воскресенье, 16 сентября 2012 г.

Clinical informatics: a workforce priority for 21st century healthcare - Australian Health Review

Abstract. This paper identifies the contribution of health and clinical informatics in the support of healthcare in the 21st century. Although little is known about the health and clinical informatics workforce, there is widespread recognition that the health informatics workforce will require significant expansion to support national eHealth work agendas. Workforce issues including discipline definition and self-identification, formal professionalisation, weaknesses in training and education, multidisciplinarity and interprofessional tensions, career structure, managerial support, and financial allocation play a critical role in facilitating or hindering the development of a workforce that is capable of realising the benefits to be gained from eHealth in general and clinical informatics in particular. As well as the national coordination of higher level policies, local support of training and allocation of sufficient position hours in appropriately defined roles by executive and clinical managers is essential to develop the health and clinical informatics workforce and achieve the anticipated results from evolving eHealth initiatives.

What is known about the topic? Health informatics is considered an emerging profession. There are not enough Health Informaticians to support the eHealth agenda.

What does this paper add? This paper considers the issues, barriers and facilitators of capacity building in the health informatics workforce with a special emphasis on Clinical Informaticians. The authors conclude that resources and awareness at the national, state and local health service levels is required to facilitate health and clinical informatics' capacity building.

What are the implications for practitioners? Recognition and support of the health and clinical informatics workforce is required to improve the appropriate implementation and use of Health Information Technology for clinical care, quality and service management.

Knowledge is the enemy of disease. [Sir Muir Gray, DirectorNHSNational Knowledge Service andNHSChief Knowledge Officer]1

Health information is fundamental to healthcare at every level from the macro level of global health system appraisal and strategy to the micro level of individual personal healthcare services available to consumers as patients .2 This paper examines the health informatics workforce requirements to support systems delivering the health information needs of health services in Australia, with a special emphasis on clinical informatics. The role of clinical informatics in healthcare delivery is described; the known status of the current workforce is examined; workforce issues are identified and potential solutions and barriers are explored, including findings from investigations and strategies overseas.

What are clinical informatics and health information technology?

Patient-centred informatics and the Clinical Information Systems focussed on improving health outcomes are understood to support the ability to deliver effective, quality care3 and are an essential component of the Chronic Care Model4 as shown in Fig. 1.

Health informatics can be simply defined as the science and practice around information in health that leads to informed and assisted healthcare.5 Clinical informatics, a sub-discipline of health informatics, is the scientific facilitation of the effective use of information in patient care, clinical research and medical education. The ultimate goals of clinical informatics are to streamline the processes of patient care, provide clinicians with accurate data in a timely manner, improve the quality of care, and reduce costs and educate healthcare providers and patients.6 This practice of organising current medical information and related technology and applying it to clinical use is not a trivial task in the context of 21st century healthcare burgeoning with medical research literature and new technologies.7

Health and clinical data are powerful resources that can transform healthcare. However, data alone are not information or knowledge; data require a combination of analytics, visualisation and interpretation to create the knowledge which contributes to decision-making in healthcare services and policy.8 Fig. 2 shows the relationship of data and knowledge and identifies the multidisciplinary nature of the workforce roles required for this to occur. Sackett9 describes the effect of modern clinical epidemiology 'in evidence generation, its rapid critical appraisal, its efficient storage and retrieval, evidence-based medicine, and evidence synthesis', which clearly aligns with the support provided by clinical informatics.

Despite the recognised importance, the quality of the health information landscape in Australia does not effectively support activities such as health surveillance, guidance for policy, service planning, innovation and clinical and operational decisionmaking. 10,11

As part of Australia's response to improving this situation, The National eHealth Strategy recognised 'a clearly identified need to ensure sufficient numbers of skilled health Information Technology (IT) resources as this is looming as a critical barrier to the successful implementation of a national E-Health work program'.10 A US report suggests the Health Information Technology (HIT) workforce requires an approximate increase of 40% to move the American health system to higher levels of HIT adoption.12 A Canadian reports suggests 20-40% increase will be required by 2014.13

Current status of the health informatics workforce

Understanding of the health informatics workforce and its needs is poor and even more so in the area of clinical informatics. Anecdotal data support lack of skilled and qualified Clinical Informaticians in the Australian private health sector: one private hospital's Applied Medical Intelligence Research facility took 19 months in 2008 tofill three Informatics positions (Clinical Data Manager, Clinical Information System Manager, Clinical Data Analyst) with suitable staff (R. Brighouse, pers. comm., 23 October 2009). Similar delays in filling other health informatics roles have been reported.5,14 Currently there is no way to monitor demand; a job vacancies survey15 may contribute to an understanding, although such a study may not be truly indicative of the need if positions are not yet being created in the volume required to progress the eHealth agenda.

Furthermore, Australia does not capture statistics on the HIT workforce as a component of AIHW National Health Labour Force reports. Neither is the wider Health Information Technology group an occupation included in census data, which only includes health information managers and coders. Other factors that contribute to difficulties in estimating demands include many similar to those found in the Public Health profession16:

* wide variety of occupational roles and groups;

* lack of clear boundaries and definitions of professional categories;

* lack of professional credentialing requirements;

* lack of consistent formal health informatics training in much of the workforce.

The Australian Department of Health and Ageing commissioned a review of the health informatics workforce by the Health Informatics Society of Australia (HISA) which provides some perspective.5 A national survey (n = 1279) confirmed the diversity of the workforce composition, with the predominant personal attributes shown in Box 1. Extrapolation from the survey data estimates the workforce size in Australia to be ~12 000 (9000 to 15 000).

Little is known about the clinical informatics sub-discipline in Australia or elsewhere, despite recognition of the importance of this group. Efforts are being made to capture data about Biomedical Informaticians (including Clinical Informaticians) in the US HIMSS Analytics database, which has been the major vehicle to characterise the health informatics workforce in the US.12 A major UK study found 3% of the HIT workforce to be Clinical Informaticians.17 Of particular note was the finding that there was a high expected shortage in information analysis skills which are increasingly required for NHS-wide objectives, such as performance assessment.

Although a small sample (n = 111), the NHS study findings suggested their health informatics workforce to be 'embattled'; a group who felt undervalued, overworked and unable to control their own destiny. They were not well served by the recent NHS Agenda for Change job and pay evaluation process. This may well be echoed in the Australian setting, e.g. Queensland Health has excluded the Health Information Manager profession and related clinical informatics roles (e.g. Clinical Data Manager), from the higher status Health Practitioner discipline groupings during the recent Enterprise Bargaining process, despite considerable workforce discontent.14,18 This results in an inequity for the clinical informatics workforce where nursing, allied health and non-clinical professional staff may fulfil similar Clinical Information System management roles, often under significantly disparate award conditions. This lack of parity between professional streams creates the potential for interdisciplinary tensions and poor networking in an environment of increasing clinical information system use.

Other issues affecting the clinical and health informatics workforce include:

* lack of self-identification of the group; individuals may relate more strongly to their original occupational groups such as Health Information Managers and coders, medical/nursing, pathology/health sciences, medical imaging and diagnostics, pharmacy and allied health, IT/computer sciences or health administration5,17,19;

* status as an emerging profession5,17,20; interestingly this closely parallels Public Health workforce development in Australia, which in 1998 was characterised by: 'diversity and complexity, composed of mature, highly qualified, multi-skilled individuals from a variety of backgrounds performing a multiplicity of functions and its high turnover which is not assisted by many working in isolation, poor career prospects and lack of identity'21;

* complexity and advanced level of skills and interdisciplinary/ multidisciplinary knowledge domains required across health and clinical sciences, computational and statistical sciences and management and social sciences5,19,22; and

* reduction and restructure of tertiary education and training in health informatics related programs, which affects both new recruitment and vocational training of current staff.5,14

Clinical informatics capacity building

Building capacity in all aspects of theHITworkforce will promote development in the clinical informatics sub-discipline; however, this key group should not be overlooked.AUS workforce summit recommends involvement from multiple stakeholders including government, employers, HIT vendors, employees, academic institutions and professional associations.23 In Australia a similar approach could include:

* Government and policy support: Australia's National eHealth Strategy10 identifies HIThuman resources 'looming as a critical barrier to the successful implementation of a national eHealth work program' and includes professional accreditation, education and training as part of it's Implementation Roadmap. General governmental policy such as the Queensland Government Information Management Skills Action Plan24 needs to be implemented in the health sector.

* Professional organisations: These play a leading role in supporting the quality of the health informatics workforce. They include Health Informatics Society of Australia, Health Information Management Association of Australia, Australian College of Health Informatics, and many more with a strong stake in this area. The Coalition for eHealth, which includes these and more,25 is well-placed to progress the agenda for professionalisation, accreditation and vocational training, given appropriate resources from government, academia and health services.

* Tertiary education: Lau26 identifies the need for the national coordination of changes to vocational and tertiary training programs. Recruitment of students to undergraduate and postgraduate training, or 're-tooling' health professionals via vocational and post-graduate training, contributes to capacity. Health informatics competencies should also be included in the undergraduate curricula of all health and medical education programs.

* Health services: Although awaiting the anticipated benefits of eHealth initiatives, much can already be done to prepare the workforce to ensure success. For example:

* State Health Systems - have the capacity to practically implement the general national strategy, supported by the relevant central divisions responsible, such as Information Technology and eHealth, Quality and Safety, Human Resources and Organisational Reform. It is possible to begin growing capacity immediately by promoting and providing incentives specific to health informatics education through scholarships and other professional development schemes and developing state-wide career structures.

* Hospital administration - the attitude of the hospital Chief Executive Officer has been shown to significantly correlate with the progressive use of information technology27; and the role of local management to 'unlock the benefits of IT' is recognised.28

* Clinical service units - should include health informatics as an element of competencies and training objectives in staff; should develop clinical champions fostering the implementation of clinical tools rather than administrative systems; should create positions and dedicate resources for adequately trained clinical informatics personnel; should recognise that good clinical informatics support provides clinicians more time to better perform clinical duties.

The establishment of career pathways and professionalisation, as is occurring internationally.5 should assist in defining professional roles and improve equity and inter-relationships. For example, in England the NHS developed the Health Informatics Career Framework which defines job roles for clinical informatics (Box 2).29 Canada's Health Informatics AssociationCOACHhas developed a career matrix incorporating 65 jobs in seven competency areas over five proficiency levels.30

Tradeoffs, undesirable effects and barriers

In any strategy there will be tradeoffs to the potential planned benefit. Certainly there will be financial costs in the training of current staff and in creating positions for the required additional workforce. However, there is consensus that eHealth will provide efficiencies and facilitate the core common competencies the World Health Organisation suggest healthcare professionals will need in the 21st century: (1) patient-centred care; (2) partnering; (3) quality improvement; (4) information and communication technology; and (5) public health perspective.31

Incentives to develop the health informatics workforce could potentially cause loss from other disciplines including nursing, clinical sciences, allied health and other health professionals. However, many of these may already have been performing clinical informatics tasks in their prior professional designations; thus already reducing their time for their primary clinical roles.

Although clinicians may be pleased to access the potential benefits for clinical services gained from clinical informatics implementations, there will likely be resistance to the allocation of service funds for what is not perceived as core clinical staffing. One may also speculate that the public may object to the relative growth of non-hands on clinical practitioner numbers in health services, regardless of the fact that this strategy 'stretches' the limited clinical resources.

The perception of senior management towards Health Information Technology can be a significant barrier to its adoption: a reticence by management to accept the utility of informatics will potentially inhibit the adoption and diffusion of information technology in health. A current lack of empirical evidence demonstrating the value of informatics in clinical practice may contribute to this reticence.32 Similarly, support by leaders is also required to promote professional development in health informatician roles.33

Prior to developing it's Health Informatics Career Framework, the NHS recognised that the lack of a clear career pathway was a barrier to developing a workforce with a recognised identity and measurable competencies.33

Australia's fragmented government structures and mixed public and private systems may be a significant barrier to an integrated approach to building the informatics workforce as it is for eHealth implementation itself.34 It has been observed in Canada that the lack of a coordinated strategy for building health informatics is a significant barrier: neither the government healthcare ministry, nor the higher education ministry have embraced capacity-building of the workforce in their portfolios.26 As with medical workforce planning in Australia,35 progress will require collaboration between the stakeholders involved - government health ministries, education facilities, healthcare professional associations and healthcare organisations.

Action needs to be taken quickly because workforce response is likely to be slow due to the shortage of qualified and experienced health informatics professionals able to provide training and education.26,36 Due to the knowledge and background diversity and multidisciplinary nature of the field, development of competencies, a coordinated education program and certification of professional status will not be a trivial task. The Australian Health Informatics Education Council created a comprehensive Strategic Work Plan in 2009, which is expected to take up to 18 months if funding of AU$956 000 could be made available, or considerably longer otherwise. The plan would deliver: (1) a workforce and career pathway; (2) educational capability and delivery; and (3) educational program accreditation.36 There will be a further time lag for the implementation of individual educational programs and until the graduation of significant numbers of students. The development of the public health workforce in Australia demonstrates similarities and, with considerable Commonwealth funding over the last decade, has produced successful collaborative approaches in training such as the Biostatistics Collaborative of Australia.37

Discussion

Regardless of how good are the available Clinical Information Systems and eHealth tools, without adoption and appropriate utilisation in the clinical environment, eHealth initiatives are unlikely to succeed and have the potential to be harmful.38 An increase of HIT support staff has been found to be a strong facilitator of implementation, second only to financial incentives39 and provides the 'missing links' between clinicians and technologists.38 The knowledge of how to best use these tools to both improve care and efficiency is still in its infancy.40 The importance of health informaticians as 'special' people required for success of HIT initiatives should therefore not be underestimated. 12,19 This is especially true of the informaticians working directly in the clinical environment and bridging the clinical practice and information technology gulf. According to the Australian Health Information Council (AHIC), eHealth professionals 'bridge the worlds of technology and health service delivery, are expert in the unique challenges of using IT in healthcare, and are crucial to effective eHealth strategy development, service design, implementation and outcome evaluation'.34 A practical response to this requires:

* recognition of clinical informatics and its benefits at all levels;

* training of the incumbent clinical staff and managers in salient health informatics competencies;

* development of supporting specialised health informatics roles; and

* allocation of sufficient and appropriate staffing resources for clinical informatics tasks including implementation and ongoing maintenance and development, clinical information system management, analytics for service management, quality improvement and research purposes.

In its report on Electronic Decision Support Systems,41 AHIC recommends that 'one of the jointly funded initiatives that sit under the National E-Health Strategy should support health informatics knowledge provision and the development of eHealth competency standards and leadership'. However, Australia's Commonwealth funded leading eHealth facilitator NEHTA provides little direction and detail for workforce capacity-building compared with other work agenda areas.42

Yet although a more broadly coordinated Australian approach awaits Government prioritisation and financial support, State and district health systems are able to act immediately through increased recognition of the potential for gain at clinical service level. This could assist in the common situation where clinical information systems are managed by clinical staff as a secondary duty, without formal data management and analytics training or the allocation of sufficient hours. The risks of not recognising and adopting adequate informatics standards and supports include:

* costly rejection or failure of clinical information system initiatives5; and

* decreased quality of care and increased adverse events.38

In 2007 AHIC guided development of Australia's National E-Health Strategy, noting the need for jurisdictional and national eHealth programs to have access to appropriately skilled eHealth professionals through an ongoing capacity-building program.34 The National E-Health Strategy reflected this. Although the passing of the Individual Healthcare Identifiers Bill indicates that some progress is occurring along the eHealth agenda, little attention has been directed to the informatics workforce shortage issues repeatedly identified. It is quite possible that the observed slow pace of eHealth development in Australia is due more to a lack of power and capacity in the workforce that facilitates uptake, implementation and sound utilisation of clinical information systems and eHealth than is recognised. In comparison to Australia, some overseas health systems have produced HIT workforce building strategies which are much more advanced5,11 and are arguably more progressed in their eHealth agendas.

Conclusion

Health and clinical informatics are vital to the progression of 21st century healthcare. The workforce is little understood, so capacity- building will be required to support the desired outcomes of eHealth. Prioritisation of the issue is required in the areas of national and state policy, education and local health services.

Conflicts of interest

Four of the authors (S. E. Smith, L. E. Drake, J.-G. B. Harris and K. Watson) work in the field of clinical informatics and therefore have a professional interest in the development of a career structure. The opinions presented are those of the authors and are not intended to represent their employer Queensland Health.

[Sidebar]

Box 1. The Australian archetypal health informatician

Source: HISA5

Most health informaticians:

* are female;

* work in large organisations that provide healthcare;

* are aged 45 or more and expect to work for more than 10 years;

* work broadly across 12 areas of work but are more likely to work fulltime in systems, records or improvement related activities;

* have postgraduate or multiple degree qualifications; and

* have education and training in two or more distinct domains of knowledge with their first training most likely to be in a health discipline.

Box 2. The eight job roles of the NHS Clinical Informatician career discipline

Source: NHS Health Informatics Career Framework29

Job role:

* Clinical Audit Facilitator

* Clinical Director Lead

* Clinical Engagement Lead

* Clinical Informatics Specialist

* Clinical Informatics Specialist Manager

* Clinical Knowledge Engineer

* Clinical Lead

* Senior Clinical Audit Facilitator

[Reference]

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Manuscript received 10 June 2010, accepted 11 August 2010

[Author Affiliation]

Susan E. Smith1,2 BSc(Hons), Cardiac Surgical Register Coordinator

Lesley E. Drake1 RN, BBus (HIM), GradCertHlthSci (CDM), Clinical Audit

Research Officer

Julie-Gai B. Harris1 RN, GradCertHlthSci (CDM), Clinical Data Manager

Kay Watson1 RN, BBus (HIM), Clinical Data Manager

Peter G. Pohlner1 MBBS, GradCert Management, FRACS, Medical Director

of Cardiothoracic Surgery

1 Department of Cardiothoracic Surgery, The Prince Charles Hospital, Rode Road, Chermside,

QLD 4032, Australia. Email: lesley_drake@health.qld.gov.au; gaiharris@health.qld.gov.au;

kay_watson@health.qld.gov.au; pohlnerp@health.qld.gov.au

2 Corresponding author. Email: susan_e_smith@health.qld.gov.au