Wide scope 'creates squid-like synergy'

Jean Roberts explores the way health informatics (HI) has grown organically, by being inclusive of all participants and those with an interest in the subject, regardless of their background and prime discipline. She argues the case for maintaining this broad church for the further development of the profession.

BCS HI Forum (BCSHIF) currently acts synergistically with its constituent groups on initiatives such as the recent statement on 'The Way Forward for NHS Health Informatics', the annual national HC Congress and an exploration of the actual domain scope. Current confusion about what HI really should encompass is reflected in the statement made five years ago that 'Health Informatics is like a 40-year-old adolescent wandering in the desert' [1].

Within the Forum, the specialist groups and member group carry out specialist initiatives. Synergy and subsidiarity work well within the groups and also with other liaison bodies with HI interests.  

The ASSIST workforce survey - www.bcshif.org/assist - presents a reasonable proxy for actual HI distribution with the relatively 'non-techie' disciplines making up 38 per cent. An inclusive HI community has layers of complexity.

Firstly, patient/client health status and care intervention data comes from many sources: mainstream NHS facilities, Foundation Trusts, private healthcare facilities, commercial organisations or at home - in other (home) countries. Understanding how such organisations interwork and technical skills are necessary to design, develop, test and implement HI solutions to support collective clinical databases and individual patient records.  

100 staff for one patient

Estimates state over 100 clinically-related staff are involved in care of an acute inpatient. Extrapolating to include all other areas of care results in many different professions inputting to, and requiring information from, current systems. Making decisions will necessitate patient-specific and evidence-based reference data as context. To validate, verify the content and delivery mechanisms and check interpretation involves all aspects of the professional spectrum. To alienate any part of the process could jeopardise data quality which in turn could put patient safety at risk.

Looking (not far) forward, vital signs monitors, diagnostic aids and lifestyle management devices will be pervasive, technology-based, and perhaps bodily embedded [2]. Increased use of virtual reality, artificial intelligence and genomics will extend the community, which must be flexible enough to encompass all. 

Patient-side data is also used for other management and strategic planning, to profile activity and service demands. Data collected 'at source' must be correct and appropriate if audit, performance management and decisions on planning new facilities are based on it.

Such data must be appropriate and be interpreted by people who really understand it. Three out of five top safety issues as described by the National Audit Office have informatics-related components. Inappropriate data and misunderstanding of its meaning may call into question the conclusions made under, for example, the Clinical Negligence Scheme for Trusts audit process.

Health data cannot be handled in a silo behind closed doors. Context is imperative to make valued judgements about its implications. Those working with the technologies and the data processing cannot contemplate the appropriateness of their deliverables, or the worth of their contribution, unless they have domain sensitivity. HI processes are in fact integral to the business of care.

Our business environment is complex and layered for reasons that are difficult to challenge. For example some hospitals take local patients and international referrals. Sophisticated systems (technology and human) are necessary to answer questions about appropriate local service provision in parallel to doing ‘heroic’ world-leading interventions.

Should we seriously devolve the responsibility for analysing that data and presenting its interpretation relative to national evidence to someone who has no ‘feel’ for the environment?

Setting answers into context needs input from those translating data into information, probably clinical codes and management classifications. Evidence that sets local situation into a national, similar operational or clinical specialism context uses competence in knowledge management to ensure adequate comparability.

Health informaticians need to ensure that other health professionals, informatics professionals in other sectors and the general public understand how we contribute in the health domain. Identified difficulties exist in recruitment and retention in some techie areas of our community. Distinguishing our domain from others that attract such professionals might increase the numbers making informed choices to come into health and stay.

Promoting HI explicitly in adverts and job specifications could perhaps do this?

This suggestion fits nicely with the focus by the UK Council for Health Informatics Professions - UKCHIP - (its catchment currently the broad church) on 'Registration, Regulation and Professionalism’ for the benefits of protecting patients' safety.

Currently much domain activity relates to education/personal development, expert commentary on policy and aspects of moving forward. Further benefit can be released from rationalising the mishmash of bodies getting involved in defining, determining, confirming, and enabling who does what.

A clearer, inclusive, domain description might attract more people to voluntarily participate. The complex activity network addresses HI from all angles - national / international, in and for the NHS and other healthcare providers. To alienate / fragment this eclectic community would, I propose, be dangerous to our identity and the quality of our deliverables.

Why do (some of us) slavishly describe HI as different from (a) any other informatics and (b) different from the IT industry generically? Whilst IT is still the most widely used term, its deeper meaning may be nearer our broad church than first thought.

Governmental proposals for a single major database stated that 'Some individuals can regularly deal with as many as 30 different agencies, none of whom share information on that individual... [would] people be in favour of relaxing current privacy procedures and data sharing laws if it would mean improved public service, particularly at points of great stress?'

All five communities in the 2002 report 'Making Information Count' by the Department of Health, are actually informed members of the public. The ICT cohort can input technical concerns, records managers comment on data handling, information managers on data validation and interpretation whilst knowledge managers provide evidence and clinical informaticians comment on enabling sharing.

The broad HI community can powerfully contribute on topics wider than our specific domain. 'IT' in the manifesto of the Government IT Academy is inclusive of 'facilitating learning in delivering policy, managing change, leadership, and will include secondments to understand domains'.

In preparation to air this topic, the Prof IT Programme Steering Board (an alliance between the NCC, Intellect and the BCS) commented that: 'it has unequivocally concluded that we must define the scope of the profession broadly. It must include security and information management professionals and recognise domain-specific expertise, for example health informatics. We are moving the profession to make a bigger contribution to IT-enabled business change and [therefore] business/domain knowledge is an important competence.'

We would be the poorer if some parts of the community were uncoupled from the wider ‘IT’ professional agenda or from effective, efficient, and in our case, efficacious, deployment of IT and information management as an integral part of the activity of the domain.

The media have been known to ‘interpret’ IT issues emotively to gain higher prominence; putting appropriate evidence up to refute their mistaken interpretation requires in-depth domain competence. Effective professionalisation requires synergy. We have inherent specialisms / capabilities. Without working together we cannot maximise effective outcomes.

A squid's natural competence to concentrate and release energy to move forward can be used as an analogy to HI. Only since high temperature alloys were developed has it been possible to use such latent squid capabilities in jet engines.

Similarly, I suggest that if we do not have an inclusive profession of HI (a human 'alloy') then the benefits of informatics components in support of health will not achieve their highest value and we will not have the (squid-like) synergy to effect business changes in the health domain.


1. Shahar, Y Medical Informatics : Between Science and Engineering, between Academia and Industry  Methods Inf Med 41, 1/2002, p8-11 (2002)
2. Pervasive Health Management and Health Management utilizing Pervasive Technologies: Synergy and Issues in Pervasive Health Management: new Challenges for Health Informatics, Black, McAllister, McCullagh, Nugent, Augusto (Eds), special issue of International Journal of Universal Computer Science, Vol. 12, No. 1, pp. 6-14 (2006)

Jean Roberts has been in health informatics almost throughout its whole development and sits on the Strategic Panel of BCSHIF and the Board of UKCHIP. She is, by day, a senior lecturer in health informatics at the University of Central Lancashire.