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I Summary - Health Promotion Informatics

A. Introduction

"No issue that engenders more interest, is more universally accepted or is fundamentally more important than the health of each person and every nation" is one of the favorite statements of Dr. Robert Karch, Executive Director of the National Center for Health Fitness. Many of the best minds in the world would agree with Dr. Karch. Moreover many visionaries are convinced that technology offers the best solutions to some of the most pressing national and international health issues as well as the economic crisis that every nation is facing as a result of trying to provide for the well-being of all of its citizens.

In their book Technology for Teams, Opper and Fersko-Weiss' statement, "Today, power comes from knowledge" set the foundation for our understanding of the importance of information for the 21st century. Those who can access information will have much greater control over their destiny. The authors go even further by noting that, "The hunger for information permeates every aspect of society" (Opper and Fersko-Weiss, 1992, p. 15). Authorities throughout the world realize as industrialized nations migrate toward more information-based societies they will find themselves moving at relentless pace. It is the revolutions that are taking place in the communications and information technology industries that offer the most hope by providing universal access to information for those who choose to pursue it.

The purpose of this paper is to explore several critical factors related to the revolutions in health care, communications, and technology since they will have a profound impact on every individual and country in the world. The assumptions, statements, and conclusions are based on a survey of what has worked and what has not. The motivation for this research is to develop a greater awareness and understanding of how we can take advantage of phenomenal advances in telecommunications, technology, and multimedia; in combination with the best principles of information technology (IT); and merge them with the most promising practices of health promotion. Ultimately the goal of this multidisciplinary collaborative approach is to enable individuals and countries to achieve an optimal or higher quality of life. This will be accomplished through technology-based health promotion systems that are transmitted over an ubiquitous telecommunications infrastructure that will allow for the maximization of the capabilities of the new technologies. However, to realize the maximum level of effect these systems must be based on the best principles of systems design, human factors concepts, and health promotion research or they will fail. For the purpose of this paper this emerging domain is called "health promotion informatics".

This new term health promotion informatics has been coined to describe the multidimensional scope of this investigation. There is not presently any evidence that the term exists in the literature. From the readings and conversations with several health and technology visionaries it is apparent that many of them are grappling with similar and overlapping issues. However, at the moment some of these pioneers and practitioners are beginning to focus on more than one or two of four core areas identified in this research. The four areas are;

• the development of systems and applications for the rapidly emerging technologies and/or the advances related to the telecommunications revolution,
• human factors issues related to the human-to-computer and/or systems interaction and interface,
• the changes and development in health care and/or medical informatics systems, and
• the sociological, cultural, psychological, environmental, and ethical implications of the megatrends and drivers that are impacting on individuals, societies, nations, and the global community.

The span of research for this paper has led to readings in computer systems and information technology, telecommunications, business, accounting, psychology, sociology, education, public health, medicine, and communications, to name a few. The most difficult part of this assignment has been trying to consolidate and condense the massive array of diverse yet interrelated components from each of the four major fields. Developing a coherent and meaningful understanding of the issues necessitates an awareness of factors that influence individuals and systems at the microlevel while simultaneously conceptualizing each of the essential elements from the macro view. To date very little has been written about how to put all four of these components together based on the optimal wellness model that will be described in greater detail below.

B. Definition of Terms, Authorities, and Significant Players

Two of the foremost contemporary authorities on corporations and management, Tom Peters and Warren Bennis, begin their examination of organizations with a search for a common mission or vision for the group. Peters and Bennis contend that without a clearly stated and shared vision no group can reach an optimal level of effectiveness. Therefore, the first task of this paper is to identify a goal for this movement.

Former Surgeon General C. Everett Koop in a recent speech before a Pan American Health Organization (PAHO) conference on "Telecommunications in Health and Health Care" stated that the mission of these technology-based health care systems is, "to deliver a healthy society through wellness affirming lifestyles". At the personal level, Koop sees one of the most fundamental objectives of this movement is for everyone to share a personal responsibility for health. From a global perspective he sees the need to develop and implement technology solutions that can change the information differential between the haves and have-nots. Therefore the final outcome of this paper is to craft a vision and outline some of the elements that will be necessary to achieve a global healthy village such as depicted below in the Geneva Health Village figure. It is one that is based on the distribution of and universal access to information.

Two terms, informatics and health promotion, will be used throughout this paper. Health promotion informatics as it is used in this paper will be the intersection of the two concepts.

Health promotion has a fundamentally different connotation when it is contrasted on a continuum with the traditional medical model. The traditional medical model views health as merely a disease-free state. The National Center for Health Fitness uses the following definition for health promotion:

"to obtain optimal wellness the individual must assume responsibility for the continued development and maintenance of the physical, social, intellectual, spiritual, emotional, and environmental components of their health that is consistent with the culture in which they reside" (Karch et. al. 1989).

At the PAHO conference, C. Everett Koop captured the essence of health promotion in the phrase, "personal responsibility for a wellness affirming lifestyle".

There are a great many implications and obvious differences between an individual who acts as their own advocate and actively seeks to address their needs from a holistic perspective and one who relies on the traditional medical and public health models. Medical informatics which has a 30 year history is based on the traditional model. The vast majority of work in the informatics and health care arena is presently taking place in the United States. There are two primary goals of most medical informatics systems and applications. One is using informatics to assist with the management all aspects of health care, disease, injury, and illness. The other aims to improve the efficiency of the business side of the industry. The implication of these issues, as they apply to human factors and new technology informatics will the primary focus of the discussions in the following sections.

The research for this paper began with an attempt to clearly define the terms. The first keyword searches of Aladin with "health" and "computerization" produced no references. Related keyword searches however, found 50 references to informatics. Subsequent searches lead to the term medical informatics.

The first instinct of most people would be to mistakenly assume that the United States because of its technological breakthroughs, the wealth of research in cognitive psychology, and its vast economic resources and business acumen would be the clear leader in this field. It was amazing to find the majority of the authors in the books on medical informatics were European. The number of articles from American and international contributors in journals was more evenly split. Interestingly, the overwhelming majority of the web sites and home pages on the internet were American.

Informatics has multiple meanings and connotations. It is defined differently in some parts of the world and its meaning has changed in the last three decades. The differences are most apparent between the US and Europe authors. For example, Mikhailov presented a definition for informatics that is representative of the European view, "that scientific discipline that studies the structure and general properties of scientific information and the laws of all processes of scientific communication" (Mikhailov, 1984, p. 5). In 1984 few authors made any mention of the principles of human factors and cognitive research nor did they consider informatics when dealing with larger and more inclusive applications and systems such as groupware.

In the United States, most authorities do not restrict their conceptualization of informatics to only information. Instead they have adopted a broader view that incorporates many forms of information technology including most of the topics that were covered in our three class texts such as psychological, sociological, and interface design factors. For the purpose of this paper, Mikhailov's definition will be enlarged to include the tenants and principles of human factors research. This more expansive scope is necessary and appropriate because many of the state-of-the-art developers and researchers are now dealing with highly advanced and sophisticated systems and applications such as groupware, intelligent agents, decision support systems, language independent systems, and personal or population wide artificial intelligence and expert systems. All of these have the potential to make significant contributions to the future of health promotion informatics.

With this broader view of informatics it is easier to begin to merge those principles with the current arena of health. Over 20 years ago, in his book titled, "Education in Informatics of Health Personnel", Anderson predicted that people would understand that one should accept, "as an axiom that the marriage between information and medicine is not only unavoidable but also fruitful for the health of individuals and of the community" (Anderson, 1974, p. xii). In 1985, Peterson linked health care and communication by mentioning that, "health care delivery, interaction and communication are inseparably related to each other". He maintains that without interaction there is no health care and interaction implies communication. Consequently "changes in a health care delivery system or process generate inevitable changes in the related interaction process and consequently in the communication activities involved" (Peterson, 1985, p. v). It is vital that systems designers and health providers realize the impact of this statement at the design level as well as the implications for all levels of communication from interpersonal to virtual computer interactions.

It is also worthwhile to include Shortliffe and Perreault's comprehensive definition of medical informatics:

"...we define medical informatics as the rapidly developing scientific field that deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for problem solving and decision making. It accordingly touches on all basic and applied fields in biomedical science and is closely tied to modern information technologies, notably in the areas of computing and communications (medical computer science). The emergence as a new discipline is due in large part to advances in computing and communications technology, to an increasing awareness that the knowledge base of medicine is essentially unmanageable by traditional paper-based methods, and to a growing conviction that the process of informed decision making is as important to modern biomedicine as is the collection of facts on which clinical decisions or research plans are based." (Shortliffe and Perreault, 1990, p. 20)

A 1996 Government Accounting Report defines consumer health informatics as, "the use of modern computers and telecommunications to support consumers in obtaining information, analyzing their unique health care needs, and helping them make decisions about their own health" (United States General Accounting Office, 1996, p.1). This definition leads to a more personal approach to health promotion informatics.

This November, the Pan American Health Organization sponsored a conference on "Telecommunications in health and Health Care" in Washington, DC. Their working definition is the one adopted by the World Health Organization which sees, "health informatics as being an umbrella term used to mean and to encompass the rapidly evolving discipline of using computing and communications, methodology and technology, to support health related fields" (Pan American Health Organization, 1996, p. 1). Their efforts are being developed from a continental and global perspective. Again most of their work has been built on the development and application of medical informatics.

A 1996 report titled "Informatics; Emerging Issues" was published by The United States General Accounting Office. It includes an excellent summary of the current state of informatics in the United States. As was stated earlier, by far the largest portion of the current work in informatics is taking place in the field of medicine and more recently in health care.

The National Health Information Infrastructure (NHII) is charged with developing the capacity for agencies, organizations, and institutions to efficiently and effectively communicate, access, transmit, and deliver data and information throughout the United States through a variety of infrastructure networks. (United States General Accounting Office, p.20).

As a historical note it is interesting to point out that the two most influential presidents behind the recent developments in technology were Presidents Carter and Clinton. President Carter signed legislation and "committed himself to working toward a universal national health insurance program, and even political liberals are looking desperately for a means to cap or reduce expenditures for medical care" (Lindberg, 1979, p. vii). This set the stage for the formation of the Agency for Health Care Policy and Research (AHCPR ) in 1989 (P.L. 101-239). As required in that legislation, the AHCPR and the NLM began to work together to improve the utility of databases for health technology assessment. The work was expanded when NLM established the National Information Center on Health Services Research and Health Care Technology (NICHSR). In response to the 1993 NIH Revitalization Act, P.L. 103-43, it sought to improve, "the collection, storage, analysis, retrieval, and dissemination of information on health services research, clinical practice guidelines, and on health care technology. Such purpose includes developing and maintaining data bases and developing and implementing methods of carrying out such purpose" (Donaldson, 1994, p. 40). Moreover, the Clinton administration's proposed Health Security Act (HSA, 1993) gives, "appreciable attention to information systems and related matters. It calls for the establishment of a National Health Board to oversee the creation of an electronic data network consisting of regional centers that collect, compile, and transmit information. The board will, among other things, provide technical assistance on; 1. the promotion of community-based systems and 2. the promotion of patient care information systems that collect data at the point of care or as a by-product of the delivery of care" (Donaldson, 1994, p. 40).

The law stipulated that the types of information collected would include: "enrollment and disenrollment in health plans' clinical coverages and other items and services provided by health care providers; administrative and financial transaction and activities of participating states, regional alliances, corporate alliances, health plans, health care providers, employees and individuals; numbers and demographic characteristics of eligible individuals residing in each alliance area; payment of benefits; utilization management; quality management grievances and fraud or misrepresentation in claims or benefits" (Donaldson, 1994, p. 40).

The final contribution of the HSA is that it further specifies the use of: "1. uniform paper forms containing standard data elements definitions, and instructions for their completion; 2. requirement for use of uniform health code sets with one definition to standardize the collection of transmission of data in electronic form; 3. uniform presentation requirements of that in electronic form; and 4. electronic interchange requirements for the expanse of data among automated health information systems" (Donaldson, 1994, p. 40). These developments have done a great deal toward setting the stage for the proper standardization of medical records and they provide the basis for alleviating the questions about security, confidentiality, and privacy.

C. Drivers/Megatrends

Several knowledgeable authorities in the field have identified some of the significant forces that are driving and serving as catalysis for our current situation. Beginning with the book Megatrends Nesbitt captures the essence of many of the revolutions such as the transformation from an industrial based to an information based economy, the increase in speed and ease of the transmission of data and information, the graying of the population, and the trends toward globalization. Additionally, C. Everett Koop cites trends such as changes in health care delivery and financing, the capacity of information technology, and changing attitudes of consumers for amount, quality, and increases in personal advocacy for health. Every one of these trends has a profound effect on the sociopolitical climate of the countries in the world. At the moment, the greatest movement and sense of urgency is driven by the economic implications of these trends.

D. The worth of this study

Lindberg captures much of the current feeling about health informatics when he noted; "The United States health care system has become subject to increasing public criticism. At the same time, computing systems are ever more ubiquitous and successfully used in nonhealth fields to increase management capability and labor productivity. It is natural to wonder why health system management problems have not also benefited from a dosing with the remedy of computer systems. It is this overriding simple question which makes the case of interest. Why has medicine not been able to use computer systems to solve its information processing problems" (Lindberg, p.1).

If we do not learn to develop and use the best technology, principles of human factors, and health promotion a great deal of resources, opportunity, and human capital will be uselessly squandered. The political, sociodemographic, economic, and humanistic pressures and trends of the 21st century will not allow us to continue to keep doing business as usual.

II. Viewpoints and Rationale from Sources

A great deal of the rationale and support for the premises by author, citations from interviews, and references has been given in the previous sections. Additional information about the need for development of informatics, barriers, human factors principles, current programs, and some of the key players will be provided in the five following sections.

E. The Need

A great deal of the success at the beginning of the 21st century will be determined by how we develop and apply the phenomenally powerful communication and information technology tools that are being developed and tested today. Each year the crisis caused by the current economic conditions and the greatly increased availability of and demand for information and services by individuals and providers will rise exponentially. If systems and applications are developed and designed correctly they will help to decrease the adverse effects of these pressures. However many factors such as; delays in addressing all of the critical issues, insufficient resources, lack of attention to the state-of-the-art research of human factors, lack of coordination and collaboration among all professionals who should be part of the unified approach to solutions, lack of attention to individual, societal and cultural, political, environmental, and other barriers are some of the most important factors that have been identified by authorities as the ones that will increase the likelihood that we will be facing times of catastrophic consequences in the near future. These phenomenon are not restricted to only America or the underdeveloped countries.

Many of the non-dollar statistics related to the demand and urgency for addressing the health care crisis in the United States are staggering;

• 70% of health care costs are consumed by the chronic users, those with diabetes, asthma, heart (Babon, 1996)
• inquires to the Public Health Service's health information clearinghouses more than doubled in the early 1990s, while mail inquiries grew by 43 percent.
• a recent survey indicated that more than two-thirds of consumers have questions about their personal health, such as questions on illness prevention or disease management.
• public libraries reported in 1994 that 10 percent of all reference questions are health-related, accounting for 52 million inquiries annually. Despite this interest, however, in a 1994 survey published by the Medical Library Association, almost 70 percent of the respondents reported problems in gaining access to appropriate health information. 60% said they would be willing to pay for an easy way to access an integrated resources to provide such health and wellness information. In fact several informatics projects have been developed by consumers frustrated by their inability to find needed information for their own health conditions or those of friends or family.
• health agencies such as the American Heart Association, and the American Lung Association, have reported reaching 82 million potential customers with health information, and answering over 4 million direct inquires each year.
• the need for information is particularly apparent in self-care situations. Healthwise, Inc. reported that 80% of all health care involves problems that could be treated at home. The Center for Corporate Health, Inc. estimated that as many as 67 million clinical visits are unnecessary or highly discretionary, and that many of these could be avoided in the proper health education materials and decision support tools were provided earlier. However, if a consumer maldiagnoses his or her health problem and then goes on to "treat" it, benefits from automated dissemination of information could be negated and may even result in higher medical costs. (United States General Accounting Office p. 4 - 7)

There is ample evidence to support the assumptions that growth and expansion of computing power, capacity, and access of consumers will continue to grow exponentially;

• The 1995 report by the Council on Competitiveness showed that 37 percent of U. S. households had computers, and the number was expected to reach 40 percent by the beginning of 1996. (United States General Accounting Office p. 6)

Many of these same reports are full of statistics and antidotes about the problems and failures of many of systems that are currently in place;

• over half of the 78 projects we surveyed were either in operation for two years or less or were under development. Many project officials did not have maintenance costs data available. Since informatics is a new field, only limited research has been performed to confirm its full monetary value.
• in response to our questionnaire, the 80 experts identified three issues as most significant: access, cost, and information quality. Other issues identified as important to ensuring effective development and use of consumer informatics include security and privacy, computer literary, copyright, systems development, and information overload.
• from 70 to almost 80 percent of the experts rated access, cost, and information quality as significant or very significant issues affecting the future of consumer health information. In terms of access health informatics is largely available only to those with computers, modems, and telephones.
• at least 6 percent of U. S. households lack telephones, and about 60 percent lack computers. Other issues influencing access were physical barriers, such as those affecting residents of remote or rural areas, and physical handicaps, hindering easy access to and user of computers. Finally, information quality was raised by the experts as a very significant issues.

One expert noted, being on the Interment is "like filling a water glass with a fire hose." (United States General Accounting Office p. 15 - 17)

Consumer health informatics can be organized into three general categories: systems that provide health information to the user (one-way communication); tailor specific information to the user's unique situation (customized communication); and allow the user to communicate and interact with health care providers or other users (two-way communication). There are many and clear advantages to such systems:

• advantages cited by project developers and system users include; anonymity, outreach, convenience, scope, and support. Officials at Harvard Medical School's Center for Clinical Computing stated for instance, that patients were more honest with the computer because the system is "faceless and anonymous". A classic example was cited where in the care of one patient, where doctors notes indicated that "[he] uses alcohol socially"; in contrast, the computer assessment found that the patient had monthly blackouts.

Another important advantage of informatics systems is scope; using on-line networks allows information to reach large numbers of consumers. For example, with a computer self-help group, a dozen to 20 people use the computers at the same time and receive instantaneous input from all of the people. "Groups supported by tech help people network, understand their disease, and communicate their needs [to health care providers] more quickly" (United States General Accounting Office p. 13 - 14).

In the congressional testimony that was given for the General Accounting Office report (United States General Accounting Office) Experts discussed several options for addressing each informatics issues. They ranged from board practices (such as establishing public- and private-sector partnerships and using diverse and complementary teams of experts to develop informatics systems) to very specific suggestions (such as notifying consumers if the information is from an unknown source). The importance of following sound systems-development guidelines in developing consumer health information needs, and developing technical specifications can not be overstated. One expert summed up the bottom line when he said, "the more that individuals are empowered directly in wellness and preventative care issues, the less it will cost the government to pay the health bills; it will be an investment for the future."

Some organizations have set out plans for developing systems that they hope will be models for regional or international solutions. The Pan American Health Organization has identified six areas of concentration:

• Challenges and Achievements of Telecommunication Applications in Health
• Health Organizations and lnformatics - an International Perspective
• Infrastructure Requirements in Health Telecommunication Projects
• Telecommunication Applications in Health Care
• Knowledge-Based Systems - Content and Service Issues

They also listed several issues for the user, industry and the academic and public sectors in health telecommunication projects; 1. administrative information systems (including a universal electronic claims structure); 2. clinical information systems (including but not limited to the computerized patient record and clinical decision making); 3. telemedicine (both health facility and home-based teleconsultation and telementoring interventions); 4. personal health information systems (providing health information and decision-support directly to the general public); 5. population data structures (supporting the health needs of populations); 6. system coordination (aiding in the coordinated management of health systems at the local, regional, national, and international levels); and 7) community networks (enabling the public to collaborate in collective addressing health problems that can not be solved at the individual level alone).

The seven elements of telehealth that were identified in the PAHO report were built upon work done in the international medical informatics community. Its framework was built on earlier sessions in 1992 and 1993 by the National Health Information Infrastructure Plenaries, and the National Academy of Sciences.

F. Human Factors Principles

Thus far in this report a great many components of human factors have been discussed. The figure below from Shackle clearly depicts the wide variety of components that must be considered when designing and deploying highly complex and sophisticated systems such as expert systems. Even at the lower end of systems development, the first principal always applies, design it with the user in mind. If the design team is assembled from the outset of the project, and they keep a holistic perspective throughout that is client centered, the chances of a system living up to its potential are greatly enhanced.

Mikhailov also gave a comprehensive overview of many of the aspects related to the human factors components; 1. Can the concept of selective information be extended to permit the measurement of semantic or qualitative information? If so, how? If not, what concept of semantic or qualitative information allows quantitative analysis? (Information Theory, Semantics), 2. Can the various forms of information processing be analyzed in the form of common elementary processes, and can these processes be described by fundamental laws? (Mathematical Logic, Automata Theory, Computer Sciences), 3. How can different methods of information processing, which achieve the same results, be compared, and what are suitable quantitative measures that will enable the differentiation of the complexity and efficiency of operations on information? (Computer Sciences, Computation Linguistics), 4. How does man associate meaning with information, and what is the relationship between meaning and his established value system? (Psychology, Philosophy, Semantics), 5. What are the laws that make natural languages the universal means of formulating (creating) and communicating new concepts and ideas? (Linguistics, Semantics). Natural languages in the widest sense (including music and forms of artistic expression) permit the creation of new concepts. Even if there exists no equivalent (in nature or in man's history) for these new concepts, they become immediately understandable to persons other than the creator by virtue of the context of the language and the situation. Are there fundamental laws that govern the conditions under which "creation" can take place? How can new creations (concepts) be understood if the description can only indirectly suggest a thought process? 6. What are the interrelations between the forms of energy, matter, and order (or structure), and the use of these forms to represent (selective) information? Selective information, when communicated, is always associated with some form of physical representation: as matter, or energy, or both (molecules in a genetic code; energy quanta in communications via light). The degree of order of the physical form is correlated with information. What are the laws that govern the ordered use of matter or energy to represent information?, 7. What are the physical limitations of communication, information processing, and information storage" (Communication Theory, Brain Research, Research in Memory Technology), 8. What are the laws governing the organization of information as it applies to mass information storage and retrieval? (Experimental Psychology, Library Sciences, Computer Sciences, Brain Research), 9. What are the laws of information dissemination which explain the processes of cognitive perception? (Education Psychology, Theories of Self- Adaptive Systems, Cybernetics), 10. What are the properties of information which stimulate creativity Is creativity an information processing function for which laws can be developed? (Cybernetics, Artificial Intelligence, Semantics), 11. What are the laws of information accumulation, updating, and assimilation? (Education Psychology, Library Sciences, Computer Sciences)" (Mikhailov, p. 367)

Peterson offers five principles of human factors design; "1. operation of a system is a control task, 2. the operator is not just another computer, 3. the operator is a perceptual system, and not only a thinking system, 4. the task must fit the human mode of functioning, 5. communication requires a shared perceptual world." Finally he reminds us "It is important to remember why we care to operate systems at all: it is to make the systems do things for us" (Peterson, p7.)

For designers of expert systems which will play a major role in the future of informatics, Fieschi offers the following observation, "the workers in artificial intelligence want to know how to program a machine in such a ways that it understands a human question, that it is capable of performing the tasks asked of it, that it reacts 'intelligently' however, the calculations are mathematical, but the operations are symbolic. (Fieschi, p. xiii)

The figure below from the PAHO conference summarizes many of the issues relating to comprehensive health informatics systems.

G. Barriers

From the readings in the health and medical informatics literature, a great many barriers have been identified that are identical to those cited in the readings in Opper, Constantine, and Gabarro. Systems designers often do not take sufficient time to take into account the barriers that the users will face or even worse, they ignore them. These gross errors and faux pas can partially explain why roughly 70% of groupware applications fail. Although there is scant evidence of evaluation of medical informatics systems, one would anticipate comparable failure rates. Barriers can be grouped according to one of two types of issues, technical and social.

Technical

The bulk of these barriers relate back to design errors or issues. The first relates to standardization. A number of national and international groups are working toward massive databases that can track usage patterns, enable providers to assign each person a unique Personal Client Record (PCR), and perform other types of surveillance. To say that there is a great deal of inconsistency across databases is an understatement.

Lindberg outlines some of the issues and problems of these records; "some relate to the content and structure of current health databases; others difficulties and costs of creating and maintaining comprehensive databases; need to created longitudinal records to understand how patients fare "in the system as a whole"; need to adjust for important characteristics about patients' sociodemographic circumstances or health status (risk and severity adjustment); and the need of information on the health of the population as a whole, not just those who use the health system; the need for information on both end results (outcomes) of care as well as on the process of care poses great challenges to database developers" (Lindberg, p. 2). Finally, Lindberg has forecasted that as the reasons for creating large health databases mount, so to will the possibilities that such databases will do harm to patients, providers, players, and the public at large. The correct balance between the advantages of such databases and their potential for harm has not been found. Those who are funding such projects feel they need, "to control business costs attributable to health benefits, the desired to use technological and computer applications to decrease administrative costs of processing insurance claims, the wish to experienced health services researcher to point the potential of health database to evaluation and prove health care, the responsibility of community leads to plan expansion and contraction of health care facilities an services, and he need to transmit medical history information for an increasingly mobile population". At the end of his book, The Growth of Medical Information Systems in the United States, Lindberg leaves the reader with a positive tone by noting, "innovation in medicine takes place within a scientific community whose norms, .. welcome change. Yet the are of adoption of innovative practices in U.S. hospitals varies greatly, depending on both the size of hospitals an possibly upon the characteristics of the innovation" (p. 140).

Social barriers

Lindberg also discusses some of the sociological barriers to diffusion of medical informatics systems. He says that problems have been, "sociological and behavioral as well as technological. In addition, management difficulties spanned the two. The speed of technical change in this field has been far greater than the speed of social adoption" (Lindberg, p. 105). Social barriers include slow adaptability by health professionals, even to the educational requirement, and the seeking of short-term profits and earnings by both the computer and hospital industries. Donaldson lists two kinds of technical barriers have been identified that are largely sociological; "those typical of any newly evolving technological enterprise, and those more specific to the medical environment. Medicine seems to suffer greatly from an administrative pattern of extreme balkanization" (Lindberg, p. 105)

H. Recommendations and Benefits

The PAHO conference devoted a section of the report to the positive attributes of medical informatics. Among the benefits listed were:

• Benefit health sector clients by improving access to services and quality of care and preserving equity.
• Best support the information and knowledge needs of health professionals, managers and researchers and client requirements in relation to health interventions.
• Promote the development of medical and organizational infrastructure most appropriate to take advantage of the methods and technology of telecommunications and computing.
• Manage the knowledge content of applications and the role and responsibilities involved.
• Foster the multidisciplinary approach and strategic perspective required to take full advantage of Health lnformatics applications.
• Face the variety of needs and implementation environments found in Latin America and the Caribbean." (PAHO, p. 9)

I. Current Programs

The recent literature and internet resources describe several programs that have great promise. Generally the author found that now these programs were being developed through the efforts of multidisciplinary teams. Representative from telecommunications, IT, human factors, cultural, and health fields are assembled from the beginning of the project.

One particularly ambitious international program is worth mentioning. The Global Intelligent Network or Global Information Infrastructure (GII) can be thought of as a human/machine network, which today resembles in many ways a human nervous system. The GII is already present in 82 countries. It is used by more than 36 million people internationally on the internet and is expanding at an exponential rate in most areas of the world.

The health component of the GII, is often referred to as the Health Information Infrastructure (HII) . Its aim is to dramatically improve: "1) the practice of knowledge enhanced telehealth and medicine; 2) the constructive reengineering of national and international health systems; 3) the creation of local, national, and global markets for the exchange of health products and services; 4) a continual iterative decentralized improvement of health and human prosperity; 5) the protection of the biodiversity of ecosystems; as well as 6) the prevention and management of social crises." The Global Intelligent Network has the potential for another quantum leap in health and the quality of life. The PAHO report states that, "the benefits of the GII will only be realized and sustained if the Global Intelligent Network is designed to simultaneously address the impending macro challenges we must now collectively face on a global basis" (PAHO, p4). From the human factors specialists perspective, one of the more interesting aspects of the GII project is its work with "social ecology". The GII defines social ecology as, "the complex web of social interaction, environment, and infrastructure which heavily influences the well-being and productivity of societies and their inhabitants as related to such concerns as jobs, societal vision, economic market development, communication patterns, services, individual and community aspirations, personal and political relationships, and diffusion of technology. Socioecological factors, more so than medical care or public health, determine the health differences observable between countries (e.g., Japan, the Sudan and the United States). Through the use of advanced computing and communications as well as the emerging methodologies of the sciences of complexity, a broader set of professionals, policy makers, and the public are beginning to understand how we can intervene on these socio-ecological factors as major determinants of health and disease" (PAHO, p.5)

J. The players

The three types of groups; universities and teaching hospitals, managed care organizations, and governmental entities are the clear leaders in informatics. Each one has its own niche and focus that is driven by its environmental scan and the nature of its business. All are making contributions to the general body of knowledge on which informatics is built. The primary focus of universities and hospitals has been on medicine and education. Managed care organizations have medical treatment and business considerations as their primary concerns. The govenrnment is heavily into coordination and legislation for national initiatives. They also are one of principal providers of educational information. Although their efforts are not coordinated on the basis of a national vision, the collective weight of their efforts has driven the field forward.

Major universities with strong medical schools and teaching hospitals such as Stanford, Harvard, Yale, Georgetown, University of Saint Louis, University of Wisconsin, University of Washington, and Columbia University are at the leading edge of development and implementation of medical informatic systems. They also are doing a great deal of exploration about how to educate physicians in medical informatics.

Several governmental agencies have intensified their efforts for the advancement of informatics due to the urgency of President Clinton and Vice-President Gore's task forces on Health Care Reform and Reinventing America. At the forefront of the governments efforts are;

• The National Institute for Health's' (NIH) National Medical Library (NLM) universal access to information projects.
• The Health Care Financing Administration (HCFA) efforts to promote timely delivery of health care information to its beneficiaries.
• The Food and Drug Administration which has national information dissemination programs surveillance systems.
• Agencies within the Health and Human Services (HHS) who strive to prevent and control disease by disseminating consumer health information such as;

- Centers for Disease Control and Prevention (CDC)

- Agency of Health Care Policy and Research

- National Institutes of Health (NIH)

- Office of Disease Prevention and Health Promotion (ODPHP), and

- National Health Information Center

Time and space prevent a discussion and comprehensive listing of more of private groups that are major players in the field of health informatics. However from the listing of companies below, it is apparent that there will be a great deal of resources devoted to this area in the foreseeable future. All of the companies are highly experienced in the field of technology and/or communications. The biggest questions will be have they learned enough from their past failures.

Among the most prominent private players are; Oracle, IBM, AT&T., PacificBell, MCI, Kaiser Permanente, Blue Cross and Blue Shield, and Johnson & Johnson. Also worthy of mention is the announcement of Healtheon, the web based health service provider, that will be headed up by Jim Clark.

III Personal Perspective and Conclusions

K. Viewpoints and conclusions

As a stand alone section, this section of this paper is underdeveloped. However, the books, articles, references, web searches, and personal interviews conducted all pointed to one objective; finding the best of the best programs and practices and then putting them into a framework that allows for an understanding of the basic and essential elements of the health promotion informatics field. The field of health promotion informatics is and has been out there. A great many good programs and minds are devoted to addressing the health needs at a personal and economic level. Like so many areas in technology that are new, massive and untested, the field of infomatics is severely fragmented. The pioneers and early adopters are making a lot of what they are doing as they go along. All to often well-intentioned individuals and groups try to port over programs from one field to another. This usually leads to disastrous consequences.

That is one of the most important lessons of this course. In order for systems to succeed, things must be done the right way. There must be a vision and leadership. That drive must be maintained and woven into the fabric of the organization. The culture of the organization must support the vision in all levels. As Hammer and Champy have repeatedly said, the process is dynamic. For us to make the progress in health care, we will need to develop and use processes that are based on continuous, fundamental, radical change. Fortunately, the economic crisis, technology, information, and communications revolutions and other drivers and megatrends have provided us with an exciting time and golden opportunity to make quantum leaps forward. It is up to the developers and systems planners to design systems and develop tools that will make the leap attainable.

A second major point from this course lends itself as a solution to this issue. The very nature of this problem is so massive that no one person can comprehend all implications and ramifications. However this problem can be effectively addressed within the context of groupthink and groupware applications. A phenomenal amount of talent and expertise is available to tackle these kinds of problems. Everyone agrees that this problem is important to the future of our existence that we must work toward its resolution. The diversity of talent, ideas, and solutions that is inherent in groups can be devoted to finding some of the answers. Groupware applications can support them in their mission.

Convening groups in itself is not the answer. In their books, Opper and Gabarro present much of the research and current thinking about how effective groups work best. Further, they discuss the important of understanding and applying all of the principles of human factors research for working in groups. With so much at stake, no shortcuts are worth the risk of failure.

Hope, vision, and passion will be extremely important for this field in the coming years. Enough bright minds are coming together around these problems. The most passionate will emerge as the leaders in the 21st century. Hope if created through the dreams of people who can see the tools and the needs and develop a picture of the solutions. Research on this topic has uncovered many wonderful potential solutions.

For those who can dream and see ahead, robust systems that use the right tools such as decision support systems, global warehouses of data, intelligent agents, artificial intelligence, expert systems, groupware applications, speech recognition, communications apparatus such as microwave, satellites, and infrared technology all will have a place in the future. Devices such as personal digital assistant (PDA)'s also open up many new avenues for collection and delivery of health information. But again, if they are not designed and implemented with sound principles of human factors, their potential will be underutilized. We must not be handicapped by our imagination, but not blinded by our ignorance of the common principles of utility, interface, and design.

Two new technology tools that combine technology and communications have come on the market and been in the news recently. Both offer a glimpse of the possibilities for the future if we look beyond the product not at it. The first is a wristwatch that acts like a personal health monitor (PHM). They are currently being tested with the global positioning system (GPS) and satellite transmissions. The purpose of the test is to be able to monitor vital signs and then transmit them to hospitals. If the patient has trouble, help could arrive immediately. Imagine PHM's being used in conjunction with intelligent agents that are maximized through human factors principles and based on an expert system developed by health promotion specialists. Both are representative of a generation of devices that could be used not to respond to life threatening conditions, but they could be used to move toward optimal wellness and enhance our quality of life.

The second tool is one that was discovered in the research for this paper. It is called a Guardian Angel.

It is described as a software agent that "integrates all health-related concerns, including medically-relevant legal and financial information, about an individual (its subject). This personal system will help track, manage, and interpret the subject's health history, and offer advice to both patient and provider" (Guardian Angel, 1996). Imagine having a Guardian Angel looking out for you. One that knows how you tick, and is intelligent to know how to best work with you. Best of all, it is not a static devise. It is client centered and it changes, grows, and learns with you.

In closing, two quotes are worthy of mention as they embody many of the thoughts that are relevant to this topic. Fieschi states. "that telecommunication and artificial intelligence are perhaps the means of allowing us to diminish man's isolation and the pressures which surround him" (Fieschi, p. ix). Anderson offered a very salient remark by the French writer Diderot "Never mind if you accept or reject my ideas, provided that they retain all your attention" (Anderson p. xiii). Some day this author may say something profound like, massive problems can be solved on a grand scale, using the right solutions that are based on principles of good common sense.

The field of informatics is really only about 35 years old. It is not even in its infancy yet. It is a moving target, but we had better take our best shot, because so much is riding on it; our health.

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