks of medical practice, education and research, including the information science and technology to support these tasks” (Greenes & Shortliffe, 1990)
The art and science of organizing knowledge of human health and disease, and making it available and useful for problem solving.

3. Informatics vs. Information Technology (IT) and Data Processing
Informatics uses Information Technology as an infrastructure, but is focused on the semantics of what information means
E.g., a data processing system reports a serum K+ value; an informatics system knows that serum K+ has implications for cardiac & renal physiology, drug-drug interactions and drug dosing

4. Goals for Effective Healthcare
Deliver the right services to the right patient at the right time.
Do not deliver services that will not help the patient.
Deliver services that are cost effective.
Do nothing to harm patients or health care workers.
Respect each patient’s unique needs and preferences.
Why is this hard to do, and getting harder?

5. Issue 1: Too Much to Know

6. Growth of new information
The Biomedical Literature
Molecular Life Sciences
                                                                
MEDLINE:
15 Million journal articles
Growing at 576,000 new articles per year
GENBANK as of Feb 2007:
2.47 million genes
85+ Billion DNA base pairs

7. Be diligent. Read two journal articles every night
Be diligent. Read two journal articles every night. At the end of a year a you will be 1275 years behind the literature.
Assume only 1% of the new literature is relevant to what any individual physician does. At the end of a year you are 12 years behind.

8. (Partial) solution: Just-in-Time Learning
Issue 1: Too Much to Know
(Partial) solution:
Just-in-Time Learning
Wireless-enabled PDA

9. Issue 2: Fallibility of your own memory and that of colleagues

10. The Two Sides of Errors Commission Omission
44,000+ hospital deaths due to medical error
50 adverse events/1000 outpatient pt-years (Gurwitz 2003)
Patients receive 55% of recommended care (McGlynn, 2003)
Commission
Omission

11. Issue 2: Fallibility of your own memory and that of colleagues
(Partial) solution:
Consult the literature early and often

12. …we just don’t know which half
Issue 3: Half of what you have learned in med school will be shown to be incorrect
…we just don’t know which half
(Partial) solution:
Don’t assume that nothing has changed since the last time you saw a similar case.
Refresh your knowledge a patient at a time

13. Issue 4: More factors bear on many clinical decisions than unaided human cognition is capable of handling
Citation classic ref.:
Human Problem Solving
Simon and Newell, 1972
Observation: To solve problems that exceed 4-7 inputs, humans extinguish inputs to simplify the problem

14. The world of personalized, molecular medicine

15. Issue 4: More factors bear on many clinical decisions than unaided human cognition is capable of handling
(Partial) solution:
Seek practice environments that provide patient-specific clinical decision support. You will need it.

16. Clinical Decision Support

17. 35 30 Errors per 100 Orders 25 20 15 10 5 pre-CPOE post-CPOE
Computerized Provider Order Entry (CPOE) at Vanderbilt 35
30.1 30 25
Errors per 100 Orders 20 15 10
6.8 5
2.2
1.3
0.2
0.1
pre-CPOE
post-CPOE
Potential ADE's
Medication Prescribing Errors
Rule Violations
Potts, A. et al. PEDIATRICS 2004;:113:59-63

18. RxStar Provides Guidance, Alerts and Reminders
Dosing and allergy alerts
Include some screen snapshots
Serifed fonts (avoid)

19. Issue 5: Changing roles of providers: from captain of the ship to coach

20. MyHealth portal at Vanderbilt:
25,000 users, increasing 1K/mo
1500 sessions/day

21. Clinical Practice in the Information Age

22. Issue 5: Changing roles of providers: from captain of the ship to coach
(Partial) solution:
Stay flexible, learn new communications tools (e.g., patient portals) and roles, enjoy the ride

23. Summary

24. Five Informatics Challenges in Clinical Practice
Issue
(Partial) solution
1. Too much to know
Develop skills in Just-in-Time learning
2. Fallibility of your own memory and that of colleagues
Consult the literature early and often
3. Half of what you have learned in med school will be shown to be incorrect
Don’t assume that nothing has changed since the last time you saw a similar case

25. Five Informatics Challenges in Clinical Practice, cont’d
Issue
(Partial) solution
4. More factors bear on clinical decisions than unaided human cognition is capable of handling
Seek practice environments that provide patient-specific clinical decision support
5. Changing roles of providers: from captain of the ship to coach
Stay flexible, learn new communications tools (e.g., patient portals), enjoy the ride

26. The only thing we know for sure about the future is that it will be different
-Alan Kay

27. Vanderbilt can do it. We can help.