Applied Medical Informatics for the Chest Physician: The Challenge of Understanding Clinical Workflow
The root causes for problems with interoperability include changing information technologies, competing proprietary vendor systems, and, simply, the complexity of clinical information systems. More recently, it has been recognized that standardization will be essential to the success of the National Health Information Network. Regional Health Information Networks are now beginning to appear in many states as networks of EMRs. All of this interconnection, though, clearly demands the standardization of systems and communications; in a word, interoperability. more
In the discussion of standards and interoperability, however, has appeared the additional issue of the standardization of language. In the AMI world, this notion of standardized medical terminology usually leads to the term lexicon, or dictionary. There are many examples of standardized medical lexicons (Fig 3). However through the efforts of Dr. David Brailer and the Office of the National Center for Healthcare Information Technology, the lexicon SNOMED has been acquired for use throughout the United States in an effort to catalyze the effective information interchange between information systems. The manufacturers of EMRs are now rapidly incorporating this particular lexicon. It has been said that the complexity of the automation of health care is much like the automation in the aerospace industry. Although the precise complexity grading of health-care automation may never be done, the fact is that there are numerous examples of failed clinical information systems over the past 30+ years that are related in part to the poor understanding and oversimplification of the process of clinical care.
One poorly understood dimension of workflow analysis in health-care information systems is group interactions. In the history of AMI, this has led to the use of systems that worked well for one group (eg, physicians, registered nurses, or pharmacists), yet were very poor at effective and safe communication among members of the health-care team. For example, CPOE systems have been created that allow the flagging of order as “STAT,” yet provide no effective means of notification of nursing and other groups workers who actually have to move a STAT order forward expeditiously.
Modern systems are improving in recognition of the complexity of actual health-care workflow as a result of increased emphasis on reduction in errors and improvement in quality of care A growing literature now is appearing that also recognizes the importance that the placement and availability of computer hardware varies among members of the health-care team.
In our third and final installment of this series, we will complete our discussion of the conundrum of effective clinician use of the EMR, including issues of interoperability, clinical workflow, and competing agendas in American health care. We will also look ahead to achieving the benefits of EMR, the personal health record, and the virtual ICU.
Figure 3. Catalog of controlled clinical terminology. See Table 2 for abbreviations not used in the text.