2a Informatics, Analytics & Decision Making Foundations-2

Health Informatics, Analytics &
Decision Making
Foundations
Power
What are the most common forms of power

encountered in health care organizations?
2
Power
• Legitimate
• Resource Control
• Tradition
• Influence / Charisma
3 © Alan F. Dowling 1985, 2017

Power
• Legitimate
• Tradition
• Expertise

Power
• Legitimate
• Tradition
• Expertise
• Information

Knowledge and Expertise
• Health disciplines are based on knowledge and

expertise.
• Fundamental to ‘knowing’ or ‘being skilled’ is

information and its assimilation by us to:
– Know and
– Know how.
6
Data → Action
Data
Analysis
Insight
Alternatives
Decisions
Therefore, the success of a
decision is dependent on the Action
underlying data & its analysis.
7
Information Centricity
• Virtually all health care processes are dependent on

information and knowledge.
• Medically-related information is multi-sourced and
has multiple uses.
• Information is no longer a “free good”.
8
Health Informatics, Analytics &
Decision Making
Informatics Foundations
9
Health Informatics Subsets
COMPUTATIONAL
HEALTH
TRANSLATIONAL
& CLINICAL
RESEARCH
© Alan F. Dowling, PhD 2012-2013
10
M I scope for this course
Informatics
⊂ Health Informatics
⊂
Health Informatics Biomedical Informatics
⊂
Biomedical Informatics Medical Informatics
But, is:
Medical Informatics ≅ Clinical Informatics * ?
* “Clinical Informatics” has recently become a medical

subspecialty for physicians. What does this mean for the field?
For physicians? For other related professionals?

11
Clinical Informatics
• Clinical Informatics is the scientific discipline that seeks to enhance human

health by implementing novel information technology, computer science and
knowledge management methodologies to prevent disease, deliver more
efficient and safer patient care, increase the effectiveness of translational
research, and improve biomedical knowledge access. (Stanford)
• Clinical Informatics is the application of informatics and information

technology to deliver healthcare services. … AMIA considers informatics when
used for healthcare delivery to be essentially the same regardless of the health
professional group involved (whether dentist, pharmacist, physician, nurse, or
other health professional). Clinical Informatics is concerned with information
use in health care by clinicians. Clinical informatics includes … topics ranging
from clinical decision support to visual images (e.g. radiological, pathological,
dermatological, ophthalmological, etc); from clinical documentation to provider
order entry systems; and from system design to system implementation and
adoption issues. (AMIA)
12
AMIA Clinical Informatics Intersection
But, since “Clinicians”

includes health
professionals other than
physicians, for our
course, we can roughly
equate clinical
informatics with medical
informatics.
Source: AMIA Board White Paper: Core Content for the Subspecialty of Clinical Informatics, Journal of the
American Medical Informatics Association, Volume 16 Number 2, March / April 2009
13
M I Working Definition
For our operating purposes, Medical Informatics is the application of

information sciences, systems and technologies to health-related
activities in order to improve medical effectiveness and efficiency.
We’ll modify and use AMIA’s Clinical Informatics definition as our working
definition of Medical Informatics:
• Assess and satisfy information and knowledge needs of health care
professionals (clinical and non-clinical) and patients;
• Analyze, evaluate, reengineer, innovate and/or refine clinical processes
using information technologies;
• Develop, implement, and refine clinically-related knowledge and
decision support systems; and
• Lead or participate in the planning. design, development and/or
acquisition, adaptation, implementation, evaluation, and continuous
improvement and management of clinically-related information systems.
14
Clinical Informatics - Medical Subspecialty
“Clinical informaticians use their knowledge of patient care

combined with their understanding of informatics concepts,
methods, and tools to:
• assess information and knowledge needs of health care
professionals and patients,
• characterize, evaluate, and refine clinical processes,
• develop, implement, and refine clinical decision support
systems, and
• lead or participate in the procurement, customization,
development, implementation, management, evaluation, and
continuous improvement of clinical information systems.”
Source: Core Content for the Subspecialty of Clinical Informatics, Journal of the
American Medical Informatics Association, Volume 16 Number 2, March / April 2009
15
M I Elements
Medical Informatics applies (at least) the following knowledge sets:

• Health Systems • Computer Science
• Health Management • Information Systems
• Clinical Disciplines & Technologies

• Systems Engineering
• Information Sciences
• Psychology
• Cognitive Sciences
• Ergonomics
• Decision & Game Theory
• Research Methods
• Knowledge Engineering • ____________________

16
Information & Knowledge Management
Processes
• Information & knowledge requirement planning,

definition & architecture
• Information & knowledge acquisition & management
– Borrow, buy, develop, classify, date, store, etc.
• Information & knowledge transfer
• Information & knowledge application
– Decisions, processes (TSS, MCS), products, etc.
…to do this, you must understand the attributes and value of the
underlying data/information…
17
Information Attributes
Data
Raw facts
Atomic vs. Molecular
Information
Data w/ relevance & purpose
Knowledge
Contextual information, values, rules synthesized to provide understanding
& value
Tacit (experiences, beliefs, skills) vs. Explicit (structured)
Intelligence
Data / information / knowledge organized to infer action
18
A Management Axiom
INFORMATION
is an
Asset
it has
Value
Therefore, the asset must be managed…

19
Contributive Domains
CLINICAL
SCIENCES &
PROCESSES
EPIDEMIOLOGY
COGNITIVE
AND
SCIENCE
BIOSTATISTICS
MEDICAL
INFORMATICS
DECISION BASIC MEDICAL

SCIENCES SCIENCES
COMPUTING &
COMMUNICATION
TECHNOLOGY

20
Contributive Domains
CLINICAL
SCIENCES &
PROCESSES
EPIDEMIOLOGY
COGNITIVE
AND
SCIENCE
BIOSTATISTICS
MEDICAL
Stasis INFORMATICS
DECISION BASIC MEDICAL

SCIENCES SCIENCES
COMPUTING &
COMMUNICATION
TECHNOLOGY
INNOVATION,
ADOPTION AND EXPERIMENTAL
SYSTEMS
Transformation ENGINEERING &
CHANGE DESIGN &
MANAGEMENT EVALUATION
TRANSFORMATION

21
Cognition
• Mental processes that CLINICAL

SCIENCES &
includes attention, memory, PROCESSES
EPIDEMIOLOGY
COGNITIVE
producing and SCIENCE
AND
BIOSTATISTICS
understanding language, MEDICAL

INFORMATICS
solving problems, and DECISION BASIC MEDICAL

SCIENCES SCIENCES
making decisions. COMPUTING &
COMMUNICATION
TECHNOLOGY
• That which is known, INNOVATION,

perceived, or believed SYSTEMS
ENGINEERING &
TRANSFORMATION
CHANGE
MANAGEMENT
DESIGN &
EVALUATION
(rightly or wrongly): a fact,

belief, or assumption. So, that lab result in your EHR fact, or is
it a guess, opinion or transcription error?
22
Ontology
• Study of the nature of being,

existence, or reality, as well as CLINICAL
SCIENCES &
the basic categories of being COGNITIVE

PROCESSES
EPIDEMIOLOGY
AND
SCIENCE
and their relations. BIOSTATISTICS
MEDICAL
INFORMATICS
• Part of metaphysics, ontology DECISION BASIC MEDICAL

SCIENCES SCIENCES
deals with questions COMPUTING &
COMMUNICATION
concerning what entities exist TECHNOLOGY
or can be said to exist, and INNOVATION,

SYSTEMS
how such entities can be ENGINEERING &
TRANSFORMATION
CHANGE
MANAGEMENT
DESIGN &
EVALUATION
grouped, related within a

hierarchy, and subdivided So, if you’ve been diagnosed with a
disease, does that disease really
according to similarities and exist in you ?
differences. 23
Epistemology
• Study the nature and scope CLINICAL
(limitations) of knowledge. SCIENCES &

PROCESSES
EPIDEMIOLOGY
COGNITIVE
AND
SCIENCE
BIOSTATISTICS
• It addresses: MEDICAL
INFORMATICS
–What is knowledge? DECISION BASIC MEDICAL

SCIENCES SCIENCES
COMPUTING &
–How is knowledge COMMUNICATION
TECHNOLOGY
acquired?
INNOVATION,
–To what extent is it possible SYSTEMS

ENGINEERING &
TRANSFORMATION
CHANGE
MANAGEMENT
DESIGN &
EVALUATION
for a given subject or entity

to be known? Do you really know your LDL or was the
value acquired in error due to an
analyzer failure ?
24
Some General Systems Theory concepts
that are useful…
25
Systems: Closed & Open
CLOSED
OPEN
26
Systems: Decomposition
27
Input / Process / Output
Input Process Output
28
Input / Process / Output
Input Process Output
Patient’s Request Appointment to Patient
Clinic Schedule Outpatient Update to Schedule

Scheduling
Physician’s Orders Request for Medical Record
In each functional user area, requests are received, work is

performed, and results are achieved. The input to this process
may be the output from a prior process, and the output from this
process may be in the input to a follow-on process.
29
Functions / Processes
HC Delivery
External IDS Processes External
Resources Customers
FUA-1
Member Ambulatory
Patients
P1-1 Service FUA-3
Member
P1-3
Patient
In-patient
Production P1-2 Service P3-2
Resources P3-1
FUA-2 P3-3
P2-1
Entitlement
Information Finance Members’
Employer
or HA
© Alan F. Dowling 1985, 1999

30
Tight vs. Loose Coupling
Tightly Coupled inside;

Loosely Coupled between
Member Ambulatory
Patients
P1-1 Service
Member
P1-3
Patient
In-patient
Production P1-2 Service P3-2
Resources P3-1
P3-3
Entitlement
P2-1 Members’
Information
Finance Employer
or HA
Coupling can help delineate the boundaries of sub-systems…
© Alan F. Dowling 2002,2009
31
Systems: Equifinality
Origin Destination
32
Data → Action
Data
Analysis
Insight
Alternatives
Decisions
Therefore, the success of a
decision is dependent on the Action
underlying data & its analysis.
33
Types of Computer-Based MI Systems
Unstructured
D&KSS
Decision +
Knowledge
Support
MCS
Management Control
Systems
(Information forPerformance
Feedback & Control)
TSS
Task Support Systems
(Information at Operational Level in
Support of Work Process)
Process Control
Structured

34
HCIS Application’s Purposes
Task Support - for care delivery and management

operations, infrastructure operations, and documentation
Management Control - for measurement and management of
clinical, contractual, and organizational performance
Decision & Knowledge Support - for providing greater
decision structure, decision testing, knowledge transfer,
and risk reduction
Competition Support - for creating or defeating barriers, and
enabling strategic actions
35 © Alan F. Dowling 1985, 2017

Clinical Task Support
Process and Information Support for:

• Routine care activities (Hx, Dx, Tx, Rx, etc.)
• Triage and urgent intervention
• Case management
• Member-specific information gathering, processing &
documentation (e.g., enrollment & case-specific)
• Health status determination and health / wellness intervention
• Epidemiological inference and intervention
• Consultation and knowledge sharing
• Virtually ALL tasks performed in health care
36
Overlap Issue
• Overlap issue: Other types of systems (MCS, TSS,

CSS) may also have elements of task support:
– The task of a decision maker is to make decisions.
So, is a DSS really a TSS for a decision maker?
– One task of a clinician is to monitor care so that a
treatment plan may be adjusted if needed. So, is a
clinical MCS a TSS for a decision maker?
37
Systems: Feedback
Input System Output
Feedback
Feedback is the core underlying principle for control systems.
38
Clinical Process Control
• A failure in clinical
process control…
39
Clinical Management Control System
Activate
Sense
Correction
CURRENT
OBJECTIVE
STATE
Compare
Reality vs. Objective
For example Interpret & Decide on

Corrective Action
• Activate treatment plan
• Measure key physiological levels
• Compare measured values vs. planned values
• Modify treatment plan, if necessary
• Activate revised treatment plan
• Continue treatment
• [Conduct quality processes] © Alan F. Dowling 1985, 2017
40
Clinical Control
Measurement / Monitoring and Feedback:

• Per Patient
– Treatment efficacy
– Protocol effectiveness
– Case management effectiveness
• Across the Practice
– Protocol compliance and effectiveness
– Multi-entity practice contribution & economics
– Member health management & care delivery quality
41
Info Systems vs. Process Control
D&KSS
Decision +
Knowledge
Human
Support
Mediated
MCS
Management Control
Systems
Systems
(Information forPerformance
Feedback & Control)
TSS
Task Support Systems
(Information at Operational Level in
Support of Work Process)
Process Control
42 © Alan F. Dowling 1985, 2017

Types of Computer-Based MI Systems
D&KSS
Human
MCS
Mediated
Systems
Expert EIS
System
TSS
Process Control
43
HC Enterprise Info Systems Layers
External Business Processes
Enterprise Management
Extra-organizational interoperation
Organization Management
Patient Management
Patient Care
HC Organization Management
Organizational
Patient Management
Inter-Organizational
Patient Care
Extra-Organizational

44
Early HCIS
• Initial focus on the hospital & clinical applications in the

“automated data processing” days
• HCIS as novel research (e.g., universities, AMCs)
• Government funding of innovation (e.g., Lockheed)
• Large computer vendors (e.g., Honeywell, DEC, IBM, NCR)
• Later: entry of application vendors
HC Organization Management
Patient Management
Patient Care
45
Vendors’ Solution Strategies
Late ’60’s – mid 70’s…
HC Organization Management HIS Vendors

Patient Management
Patient Care

46
Late ’70’s – early 80’s...
Patient Management
Clinical
Patient Care Vendors

47
Early ’80’s – early 90’s...
Patient Management
Clinical

48
Mid ’80’s – early 2000’s...
Extra-organizational interoperation ERP

Vendors
Patient Management
Clinical

49
Why are so many information systems problematic?
50
Organizational Subsets
Technologies
(Computer-Based
& Manual)

51
Mission,
Process,
& Work-
Culture
Technologies
(Computer-Based
& Manual)

52
People Mission,
& Process,
Social & Work-
Culture Culture
Technologies
(Computer-Based
& Manual)

53
Ergonomics
• International Ergonomics Association:

“Ergonomics (or human factors) is the scientific discipline
concerned with the understanding of interactions among
humans and other elements of a system, and the profession that
applies theory, principles, data and methods to design in order
to optimize human well-being and overall system performance.”
• Human factors and ergonomics is concerned with the ‘fit’

between the user, equipment and their environments. It takes
account of the user's capabilities and limitations in seeking to
ensure that tasks, functions, information and the environment
suit each user.
54
Macroergonomic Systems
People Mission, • Macroergonomics is the union

& Process, of three major elements of
Social & Work- technology-enabled human
Culture Culture
work & decision systems.
Technologies
• It provides an inclusive
(Computer-Based framework for MI systems
& Manual) design and evaluation.

55
Macroergonomic Systems
Macroergonomics recognizes that a

holistic system has three major
People Mission,
interrelated components:
& Process, 1) the mission, processes, and
Social & Work-
Culture Culture
work culture of the organization;
2) the people who carry out this
Technologies
work; and,
(Computer- 3) the tools and technologies
Based (including hardware and software)
& Manual) that people use to do the work.
Systems design must address all

three components to be effective.
56 © Alan F. Dowling 1985, 2017
Thoughts?
57

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Health Informatics, Analytics &

What are the most common forms of power

3 © Alan F. Dowling 1985, 2017

4 © Alan F. Dowling 1985, 2017

5 © Alan F. Dowling 1985, 2017

• Health disciplines are based on knowledge and

• Fundamental to ‘knowing’ or ‘being skilled’ is

• Virtually all health care processes are dependent on

* “Clinical Informatics” has recently become a medical

© Alan F. Dowling, PhD 2012-2017

• Clinical Informatics is the scientific discipline that seeks to enhance human

• Clinical Informatics is the application of informatics and information

But, since “Clinicians”

For our operating purposes, Medical Informatics is the application of

“Clinical informaticians use their knowledge of patient care

Medical Informatics applies (at least) the following knowledge sets:

• Clinical Disciplines & Technologies

© Alan F. Dowling, PhD 2012-2017

• Information & knowledge requirement planning,

Therefore, the asset must be managed…

DECISION BASIC MEDICAL

© Alan F. Dowling, PhD 2012-2017

DECISION BASIC MEDICAL

© Alan F. Dowling, PhD 2012-2017

• Mental processes that CLINICAL

understanding language, MEDICAL

solving problems, and DECISION BASIC MEDICAL

• That which is known, INNOVATION,

(rightly or wrongly): a fact,

• Study of the nature of being,

the basic categories of being COGNITIVE

• Part of metaphysics, ontology DECISION BASIC MEDICAL

concerning what entities exist TECHNOLOGY

or can be said to exist, and INNOVATION,

grouped, related within a

• Study the nature and scope CLINICAL

(limitations) of knowledge. SCIENCES &

–What is knowledge? DECISION BASIC MEDICAL

–To what extent is it possible SYSTEMS

for a given subject or entity

Input Process Output

Input Process Output

Patient’s Request Appointment to Patient

Clinic Schedule Outpatient Update to Schedule

In each functional user area, requests are received, work is

© Alan F. Dowling 1985, 1999

Tightly Coupled inside;

© Alan F. Dowling 1985, 2017

Task Support - for care delivery and management

35 © Alan F. Dowling 1985, 2017

Process and Information Support for:

• Overlap issue: Other types of systems (MCS, TSS,

Input System Output

Feedback is the core underlying principle for control systems.

For example Interpret & Decide on

Measurement / Monitoring and Feedback:

42 © Alan F. Dowling 1985, 2017

External Business Processes

© Alan F. Dowling 1985, 2017

• Initial focus on the hospital & clinical applications in the

Late ’60’s – mid 70’s…

HC Organization Management HIS Vendors

© Alan F. Dowling 1985, 2017

Late ’70’s – early 80’s...

2a Informatics, Analytics & Decision Making Foundations-2

2a Informatics, Analytics & Decision Making Foundations-2