Clinical Informatics: To Measure Once, Think Twice

The clinical informaticist is a systems-oriented physician who sees possibility in ambiguity and has the interpersonal, computational, and mechanical skills to resolve structural barriers to excellence. Alexis Byrne Carter, MD, FCAP, has all that, along with a pathologist's curiosity and clinician's interest in how people think. She embraces the whole messy pursuit.

"Clinical informaticists need to know how to remove ambiguity in systems and processes so that everyone, new employees included, is clear on what to do from day one," says Dr. Carter, a clinical informaticist in Laboratory Services at Children's Healthcare of Atlanta (CHOA).

The core required skills, Dr. Carter says, are those learned in medical training. Clinical informatics is making the system work for your patients. It's observation, evaluation, and negotiation. It's building bridges that enable the pathologists and other physicians, laboratory information system staff, and hospital IT professionals to see that they can get what they want by supporting one another.

"Clinical informatics is looking at things from somebody else's perspective," says Dr. Carter. "It's saying, OK, this is not working for people. What can we do? What are the constraints in the system? How can we improve it? Is the vocabulary appropriate? Does the name of this test accurately reflect what is actually being done? You have to use the medical knowledge piece."

The advent of big data and growth spurt in next-generation sequencing (NGS) are driving accelerated demand for clinical informatics, says Dr. Carter, who was the 2014 president of the Association for Pathology Informatics and chairs the informatics subdivision of the Association for Molecular Pathology. Building and maintaining an infrastructure that coordinates all the moving parts is a perpetual work in progress.

So pathology departments are hiring specialists—clinical informaticists and bioinformaticists—who can help them get their hands around a tsunami of potentially useful information. (Bioinformaticists are specialists who write computational algorithms to analyze complex sets of biological data. Clinical informaticists are typically physicians who work to improve interactions between humans, information, and information technology to improve clinical patient care. Most institutions will need both.) Hospitals are finding the talent they need, Dr. Carter says, but when these specialists come on board, "Sometimes they really don't know what to do with us."

Before coming to CHOA, Dr. Carter, who is board certified in anatomic, clinical, and molecular genetic pathology as well as clinical informatics, was director of pathology informatics and an assistant professor in the Departments of Pathology and Laboratory Medicine and Biomedical Informatics at the Emory University School of Medicine. Intellectually curious and hands-on by nature, she learned from experience that what someone wants measured is not always what they need to know. The questions have to be exactly right because what gets measured is what gets done.

At CHOA, Dr. Carter's day-to-day work involves a good deal of negotiating. "Everything we do in clinical informatics affects multiple parties," Dr. Carter says. "Somebody has to sit in the middle and consider all the aspects—that we make sure we've paid attention to this, that we have a standard for how those things are going to be done, and that it's medically relevant and understandable to all the end users." And end users include everyone who will read, employ, or manipulate the content—physicians, patients, pharmacists, nurses…everyone.

A hiccup in the workflow, Dr. Carter says, is almost always a process issue. In the business office, for example, where well-designed clinical informatics processes will streamline systems so that billing is accurate and efficient, how do you demonstrate that inefficient workloads lead to errors and that the small things eat up your time?

"I don't like to use this term," Dr. Carter says, but to make your contribution visible, "You have to be prepared to do a lot of bean counting—or really inverse or reverse bean counting." Tallying the number of times people are making certain errors before and after a change in process demonstrates the value of a clinical informaticist in concrete terms.

Showing the financial value in hiring an informaticist, Dr. Carter adds, means showing both money and time saved when he or she has an integral role in planning and execution. "How long did this project sit and not go anywhere because everybody was confused and nobody had good direction?" she says. "It's a clinical informaticist's job to get the pros and cons together and get people to make decisions that are good for right now and will help lift you to where you want to be five to 10 years in the future. That strategic vision is critical to avoiding the need to undo and then redo a project. It's money and time that the organization is not going to have to spend later."

For a multimillion-dollar, big project like an LIS upgrade, Dr. Carter says, "The return on investment on that one project alone can pay your salary." At the same time, she adds, "The value of smaller initiatives will persist and multiply as the efficiencies they enable accumulate."

Dr Carter is a current member of the CAP Informatics Committee and Clinical Informatics Steering Committee who has completed terms on the CAP Personalized Healthcare Committee and the Digital Pathology Working Group. Credits outside the CAP include past chair of the International Health Terminology Standards Development Organisation and secretary of the Clinical and Laboratory Standards Institute AUTO14 Revision Committee. Dr. Carter has also served on the Centers for Disease Control and Prevention Communication in Informatics Working Group and the Pathology Informatics Essentials for Residents (PIER) Collaboration Working Group of the Association of Pathology Chairs.