Medical Informatics and Institutional Strategy* G. Anthony Gorry, Ph.D. Vice President for Information Technology Rice Uiversity, Houston, Texas
*Supported by The National Library of Medicine (LM04905) and The W. M. Keck Foundation ABSTRACT Programs in medical informatics can help academic medical centers make effective use of information technology. But to achieve the greatest strategic benefitsfrom these programs, an institution must forge proper linkage between informatics and its overall effort to deploy computing in research, education and patient care. Here we explore this linkage and the ways in which it can be established and managed. INTRODUCTION For many medical schools and hospitals, advanced information technology is a key to increased organizational effectiveness. Computing already is reshaping aspects of research, education and patient care, and its rapid evolution has stimulated optimistic forecasts of new ways to acquire, share and manage information in the academic medical center.[1] But the effort and commitment required to reach the high levels of information management that present technology permits will be very considerable. To succeed, an institution must muster an impressive array of technologic and intellectual resources, and probably make significant organizational changes. To meet that challenge, the leaders of medical centers need to understand how to exploit computing and its related technologies in a brQad and effective manner throughout their institutions.
However, in all too many cases, developments in information technology have left behind those in medical centers responsible for managing computing and telecommunications. So the institutional leaders receive inadequate or confusing advice on direction and priorities. The decentralization of computing, too, has exacerbated problems of coordination and control. To a large extent, an information technology strategy must be crafted by each institution to accommodate the dynamic interaction of a number of factors beyond the technology
0195-4210/92/$5.00 X)1993 AMIA, Inc.
itself. While aspects of a fully-developed information technology program may be common across academic medical centers, largely because of commonalities in their missions and activities, there are certain to be considerable differences. Four determinants of a successful information technology strategy are: * Information technology development itself, its current state within the organization and its likely future development, * Organizational competence to deal with both the technical aspects of computing and telecommunications as well as the changes in the nature of work that the technology can induce, * The linkage of information technology to the strategic purposes of the institution, and * The leadership and vision that motivates and sustains the entire information technology program. Enhancements of an institution's position along these dimensions will strengthen its overall information technology enterprise, the institutional part of which I will call the information technology program. I take that program to encompass deployments of computing, the organization of development and support functions, and a range of management processes. The question here is the extent to which the emerging field of medical informatics synergistically interacts with the information technology program to help meet institutional needs along these four dimensions. In my view, medical informatics can play a vital role in information technology development in the academic medical center, but only when it relates properly to the institutional computing within the information technology program.
MEDICAL INFORMATICS A recent book on the subject of medical informatics defines it as "the rapidly developing scientific field that
532
deals with the storage, retrieval and optimal use of biomedical information, data, and knowledge for problem solving and decision making." [2] This definition is appropriately expansive given that medical informatics now encompasses a diversity of theoretical explorations and practical applications in education, patient care and research. The matters addressed by medical informatics are central to the enhanced effectiveness of academic and administrative efforts in biomedical institutions. Therefore we might look for a well-developed informatics effort at the heart of an institutional thrust in information technology. But, we need to temper this expectation with an appreciation of the differences between the academic endeavors of medical informatics and the pragmatic problems of creating and sustaining an effective information technology program within a medical center. From the interaction of the two, however, can come important ideas concerning the institution's strategic exploitation of computing and telecommunications.
LINKING INFORMATICS TO STRATEGY A medical informatics program can enhance an institution's strategic use of information technology in a number of important ways. For convenience, I shall discuss these ways in terms the success factors set forth above - technology, organizational competence, strategy and leadership.
Technology forecasting. An academic medical center that seeks to exploit advances in information technology needs guideposts to the development of computing and telecommunications. The pace of development in computer science and technology threatens conventional institutional planning processes which are oriented largely to the extrapolation of linear trends and which are staffed by people absorbed in current applications. The kinds of nonlinear changes that are driving the computer industry cannot be accommodated within the capacity-planning frameworks that have been in place for many years. Further, it is often the case that the managers of the current information technology efforts within an institution, for a variety of reasons, do not appreciate the significance of the changes that are occurring.
Shortsightedness with respect to technologic development is particularly damaging to the integration of computing with strategy. Strategic development will be successful only if it is informed by a well-founded vision of the technology of the future.
533
At its best, medical informatics can help us go beyond traditional planning methodologies to assess the strategic relevance of particular information technologies. Informatics professionals can help construct expansive scenarios that widen our vision of what will be possible. Thoughtful extrapolations of ongoing informatics work can sensitize academic leaders to the potentially significant changes in biomedical work that the computer may induce. The informatics program can serve as a conduit by which new technologies can enter the institution. When computing innovations - optical technology, neural computing, voice recognition systems and the like - enter the laboratory setting of the informatics program, they can stimulate creative strategic thinking. Before the net of organizational constraints (budgeting, control, change) are cast over them, these technologies are as much ideas as devices. As such they can more easily enter into expansive thinking that underlies sound strategy. Informatics researchers should draw academic leaders into their early assessments of technology, perhaps even before the developmental direction for the technology has been set. When a particular technology is envisioned in a certain role by the informatics professionals, prototyping becomes very important. Thus mock-up demonstrations of the use of various technologies for the future can have a great impact on the strategic awareness of an academic leadership. Much as an architect might build an elaborate model to help clients envision the building that is in a sense already logically described in the blueprints, so informaticians might build dynamic, computer-based models of the systems to which their research is pointing. In seeking an impact on the strategic thinking of the institution, the informatics professional should view publications as blueprints. Only a trained person can infer from them the dynamics of the computers and processes described. In the construction of models and prototypes for strategic purposes, however, recognize that the context should not be the world as it is, but the world as it is becoming. So forecasting must accommodate many important features of this emerging world that are not primarily computational. Truly invention will be the mother of necessity, and those organizations that will achieve the greatest success will adapt their structures and processes to new technology. [3] Thus the besl strategic forecasting will involve the continuing interchange of ideas among informaticians and individuals and groups with diverse perspectives on the work, organization and environment of the institution.
Organizational competence. The successful use of modern computing in academic medical centers demands higher levels of technical understanding and competence.
Presently, many information technology programs are limited by a lack of skilled people. This lack can be found at all levels of the program - in programming, in networking, in analysis, in project management and in leadership. So a very high priority for an institution seeking to capitalize on advances in computing is the strengthening of the intellectual infrastructure of its effort. Here the medical informatics program can play several roles.
First the presence of a well-developed informatics research and education program enhances the environment, making it more attractive to the people of the information technology program. The excitement of advanced research and development associated with medical informatics can be a powerful inducement to potential recruits into other aspects of the institution's information technology organization. An informatics program can provide intellectual and technical support for the research and development conducted within the institutional framework for computing and telecommunications. The significance of the latter research and development is oftenr unappreciated by the leaders of medical institutions who may see little need to fund such work in what is perceived as an operational unit or activity. But such a view is shortsighted for several reasons.
The information technology program of an academic medical center, depending on the aspirations of the organization in science, education or patient care, can face difficult challenges of orchestrating technology to support information acquisition, management and sharing. Because of the organizational and technologic intricacies of a given situation, research and development may be required for timely progress. This may be true even with substantial vendor involvement and support.
Second, an advanced information technology program requires an environment that supports innovation. In this regard, there can be an important complementarity between medical informatics and the information technology program. Often the concerns of informatics are generic with specific applications being suggested by the particular organizational setting, and these concems can be matched with the research interests of the information technology program which typically arise from the setting and may or may not become generic. Leadership and vision. Leadership is required to ensure that the greatest benefits of this complementarity are achieved. When the concerns of the medical informatics program are consonant with the strategic purposes of the information technology program, the institution gets the greatest secondary benefit from the informatics research
534
program. When these concerns and purposes are not aligned, an institution is less likely to see excellence in either effort. An institution can seldom legislate the course of research, so a medical informatics effort might well move in directions that are markedly different from the broader thrust of the information technology program. I have, in fact, visited a number of academic medical centers where there is such a divergence. And my impression is that greater organizational effectiveness would have been achieved had this divergence not been permitted.
The remedies for this separation are several. An institution developing a new effort in medical informatics can critically review its strategy with respect to information technology, and make a deliberate attempt to harness the new program to its central concerns. When an existing informatics program is strong, the institution might want to make changes in the organization and management of the information technology program to exploit that strength. In either case, investments in people and resources, at the margin, should reflect an overall institutional concern with the strategic uses of computing.
These are only broad guidelines, and they will not restrict the academic growth of a medical informatics program. But just as an institution would not develop a new basic science department without consideration of institutional purposes, strengths and weaknesses, it should not fail to develop a vision of how it will be made more effective and successful through the establishment of a new informatics program. The perceived linkage of computing and telecommunications to strategy is a key to realizing the synergy suggested above. But in many academic medical centers, this perception is muddled, and as a result, leaders are uncertain how to organize and manage their computing efforts. Practitioners of medical informatics can help alleviate this problem in several ways.
Typically the aim of research in medical informatics is to enhance the effectiveness of education, patient care or research in the academic medical center. Therefore participants in the informatics program are involved to some degree in ongoing institutional efforts from which strategic thrusts of the institution arise. The potentially close association between informatics teachers and researchers and the leaders of important programs within the organization should be exploited.
Although it is commonly conceived that institutional strategy is promulgated from the top of the organization, in
fact, many important innovations emerge from lower levels. These innovations suggest strategic initiatives that are subsequently incorporated into the overall aims of the institution. In an academic medical center, the participative development of strategy is quite common. This means that informaticians may well be able to influence members of the organization who in turn influence those who develop strategy. Interestingly, it is often the information technology program that needs heightened awareness of the ways in which computing can transform the enterprise of the organization. Too often, the leadership of the information technology program has no real understanding of the work of much of the faculty. That work is typically described in general terms - education, patient care, and research - that hides much the interesting detail of the actual enterprise. For members of the information technology program, one path to a better understanding of the work of the institution is through the activities of the medical informatics group. The perspective of the latter, emphasizing computing as it does, can make particular patient care, research and education more comprehensible to member of the information technology program. A better understanding of these matters would help the architects of the institution's overall computational program better match it to the needs of the
faculty. In far too many institutions, however, there is no continuing effort to intermingle the concerns of medical informatics with those whose computing interests are seen as more pragmatic. Thus educational programs such as the one suggested above do not take place. This lack deprives the institution of an opportunity to enhance its linkage of computing to strategy and organizational development.
One of the most vital strategic roles that an informatics program can play with respect to the use of information technology in an academic medical center is visionary. One of the key enabling factors in a successful information technology strategy is leadership at the highest levels of an institution. From that leadership must flow a vision of the way in which computing can transform the organization. Because, in its best realizations, medical informatics is envisioning transformations of biomedical work, it can contribute a great deal to the development of motivating scenarios of the future. And with its technologic concerns, informatics can inject both dynamism and realism into these scenarios. The nature of the informatics view of the future, however, bears some additional comment, for without the widened perspective suggested above, its strategic importance will be lessened. In brief, for the institution to gain the greatest
535
benefit from the ideas emerging from medical informatics, informaticians must place these ideas in an appropriate organizational and cultural context. For medical informatics to contribute most effectively to the vision of information technology deployment, it needs an increased emphasis on the organizational processes within which computing is used. With a few notable exceptions, informatics has followed the traditional approach to research, attempting to narrow the focus and limit the domains of its investigations. So a greater strategic concern will place additional demands on informatics practitioners.
FORGING THE LINKS A knowledge-intensive organization such as an academic medical center cannot long prosper without a substantial and effective information technology program. The continued success of the educational, clinical and scientific programs will demand excellence in information management and computer science.
Medical informatics is concerned with achieving that excellence, but within its own agenda of research and education. An information technology program aims for excellence from a different vantage point. For an academic medical center seeking to gain the greatest advantage from computing, both the informatics effort and the broader organizational undertaking are important. While medical informatics may accept the traditional tripartite academic model, its service mission may be unable to encompass ongoing computing development, maintenance and operations for the organization as whole. And exactly these latter involvements of the information technology program restrict its participation in technologic innovation. There are, however, fruitful areas of collaboration and cooperation for informatics and the information technology program which will benefit the institution as a whole. I have discussed a number of these possible interactions above. Joint endeavors will depend upon a complex set of institutional factors, and even within the context of a given academic medical center, alternative paths for cooperation are possible. The best that can be offered here are broad guidelines and admonitions which must be interpreted with care and tested in particular situations. But one particular matter, the information technology architecture, should be of joint concern in any major academic medical center.
A vision of academic and administrative processes transformed through the use of advanced computing and tele-
CONCLUSION
communications implies an architecture - the technical infrastructure and organizational framework for capitalizing on advances in computing. Among the architectural building blocks are high-speed networking, standards and technology for information management and distribution and linkages to affiliated institutions and regional and national resources.
An institution's success with computing and telecommunications will depend on more than just mastery of the technology. Regardless of the technical sophistication or merits of an implementations, any organizational endeavor that does not support the strategic goals of an institution will fail to reach its full potential. Both medical informatics and the information technology program have roles to play in achieving increased institutional effectiveness, so the leadership of both should be closely allied with the leadership of the institution as a whole, and those responsible for setting strategic goals should be actively involved in setting the direction of both efforts.
In many academic medical centers, technologic homogeneity is not possible, because the latest and best information is sought for the faculty and staff. So the success of the information technology program will depend on the creation of realistic technical solutions to problems of information access and integration, solutions that accommodate the independent development of information resources. An informatics program is generally unable to commit the necessary sustained attention to accommodating the technologic diversity commonly found in entrepreneurial medical centers. But if its members are properly attuned to the technologic realities of the environment, they can provide valuable consultative support in this arena. For all its power, computing in many cases remains complex, and the diversity of its applications in the academic and administrative programs of a major academic medical institution makes for markedly varied degrees of success. The information technology program, therefore, must provide extensive support for the users of its information resources and systems. Given the diverse nature of the distributed systems that will undoubtedly be encouraged by the architecture, the information technology program will face substantial service demands. Consequently, the information technology program may need a consulting group, separate and apart from the systems and networking support groups, to facilitate the development of new programs which more fully utilize the new architecture, to port older software into the new environment, and to consult with the community of faculty and staff on the effective use of computing in a distributed, more standardized environment
So we return to the question of how to bring the informatics program together with institutional computing at this high level. No single organizational structure will encompass the need, people and culture of diverse medical centers. Leadership is the key. With breadth of vision and interest on the part of the leader of the informatics program, one could entertain the subsumption of the institutional computing effort as part of the program's service mission. With strong intellectual leadership in the information technology program, one could view informatics as the elaborated research and development function of that program. In either organization, concerns about balancing service and academic activities of the program would naturally arise. And a highly-qualified individual is required to manage either effort. For most organizations, some hybrid approach will be necessary. The benefits recounted above will be achieved to a greater or lesser degree through cooperation. But cooperation is not leadership, and above all, it is that which is demanded. So, an institution that aspires to exploit computing to achieve its strategic ends must identify a leader and provide resources consistent with its aspirations. To a large extent, the technologic future is a matter of will for an institution, and once a commitment is made to vision and leadership, many of the seeming complexities of organizational structure will drop away.
But beyond the basic services it provided to all participants, the information technology program may need to offer extraordinary services to certain clients. In the latter case where the capabilities and resources of the program would be strained, consulting might be subsumed within the service mission of the informatics group. Such specialization would insulate the informatics program from the crush of routine consulting, better matching their expertise with situations that are beyond the competence of the information technology program.
536
REFERENCES I
2
3
Matheson, N.W. and Cooper, J.A.D., Academic Information in the Academic Health Sciences Center, J. Med. Educ., Vol. 57, Pt. 2, 1982, pp. 1-93 Shortliffe, E.H. and Perrault, L.E. (eds.), Medical Informatics: Computer Applications in Health Care, Addison-Wesley, Reading MA, 1990, p. xi DeGregori, T.R., A Theory of Technology, Iowa State University Press, Ames, Iowa, 1985
*Supported by The National Library of Medicine (LM04905) and The W. M. Keck Foundation ABSTRACT Programs in medical informatics can help academic medical centers make effective use of information technology. But to achieve the greatest strategic benefitsfrom these programs, an institution must forge proper linkage between informatics and its overall effort to deploy computing in research, education and patient care. Here we explore this linkage and the ways in which it can be established and managed. INTRODUCTION For many medical schools and hospitals, advanced information technology is a key to increased organizational effectiveness. Computing already is reshaping aspects of research, education and patient care, and its rapid evolution has stimulated optimistic forecasts of new ways to acquire, share and manage information in the academic medical center.[1] But the effort and commitment required to reach the high levels of information management that present technology permits will be very considerable. To succeed, an institution must muster an impressive array of technologic and intellectual resources, and probably make significant organizational changes. To meet that challenge, the leaders of medical centers need to understand how to exploit computing and its related technologies in a brQad and effective manner throughout their institutions.
However, in all too many cases, developments in information technology have left behind those in medical centers responsible for managing computing and telecommunications. So the institutional leaders receive inadequate or confusing advice on direction and priorities. The decentralization of computing, too, has exacerbated problems of coordination and control. To a large extent, an information technology strategy must be crafted by each institution to accommodate the dynamic interaction of a number of factors beyond the technology
0195-4210/92/$5.00 X)1993 AMIA, Inc.
itself. While aspects of a fully-developed information technology program may be common across academic medical centers, largely because of commonalities in their missions and activities, there are certain to be considerable differences. Four determinants of a successful information technology strategy are: * Information technology development itself, its current state within the organization and its likely future development, * Organizational competence to deal with both the technical aspects of computing and telecommunications as well as the changes in the nature of work that the technology can induce, * The linkage of information technology to the strategic purposes of the institution, and * The leadership and vision that motivates and sustains the entire information technology program. Enhancements of an institution's position along these dimensions will strengthen its overall information technology enterprise, the institutional part of which I will call the information technology program. I take that program to encompass deployments of computing, the organization of development and support functions, and a range of management processes. The question here is the extent to which the emerging field of medical informatics synergistically interacts with the information technology program to help meet institutional needs along these four dimensions. In my view, medical informatics can play a vital role in information technology development in the academic medical center, but only when it relates properly to the institutional computing within the information technology program.
MEDICAL INFORMATICS A recent book on the subject of medical informatics defines it as "the rapidly developing scientific field that
532
deals with the storage, retrieval and optimal use of biomedical information, data, and knowledge for problem solving and decision making." [2] This definition is appropriately expansive given that medical informatics now encompasses a diversity of theoretical explorations and practical applications in education, patient care and research. The matters addressed by medical informatics are central to the enhanced effectiveness of academic and administrative efforts in biomedical institutions. Therefore we might look for a well-developed informatics effort at the heart of an institutional thrust in information technology. But, we need to temper this expectation with an appreciation of the differences between the academic endeavors of medical informatics and the pragmatic problems of creating and sustaining an effective information technology program within a medical center. From the interaction of the two, however, can come important ideas concerning the institution's strategic exploitation of computing and telecommunications.
LINKING INFORMATICS TO STRATEGY A medical informatics program can enhance an institution's strategic use of information technology in a number of important ways. For convenience, I shall discuss these ways in terms the success factors set forth above - technology, organizational competence, strategy and leadership.
Technology forecasting. An academic medical center that seeks to exploit advances in information technology needs guideposts to the development of computing and telecommunications. The pace of development in computer science and technology threatens conventional institutional planning processes which are oriented largely to the extrapolation of linear trends and which are staffed by people absorbed in current applications. The kinds of nonlinear changes that are driving the computer industry cannot be accommodated within the capacity-planning frameworks that have been in place for many years. Further, it is often the case that the managers of the current information technology efforts within an institution, for a variety of reasons, do not appreciate the significance of the changes that are occurring.
Shortsightedness with respect to technologic development is particularly damaging to the integration of computing with strategy. Strategic development will be successful only if it is informed by a well-founded vision of the technology of the future.
533
At its best, medical informatics can help us go beyond traditional planning methodologies to assess the strategic relevance of particular information technologies. Informatics professionals can help construct expansive scenarios that widen our vision of what will be possible. Thoughtful extrapolations of ongoing informatics work can sensitize academic leaders to the potentially significant changes in biomedical work that the computer may induce. The informatics program can serve as a conduit by which new technologies can enter the institution. When computing innovations - optical technology, neural computing, voice recognition systems and the like - enter the laboratory setting of the informatics program, they can stimulate creative strategic thinking. Before the net of organizational constraints (budgeting, control, change) are cast over them, these technologies are as much ideas as devices. As such they can more easily enter into expansive thinking that underlies sound strategy. Informatics researchers should draw academic leaders into their early assessments of technology, perhaps even before the developmental direction for the technology has been set. When a particular technology is envisioned in a certain role by the informatics professionals, prototyping becomes very important. Thus mock-up demonstrations of the use of various technologies for the future can have a great impact on the strategic awareness of an academic leadership. Much as an architect might build an elaborate model to help clients envision the building that is in a sense already logically described in the blueprints, so informaticians might build dynamic, computer-based models of the systems to which their research is pointing. In seeking an impact on the strategic thinking of the institution, the informatics professional should view publications as blueprints. Only a trained person can infer from them the dynamics of the computers and processes described. In the construction of models and prototypes for strategic purposes, however, recognize that the context should not be the world as it is, but the world as it is becoming. So forecasting must accommodate many important features of this emerging world that are not primarily computational. Truly invention will be the mother of necessity, and those organizations that will achieve the greatest success will adapt their structures and processes to new technology. [3] Thus the besl strategic forecasting will involve the continuing interchange of ideas among informaticians and individuals and groups with diverse perspectives on the work, organization and environment of the institution.
Organizational competence. The successful use of modern computing in academic medical centers demands higher levels of technical understanding and competence.
Presently, many information technology programs are limited by a lack of skilled people. This lack can be found at all levels of the program - in programming, in networking, in analysis, in project management and in leadership. So a very high priority for an institution seeking to capitalize on advances in computing is the strengthening of the intellectual infrastructure of its effort. Here the medical informatics program can play several roles.
First the presence of a well-developed informatics research and education program enhances the environment, making it more attractive to the people of the information technology program. The excitement of advanced research and development associated with medical informatics can be a powerful inducement to potential recruits into other aspects of the institution's information technology organization. An informatics program can provide intellectual and technical support for the research and development conducted within the institutional framework for computing and telecommunications. The significance of the latter research and development is oftenr unappreciated by the leaders of medical institutions who may see little need to fund such work in what is perceived as an operational unit or activity. But such a view is shortsighted for several reasons.
The information technology program of an academic medical center, depending on the aspirations of the organization in science, education or patient care, can face difficult challenges of orchestrating technology to support information acquisition, management and sharing. Because of the organizational and technologic intricacies of a given situation, research and development may be required for timely progress. This may be true even with substantial vendor involvement and support.
Second, an advanced information technology program requires an environment that supports innovation. In this regard, there can be an important complementarity between medical informatics and the information technology program. Often the concerns of informatics are generic with specific applications being suggested by the particular organizational setting, and these concems can be matched with the research interests of the information technology program which typically arise from the setting and may or may not become generic. Leadership and vision. Leadership is required to ensure that the greatest benefits of this complementarity are achieved. When the concerns of the medical informatics program are consonant with the strategic purposes of the information technology program, the institution gets the greatest secondary benefit from the informatics research
534
program. When these concerns and purposes are not aligned, an institution is less likely to see excellence in either effort. An institution can seldom legislate the course of research, so a medical informatics effort might well move in directions that are markedly different from the broader thrust of the information technology program. I have, in fact, visited a number of academic medical centers where there is such a divergence. And my impression is that greater organizational effectiveness would have been achieved had this divergence not been permitted.
The remedies for this separation are several. An institution developing a new effort in medical informatics can critically review its strategy with respect to information technology, and make a deliberate attempt to harness the new program to its central concerns. When an existing informatics program is strong, the institution might want to make changes in the organization and management of the information technology program to exploit that strength. In either case, investments in people and resources, at the margin, should reflect an overall institutional concern with the strategic uses of computing.
These are only broad guidelines, and they will not restrict the academic growth of a medical informatics program. But just as an institution would not develop a new basic science department without consideration of institutional purposes, strengths and weaknesses, it should not fail to develop a vision of how it will be made more effective and successful through the establishment of a new informatics program. The perceived linkage of computing and telecommunications to strategy is a key to realizing the synergy suggested above. But in many academic medical centers, this perception is muddled, and as a result, leaders are uncertain how to organize and manage their computing efforts. Practitioners of medical informatics can help alleviate this problem in several ways.
Typically the aim of research in medical informatics is to enhance the effectiveness of education, patient care or research in the academic medical center. Therefore participants in the informatics program are involved to some degree in ongoing institutional efforts from which strategic thrusts of the institution arise. The potentially close association between informatics teachers and researchers and the leaders of important programs within the organization should be exploited.
Although it is commonly conceived that institutional strategy is promulgated from the top of the organization, in
fact, many important innovations emerge from lower levels. These innovations suggest strategic initiatives that are subsequently incorporated into the overall aims of the institution. In an academic medical center, the participative development of strategy is quite common. This means that informaticians may well be able to influence members of the organization who in turn influence those who develop strategy. Interestingly, it is often the information technology program that needs heightened awareness of the ways in which computing can transform the enterprise of the organization. Too often, the leadership of the information technology program has no real understanding of the work of much of the faculty. That work is typically described in general terms - education, patient care, and research - that hides much the interesting detail of the actual enterprise. For members of the information technology program, one path to a better understanding of the work of the institution is through the activities of the medical informatics group. The perspective of the latter, emphasizing computing as it does, can make particular patient care, research and education more comprehensible to member of the information technology program. A better understanding of these matters would help the architects of the institution's overall computational program better match it to the needs of the
faculty. In far too many institutions, however, there is no continuing effort to intermingle the concerns of medical informatics with those whose computing interests are seen as more pragmatic. Thus educational programs such as the one suggested above do not take place. This lack deprives the institution of an opportunity to enhance its linkage of computing to strategy and organizational development.
One of the most vital strategic roles that an informatics program can play with respect to the use of information technology in an academic medical center is visionary. One of the key enabling factors in a successful information technology strategy is leadership at the highest levels of an institution. From that leadership must flow a vision of the way in which computing can transform the organization. Because, in its best realizations, medical informatics is envisioning transformations of biomedical work, it can contribute a great deal to the development of motivating scenarios of the future. And with its technologic concerns, informatics can inject both dynamism and realism into these scenarios. The nature of the informatics view of the future, however, bears some additional comment, for without the widened perspective suggested above, its strategic importance will be lessened. In brief, for the institution to gain the greatest
535
benefit from the ideas emerging from medical informatics, informaticians must place these ideas in an appropriate organizational and cultural context. For medical informatics to contribute most effectively to the vision of information technology deployment, it needs an increased emphasis on the organizational processes within which computing is used. With a few notable exceptions, informatics has followed the traditional approach to research, attempting to narrow the focus and limit the domains of its investigations. So a greater strategic concern will place additional demands on informatics practitioners.
FORGING THE LINKS A knowledge-intensive organization such as an academic medical center cannot long prosper without a substantial and effective information technology program. The continued success of the educational, clinical and scientific programs will demand excellence in information management and computer science.
Medical informatics is concerned with achieving that excellence, but within its own agenda of research and education. An information technology program aims for excellence from a different vantage point. For an academic medical center seeking to gain the greatest advantage from computing, both the informatics effort and the broader organizational undertaking are important. While medical informatics may accept the traditional tripartite academic model, its service mission may be unable to encompass ongoing computing development, maintenance and operations for the organization as whole. And exactly these latter involvements of the information technology program restrict its participation in technologic innovation. There are, however, fruitful areas of collaboration and cooperation for informatics and the information technology program which will benefit the institution as a whole. I have discussed a number of these possible interactions above. Joint endeavors will depend upon a complex set of institutional factors, and even within the context of a given academic medical center, alternative paths for cooperation are possible. The best that can be offered here are broad guidelines and admonitions which must be interpreted with care and tested in particular situations. But one particular matter, the information technology architecture, should be of joint concern in any major academic medical center.
A vision of academic and administrative processes transformed through the use of advanced computing and tele-
CONCLUSION
communications implies an architecture - the technical infrastructure and organizational framework for capitalizing on advances in computing. Among the architectural building blocks are high-speed networking, standards and technology for information management and distribution and linkages to affiliated institutions and regional and national resources.
An institution's success with computing and telecommunications will depend on more than just mastery of the technology. Regardless of the technical sophistication or merits of an implementations, any organizational endeavor that does not support the strategic goals of an institution will fail to reach its full potential. Both medical informatics and the information technology program have roles to play in achieving increased institutional effectiveness, so the leadership of both should be closely allied with the leadership of the institution as a whole, and those responsible for setting strategic goals should be actively involved in setting the direction of both efforts.
In many academic medical centers, technologic homogeneity is not possible, because the latest and best information is sought for the faculty and staff. So the success of the information technology program will depend on the creation of realistic technical solutions to problems of information access and integration, solutions that accommodate the independent development of information resources. An informatics program is generally unable to commit the necessary sustained attention to accommodating the technologic diversity commonly found in entrepreneurial medical centers. But if its members are properly attuned to the technologic realities of the environment, they can provide valuable consultative support in this arena. For all its power, computing in many cases remains complex, and the diversity of its applications in the academic and administrative programs of a major academic medical institution makes for markedly varied degrees of success. The information technology program, therefore, must provide extensive support for the users of its information resources and systems. Given the diverse nature of the distributed systems that will undoubtedly be encouraged by the architecture, the information technology program will face substantial service demands. Consequently, the information technology program may need a consulting group, separate and apart from the systems and networking support groups, to facilitate the development of new programs which more fully utilize the new architecture, to port older software into the new environment, and to consult with the community of faculty and staff on the effective use of computing in a distributed, more standardized environment
So we return to the question of how to bring the informatics program together with institutional computing at this high level. No single organizational structure will encompass the need, people and culture of diverse medical centers. Leadership is the key. With breadth of vision and interest on the part of the leader of the informatics program, one could entertain the subsumption of the institutional computing effort as part of the program's service mission. With strong intellectual leadership in the information technology program, one could view informatics as the elaborated research and development function of that program. In either organization, concerns about balancing service and academic activities of the program would naturally arise. And a highly-qualified individual is required to manage either effort. For most organizations, some hybrid approach will be necessary. The benefits recounted above will be achieved to a greater or lesser degree through cooperation. But cooperation is not leadership, and above all, it is that which is demanded. So, an institution that aspires to exploit computing to achieve its strategic ends must identify a leader and provide resources consistent with its aspirations. To a large extent, the technologic future is a matter of will for an institution, and once a commitment is made to vision and leadership, many of the seeming complexities of organizational structure will drop away.
But beyond the basic services it provided to all participants, the information technology program may need to offer extraordinary services to certain clients. In the latter case where the capabilities and resources of the program would be strained, consulting might be subsumed within the service mission of the informatics group. Such specialization would insulate the informatics program from the crush of routine consulting, better matching their expertise with situations that are beyond the competence of the information technology program.
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Matheson, N.W. and Cooper, J.A.D., Academic Information in the Academic Health Sciences Center, J. Med. Educ., Vol. 57, Pt. 2, 1982, pp. 1-93 Shortliffe, E.H. and Perrault, L.E. (eds.), Medical Informatics: Computer Applications in Health Care, Addison-Wesley, Reading MA, 1990, p. xi DeGregori, T.R., A Theory of Technology, Iowa State University Press, Ames, Iowa, 1985
