Health Informatics in Context: The Historical Processes to Shape the Field

While the fundamental objective of health care – the health of the patient – will forever remain static, the accouterments to support this end remain in constant flux. A key catalyst to support this effort lies at the intersection of data, information technology, and healthcare – or what is more commonly referred to as medical or health informatics. Health Informatics, also referred to as Health Information Technology (HIT), involves the infusion of data – through collaborative interfaces – into health care systems or processes to improve the processing, organization, and dissemination of data as a means to promote efficiency, share knowledge, and most of all to improve care. As a truly interdisciplinary field, health informatics draws upon the knowledge of health care practitioners and data, as well as data organization and analysis platforms to improve organizational management, patient care, and overall efficiency for the many moving parts of the health care industry.

In recent years, health informatics garnered significant attention, most notably in the American Recovery and Reinvestment Act (ARRA) of 2009. The stimulus package dispersed a $22B investment in health information technology under the aegis of the Health Information Technology for Economic and Clinical Health (HITECH). This legislation similarly strengthened HIPPA regulations, established legal protections for patients, but also set national standards for electronic patient records (EPR) systems (Hersh 2009). No doubt such legislation is needed based on President Barak Obama’s assertion in the value of health information technology to “reduce error rates, reduce our long-term costs of health care, and create jobs right now (as quoted in Hersh 2009)?” Indeed, health informatics enjoys a prominent role in the health care industry and the broader economy. The significance this field enjoys, however, raises questions as to how and why the health information technology industry became the multi-billion dollar emerging discipline and industry it is today?

While any number of historical and economic factors contributed to industry growth, the twin historical processes of institutionalization and application crystallized the value of health informatics as a discipline and practice. This paper examines these two steps in the historical development of health informatics as a way to unpack the current prominence the discipline enjoys.

This paper is organized into two sections to dissect the underpinnings of the current health informatics paradigm. First, the institutionalization section outlines the organizations to define and promote the niche discipline. Second, the paper takes aim at the successful application of health informatics as an impetus to the current prominence of health informatics in recent years.

Institutionalization

The foundations of health informatics were seeded in the late 1940s, 1950s, and early 1960s, however, these years of infancy in the discipline were marked by disparate individual contributors without institutional framework to facilitate collaboration. Two notable examples are indicative of the core challenge and models for success in the early stages of the health informatics. On the one hand, Dr. Morris Collen, a practitioner and early advocate for health informatics, sought to leverage electronic systems for the management of information in the late 1940s but met with little success to integrate computerized technology in his lab in California (Collen 2006). On the other hand, Collen’s contemporaries, Robert Ledley and Lee Lusted, both radiologists with expertise in electrical engineering and significant institutional backing; Ledley was affiliated with the National Academy of Sciences – National Research Council and National Bureau of Standards whereas Lusted was a former radiologist and professor at the University of Rochester (Ledley and Lusted 1959). The institutional and intellectual resources available through their collaboration and affiliations presumably proved invaluable to the success of their study. Thus, it became clear an institutional platform was critical to facilitate collaboration in the burgeoning field of health informatics.

The need for an institutional platform increased in the years following Ledley and Lusted’s article. In 1967, the organization now referred to as the International Medical Informatics Association (IMIA) was established as Technical Committee 4 (TC4), a working group from the International Federation of Information Processing (IFIP) (Peterson 2006). TC4 conducted regular meetings in the subsequent years, then the committee would secede from IFIP as a spin-off entity with the core group members of IMIA in 1974 (Peterson 2006).

The institutionalization process proved crucial to the formation of the discipline. As Peterson (2006) notes, IMIA served as an organizational “bridge” to facilitate dialogue, encourage research, and to advocate for the salience of medical informatics. Furthermore, IMIA sought to define and “advance” the field of health informatics. This was achieved in two ways. First, through the popular tri-annual MedInfo conferences, first held in 1974 for which the proceedings are published and widely available (Peterson 2006). Second, IMIA granted an “intellectual framework” to foster the collaboration of scientists, researchers, and informatics practitioners, as well as to promote the exchange of ideas through conferences and publication of journals (Haux 2010; Peterson 2006). No doubt, IMIA was instrumental in the transformation of compartmentalized, ad hoc field of study into systematic discipline.

While IMIA retains an important position in the current state of health informatics, the field of American health informatics organizations took shape in the 1980s. The American Association for the Medical Systems and Informatics (AAMSI) emerged from the unification of the Society for Computer Medicine (SCM), the Society for Advanced Medical Systems (SAMS) in the late 1970s. While AAMSI lacked the resources leveraged by IMIA, the organization promoted health informatics throughout the United States in the early 1980s (AMIA 2013). AAMSI merged with the Symposium on Computer Applications in Medical Care (SCAMC) and the American College of Medical Informatics (ACMI) to form the American Medical Informatics Association (AMIA) in 1989 (AMIA 2013). The consolidation of the field into AMIA only strengthened the visibility of health informatics in the US, however, the organization was oriented more toward an academic orientation without the practical application (Hersh 2006).

A separate prominent feature to mark the institutionalization phase was the development of academic journals. Academic journals amplified the tri-annual MedInfo Yearbook of conference proceedings and contributed to the definition and research agenda of health informatics. Such journals were crucial to the dissemination of research, and as fora for researchers and practitioners to engage with health informatics-related research, as well as provide a rubric for collaboration. The International Journal of Medical Informatics (IJMA), founded in 1982, served as a crucial publication toward this end, however, the proliferation of academic journals throughout the 1990s and 2000s demonstrates the increased academic and practitioner interest in health informatics. A sampling of prominent journals and the years of their establishment are as follows: Journal of American Medical Informatics Association (JAMIA) (1994), Health Informatics Journal (1995), Medical Informatics and the Internet in Medicine (1999), Electronic Journal of Health Informatics (EJHI) (2006), Journal of Health and Medical Informatics (2010). The consolidation of a core research body through academic journals and the Yearbook not only codified the precise definition of health informatics but also disseminated influential research to affect further applications of health informatics.

Application

The foundational organizations to establish the core tenets, as well as the platforms to disseminate those ideas, were formative to health informatics, however, the widespread application of the health informatics technologies served as a crucial step to demonstrate the value of the discipline. This section outlines a handful of the core historical applications of health informatics, and their impact on medicine.

An essential application and initial success in the field was found in the transition to computerized patient records (CPR). Computerized records allowed for the dissemination and the manipulation of patient data at hospitals to improve diagnostic support, knowledge sharing, workflow, and decision support (Ginneken 2002). CPR first appeared as a trend in the 1970s with the development of a variety of tools, but one proved significant for the development of CPR, Computer Stored Ambulatory Record (COSTAR), an organizational and management platform developed by the Jerome Grossman and Octo Barnett, two administrators at the Massachusetts General Hospital (Collen 2006). COSTAR provided medical records, hospital billing information, and offered a medical dictionary for practitioners (Barnett 1983). The system proved influential in the historical development of health informatics and would serve as a key driver for the first commercially available CPR system – based on a modified version of COSTAR – in 1984 (Peterson 2006). CPR provided the framework for future applications of information management to streamline health care systems around the world.

The influence of CPR is currently felt in the current array of tools for knowledge management with information technologies. Two notable examples appear in electronic health records (EHR) and electronic medical records (EMR). These integrated platforms continue to streamline health care management through resource sharing and readily available patient information valuable for diagnosis for health care providers, although their widespread implementation has lagged in the US (Hsaio 2010). These systems provide an input interface for hospital staff to input patient information, including symptoms and, in turn, generates an “order” for a physician, who may review the issue prior to patient exam. A separate, but similar innovative use of information technology to streamline health care management appears in the computerized physician order system (CPOE). This system provides physicians with direct communication with pharmacists to fulfill orders for patient as a way to mitigate dispensement errors (Healthcare IT 2013). These different platforms to disseminate knowledge and improve access to resources continue to increase efficiency in the provision of health care.

Conclusion

This paper sought to explain elements of the two historical processes, which contributed to the current prominence of health informatics. The institutionalization and application processes extend far back throughout medical history, but the mid-to-late 20th century unto the present witnessed drastic changes. Much of these changes are attributable to health informatics and the technologies associated with the discipline.

Yet challenges remain. The single most significant challenge faced lies in the standardization of the application of health informatics and health information technologies. Without the proper “structural frameworks” – i.e., the qualified practitioners or staff – the widespread implementation of these technologies remains a challenge (Haux 2010). Health informatics intellectuals and practitioners explain this collaboration across platforms as “interoperability” (Collen 2006). Thus, integration to increase interoperability emerged as a core tenet to health information technologies. To this end, one international nonprofit, Health Level 7 (HL7), works in various countries to promote international interoperability standards and architecture for health information technology (Dolin et al. 2001). This is an important step, but more work remains. And this work toward the increased integration will need to continue for the health informatics discipline to continue to grow and prosper.

References

Barnett, O., McLatchey, J., McDonnell, G., Piggins, J., Zielstorff, R., Weidman-Dahl, F., Hoffer, E., and Hupp, J. (1983). The Capturing of More Detailed Medical Information in COSTAR. Proceedings from Annual Symposium of Computer Applications in Medical Care, 329-332.

Collen, M. (2006). Fifty Years in Medical Informatics. IMIA Yearbook of Medical Informatics, 174-179.

Hsiao, C., Hing, E., Socey, T, Cai, B., et al. (2010). Electronic Medical Record/Electronic Health Record Systems of Office-based Physicians: United States, 2009 and Preliminary 2010 State Estimates. Center for Disease Control-National Center for Health Statistics.

Dolin, R., Alschuler, L., Beebe, C., Biron, P., Boyer, S., Essin, D., Kimber, E., Lincoln, T., Mattison, J. (2001). Journal of American Medical Informatics Association, 8(6), 552-269.

Detmer, D., Benson, S., Lehmann, C. (2010). Clinical Informatics Board Certification: History, Current Status, and Protected Impact on the Clinical Informatics Workforce. Applied Clinical Informatics, 1(1), 11-18.

Ginneken, A. (2002). The Computerized Patient Record: Balancing Effort and Benefit, International Journal of Medical Informatics, 65, 91-119.

Haux, R. (2010). Medical Informatics: Past, Present, Future. International Journal of Medical Informatics, 79, 599-610.

HealthCare IT Index – Computerized Physician Order Entry (CPOE). (2013). HealthCare.com. Retrieved on October 17, 2013 at http://www.healthcareitnews.com/directory/computerized-physician-order-entry-cpoe

Hersh, W. (2006). Who are the Informaticians? What We Know and Should Know. Journal of American Medical Information Association, 13(2), 166-170.

Hersh, W. (2009). A Stimulus to Define Informatics and Health Information Technology. BMC Medical Informatics & Decision Making, 9(24), 1-5.

Ledley, R. and Lusted, L. (1959). Reasoning Foundations of Medical Diagnosis. Science, 130(3366), 9-21.

Peterson, H. (2006). From Punched Cards to Computerized Patient Records: A Personal Journey. IMIA Yearbook 2006: Assessing Information Technologies for Health, 180-186.

Thede, L. (2012). Informatics: Where Is It? The Online Journal of Issues in Nursing, 17(1), 1-4.