Medical informatics meets medical education

There's more to understanding information than technology

MJA 1998; 168: 319-320  

The decades-long predicted arrival of the information revolution in healthcare has taken perhaps no more than four years to go from a matter of minority opinion to one of general consensus.1,2 Not long ago, medical journals rarely discussed information technology, but now most carry regular articles on the subject. Indeed, all the major journals are now available in electronic form on the Web, and some argue that the paper journal is a dinosaur at the end of its time.3 Evidence grows for the value of using the computer to assist in routine tasks like prescribing4 and reminding general practitioners to carry out screening procedures.5 It is conceivable that, in the future, failure to use such tools could come to be regarded as negligent practice. Change such as this can often be abrupt and distressing, no matter how beneficial it may ultimately be. Existing skills become redundant and the young, who have time and energy to learn, have the advantage over those who may be more experienced but are constrained by existing clinical responsibilities. Clinicians with years of experience might thus be forgiven for throwing up their hands in despair at the sudden enthusiasm for computers and telemedicine, apparently at the expense of hard-won clinical skill and human empathy. However, if the scenarios that Carlile and Sefton paint in this issue of the Journal come to pass, then our dependence on information and communication technology can only deepen over the years.6 They draw our attention to the need to prepare medical graduates for work in a world where the inability to use this technology would be as debilitating as the inability to read or write is today. The ambitious new graduate medical program they describe at the University of Sydney is almost entirely structured around teaching material in the form of multimedia documents on the Web. Whether this move to a computer-based and problem-oriented curriculum will produce better-prepared graduates will no doubt become clearer with time. Certainly, all students in this program should graduate with proficiency in using the technology. In comparison, at the beginning of this decade only 25% of medical students at a comparable institution felt they could use computers well.7 While such an educational program is to be lauded, there is probably a greater educational challenge within the community of practising clinicians, most of whom have never had any formal training in information technology (IT). Nevertheless, they will be expected to work for many decades in an environment in which IT illiteracy will become increasingly burdensome. It is for these individuals that the immediate urgency lies. Certainly there is a case to be argued for basic postgraduate education in the use of IT in patient care, and if some medical colleges do not consider IT literacy a core component of their continuing education programs then perhaps they need to think again. Just how much training is needed depends on the systems clinicians need or want to use, and their current skills in doing so. If we are optimistic, these barriers for working clinicians will diminish over time as the technology becomes easier to use, and progressively develops into a commonplace and natural part of the clinical environment. However, we have no guarantees that such optimism is warranted. There is at least one major caveat in this rush to master the new technologies -- we must not forget that basic computer skills are not the same as being skilled in the management of information. Simply teaching practising clinicians or medical students to use IT is not enough. Just as the ability to suture doesn't make one a surgeon, the ability to surf the Web does not imply that one understands the principled use of information. With the current emphasis on evidence-based practice highlighting the skills needed to collate, distil and apply clinical research, we have a powerful example of the broader information and communication skills needed in healthcare. Information skills are basic to good medical practice. Every clinician needs to understand the principles of data interpretation, the logical foundations of the diagnostic process, and the management of uncertainty in clinical knowledge.8 The problem-oriented medical record is just an information instrument, and clinicians need to know when it is appropriate, and when indeed other formulations might be better choices. The dynamics of communicating with patients and with colleagues are altered when the exchange moves from a face-to-face interaction to the telephone, e-mail, voicemail or video.9 Understanding the implications of using one medium rather than another is central to developing effective communication skills as these communication options become commonplace in the community. Medical informatics is the name now given to the study of clinical information and communication processes. It is the rational study of the way we think about patients, and the way that treatments are defined, selected and developed. It is the study of how medical knowledge is created, shaped, shared and applied. Ultimately, it is the study of how we organise ourselves to create and run healthcare organisations.10 Understanding how to use information technology appropriately can only ever be one small component of this wider discipline. Where once these disparate elements of informatics were taught piecemeal, there is now growing consensus about the essential information skills needed by clinicians, and medical informatics is now appearing on more curricula as a distinct entity.11 A proposal for 10 essential clinical informatics skills is provided to give flesh to these ideas, and to stimulate debate about the role of informatics in medical education. So, the computer, the telephone, the Web, video -- these, and all that is still to come, are unquestionably powerful tools. Used badly, they do indeed waste time and money, create inefficiency, and dehumanise our interactions with each other. Used well, they are neither to be feared, loved nor loathed. They are simply to be used. And in the next century, the study of informatics will become as fundamental to the practice of medicine as anatomy has been to the last. Enrico Coiera Senior Project Manager Hewlett-Packard Laboratories, Bristol, UK E-mail: ewc AT pobox.com Coiera E. Medical Informatics. Med J Aust 1994; 160: 438-440. House of Representatives Standing Committee on Family and Community Affairs. Health on line: a report on health information management and telemedicine. Commonwealth of Australia. Canberra: The Committee, 1997. LaPorte RE, Marler E, Akazawa S, et al. The death of biomedical journals. BMJ 1995; 310: 1387-1389. Walton RT, Gierl C, Yudkin P, et al. Evaluation of computer support for prescribing (CAPSULE) using simulated cases. BMJ 1997; 315: 791-794. Shea S, Du Mouchel W, Bahamonde L. A Meta-analysis of 16 randomised controlled trials to evaluate computer-based clinical reminders for preventative care in the ambulatory setting. J Am Med Informatics Assoc 1996; 3: 399-409. Carlile S, Sefton AJ. Healthcare and the information age: implications for medical education. Med J Aust 1998; 168: 340-343. Kidd MR, Connoley GL, Cesnik B, McPhee W. What do medical students know about computers? Med J Aust 1993; 158: 283-284. Haynes RB, Ramsden M, McKibbon KA, et al. A review of medical education and medical informatics. Acad Med 1989; 64: 207-212. Coiera E, Tombs V. Communication behaviours in a hospital setting -- an observational study. BMJ 1998; 316: 673-677. Coiera E. Guide to medical informatics, the Internet and telemedicine. London: Chapman and Hall, 1997 ( see also http://www.coiera.com). Greenes RA, Shortliffe EH. Medical informatics -- an emerging academic discipline and institutional priority. JAMA 1990; 263: 1114-1120.