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Corresponding author. Department of Surgery, University at Buffalo, 462 Grider Street, DK Miller Building, Third Floor, Buffalo, NY 14215. Tel.: +1 716 898 6515; fax: 716-898-3194.
Departments of Surgery and Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
IBM Watson Health, Cambridge, MassachusettsDepartments of Pediatric Surgery, Pediatrics, and Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
Clinical informatics is an interdisciplinary specialty that leverages big data, health information technologies, and the science of biomedical informatics within clinical environments to improve quality and outcomes in the increasingly complex and often siloed health care systems. Core competencies of clinical informatics primarily focus on clinical decision making and care process improvement, health information systems, and leadership and change management. Although the broad relevance of clinical informatics is apparent, this review focuses on its application and pertinence to the discipline of surgery, which is less well defined. In doing so, we hope to highlight the importance of the surgeon informatician. Topics covered include electronic health records, clinical decision support systems, computerized order entry, data analytics, clinical documentation, information architectures, implementation science, quality improvement, simulation, education, and telemedicine. The formal pathway for surgeons to become clinical informaticians is also discussed.
Like most industries, health care has become increasingly intricate and digitized. We have the ability to store diverse types of health information in electronic formats, and new therapies and technologies are constantly being introduced. Patients as consumers have the ability to travel long distances for the care they desire and can fact check within the matter of seconds, thanks to smart mobile devices. Health care providers are expected to produce better, safer, and more cost-effective outcomes in less time to a greater volume of patients.
Surgeons face additional layers of complexities because of the procedural nature of their work, which can occur across highly varied settings, from the operating room and ambulatory surgery center to the endoscopy suite, from the clinic to the emergency department and the intensive care unit. As health care becomes more digital, technology-dependent, and data-driven, an important and unmet challenge is ensuring that the systems and associated processes work efficiently and effectively for surgeons and their associated teams, without compromising patient care or security. In order for informatics to meet the workflow demands unique to surgical care delivery, we need a trained workforce with practical clinical expertise that can interface with the technical and data aspects of our multifaceted health care environment.
In this review article, we aim to introduce the field of clinical informatics and its core competencies, to highlight the value of this discipline to surgeons, and to discuss the training paradigm toward becoming a surgeon informatician.
What is clinical informatics?
Clinical informatics—also known as applied or operational informatics—is a subspecialty of biomedical informatics (Fig. 1). Clinical informatics is the application of informatics and information technology (IT) to deliver health care services by clinicians (Fig. 2).
Physicians who practice clinical informatics—known as clinical informaticians or clinical informaticists—analyze, design, implement, and evaluate information systems and their associated data and processes to enhance individual and population health outcomes, improve patient care, and strengthen the clinician-patient relationship.
Clinical informatics was established as a board-certifiable subspecialty for physicians in 2011 because of the recognition of technology and big data's increasing presence in the practice of health care. Much like how the radiologist is to be distinguished from the radiology technician or the pathologist from the laboratory technician, the role of the clinical informatician is separate from that of an IT professional who helps to build, implement, and support clinical information systems.
Fig. 1Biomedical informatics and various subspecialties by area of application area. There are others that are not captured in this figure. Some classifications of informatics also use methodological expertise (e.g., terminologies, human-computer interaction and usability, and natural language processing). (Color version of figure is available online.)
Fig. 2Clinical informatics as the intersection of clinical care and information technology within the context of the greater health care system. (Color version of figure is available online.)
The core competencies expected of clinical informaticians include the following: having a fundamental understanding of informatics as a discipline, developing, selecting, and maintaining effective health information systems, being able to implement clinical decision-making systems and care process improvement, and leading and managing change.
Many opportunities exist which combine surgery with informatics. Examples range from leveraging electronic health records (EHRs) for data collection to improving the perioperative workflow with real-time data analytics and to improving communication with patients through telehealth and patient portals. In 2017, an expert panel at the Surgical Outcomes Club meeting was convened to discuss opportunities for innovation and improvement in surgical care through health IT.
In 2018, the American Medical Informatics Association Clinical Informatics Conference dedicated a session in its programming solely to surgery and informatics, emphasizing the growing awareness within the informatics community itself of the need to expand the representation of clinical informatics beyond primary care and pathology. In 2019, a hot topic panel was hosted at the Academic Surgical Congress to discuss the role of the surgeon informatician as both surgeon researcher and surgeon advocate. Efforts are currently being taken by the American College of Surgeons Health Information Technology (HIT) committee to establish a library of known surgically relevant mobile applications, wherein committee members use a standardized rubric to describe and rate each application to help American College of Surgeons members navigate the multitude of mobile applications available. Surgeons formally trained as clinical informaticians—with their commensurate clinical, technical, and leadership qualifications—are indispensable to ensuring that the implementation and integration of information technologies optimally support surgical practice and research.
Understanding the informatics environment
On February 17, 2009, the American Reinvestment and Recovery Act was passed as an attempt to modernize the nation's infrastructure.
Centers for Disease Control and Prevention Public health and promoting interoperability programs (formerly, known as electronic health records meaningful use).
Included was the Health Information Technology for Economic and Clinical Health (HITECH) Act, an effort pushed by the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT, to support the “meaningful use” of and widespread implementation of EHRs throughout the United States as critical goals. Meaningful use is defined as the use of certified EHR technology in a meaningful way; for example, to meet meaningful use criteria, EHRs must offer features such as electronic prescribing, EHR interoperability, and reporting of quality metrics. Meaningful use relies on the following five health policy priorities: (1) improving quality, safety, efficiency, and reduce health disparities, (2) engaging patients and families in their health, (3) enhancing care coordination, (4) improving population and public health, and (5) ensuring adequate privacy and security protection for personal health information.
Rollout of meaningful use was split into three stages, spanning 2011 (data capturing and sharing), 2013 (advanced clinical processes), and 2015 (improved outcomes). Financial incentives were provided to voluntary early adopters, and penalties with reduction of Medicaid/Medicaid fees began for nonadopters in 2017.
An important driver for the 32-billion dollar HITECH Act was the inability to efficiently measure quality of care being delivered on a population basis nationally. Meaningful use criteria reporting was meant to hold health systems accountable for implementation milestones but instead resulted in the overuse and waste of resources. In recent years, meaningful use has shifted to focus more on interoperability, which remains a challenge between health care facilities.
A significant goal of meaningful use was to make patients stewards of their own health care. In meaningful use stage two, patients were supposed to be able to view, download, and transmit their data from EHRs. This was most often implemented through patient portals. In meaningful stage three, this was extended to require all EHRs to expose an application programming interface (API) to view, download, and transmit. This API rule came into effect from January 2019. The vision is that many innovations will be built on top of the EHR layer.
Increased adoption of many technologies is a result of health care organizations responding to meaningful use incentives and disincentives laid out in the HITECH Act of 2009. Future challenges—including curating and effectively displaying data and information, optimizing systems for usability and clinical workflows, and incorporating clinical decision support and artificial intelligence—will rely on well-trained clinical informaticians to help navigate the changing landscape between patient care and information technology.
Developing, selecting, and maintaining effective health information systems
Health information system design, implementation, and adoption are foundational aspects of clinical informatics. Surgeons use a variety of health information technologies to take care of patients, including but not limited to EHRs, picture archiving and communication systems, endoscopy platforms, anesthesia platforms, and operating room tracking boards. Considerations regarding ease of use, cost, surgeon buy-in, ability to customize, and interoperability with other existing platforms go into the selection process. At times, the surgeon informatician must make the difficult yet ultimately savvier strategic decision to forgo implementation of new IT for the time being until better, more interoperable technologies can be developed. Once implementation occurs, ongoing assessment and reassessment is mandatory. In the process, new workflows may emerge.
Adequate security measures have to be considered to prevent unethical agents from hacking into the system and compromising patient care and safety, whether that be with regard to robot-assisted surgery, mechanical ventilation, or intravenous pumps. Care must be taken that the update of one platform does not cause one or more of the others to malfunction or lose interoperability.
Not only does the clinical informatician have to be concerned about the information architecture within his or her own health care system but also interoperability with other systems. This requires stakeholders to build and use a shared language. Familiarity and an understanding of health care messaging standards (e.g., classic Health Level Seven or HL7) and API frameworks including interoperable solutions (e.g., API platforms as a service, Fast Healthcare Interoperability Resources or FHIR), and reference terminologies (e.g., Systematized Nomenclature of Medicine–Clinical Terms or SNOMED CT, Logical Observation Identifiers Names and Codes or LOINC, and RxNorm) are highly useful. These solutions are starting to allow the introduction of several new data points, such as patient collected data (e.g., pictures of wounds) and intraoperative recordings, that can be directly integrated into the EHR and between EHRs, making the potential for surgical care delivery endless. Currently, patients who live in a city with different health care systems may agree to have their records uploaded to the regional health information organization, which can allow sharing of information online for providers. The future of health care may one day allow interoperability between all health care information systems without the need for a regional health information organization as a middleman. True interoperability will help cut down on excess radiation because of duplicate scans, streamline the time period between preoperative visit and surgery, and free patients with complex medical and surgical histories from being tied to one physical location.
Clinical decision support systems & computerized provider order entry
Clinical decision support (CDS) systems are applications that provide pertinent, organized knowledge to clinicians at keys points of clinical care to enhance health-related decisions and actions.
The five “rights” of CDS systems include the following: the right information, to the right person, in the right intervention format, through the right channel, and at the right time in workflow.
CDS systems can be offered within or separate from EHRs. Many EHR vendors offer simple CDS features such as medication prescribing assistance with dosing and alerting for drug-drug interactions or allergies. CDS systems that assist with diagnosis and care pathway–based management are being introduced with increasing frequency.
CDS systems are particularly useful to surgeons who have to be aware of multiple different patient data streams at any single point in time, by facilitating the integration of the data and visualization in such a way that surgeons can make important decisions in a time-sensitive manner.
Everyday examples of CDS systems include extreme vital signs or laboratory values that change color or graphs that depict trends. CDS systems can help surgeons avoid duplicate narcotic prescriptions, increase adherence to enhanced recovery after surgery protocols, automatically calculate the Caprini score to determine which postoperative patients would benefit from being discharged on anticoagulation, detect aberrant anatomy intraoperatively, and so on.
There is widespread interest in leveraging CDS systems to grade the difficulty in obtaining the critical view of safety for cholecystectomies, optimizing the detection of polyps during colonoscopies, and anticipating patients at risk for decompensation to help justify a hospitalization, all motivated by a need for improved mechanisms for coaching, reimbursement, medicolegal protection, and patient safety.
Computerized provider order entry (CPOE) refers to the process by which health care professionals enter and send treatment instructions with orders on the computer rather than verbally or on paper, fax, or telephone for fulfillment.
Implementation of effective CPOE often takes a concerted effort by multiple stakeholders in that it is not simply a matter of automating existing processes but rather ensuring that the CPOE meets user-defined functional requirements, integrates well with existing system infrastructure, and supports the hospital's mission statement and strategic goals. Appropriately implemented, CPOE can help reduce errors, such as those associated with incorrect dosages or typographical errors, improve patient safety, enhance efficiency through the use of order sets by the reduction of unnecessary clicks, and even facilitate reimbursements by flagging orders that require preapproval and thus minimizing denied insurance claims. By decreasing cognitive and administrative burdens, effective CPOE allows surgeons to focus more on other aspects of surgical planning and patient care.
Process improvement
Clinical informaticians are tasked with enhancing care delivery while ensuring that quality remains high, and resources are dealt with in a cost-effective manner. Endless opportunities exist to leverage health IT to improve surgical processes related to clinical workflow, research data extraction and collection, communication with patients, and education and training.
Multiple technologies already play roles in improving workflow processes. Rounding reports, speech recognition software, augmented reality, three-dimensional print models, smart dashboards, and risk calculators built into existing health IT represent the tip of the iceberg in terms of how big data can be useful for surgeons.
Development of electronic medical record-based "rounds report" results in improved resident efficiency, more time for direct patient care and education, and less resident duty hour violations.
Secure text messaging allows for the transfer of clinical information without violating privacy and gives the sender and recipient peace of mind that the information will auto-delete within a certain time frame. Virtual visits cut down on travel and preserve communication between surgeons and patients. Patient portals and personal health records which allow for secure messaging and access to clinical documentation improve communication and compliance as well as empower patients to be more engaged with their own health care.
Geomapping technologies allow for near real-time location tracking, which can be used by providers or patients and their families depending on the context. Health IT affords surgeons to know when their patients are off the floor, patients to anticipate if and by how long their surgeon will be delayed in seeing them, and family members to know when their loved ones are finished undergoing surgery.
From a research standpoint, large database studies are often criticized for including flawed or inconsistent data, errors made during data entry, or failure to keep data current as patients’ clinical situations evolve. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP), created with input from clinical informaticians, has won accolades for its data quality.
NSQIP unfortunately is expensive to maintain because it relies heavily on highly trained personnel to manually enter data. Hopeful informatics solutions are being found in natural language processing (NLP), a computing technique that parses and makes sense of written language. NLP can be used to analyze text to determine its meaning or to populate a structured data model. Beyond its utility in data mining for research, NLP algorithms in the clinical context can be used for speech recognition, clinical documentation improvement, automated registry reporting, computer-assisted coding, clinical trial matching risk adjustment, scribing, population surveillance, and computational phenotyping and biomarker discovery.
Informatics solutions can also be used to address the growing clinical documentation problem contributing to wide-spread burnout among surgeons. Efforts include tackling the epidemic of “note bloat” to streamline documentation in the EHR.
If copy forward is used, copied text can now be tagged and credit can be given to the original author. Voice recognition devices aid in transcription, and templates allow notes to prepopulate with vital signs, laboratory values, pathology results, and radiology findings.
A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.
Audit information that has to be stored for security purposes can be studied to reveal how long clinic visits take and how accurate scheduled appointment times are, thereby helping to provide transparency and insights around clinical operations.
These efforts allow surgeons to spend more time at the patient's bedside and in the operating room, be present for multidisciplinary conferences, and when off the clock, to truly disassociate from work.
General, vascular, cardiothoracic, and pediatric surgical residencies have embraced online media for housing a learning management system consisting of shared context, such as specialty-specific text, questions, and videos.
Social media platforms, such as Twitter (http://www.twitter.com), blogs, YouTube (http://www.youtube.com), and Instagram (http://www.instagram.com) have become platforms for sharing information on techniques, providing conference updates, discussing journal clubs, and offering mentorship.
CSurgeries (http://www.csurgeries.com) and GIBLIB (http://www.giblib.com) offer peer-reviewed video libraries of surgeries and 360-degree virtual reality footage, respectively. Simulation is used to prepare junior surgeons for novel or difficult cases as well as to test aging surgeons to assess for deterioration of skill set. Programs like Project ECHO (Extension for Community Healthcare Outcomes) provide tele-educating and tele-proctoring.
Mobile applications such as the Accreditation Council for Graduate Medical Education (ACGME) case log (https://apps.acgme.org/connect/login), MedHub (http://www.medhub.com), and SIMPL (http://www.procedurallearning.org/simpl), that have facilitated logging of duty hours, evaluations, cases, and assessments of resident performance, illustrate some examples of how information technology can be adapted to facilitate the workflow of surgical trainees and faculty and improve engagement and wellbeing.
Leadership & change management
Clinical informaticians leverage their technical and nontechnical knowledge and skills to lead implementations of health information systems and promote adoption by health professionals. Constant vigilance is necessary to plan for and manage any unintended consequences that may arise during implementation. There needs to be enough flexibility and innovation to be able to adapt to crisis situations such as ransomware attacks, public health scares, and natural disasters that may compromise or tax the existing health information structure. Informatics leadership and change management have significant implications for surgeons. For instance, as surgery becomes increasingly regionalized, investments into telehealth will grow. Critical care surgeons can remotely monitor patients from home. Surgeons may even one day routinely perform robot-assisted surgery remotely with a local surgeon assisting. Proof of concept trials has already taken place.
With adoption of these programs, models for appropriate compensation and quality assurance will need to be considered. Large data storage requirements due to patient pictures and intraoperative videos may slow down day-to-day processes and cost health care organizations too much money to maintain. Consumer demands and cost considerations will need to be balanced against compliance with regulatory pressures regarding the duration and location of data storage.
Clinical informatics also has a close relationship with health policy and advocacy. The increased adoption of patient portals, personal health records, and telehealth has created new avenues for patient-surgeon communication and delivery of care.
Reimbursement modalities have lagged behind, resulting in surgeons providing countless of hours of work that are not compensated. By studying clinical documentation trails, surgeon informaticians were able to present evidence to support advocacy efforts that ultimately led to fairer compensation.
CMS is launching a “Patients Over Paperwork” initiative projected to take effect in 2021, with plans to streamline levels of service and documentation requirements.
Controversy remains over whether more time should be spent on collecting a comprehensive review of systems or elaborating on the chief complaint. Evidence has shown little benefit in patient care with a comprehensive review of systems, revealing that many of the rules and regulations pertaining to clinical documentation can still be optimized and tailored for clinical relevance.
In February 2018, when the CMS changed reimbursement policies to permit teaching faculty to verify—rather than redocument—medical student documentation, it triggered a change in a pre-existing workflow and EHRs across the nation had to be adapted accordingly.
Challenges lay ahead for clinical informaticians as more technologies and larger, more diverse data sources are introduced into the health care settings. Solving problems in a clinical environment that is not under statistical process control can result in scenarios where the benefits of innovation are indecipherable from the noise in which it is imbedded.
Tensions between quality improvement and research will be rife. Furthermore, the evolution and adoption of health IT and applications are storing a wealth of data not only on patients but also on practicing surgeons and trainees and their performance. There is great interest in using predictive analytics for the purposes of hiring and retention. Surgeons with formal training in clinical informatics are needed to help obtain, manipulate, display, interpret, and ultimately transform the data into useable information and shared knowledge for the practice of surgery.
Finally, although the benefits promised by CDS systems are innumerable, real life applications have proven to be at times suboptimal, leading to what has been popularly described as “alarm fatigue.” Alarm fatigue refers to sensory overload from exposure to excessive alarms, resulting in desensitization to alarms and ignoring or dismissing alarms when they legitimately signal impending patient harm or death.
CDS can improve care but also introduce errors, especially if the data in the CDS are not current. Take, for instance, a scenario in which the perioperative antibiotic recommendation in a CDS system is not up to date, and the patient has an allergic reaction to an antibiotic that is no longer recommended in current guidelines. It is imperative for surgeons to understand not only the benefits of CDS systems but also their limitations. As EHRs start to incorporate CDS systems, they will behoove surgeons to pay attention to not only the quality of these systems but also whether their deployment fits seamlessly into the workflow of surgical specialties.
Becoming a surgeon informatician
As surgeons, we understand how to work within innovative arenas and position ourselves and our resources for success. Surgeons are used to being captains of an expert multidisciplinary team. The best way to maximize the potential of the increasingly data-driven and technology-centric health care setting for surgeons is to formally train surgeon informaticians.
Clinical informatics is an American Board of Medical Specialties subspecialty that is unique in that board-eligible or board-certified physicians from any specialty can enter the clinical informatics subspecialty. Surgeons interested in formal training can pursue an ACGME-accredited 2-year fellowship after completion of their residency. Qualified candidates can petition to pursue fellowship training midway between their residency in the years traditionally reserved for other academic pursuits such as research.
The American board of Preventative medicine has obtained approval from the American board of medical specialties’ (ABMS) to offer surgical residents Mid-residency training programs in clinical informatics (MRTP). American Board of Preventative Medicine,
2019
Board certification is awarded through the American Board of Preventative Medicine. Until 2022, those with at least 3 years of practice in clinical informatics—with practice time being at least 25% of a full-time equivalent to be considered significant—may petition to sit for the clinical informatics board examination. Starting in 2023, the examination will only be available to physicians who have completed an ACGME-accredited fellowship.
As the world moves toward board certification as evidence and verification of safe, standardized training, it will likely be the norm that those interested in becoming surgeon informaticians pursue formal ACGME-accredited clinical informatics fellowships.
Despite the pervasiveness of information systems in surgery and the establishment of clinical informatics training, many surgeons remain unfamiliar with formal informatics training. For surgeons who choose to complete both a surgical subspecialty and clinical informatics fellowship, formal training can significantly lengthen the duration of training at a high-opportunity cost. There is increasing momentum at the medical school and residency level across all specialties to require informatics training within the curriculum. For surgical residencies, this may include informatics didactics, formal rotations, or electives. Relevant content may include legal and ethical use of health information, informatics approaches to improve surgical quality and safety, and HIT implementation benefits and unintended consequences.
Additional opportunities to gain exposure to other informatics specialties (Fig. 1) include taking a 10x10 Virtual Informatics course through the American Medical Informatics Association, the parent organization for informatics in the USA. The National Library of Medicine has also long been a key supporter of biomedical research and training. Its Extramural Programs Division has long funded predoctoral and postdoctoral training programs in biomedical informatics. Such programs offer MS and PhD degrees or postdoctoral fellowships with multidisciplinary education that included training computer science, information science, decision science, health services research, and policy.
After training, there are tiers of informatics roles which exist in hospitals, health care systems, telehealth, innovation centers, and industry. These include chief medical informatics officer, chief informatics officer, chief innovation officer, chief digital health officer, medical director, quality champion, departmental or divisional chair, chief executive officer, and physician champion. A wide range of career opportunities exist, spanning clinical operations, research, academics, and industry.
Conclusion
The field of clinical informatics has gained increasing attention over the last decade. Medical knowledge is projected to double every 73 days.
Innovative technologies are being introduced at a rapid pace. There is simply no way for practicing clinicians to keep abreast of all relevant information and technologies in isolation.
Appropriately trained clinical informaticians can be stewards of quality assurance and effective HIT implementation and use. The need for clinical informaticians will increase in every specialty, including surgery.
Career pathways in clinical informatics include research, health care technology operations, administration, and industry. Formal clinical informatics training can be obtained through board certification.
Surgeons are well suited for clinical informatics because of the familiarity with technologies present across many settings, including inpatient and outpatient environments, the emergency department, the operating room, endoscopy suites, and the intensive care units. Efficiency and throughput are important to surgeons as they must often obtain and synthesize health care information from a variety of different sources to make important decisions quickly. Surgeons are underrepresented in informatics and needed to enable effective creation and use of health information technologies and leverage of health care data for surgical practice.
Acknowledgment
The authors would like to thank the program committee of the 14th Annual Academic Surgical Congress for hosting the hot topic panel titled, “The Surgeon Informatician: Both Surgeon Scientist and Surgeon Advocate” and the Journal of Surgical Research for recognizing the importance of clinical informatics to surgery.
Authors' contributions: J.Z. performed the literature review, created the figures, and wrote the review article; R.F., A.L., G.B.M., D.F.S., and G.P.J. contributed content expertise and performed critical revisions necessary for the final version of the review article.
Disclosure
The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.
Development of electronic medical record-based "rounds report" results in improved resident efficiency, more time for direct patient care and education, and less resident duty hour violations.
A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.
The American board of Preventative medicine has obtained approval from the American board of medical specialties’ (ABMS) to offer surgical residents Mid-residency training programs in clinical informatics (MRTP). American Board of Preventative Medicine,
2019 (Available at:)
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