What Next After Implementation? Challenges For the Informatics Community

I had the opportunity recently to attend this year’s Healthcare Forum, put on by Xerox’s the Breakaway Group,  an organization whose mission is to improve healthcare through optimization of the electronic health record (EHR). The forum brought together about 100 leaders from healthcare delivery organizations, academia, and industry. We had the great opportunity to take a break from our daily grind to step back and take a look at the big picture. Clearly much progress has been made, but there is still so much more to do to improve healthcare and its use of information technology.

In my reflection of the event, I had the opportunity to gather some thoughts on what the biomedical and health informatics (BMHI) field must do to contribute to the larger picture going forward. The last few years have been very good for those who work professionally and academically in BMHI, which I have defined as the field that is concerned with the optimal use of information, often aided by the use of technology, to improve individual health, health care, public health, and biomedical research [1]. The Health Information Technology for Economic and Clinical Health Act (HITECH) Act has provided tremendous opportunity to expand the use of informatics systems to improve health.

Much of the focus of the early (2009-present) HITECH era has focused on implementation of electronic health record (EHR) systems. Many healthcare organizations, especially larger ones, have made the transition to electronic systems and collected their meaningful use dollars.

Sometimes I am asked what the informatics community will do next once everyone has implemented systems. Some who work in the field professionally worry what jobs will be available. Although there is plenty of implementation work still to be done, to me the real interesting work begins once everyone has implemented EHRs. After we reach this point, we can get on to the work of building a better healthcare system and otherwise improving people’s health.

Certainly the major challenge for the informatics community after implementation is to help make use of all the data in these systems. Unfortunately much of this data is still unusable, at least for achieving the goal of the learning healthcare system. One critical contribution we can make is to solve the data quality problem, which includes everything from making the entry of high-quality data by clinicians as easy as possible to adhering to standards to make it interoperable and reusable.

Another role where the informatics community can help is achieving true health information exchange (HIE). One of the best definitions I ever heard of HIE came in a conversation years ago with Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality (AHRQ), which is that “data should follow the patient.” Of course, HIE lets us do more than that important task of having all needed information available for care of the patient. It should also allow us to perform clinical and translational research, measure and improve healthcare quality, and advance public health [5].

An additional important task for informatics is patient engagement. As the healthcare system necessarily becomes more patient-focused, we must not only help patients access their data and information, but also understand how to use it to improve their health.

A final contribution that the informatics community can make is to improve EHR and related systems. This was exemplified earlier this year by a lively debate that was prompted by the publication of “Escaping the EHR Trap” in the New England Journal of Medicine by Mandl et al [3]. These authors expressed concern that the HITECH program and evolving market was locking in monolithic systems that impaired clinical workflow. They instead advocate that the health information ecosystem be a platform upon which applications can access a patient-controlled but highly secure and validated data store.

A final point about next steps for EHR and other systems concerns healthcare reform. I agree with those who argue that the true value of information systems in healthcare will only be reached when we have a system that values information. Our current fee-for-service system does not value information, and sometimes even counter-values it.

A healthcare system that stresses accountability, value, and coordination of care will necessarily value information. I doubt anyone in a bank or at a retailer needs to convince anyone in those companies about the strategic importance of information. Yet in healthcare, information collection and integration is not valued. Clinicians view data entry as a chore, often the activity that stands between their work day and going home.

As we move into what might be called the post-HITECH era, the informatics community must lead the charge in building systems that are secure, usable, and built with the goal of improve health and healthcare in mind.


1. Hersh, W. (2009). A stimulus to define informatics and health information technology. BMC Medical Informatics & Decision Making, 9: 24. http://www.biomedcentral.com/1472-6947/9/24/.

2. Hersh, W. (2012). From Implementation to Analytics: The Future Work of Informatics. Informatics Professor. Portland, OR. http://informaticsprofessor.blogspot.com/2012/04/from-implementation-to-analytics-future.html.

3. Mandl, K. and Kohane, I. (2012). Escaping the EHR trap–the future of health IT. New England Journal of Medicine, 366: 2240-2242.

William Hersh, MD is Professor and Chair of the Department of Medical Informatics & Clinical Epidemiology at Oregon Health & Science University in Portland, OR. He is a well-known leader and innovator in biomedical and health informatics. In the last couple years, he has played a leadership role in the ONC Workforce Development Program. He was also the originator of the 10×10 (“ten by ten”) course in partnership with AMIA. Dr Hersh maintains the Informatics Professor blog.

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