Titus Schleyer, DMD, PhD

on biomedical informatics and health information technology

Category Archives: Computing

Time for a “biomedical informatics singularity” – Part I?

A common question in biomedical informatics circles these days is: What role does the traditional, academic biomedical informatics enterprise play in the increasing computerization of healthcare? Current signals are mixed. Some point to the essential quality (and track record) of informatics in building successful health information technology (HIT) applications. Others make it look as if informatics were irrelevant. In this post, I will take a look at the state of current affairs. In a future installment, I will discuss two other important questions: What role should informatics play in the continued development of health information technology (HIT)? And, how should it get to play that role?

Those of us who have been in informatics for a while have been part of an amazing story arc. It is rare to get to witness something close to the birth of a discipline (medical informatics in the 60s and 70s), and then see that discipline grow to exert a larger and larger influence in real life. Yet, this is exactly what happened with the modern discipline of biomedical informatics. From its humble beginnings with a few local computer systems in the medical space to its pervasive influence in healthcare today, biomedical informatics has had a truly astounding trajectory. Morris Collen’s History of Medical Informatics in the United States documents that trajectory very nicely.

100_0430At the same time, who works in informatics and how we work has changed significantly. Early on, it was the discipline of a few pioneers, many of them with a medical, some with a computer science or engineering background, and several with a combination. Those pioneers often developed visionary solutions that applied early computer technology to important, but highly specific problems, in a local context. Most or all of them had an association with and/or were funded by the National Library of Medicine (NLM), an institution who played a key role in the development of medical informatics. Many of the early medical innovations live on in healthcare computing applications to this day, whether in concept or actual implementation.

But, something changed along the way. Did traditional informatics become irrelevant? Depending on who you are, you may scoff at this notion. The American Medical Informatics Association, our major professional organization, now boasts  a membership of over 4,000 informatics professionals. Informaticians continue to produce important and seminal research findings, many of which get published in high-quality, (mainly) informatics journals. We sometimes make it into the press (but maybe not as often as we like). We help set important policies and standards.

Yet, as an informatician it is hard not to feel somewhat lost in today’s large and complicated health information technology landscape. Most academic software development, once focused on computer-based physician order entry, decision support and similar applications, has either atrophied or ceased. The number of NLM-funded training programs in biomedical informatics, as well as the number of trainees in them, has shrunk dramatically. Most informatics departments/centers continue to compete heavily for a largely shrinking federal pool of funds for grants. The NLM’s budget (~$350m) is a fraction of what many in the informatics community think it should be.

Instead, the HIT industry is now dominated by multi-billion dollar giants, such as Epic, Cerner and Siemens. A torrent of medical computing innovations, such as apps, devices, applications and services is gushing forth from an ocean of entrepreneurs, startups, and small and midsize companies, many of whom have never heard of “biomedical informatics.” Technology leaders, such as Apple and Google, are helping reinvent healthcare.  

Is it time for biomedical informatics to let one of its children, health information technology, grow up and move on to other things? It may seem to be the reasonable thing to do. The real-world innovations that basic and foundational informatics research have produced are quite a success, any way you look at it. Many would say that industry has a firm understanding of the innovations and advances that healthcare needs, is able to drive the necessary developments, and has the capital to do so. There might be little to no place for academic informatics research, basic or applied. 

However, in my opinion doing so may be the equivalent of walking away from a child when they need you most. I base that assessment on four major points: 

  1. Few in the HIT industry would contend that the development of clinical applications is finished. Many drivers require continual evolution and advancement of clinical applications. Among these are regulation, the continuing rapid expansion of biomedical knowledge, the continually changing healthcare workflow and disruptive innovations.8-29-2014 9-56-37 AM
  2. Most of HIT’s users are far from happy with the tools at hand. Satisfaction ratings with clinical applications are low across the board. Cumbersome, barely usable and, often, less than useful, these applications have contributed to a significant reduction of the time that clinicians are able to spend with their patients, as well as increased job stress.
  3. Truly disruptive innovation is unlikely to come from big vendors or institutions. Many large suppliers of HIT suffer from the “installed base” problem: As their customer bases grow, more and more resources must be directed to maintaining the existing base of code and functionality, and the path from idea to implementation gets longer and longer. In addition, the larger your customer base, the higher the degree of resistance to fundamental and disruptive changes in the software. As many historical examples show, disruptive innovations tend to emerge in small places in a bottom-up fashion.
  4. With the shuttering of most academic software development shops, an important wellspring of innovative ideas in the space has degenerated. The great thing about being an informatician is that we get “paid to dream.” No stockholder is waving a 10-k report in our face to demand an increase in the stock price or next quarterly dividend. We are able to look at problems from more fundamental and theoretical viewpoints. What emerges can become entirely new research and application fields, such as artificial intelligence, which arose from the early work on medical decision support at Stanford and other places.

So, whether it realizes it or not, the world needs biomedical informatics. There are signs that some stakeholders in HIT have caught on to that. But, what do you think? I know that strong arguments can be made on either side of the debate. Let’s hear them!



PS: What could the informatics community do (or do better) to enhance its contributions and significance to HIT? I will examine this question in a subsequent blog posts in a few weeks.

PPS: You may wonder why I included some pictures from the Hudson River Valley in this post. Today, my wife Alida and I are off to a two-week vacation, bicycling in New York’s Hudson River Valley. On the program is a self-supported tour from Bear Mountain to Rhinebeck and beyond.

Titus Schleyer, DMD, PhD
Clem McDonald Professor of Biomedical Informatics
Director, Center for Biomedical Informatics
Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012
Skype: titus.schleyer, Ph: (317) 274-9204 (direct), cell: (412) 638-3581, E-mail: schleyer (at) regenstrief (dot) org, Web: http://www.regenstrief.org/cbmi/, Blog: https://titusschleyer.wordpress.com, General: http://about.me/titusschleyer

Help us improve healthcare … by joining the Regenstrief Team!

IMG_20130618_080807As some of you may know, the Regenstrief Center for Biomedical Informatics (CBMI) is recruiting for several faculty positions. I thought the new year might be a nice moment to tell you about the top 10 reasons to work at CBMI – and maybe get you or a colleague/friend of yours to check us out ;-). Even if you yourself are not interested in a faculty position here, maybe you know someone who would be. If so, please tell them about it!

  1. Improving healthcare is our heritage … and our future. Many people are familiar with the Regenstrief name in the context of informatics, but few are aware of our original roots in manufacturing. Sam Regenstrief, colloquially named the “Dishwasher King,” at one point produced 40 percent of the world’s Eskenazi Hospitaldishwashers. He got there through rigorous application of operations management and process improvement principles. One day, he had to go to (what was then) Marion County General Hospital (now Eskenazi Health) for a physical. What he saw in the crowded waiting room and elsewhere sparked the idea for the Regenstrief Foundation, which he endowed a short time later. Its mission: “to bring to the practice of medicine the most modern scientific advances from engineering, business, and the social sciences, and to foster the rapid dissemination into medical practice of the new knowledge created by research.” The Regenstrief Institute has stayed true to this mission since its founding. The CBMI supports this mission primarily through informatics and information technology research and development.
  2. We apply and evaluate informatics interventions in real-world settings. At CBMI, informatics is not just theory. We continually apply it in the real world. A strong and enduring (nearly half a century) partnership with Eskenazi Health has produced a long string of seminal advances in health information technology. In addition, our work with the Department of Veterans Affairs Medical Center, and four large integrated delivery networks with multiple hospitals and ambulatory care settings provide access to real-world clinical environments for conceiving, implementing and evaluating informatics solutions.
  3. Jeff Warvel and Gopher retirement partyRegenstrief offers a unique set of informatics resources. Here is a partial list of our core informatics assets and competencies:
    • the country’s largest health information exchange: The Indiana Network for Patient Care (INPC), established in 1995,  includes clinical data from over 90 hospitals, public health departments, local laboratories and imaging centers, and a few large-group practices. It is used by approx. 7,000 clinicians daily and carries over 4.7 billion pieces of clinical data for over 14.7 million unique patients.
    • The (new) Gopher: Built upon Regenstrief’s legendary Medical Gopher system, the new Gopher is a comprehensive computer-based physician order entry system. Designed by clinicians for clinicians, it is a platform for not only clinical data entry and management, but also for clinical decision support, electronic data capture for research and visualization of clinical data.
    • CareWeb: CareWeb is a Web-based results retrieval and reporting tool for clinical data from the INPC. Central Indiana clinicians access this system on average 200,000 times a day.
    • Data epidemiology: Through our clinical data repositories, we have extensive experience with the capture, curation, storage and analysis of clinical data.  These data have been and are a central resource for prospective and retrospective research, including clinical and pharmaco- epidemiology studies.
    • Interested in additional informatics research and application projects? Check out our Website.
  4. We live and breathe innovation: Our faculty innovate broadly across a variety of healthcare disciplines and domains. But, we do not stop there. Regenstrief has an internal Quarterly Innovation Challenge, open to everyone, which has funded over 15 projects during the last two years. Many of these projects are initiated by staff and several are on track to become fully-scale research projects. In addition, Indiana itself is innovation- and entrepreneur-friendly. BioCrossroads is a catalyst for the continued growth of Indiana’s robust life sciences industry. Among its many activities, BioCrossroads informs and educates; raises and invests venture capital funds in promising new companies; and builds business collaborations by bridging gaps across academia and industry.
  5. Explore exciting new directions with us. One reason I assumed the position of director of the CBMI are the vast potential opportunities that exist at Regenstrief. For me, the top ones include:
    • integration of genomic, proteomic and related information with electronic health records: Some people say “CPOE is so 20th Century.” For me, it is one of the continuing challenges in informatics. Think about this: The information that clinicians must take into account to make clinical decisions is growing day by day. New results from genetic and other tests, detailed data about a patient’s medication compliance, exercise habits, health literacy and environmental factors, and local population health trends – where does it end? CPOE and clinical decision support will become even more crucial to helping clinicians make optimal decisions in the future.
    • consumer health and personal health records: With the Indiana Network for Patient Care, we have a huge resource of clinical data generated in healthcare settings. However, BMI_pagethere is a large and growing complement of patient- (or people-) related data. Patient-recorded activity/exercise data? Glucose and blood pressure readings? Standardized assessments of average daily living functions? Much of these data can be highly valuable in healthcare and integrating them with the INPC would be a powerful combination.
    • data analytics and visualization: Data analytics has been one of our “bread and butter” activities for the last several decades. However, I think we can accelerate and be more efficient in how we create knowledge from the large databases we are sitting on. My boss, Bill Tierney, always says: “We could write thousands of papers based on the INPC data.” I say: “Ok, let’s do it.”
    • implementation science: The Regenstrief Institute and IU School of Medicine recently established the Center for Innovation and Implementation Science (CIIS), an organization dedicated to the development of methods to promote the systematic uptake of research findings and other evidence-based interventions into routine practice. Informatics tools are a key intervention and the CBMI is working closely with the CIIS to bring about real change in how clinicians practice.
    • cognitive systems engineering/human computer interaction (HCI): Those of you who know me will not be surprised that I am making this area a focus. Much of my own research has been on HCI aspects of clinical systems in dentistry. And, I have seen firsthand where approaches such as user-centered design and cognitive systems engineering can take us in terms of usefulness and usability of systems.
  6. Join a world-class team of faculty, staff and fellows. Many of our approximately 18 faculty are leaders in their fields/research areas, such as computer-based decision support, computer-based physician order entry, drug safety informatics, clinical data analytics, automated patient record matching, informatics standards, public and global health informatics applications, and dental informatics. Our faculty have a variety of backgrounds, such as internal medicine, medical specialties, dentistry, physical therapy, statistics and computer science. Five of our faculty are members of the American College of Medical Informatics and two of the Institute of Medicine. Two of our faculty, Clem McDonald and Bill Tierney, have received the prestigious Morris F. Collen Award of Excellence from the American Medical Informatics Association. Our staff consists of a dynamic and enthusiastic group of software engineers, database developers, project managers and administrative assistants. Recently infused with engineering talent from a variety of industries, our team possesses expertise in healthcare informatics; contemporary Web architectures, user interface and user experience methodologies; system integration; clinical decision support; and big data storage and retrieval. CBMI typically has between two and four fellows enrolled in its training program.
  7. Regenstrief is connected to Indiana University’s vast computational and academic resources. I have worked at two major universities (Temple and Pitt) and I am happy to say that every time I upgraded my experience with information technology support in academia. At Indiana University (IU), I have topped my experience to date. IU University Information Technology Services is a national leader in IT support among major universities, earning it a Computerworld’s 100 Best Places to Work in IT award in 2010 and 2011. Not only does UITS serve the everyday computing needs of the campus, it also supports research in and application of high performance computing, advanced networking and the evolving international cyberinfrastructure. Digital textbooks, virtual software delivery, and innovative learning environments support IU’s mobile students. IU is also a global partner in creating sustainable models for the collaborative development of teaching, learning, research and enterprise software.carnival
  8. We are a fun family. A lot of faculty and staff have commented to me that they like working at CBMI “because it feels like family.” Having been here for six months now, I have become part of that family. One of the best aspects of Regenstrief is that the kind of chasm between faculty and staff that you usually find in academia doesn’t really exist. Faculty and staff interactions are characterized by mutual respect, many close working relationships, a plethora of ideas and an easy, continual exchange. Plus, we know how to have fun! In the second half of 2013 alone, we had the Regenstrief Carnival, the RIFresh Initiative (which is, among other things, designed to inject fun into the workplace) and a wonderful holiday party.
  9. Indianapolis is a great place to live. I have lived in quite a variety of places in my life, ranging from Wildflecken, a small village in the Rhön mountains in Bavaria, to the metropolis of Philadelphia. I always had been wondering about what it would be like to move to the Midwest given the various comments I heard about it. I IMG_20130615_093039have to say I love it here. Indianapolis is a very compact and understandable city. It has a variety of interesting neighborhoods, plenty of great restaurants (some of my favorites include Bluebeard, Chef Joseph’s, Iozzo’s Garden of Italy, Meridian and, of course, the Rathskeller‎) and great cultural attractions. It is easy to get around – the local joke (essentially true) is that it is takes only about 20 minutes to go from anywhere to anywhere in Indy (ok, slightly longer on a bicycle). Of the nine miles of my bicycle commute, seven are alongside a canal and the White River. And, most importantly, the people are friendly and welcoming. One of our neighbors gave us a few home-cooked meals when we were moving in, a very welcome gesture. Another set of neighbors had a welcoming party in our honor.
  10. Make a difference … : We all know that the healthcare system in the United States is in deep trouble. We also know that informatics and information technology are two key ingredients in turning the situation around. We are looking for a few people who want to make a real difference. And, Regenstrief is one of the places where you can do that best!

Interested? Take a look at http://bit.ly/RCBMI_Faculty, and then send me email or give me a call!


Titus Schleyer, DMD, PhD
Clem McDonald Professor of Biomedical Informatics
Director, Center for Biomedical Informatics
Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012
Skype: titus.schleyer, Ph: (317) 423-5522 (direct), cell: (412) 638-3581, E-mail: schleyer (at) regenstrief.org
Web: http://www.regenstrief.org/cbmi/, Blog: https://titusschleyer.wordpress.com, General: http://about.me/titusschleyer

What’s the organizational value of 40, 4,000 or 400,000 clicks?

The other day a seemingly trivial incident stimulated a discussion of how to increase process efficiency at the Regenstrief Institute’s Center for Biomedical Informatics. The original email I sent (see below) was entitled “Are process improvement and efficiency part of our culture?” (This was somewhat of a trick question.) Suffice it to say that I tried to highlight an opportunity for saving time for everyone by including an .ics calendar appointment with a broadcast email reminder of an upcoming event.

My point was that sending a reminder for an event that did not make it easy for recipients to act on it was not exactly pointless, but, well, inefficient. Of course, part of the thinking probably was: “This is just an informal reminder, so whoever wants to come probably already made themselves a calendar appointment based on earlier messages.” True. But, in our messy informational environment that the digital revolution has created it is usually not a good idea to rely on some item buried far down in our inboxes. And, in the larger scheme of things, why would I have to get a reminder anyway if I already put the event on my calendar?

The email below chronicles my futile journey across the organization’s information artifacts to see whether there was an easy way to put the event on the calendar. I ultimately did what most people in my position would probably have done first: turf the job to my administrative assistant Sandy (who, by the way, is a great help, for calendaring as well as otherwise). But, her time is highly valuable to the organization, also, and should not be wasted gratuitously.

So, what is the big deal? A few mouseclicks and keystrokes. To date, when I wanted to convert an email message to an appointment in Outlook, I pushed “Forward,” selected all text, dragged it onto the calendar, copied or typed the appointment subject, and entered date and time information. Had the original email included an .ics calendar file as an attachment, I would have double-clicked on that, pushed “Save” and I would have been done.  (Of course, receiving an Outlook invitation directly would have cut that down even further, to one click.) Total savings: about 15-20 seconds.

Let’s say I do 20 tasks like this per day, at a cost of 20 seconds each. And, let’s say that that is true for the roughly 100 employees of BMI. That means that we collectively waste 400,000 seconds (or roughly 110 hours) a year (20 seconds x 100 people x 200 workdays/year). If we budget $100 as an average hourly rate across the organization, we are talking about $11,000. This may not sound like much, but is just the tip of the iceberg in terms of how inefficiencies inherent in or resulting from information technology drain our productivity.

As soon as I sent the email message below to all faculty and staff, two things happened: (1) People agreed with me that this was an important if largely invisible issue. And, (2) they started sharing all kinds of productivity tips related to appointments in Microsoft Outlook. From those tips, I learned how to:

For me, that sequence of events begs two major questions:

  1. How do you encourage organization-wide thinking and behavior about process improvement?
  2. How do you efficiently share everyone’s knowledge of the little tips and tricks that help you become more efficient?

Regarding (1), I thought that would be a non-issue before I took this position. From my original email:

“From what I read about the history of Sam Regenstrief, I understand that one key to his success in capturing 24% of the total dishwasher market in the United States in 1970 (see the book) was his relentless focus on process improvement and efficiency.”

So, I am thinking: “This is the Regenstrief Institute – they MUST be doing what made Sam Regenstrief great.” Wrong! The more I learn about our Center and the Institute, the more I realize how far we have strayed from our original philosophy. I could write a whole stack of Harvard Business Review Case Studies about our opportunities for process improvement.

Regarding (2), this is a tricky problem that several decades of research in computer-supported cooperative work (CSCW) have so far failed to solve. Judging from the literature, the answer is not just a software application that facilitates tip sharing. Succeeding with organizational knowledge transfer most likely requires a complex amalgam of culture, education, individual and group behavior, as well as technology. Which places have succeeded in this? What organizational development interventions are particularly effective? Are there useful software applications out there for this? Please write to me with your ideas and I will try to implement them here. I will let you know how it goes.

Thanks in advance!

Original email message
From: Schleyer, Titus K
Sent: Tuesday, July 02, 2013 5:40 PM
To: mi-staff-l@list.regenstrief.org
Subject: Are process improvement and efficiency part of our culture?
Hi everybody,

The other day, I had a simple problem in putting an event on my calendar which was easily fixed. However, in the larger picture, it is a good example of how suboptimal processes sap our resources in (often invisible but substantial) ways every day.

The event in question is the Quarterly Innovation Challenge on Friday, August 9th from 1-3pm in HITS 1110. I was wondering whether it already was on my calendar since I intend to participate. It wasn’t, so I went back to Jon’s reminder email from 6/27/2013. The email was not in the form of a calendar invitation and also did not include the event as an iCalendar attachment.

Of course, I could have just dragged Jon’s email on the Outlook calendar, used copy and paste a few times, and be done with it. However, I wanted to see how difficult (or easy) BMI would make it to get this appointment onto my calendar. So, I went to the Intranet, where I remembered seeing a calendar. I navigated to 8/9/2013 and – lo and behold – this event was (and is) not on there.

So, I got a cup of tea and inspected the poster about the Innovation Challenge on the way. I thought maybe it would contain a QR code that I could scan with my tablet, and maybe I could get to the appointment that way. No QR code, however.

In the end, I just forwarded the email to Sandy with the request to put it on my calendar. Most people probably would’ve said that that’s what I should’ve done in the first place. But, Sandy has better things to do than completing the non-value added task of adding something to my calendar.

I think there is a larger lesson in this trivial event. From what I read about the history of Sam Regenstrief, I understand that one key to his success in capturing 24% of the total dishwasher market in the United States in 1970 (see the book) was his relentless focus on process improvement and efficiency. So, I am a little bit surprised that we do not live and breathe his philosophy more than we do.

Ideally, I should have been able to put this appointment onto my calendar with one or two (double) clicks from any of the places I mentioned. Try it! Double-click on the attached file and push Save & Close. Done! (I look forward to seeing you there!)

Some people may argue about debating the value of a click. But I’m not debating the value of a click. I’m debating the aggregate value of thousands of extra clicks per person per year at our Center. I am debating the value of thousands and tens of thousands of non-value added tasks that break up our ability to get real work done. Those things have a real cost, even if they don’t show up on a balance sheet.

If we want to keep the legacy of Sam Regenstrief alive (and I think we should), we need to live and breathe his philosophy. Process improvement and efficiency must become our way of thinking, deciding and acting.

With that, I am off to kendo!


Titus Schleyer, DMD, PhD

Clem McDonald Professor of Biomedical Informatics

Director, Center for Biomedical Informatics

Regenstrief Institute, Inc., 410 West 10th Street, Suite 2000, Indianapolis, IN 46202-3012

Skype: titus.schleyer, Ph: (317) 423-5522 (direct), cell: (412) 638-3581, E-mail: schleyer@regenstrief.org, Web: http://www.regenstrief.org/cbmi/, http://about.me/titusschleyer