Plethora of views aired at professionalism debate

The way forward for health informatics as a profession was the subject of the BCS Health Informatics Forum meeting on 23 January. Andrew Haw, Brian Derry, Pam Hughes and Jean Roberts, all directly involved in developing health informatics as a profession, were invited to present their points of view. This was followed by a wide-ranging discussion on the topic from all those present. Helen Boddy reports. 

Professionalism matters for a variety of reasons, said Andrew Haw, chair of ASSIST, who kicked off the presentations. These include quality of service, accountability, protection of the public, trust, salary and status.

In certain walks of life, professionalism is particularly valued, according to Andrew. It is essential for safety in architecture and building, so that we don't end up with disasters such as the collapse of the Tacoma Narrows bridge in the US. Equally, professionalism in aerospace and nuclear physics is essential to avoid catastrophes. 

Economic advantage can also be a reason for industries to follow best practice. For example in agriculture, crop rotation has become best practice because it helps increase yield. 

In software design, there has arguably not been enough of a disaster to make the public take notice and demand a higher level of professionalism from the industry, but it could conceivably happen, Andrew believed.

Professionalism could help avert future disasters, as well as improving the industry's status and profile. He suggested that the professional status achieved by economists (without mandatory registration or regulation) was an example which health informaticians could follow. 

'What makes a profession or professional behaviour?' Andrew asked participants at the forum meeting. They suggested that it was about quality, regulatory actions (code of conduct, ethics, de-registration), qualifications, continuing professional development (CPD), and a body of knowledge and skills.

For professionalism to gain support employers need to recognise all these defined criteria, he said. The journey to professionalism may therefore seem long, but health informaticians can break it down into targets to achieve along the way, rather than tackling it all at once. 

What is health informatics? 

In working towards professionalism, Brian Derry, vice chair of ASSIST, suggested that it was first necessary to define the profession. In this, there is a distinction between the various functions and tools associated with health informatics, and the specialist staff groups that might be subject to professional regulation. 

He referred the gathering to the first definition of health informatics published by the Department of Health in 2002 in the report ‘Making Information Count’ (MIC): 

'The knowledge, skills and tools that enable information to be collected, managed, used and shared to support the delivery of healthcare and to promote health and wellbeing.' 

Brian said he saw several flaws with this definition. For example, a person who simply switches on a PC could arguably be included in it; and there are multiple bodies of knowledge. The same argument could apply to finance and workforce specialists. 

He proposed therefore that the definition should be more specific - see his article 'Narrower definition would clarify identity'

Another difficulty he identified was that concepts were mixed in the groups defined under health informatics in the MIC Report.

Some of the groups - ICT, information management (IM), knowledge management, and health records - are functions, he explained, whereas senior management is a grade and clinical informatics is essentially health informatics operated by clinicians. 

The UK Council for Health Informatics Professions (UKCHIP), in defining who may join its national professional register, included the groups in the MIC Report, plus those in education, teaching and development, and research. However, these latter are applications, argued Brian, and therefore should not be listed as separate groups from the rest.

Otherwise, should business analysts, project managers and so on also be listed? 

He argued that the two groups that are core to health informatics, and have most in common with each other are ICT and IM. Each of these cannot do their jobs well without the other. By contrast, if you consider knowledge managers, they have skills in librarianship, and, beyond their knowledge of the health service, what do they have in common with those in ICT and IM?

As for clinical informaticians, they could be seen just as super-users, he said. Furthermore, they would belong to two professions - and how would that work? 

A wider definition 

However, in the next presentation, Jean Roberts, who is on the BCSHIF strategic panel and the board of UKCHIP, argued in favour of UKCHIP's wider definition by explaining the rationale behind inclusivity.

If we all hold hands, we can do more and get there more quickly, advocated Jean. And it is possible for smaller groups to exist in a wider community, a broad church, but come together where appropriate. For example, BCSHIF encompasses both synergy and subsidiarity. It works as a whole on certain initiatives, while smaller groups concentrate on specialist initiatives.

Health informatics is just as at risk from cost cutting as front-line clinical staff, suggested Jean. She proposed it would be more effective to promote as a broad church what the discipline has delivered and can do in the future to support direct care, treatment and health.

Health informatics as a discipline is by its nature multifaceted. It includes, for example: new entrants to experienced practitioners; super-users and those formally HI qualified; academia; and those in commercial service and solution provision and those who developed their HI involvement from a different professional home base. 

Equally, patient data can come from many places: A&E, GPs, dentists, therapists and so on. It has been estimated that more than 100 clinically-related staff in a hospital are involved in taking care of one patient. It's not practical to draw a circle round a subgroup of those that input or use information. If certain groups, and their knowledge and data, were excluded, patient safety would be affected, argued Jean. 

The interconnections between the many different roles are important and difficult to cast asunder. We need to know who is interacting with whom and how to find the answers, and therefore we need a broad church, she said.

A squid is a good analogy for health informatics, explained Jean at the end of her speech. To find out why, read her article expanding on her arguments in favour of a broad church - 'Wide scope creates squid-like synergy'

Professional standards  

One of the current problems in attaining professional standards is the great variation in quality of job specifications in the NHS, said Andrew Haw in the last presentation, which had been prepared by Pam Hughes, ASSIST National Council secretary. Steps towards professionalism could be taken by improving job descriptions by using an agreed knowledge and skills framework.

Health informatics practitioners, employers and the government have already agreed upon a set of National Occupational Standards for use by health informatics practitioners, explained Andrew. UKCHIP used these Health Informatics National Occupational Standards (HINOS) to help set up their standards for the entry scheme.

The Information Centre for health and social care, as part of its HINOS project work, has also been looking at the Skills Framework for the Information Age (SFIA) to see how it would help IT staff in the NHS to capture, record and develop their own skill sets. In principle, anyone working in ICT can appraise themselves against this competency framework.

The Information Centre, working collaboratively with ASSIST, ran a pilot in the NHS with around 500 participants last year. The University Hospital Birmingham NHS Foundation Trust, where Andrew is director of ICT & EPR, took part. 'We found it took a certain amount of time to get over the pain barrier to understand SFIA,' he said. See article on page 16 for further details of this pilot.

Nevertheless, SFIA has the advantage that individuals can appraise themselves and their manager can assess them too and work out gaps in their skills, said Andrew. He also used it to inform job descriptions and as an input to annual appraisals.

By taking part in this pilot, Andrew realised that there was no one in the ICT teams operating at the right level in database administration.

'We need tools like these to enable us to look at a post, work out best practice, train staff and continually improve them,’ he said. This would help in working towards a professional informatics service, which he defined as:   

  • skilled, competent people;  
  • professional behaviours;  
  • good procedures, processes and practices;  
  • clear goals, objectives, purposes and governances;  
  • measurable outcomes and benchmarking;  
  • continuous improvements. 

The discussion 

Whether creating another profession was a worthwhile pursuit at all was questioned by one participant during the open debate after the presentations. He pointed out that in the recent  television programme 'Can Gerry Robinson fix the NHS?', the barriers between professions were generally responsible for making cooperation impossible, and the problems not fixed until they were broken down.

'Are we building just one more silo if we create another profession?' asked the participant.

Another concern about pursuing professionalism expressed by an academic was that it should not be pursued to the neglect of innovation. He thought it was important that the profession be respected but equally important that research outputs are respected and enabled, moving towards a more free-thinking environment. Both streams should be pursued in parallel.

Could BCSHIF help kick start IT innovation in the UK, or at least support this within the health setting? 

Standards should help  

Most participants at the meeting thought that being able to move towards professional standards is a good thing. One person pointed out that the national workforce survey by ASSIST in 2006 showed that the right skills were not in the right place in the NHS and staff felt undervalued with no clear career pathways.

If we had professional standards and clear understanding of them, it would make life easier to say 'I want this person' and to work out what development needs that they have.

Another participant thought economic drivers would eventually lead to better training of people in post. The importance of accurate data would be an important economic driver and these in turn would help drive professionalism.  

The need for an entry gate 

A health informatics profession will need one entry gate, which ought to include both a degree and CPD, believed most participants.  

This entry gate must allow for there not being one common point of entry into health informatics, and for current health informaticians being an eclectic mix that have come into the workplace via different routes. We want an entry gate to encourage this, said one participant.

Some participants thought that new graduates entering the profession ought to be informaticians, for instance with a computer science degree, who would then learn health knowledge on the job. Others advocated qualifications that encompassed information about the health environment too.

It's easier to teach someone about the health environment, such as washing hands and not interrupting a doctor talking to a nurse, than teaching them how to design a database, said one participant. They don't need to know about the operations that the clinicians are performing.

This view was complemented by that of a participant who said he had worked in various industry sectors and that each believed it was different to others. He thought that the special features in health are not really so very different from other industries. Health informaticians of course need domain knowledge but that is mainly about understanding the business, he said.

The opposing view was that it's difficult to uncouple domain sensitivity for health informaticians, and both (informatics and health environment) ideally should be taught together. Clinical procedures, processes and standards are of course, very specific to health, believed many participants. It's not possible to design an IT system for healthcare without knowing about the processes. And there are questions surrounding confidentiality in the healthcare setting.

Lots of engineers can do harm, or make life difficult, if they don't understand the clinical side of the business, argued one participant. The complexity of the clinical arena means you can take years to be competent and work without inadvertently causing damage.

In discussing the accreditation of existing health informaticians as professionals, participants were generally in agreement that a scheme must ensure that health informaticans do have health knowledge (perhaps acquired and maintained through CPD) and are not simply IT experts with no understanding of the healthcare environment. 

Some IT practitioners who work in the healthcare sector do not have, nor require, domain knowledge and they should not be classed as health informaticians, agreed participants. For example, a case was given of Microsoft-certified engineers simply knowing what the service level agreements are for certain bits of equipment, rather than knowing their clinical use. IT functions that require domain knowledge would be classed as health informaticians. 

A UKCHIP representative confirmed that under its scheme IT practitioners would not be given registration as health informaticians unless they could demonstrate that they had knowledge of the health arena as well as informatics skills.

t was suggested that it would be a good idea for health informaticians to be registered before they were allowed to do certain roles. That should prevent IT experts designing systems that can damage patients and, inversely, avoid clinicians who are not IT experts designing databases. Accreditation could be particularly useful for companies that provided outsourcing, for example to GPs and PCTs.

Perhaps the most useful role for BCSHIF, according to one participant, would be to help employers recognise that they should only take on people who are registered as fit to practice. Otherwise, what’s the point of registration anyway?

It was pointed out that UKCHIP had already defined entry points for its voluntary registration scheme, and could these not be adopted? Such a move would be partially dependent on whether there was agreement on UKCHIP’s definition of health informatics.  

Broad or narrow definition? 

However, participants did not agree whether the profession should be defined as widely, as by UKCHIP and the MIC Strategy, or more narrowly as proposed earlier by Brian Derry. 

In arguing for a wider definition, one participant pointed out that solving technology problems was important when HI first began, but now that computing is taken for granted, the definition of health informatics is altering. It's often no longer about developing hardware and software to meet needs but about exploiting existing equipment. A definition needs to be wide to accommodate these changes.

The work in definition and strategy has moved a long way in five years, pointed out another. In 2002 it was the first time that it was defined, said another participant, who thought the best way to tackle professionalism is as a whole community. 

Over time we have come together as health informaticians because we all had common interests and mutual values, argued another. No one group is yet big enough to split off and go it alone.

Furthermore, the fact that those on the nursing register can have very different jobs has not held them back as a registered profession, agreed one registered nurse. 

Another participant countered that argument with the fact that nurses as a profession have all passed the same   basic training, whereas health informaticians have radically different qualifications. Information management experts, for instance, may have a statistics degree, rather than a computer science degree. 

If we all were asked to draw boundaries around groups that were health informaticians, some groups would be definitely in, and some definitely out, and there would be some grey areas, said one participant. Can we move forward on professional behaviour, ethics and so on without ruling out grey areas? 

Some thought this was not possible. In defining a function health informatics can be as broad as you like, but that's not possible for a profession, believed one participant.  The function depends, he said, on many types of people but this does not mean they all have to be part of the profession: IT requires electricity but electricans are not informaticians. We need to be clear about professional standards, what they are, and who they apply to. The debate continues.  

Useful links 

- Skills for Health

- BCS HIF Professional Development Board