Titus Schleyer, DMD, PhD

on biomedical informatics and health information technology

Tag Archives: AMIA

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!

Best!

Titus 

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

What are cool products/services @RCBMI?

So, the other day I asked my colleagues “What are cool products/services @RCBMI?” At the moment, we do not really have a good public, up-to-date listing of “What’s hot” at the Regenstrief Center for Biomedical Informatics. This will change in the future, but until that happens, I thought I might as well use a blog posting to get our list of “Top 10” (in no particular order) out there. So, here goes:

  1. Regenstrief CBMI goes to Washington … : contains information on most of the presentations CBMI faculty and staff made at the American Medical Informatics Association 2013 Annual Symposium.
  2. Regenstrief Institute’s Gopher CPOE System: update on the (new) Gopher CPOE System being developed by RCBMI and implemented at Eskenazi Health. Additional information about the system is contained in the paper Regenstrief Institute’s Medical Gopher: A next-generation homegrown electronic medical record system.
  3. Customizing EMR functionality and user experience: description of the Rule Authoring and Validation Environment (RAVE), an advanced rule authoring tool for clinical care, quality improvement and research targeted at end users
  4. Open Medical Record System (OpenMRS®): The OpenMRS was created in 2004 as an open source medical record system platform for developing countries. The OpenMRS is a multi-institution, non-profit collaborative led by Regenstrief Institute, a world-renowned leader in medical informatics research, and Partners In Health, a Boston-based philanthropic organization with a focus on improving the lives of underprivileged people worldwide through health care service and advocacy.
  5. Open Health Information Exchange: a demo of an OpenMRS-related system for implementing open-source health information exchanges; includes Client Registry, Provider Registry, Facility Registry, Terminology Service and an Interoperability Layer that, taken together, demonstrate a shared health record.
  6. The CareWeb Framework: The CareWeb Framework is a modular, extensible framework for building clinical applications in a collaborative fashion.  A high-level overview is available at Creating a flexible EMR architecture.
  7. The Regenstrief Notifiable Condition Detector: A public health informatics system that automatically detects and routes positive cases of notifiable diseases based on routine electronic laboratory reporting (ELR). While certified EHR systems and components enable provider organizations to manually route ELR cases reportable under state laws, none have the capacity to for automatic reporting as demonstrated in this system.
  8. Logical Observation Identifiers Names and Codes (LOINC®): A universal code system for identifying laboratory and clinical observations. From serum levels of hepatitis B surface antigen to diastolic blood pressure, LOINC has standardized terms for all kinds of observations and measurements that enable exchange and aggregation of electronic health data from many independent systems. Used in 157 countries.
  9. The Regenstrief LOINC Mapping Assistant (RELMA): Available in a hosted as well as a standalone version, the RELMA facilitates searches through the LOINC database and assists efforts to map local codes to LOINC codes.
  10. The Unified Code for Units of Measure (UCUM): The UCUM provides human-friendly codes for all units of measures with precise semantics to facilitate unambiguous and computable communication between computer systems used in science, engineering and business worldwide. A detailed discussion is available at Unified Code for Units of Measure.

To be sure, we have more than just 10 cool technologies here at CBMI, but I thought I would stop here. Want to find out more? Write, call or visit us!

Happy New Year!

Titus

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@regenstrief.org, Web: http://www.regenstrief.org/cbmi/, Blog: https://titusschleyer.wordpress.com, General: http://about.me/titusschleyer

Regenstrief CBMI goes to Washington …

Remember the old movie “Mr. Smith goes to Washington” with Jimmy Stewart? From November 16-20, the American Medical Informatics Association (AMIA) had its 2013 Annual Symposium in DC and Regenstrief Institute CBMI faculty, along with colleagues from other IU affiliates, “went to Washington.” This Symposium is the premier scientific meeting for biomedical and health informatics research and practice which takes place each year in the fall and brings together sterling informaticians from across the US and Canada, as well as many of our international colleagues.

The Symposium lived up to its – usually high – expectations as it has for the past 35 years. I might have been a little bit biased this year because I had the privilege of helping shape the program as the Applications Track Chair, along with Foundations Track Chair Katie Siek and SPC chair John Holmes. To increase program quality, we consciously lowered the acceptance rate to just over 30% from its more typical 40-43%. Together with over 2,400 attendees, we heard about conceptual and practical advances relating to biomedical information and innovations in design, technology, implementation of information systems and knowledge resources across the full spectrum of health care. Not only did we hear and learn about other’s advances and innovations, but we were able to share a few of our own with our peers.

Dave deBronkart (also known as e-Patient Dave), co-founder and board member of the Society for Participatory Medicine, gave an excellent keynote on Sunday about patient engagement in healthcare. He charmed informaticians with quotes such as “Come to the dork side. We have pi.” (That quote was just meant for Burke.) Dave even wrote a nice blog post about his experience at AMIA. From the attendee comments I heard as well as tweets about his talk, it appeared to be one of the most well-received keynotes ever given at AMIA. Even I was so taken in that I tweeted:

Pete Szolovits from MIT won the 2013 Morris Collen Award, a well-deserved honor (see the video here). For those of you who do not know much about Morris Collen, Bill Tierney wrote a very nice blog post about him on the occasion of his 100th birthday. Congratulations also go to JT Finnell, CBMI faculty member, and colleagues for receiving the AMIA Leadership Award for work on Advancing the Clinical Informatics Board Review Program. (Incidentally, JT was among the first people to pass the board exam the other day.)

After the opening session I ran a panel titled “Informaticians, CxIOs and Industry: Strengthening the Fabric of HealthIT with speakers Blackford Middleton from Vanderbilt, Bret Shillingstad from Epic and Marc Overhage from Siemens (my predecessor at Regenstrief). The panel presented viewpoints from key industry and academic leaders on strategies to improve informatics’ contribution to positive changes in healthcare. It was standing room only, and we had attendees from Epic, Cerner, Allscripts and many other HIT companies. One tweet from there that got a lot of attention:

AMIA’s Welcome Reception on opening day was held in the Exhibit Hall where Regenstrief Institute shared a booth with the IU School of Informatics. This was a perfect opportunity for AMIA attendees to visit the booths and ask questions of the exhibitors. Kudos to Emily Mitchell, our fellowship coordinator, for preparing for the exhibition, setting up the booth and staffing it!

Sunday evening was the American College of Medical Informatics (ACMI) dinner and new Fellow induction. I am proud to say that this year Paul Biondich, CBMI faculty, was one of the inductees joining Regenstrief ACMI fellows Bill Tierney, Steve Downs, Shaun Grannis and me. Paul’s accomplishment is even more noteworthy since he was one out of only six new inductees (of over 40 nominees) – making this ACMI election one of the historically most selective.

Monday our fellow Jianmin Wu presented a paper evaluating congruence between laboratory LOINC value sets for quality measures, public health reporting and then mapping the common tests. In the afternoon, investigators Shaun Grannis and Brian Dixon participated in a panel titled “How fit is electronic health data for its intended uses? Exploring data quality across clinical, public health and research use cases.” Concurrently, investigators Jon Duke and Burke Mamlin demonstrated an update on our Gopher Order Entry System for AMIA attendees. Regenstrief Investigators Brian Dixon and Shaun Grannis, and staff member Mark Tucker, presented a demo on The Regenstrief Notifiable Condition Detector, an automated public health reporting system using routine electronic laboratory data.

Tuesday IU colleague and Director of the Department of BioHealth Informatics at the IU School of Informatics Brad Doebbeling presented a paper discussing informatics challenges and strategies to prevent MRSA infections from a multihospital infection prevention collaborative viewpoint. Brad collaborated on this paper, which received an AMIA Distinguished Paper Award, with Abel Kho, former CBMI fellow, from Northwestern for several years.

CBMI investigators Brian Dixon, JT Finnell, Shaun Grannis, fellow Jianmin Wu and former fellow Jason Cadwallader also presented Variation in Information Needs and Quality: Implications for Public Health Surveillance and Biomedical Informatics, Opioid Abuse Risk Scoring within an Emergency Department, and A Practical Method for Predicting Frequent Use of Emergency Department Care Using Routinely Available Electronic Registration Data. Posters presented by Blaine Takesue, Brian Dixon, Josette Jones and some former Regenstrief fellows during the last two days of the meeting included:

• Health Literacy Redefined through Patient Engagement Framework
• Validation of Semantic Synsets in Natural Language Processing
• Patient, Caregiver, and Provider Perceptions of a Colorectal Cancer Personal Health Record
• Measuring and Improving the Fitness of Electronic Clinical Data for Reuse in Public Health, Research, and Other Use Cases
• Using SMART and i2b2 to Efficiently Identify Adverse Events
• Semantic Processing to Identify Adverse Drug Event Information from Black Box Warnings

Tuesday evening a large group of past and present Regenstrief folks embraced good food, a few drinks and a lot of conversation at a nice Italian restaurant, Bistro Bistro. It was great to catch with colleagues, staff and former trainees in a more informal setting.

Brian Dixon wrapped up on Wednesday with the inaugural and well-received “Year in Review for Public and Global Health Informatics.” The session reviewed recent literature in the areas of public health and global health informatics highlighting trends, knowledge, methods, and lessons from public health and the use of informatics in resource-constrained settings.

We have lots of hard work ahead of us to ensure next year we have even more new, exciting and innovative ideas that to showcase the Regenstrief Institute’s leadership in Biomedical Informatics. Are you interested in making that happen? We are currently recruiting for several faculty positions, ranging from the Sam Regenstrief Chair in biomedical informatics and a Chief Research Informatics Officer to midcareer and junior faculty positions. For more information, please see the postings at http://bit.ly/RCBMI_Faculty.

Thanks

Titus

PS Thanks to Sandy Poremba for helping put this blog post together.

 

Informatics giant Clem McDonald honored with endowed chair in biomedical informatics

Yesterday, Indiana University School of Medicine and the Regenstrief Institute  held a ceremony establishing an endowed chair to honor Clement McDonald, M.D., a pioneer and innovator in the use of health information to improve patient care and outcomes.

Dr. McDonald, Distinguished Professor Emeritus and Regenstrief Professor Emeritus of Medical Informatics at the IU School of Medicine and former director of the Regenstrief Institute, is currently director of the National Library of Medicine’s Lister Hill Center for Biomedical Communications.

A distinguished clinician-researcher and one of the nation’s most accomplished experts in the field of electronic health record systems Dr. McDonald has inspired and trained scores of junior faculty and fellows at Regenstrief and IU. He developed the Regenstrief Medical Record System and for decades directed its use in clinical studies of innovations in medical informatics; many were conducted at Wishard-Eskenazi Health, one of the largest safety net public health care systems in the United States. This work has illuminated the ways in which electronic medical records can improve the quality and efficiency of patient care and its outcomes.

Schleyer McDonald Tierney at presentation of McDonald chair to it's first occupant Schleyer

Clem McDonald and Bill Tierney present endowed chair to its first occupant, Titus Schleyer

Today the Regenstrief Medical Record System is one of the longest continually operational electronic medical record systems in existence. Dr. McDonald also created the Indiana Network for Patient Care for the largest and most comprehensive regional health information exchange in the country, involving more than 90 hospital systems in Indiana and more than 19,000 physicians.

Dr. McDonald is also an internationally recognized pioneer in the development of health data standards. He is the developer of Logical Observation Identifiers, Names, Codes, an identification system for tests and results that is a clinical data standard used across the nation and around the globe. A member of the Institute of Medicine, Dr. McDonald is a recipient of the President’s Medal for Excellence from IU, the highest honor an IU president can bestow.

I have the good fortune and high honor to have been named the first Clem McDonald Chair of Biomedical Informatics.  It is hard to put into words what this means to me. The following  is the text of my remarks at the ceremony:

“Dear collagues and friends,

Thank you very much for being here today. It means a lot to me.

So, what do you say when you are honored with the title ‘Clem McDonald Professorship of Biomedical Informatics?’ Well, my first reaction was to be speechless.

My second one was: ‘They must have made a mistake. They cannot possibly mean me.’ Eventually, I realized that they were serious about it and that is why we are all here today.

Of course, then the problem becomes to say something meaningful in response. So, this has become the shortest speech in my life about which I have deliberated for the longest time. I even wrote it down, which is something I never do.

To be honored with a named professorship is profoundly humbling. I consider this the most important achievement in my life to date. Actually, that is not quite correct. My most important achievement is having married my wife Alida. So, this is the most important achievement in my professional life.

Second, I see this honor not as much as a recognition for past accomplishments but a challenge for the future. In science, we are used to ‘standing on the shoulders of giants.’ The preceding remarks have driven home exactly what kind of giant Clem McDonald really is. So, the question becomes: How do we prove ourselves worthy of Clem’s legacy? The named professorship is not just an honor and challenge for me, it is one for all of us.

The Center for Biomedical Informatics is a storied institution with a rich history of accomplishments. That is good, but more is asked of us than to rest on our laurels.

McDonald Schleyer 7-8-13 handshake

Clem McDonald and Titus Schleyer

After I gave my Work in Progress presentation a few weeks ago, Tom Inui came up to me and introduced himself. It was the first time I met him. He asked me a simple question: ‘Why did Sam Regenstrief fail?’ I’m thinking: ‘Wow, here comes the real interview.’ So, I am wracking my brain, trying to remember Sam’s biography that I had read more than a year ago. So I say: ‘Sears wanted to diversify from more than one supplier for dishwashers.’ Tom shakes his head. ‘Somebody offered him the design of the first microwave to build, but he didn’t take it.’ Well, I am not sure how many of us would have chosen to build microwaves in an age when their widespread use was unimaginable! Tom shakes his head again. Then he says quietly: ‘He kept doing what he was always doing.’

At a fundamental level, Sam did not change his ways in a changed environment.  It is a lesson that we would do well to heed.

Biomedical informatics operates in an environment radically different from what we had historically. Not anymore is informatics the domain of the few bright pioneers. Not anymore can it be content with producing stellar innovations confined to local settings. Not anymore does it exist in a vacuum.

No, informatics is now alive in the daily practice of healthcare. Its fruits are at work in every practice, hospital and health system. In short, it not only affects healthcare, it is healthcare.

That puts a particular burden on us. In keeping with Sam’s charge, we must ensure that informatics continues to improve healthcare.

I always like to joke that biomedical informatics is still in the Stone Age. Some people may scoff at that, but I think it is true. Many years ago, Paul David wrote in the American Economic Review:

‘Radically new technologies diffuse gradually, because it takes a long time for companies to learn how to use the new resources effectively. … Truly revolutionary applications often require major reorganizations of production, which may take a long time to discover.’ (P. David, The dynamo and the computer: A historical perspective on the modern productivity paradox, American Economic Review, 1990).

I think the same is true in healthcare. We have not even begun to discover how to use informatics to its full potential in healthcare.

Participating in and helping drive that discovery is one of our core responsibilities at CBMI. Sam Regenstrief charged us with improving healthcare. We have done that and will do it even better in the future.

But, I cannot do this alone. I need your help. In the process, we will have to work hard. We will need to do things in ways we haven’t done them before. We will need to reach out to others in unprecedented ways. But, most importantly, we will do it together.

In the process, one thing we will do is to honor Clem and his legacy. And, I can imagine few things as worthwhile as doing that.

So, I have been working here for four weeks and one day now. I’m sure many of you are asking yourself: ‘Well, what is Titus thinking? Does he like it here? Does he like us?’ I have to tell you: I love it here.  Coming to work here was like coming home. I know that we can achieve great things together. I see it in your loyalty to the Institute. I see it in the ways you think, decide and act. I see it in your eyes. For me, the fact that we can do it means we will do it.

With that, let us raise our glasses to Clem: For what we owe to you and for what we will achieve in your honor.

Thank you very much.”

PS: Official press releases:

PPS: Recording (.wav file, 40 min.) of remarks at the ceremony by:

  • Bill Tierney, President and CEO, Regenstrief Institute
  • Charles Bantz, Chancellor, Indiana University-Purdue University Indianapolis
  • Chris Callahan, Director, Indiana University Center for Aging Research
  • Clem McDonald, Director, NLM Lister Hill National Center for Biomedical Communications
  • Titus Schleyer, Director, Center for Biomedical Informatics, Regenstrief Institute