The Argument for an R and D Agenda in Support of
Healthcare Management Informatics and Computing
Christopher Bain
Convenor, SIG in Healthcare Management Infornmatics and Computing
Information Manager - WCMICS
Albert St. East Melbourne Vic. Australia
Keywords: Health management, Computing, Informatics.
Abstract: In this paper I make the case for a research and development (R and D) agenda in support of the evolving
discipline of healthcare management informatics and computing (HMIC, pronounced “Health-mike”). The
aim of the discipline is to provide healthcare managers the information technology (IT) tools they need to
address the health needs of our communities, with the often inadequate resources they have at their disposal.
Given the needs of our communities in relation to healthcare, the establishment of this agenda and
subsequent work towards the relevant goals are critical to improving our healthcare systems, particularly in
the Western world.
This paper seeks to make the case for a Research
and Development (R and D) agenda in support of the
discipline of Health Management Informatics and
Computing (HMIC). This discipline can be thought
of as sitting at the intersection of health
management, computing and the relevant sciences.
More precisely, HMIC could be defined as that
subset of health informatics dedicated to the study,
design and implementation of information
technology solutions in support of the practice of
healthcare management in all its forms - including,
but not limited to, primary care and general practice,
sub acute and rehabilitation care, and hospital care.
Furthermore, HMIC involves the study of the needs
of healthcare management practitioners, including in
information presentation and in decision support.
Whilst far from complete, that definition should
suffice to allow readers to understand the argument
that follows.
In the Western world in particular, our
communities, our patients, are telling us about the
problems they experience as consumers of our
healthcare systems. Some of the biggest concerns
facing patients, and the cause of many complaints,
are in relation to access to care and services, the
physical environment in which they receive care,
and the quality of that care. All of these things are in
the sphere of influence of healthcare managers.
For the purposes of this paper I will define a
healthcare manager as anyone who has at least
partial responsibility for the management of a care
or support service in the health industry. The key
distinction here is with the clincian role which is
primarily about the provision of care. Clearly,
however, some managers are clincian managers.
In recent years there has been an increase in interest
in using scientific methods, including some
techniques well known in the world of management
science (Butler 1995) (Fannin 1997) to attempt to
address the problems confronting those managing
our healthcare systems. By way of illustration is the
establishment of the UK based Nosokinetics group
(Group 2006)
As stated previously, patients experience a
number of problems in our healthcare systems,
either identified by them, or evident to those of us
who work in the industry. In many cases these
problems are clearly in the domain of managers in
terms of resolving them, sometimes representing
systems failure, but often not the responsibility of
Bain C. (2009).
HEALTH –MIC: WORTH THE EFFORT? - The Argument for an R and D Agenda in Support of Healthcare Management Informatics and Computing .
In Proceedings of the International Conference on Health Informatics, pages 351-356
DOI: 10.5220/0001745603510356
individual clinicians alone. An example is
medication errors associated with role overload
(Wilkins and Shields 2008).
3.1 Drivers for HMIC
Outlined in the section that follows is what could be
considered some key drivers of this work. The
categorization of these drivers is not to ignore their
fundamental interrelationships, but to allow a
crystallization of thought around some of the key
issues facing healthcare managers.
3.1.1 The Patient Experience
In this section of the paper I will outline some of the
patient led drivers for improving healthcare systems
in more detail.
By way of scene setting, there is the worrying
assertion by certain authors that “In some cases,
health care delivery directly contributes to increased
suffering“ (Daneault, Lussier et al. 2006)
Certainly many of the problems patients report in
relation to the healthcare they receive are related to
problems that are under the direct responsibility of
healthcare managers. For example, patients have
identified staff responsiveness (Tea, Ellison et al.
2008) as a key factor in determining their
satisfaction with health services.
In patient satisfaction surveys (Research 2006)
for example, some of the following factors have
been identified as being positively associated with
improved patient satisfaction:
discharge experience
waiting experience
amount of time spent in hospital
hospital facilities and
admission experience
These and other complementary findings are also
demonstrated in other patient satisfaction surveys
(UltraFeedback 2007). In a cancer specific
satisfaction survey (Heading, Mallock et al. 2007) –
in inpatients, access to care again rated poorly as
compared to other dimensions; and in outpatients,
waits for radiotherapy and chemotherapy again rated
more poorly than other dimensions. Another
example from the cancer setting is consumer
feedback to a key 2003 report by the Clinical
Oncology Society of Australia. (Initiative 2003) In
it, it was stated that consumers want their treatment
to be “timely (no unnecessary long waits) and
organised around their wider needs, for example, the
need to travel.”
Factor like these are all influenced by the way
facilities and systems are funded, designed and
managed, much more so than they are affected by
the delivery of care by individual clinicians.
3.1.2 The Professional and Organizational
The following section of the paper outlines some
key areas of concern for healthcare professionals and
organizations, which support the argument for an R
and D agenda in support of HMIC.
As described previously, the interrelated issues
of patient satisfaction and management imperatives
around quality and safety of care are key areas for
healthcare managers.
Managing access problems of various kinds is
another ongoing issue for healthcare mangers (Allen,
Shelton et al. 2008) (Zavagno, De Salvo et al. 2004).
The dimensions of this problem include access to
services and equipment.
Of course there is always the imperative to
manage the bottom line (Young-Schmidt 1999) -
particularly in many public institutions that
chronically run over budget – but which are
arguably, therefore, under-funded. In an era of
shortages of skilled staff across the globe,
particularly nursing staff, the challenge of finding
and retaining sufficient qualified staff to run
facilities is a huge concern. (Francis 2008) (Doiron,
Hall et al. 2008) (Kober and Van Damme 2006)
Changing care models, for instance the
introduction of multidisciplinary (MD) care (Davies,
Deans et al. 2006) (Kane, Luz et al. 2007) also have
significant workforce and logistic implications for
managers, thus increasing the decision making load
upon them. Importantly also, patients support the
introduction (Initiative 2003) of such models.
Adding to this load on managers is the challenge
of integrating these various problems and views
from a management perspective given the complex
and intertwined relationships between all of them, in
the context of the ever advancing competencies
required of health managers. (Nishiyama, Wold et
al. 2008) (Kleinman 2003)
3.2 An Analogy – The ICU Patient
There is potentially a good analogy when thinking
about HMIC in relation to hospitals, although the
scope of this agenda could extend far beyond acute
hospitals, to healthcare facilities of all types and to
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private general practice, and allied health practices.
The analogy is that of the intensive care unit (ICU)
patient. This analogy is only intended as a
framework for thinking about the problems rather
than, for instance, an argument for equity of
Using this analogy, many of our public hospitals,
in particular, have been on “life support” at different
times, in the form of constant management re
structures (sometimes government imposed) and
extra financial grants and concessions. Arguably if
they were private businesses they would have gone
into insolvency; but, arguably these hospitals are
also under funded. Effectively they are like ICU
patients who are very unwell and need constant
In terms of information (gages, reports and
readouts) available to the manager of the critically ill
patient on a ventilator (the ICU specialist, and his or
her team), there is a large amount of information
available to them. In the case of the respiratory
system alone, these pieces of information include for
oxygen (O
) saturation
full measurement of all blood elements related
to breathing function (arterial blood gases) and
daily Chest x-rays to visualise the lungs.
In terms of controls (levers, dials and switches)
which allow the ICU specialist to control or improve
respiratory function, these include:
the ventilator itself – these have volume,
pressure, rate and delivery mode settings, all of
which allow optimisation of the patients
respiratory status in any given clinical scenario
the amount of oxygen that is delivered through
the ventilator and
a range of drugs in support of improving
respiratory function.
If one now moves to the management of an
unwell hospital, the information and controls
available to the managers of that system pale into
insignificance in comparison.
By way of illustration, let us consider the
example of managing the respiratory system of a
patient on a ventilator, and specifically the
measurement of oxygen saturation (the accepted
means of monitoring, in real time, whether the
patient has enough oxygen in their blood to sustain
life). In this case, the following pre work has been
the basic physiology has been described
and understood and the concept defined in a
universal way
the biomedical engineering work to develop
sensors to precisely measure this has been
the clinical trialling of the equipment has
been done, and
the real world uptake and acceptance of the
evidence around the practical application of
the tool(s) has occurred.
Let’s now compare that to the concept of
hospital occupancy (think of it as “bed saturation”)
as an example. This analogy again highlights the
size of the gap between this knowledge and
application area, and the clinical domain:
the drivers and definition of hospital occupancy
are not described in a universally accepted and
scientifically proven way.
there are no universally accepted and robust
tools to allow monitoring of hospital occupancy
in real time
there have been few real world trials of many
developed tools (as opposed to in vitro tools e.g.
- simulation studies, see (Sobolev and
Kuramoto 2005) (Ledlow and Bradshaw 1999)),
there has been limited, if any, real world uptake
and acceptance into routine use, of the tools that
are available
It bears a much more in depth analysis as to the
reasons for these differences, and that is beyond the
scope of this paper – in effect that is the work of
HMIC, or at least an important example of it.
4.1 Overview
There has certainly been work relevant to HMIC
going on for 30 or more years, especially in core
business areas like nursing scheduling systems
(Ballantyne 1979) and patient acuity and
classification systems (Coetsee 1985) (Cochran
Many of the major problems confronting the
health care industry in the Western world remain
management problems, rather than problems directly
in clinical care provision (Armstrong, Gillespie et al.
2007) which is generally of a good standard. Given
that, there seems to be a distinct lack of coordinated
effort in terms of understanding what role
information technology (IT) can have in supporting
solutions to these problems. This is particularly the
HEALTH –MIC: WORTH THE EFFORT? - The Argument for an R and D Agenda in Support of Healthcare Management
Informatics and Computing
case when compared with the clinical informatics
4.2 Establishing Answers to Core
More specifically are the following unanswered
questions in this regard:
what are the key information and decision
support requirements of health care managers?
how do we harness some of the groundbreaking
work in scheduling, forecasting, and data
presentation (Duckett, Coory et al. 2007). In
particular, how can such innovations be
operationalized and incorporated into robust,
integrated IT systems?
we know that standards based approaches can
have significant benefit in facilitating IT
development (Ludwick and Doucette 2008)
(Bouhaddou, Warnekar et al. 2008) but are there
standard definitions for management concepts
such as "congestion", for example; and how do
we represent them in a way that IT practitioners
and developers can incorporate them into
practical IT systems?
how do we ensure that HR, finance, PAS and
predictive systems (Bottle and Aylin 2008)
(Emendo 2006) can work in an inter-operable
fashion given the complex and intertwined
relationships between issues such as staffing,
finance and bed management in health care
The establishment of an R and D agenda for
HMIC would seek to answer these questions
amongst others.
4.3 Coordination
Arguably there has been no coordinated effort since
then especially in comparison with clinical
informatics; hence it is a good time before there are
too many vendors in the space, to create common
definitions and standards, to define use cases and
common management scenarios that systems can be
built to support. These kinds of activities can only
assist in achieving greater coordination of effort in
regard to solving some of the core problems outlined
previously in this paper.
4.4 Flow on Effects
There are some potential flow-on effects from the
establishment of this agenda that include:
Attracting further funding
Attracting technological development
Attracting interested and skilled people to work
on these problems
Fostering the kind of scientific and industry
collaborations that can allow the closure of the
gap between real world problems and viable
In the context of what I have stated previously, a fair
question from a sceptic may be – “why now?” Why
is it important to define, establish and implement
this R and D agenda at this point in time? The
following represent some of the key reasons:
The available technologies, now more than ever,
offer a great opportunity to advance this agenda.
New, especially mobile, devices (Garrett and
Jackson 2006) (Lin and Vassar 2004) (Siracuse
and Sowell 2008) capable of supporting rich
levels of functionality, make it easier than ever
to deliver functional software solutions to
managers at the point of decision making, whist
accommodating their workflows.
It is time to operationalize many of the scientific
innovations in this area. Too much work has not
been translated into practice, international
experts in the area acknowledge this (Brailsford
2005). Even the lessons from the work
performed in this space have not been drawn
together to inform practice. For example, where
are the systematic reviews of, and lessons from,
the multiple simulation studies regarding
management problems? The work by Fone et al
is one notable exception. (Fone, Hollinghurst et
al. 2003)
The dire financial state (Frizelle 2008)
(Werntoft, Hallberg et al. 2007), and complex
financial environment (Wagner, Valera et al.
2008) (Buchan and Evans 2008) that public
health care, in particular, operates in is a key
reason to act in this area now. The availability
of funding to support healthcare will be under
ever greater pressure as expensive care delivery
technologies and products continue to evolve.
If we do not move quickly towards establishing
and working on this agenda, the danger is that
the core needs, and robust standards and
approaches will not be defined before vendors
and solutions proliferate, leaving us with the
same sorts of inter-operability problems and
debates (Wright and Sittig 2008) (Hammond
2008) (Engel, Blobel et al. 2006) that plague
clinical informatics.
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In conclusion, the rationale for this work is that:
patients continue to experience problems as
consumers of healthcare, and there are also
problems identified by those of us working
in the healthcare system
there are often insufficient resources
available in our systems to address these
this combination of factors represents a
complex challenge for healthcare managers
information technologies can have a role in
assisting with the rationale use of limited
resources and system management, and
there has been little of the scientific ground
work done in this area to underpin the
development of robust tools, even in the
presence of adequate funding and interest in
these problems.
This is the remit of HMIC, and an R and D agenda
in support of this discipline would assist enormously
in solving some of these very important practical
problems in healthcare.
I wish to acknowledge Prof Peter Millard, founder of
the UK Nosokinetics group, who has shown the
drive and vision necessary to take the international
health community to its’ current point of evolution
in relation to these issues. I also wish to
acknowledge the assistance of Assoc Prof Caroline
Brand and Dr Gitesh Raikundalia in reviewing the
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