Informatics and Surgery

By Jane Zhao

I am currently taking two years out from my general surgery residency to complete a clinical informatics fellowship. The most common question I am asked is: What is clinical informatics? Followed by: That’s nice. But how is this relevant to surgery?

These are great questions. Let’s tackle them, one by one.

What is clinical informatics?

Clinical informatics is a multidisciplinary field with collaborative relationships between medicine and computer science, sociology, statistics, and engineering that leverages information science to improve health care. A main focus of the field has been on the application of electronic health records (EHR) systems and other health information technology (HIT) within the clinical setting. Other roles for clinical informatics can be found in the effective use of algorithms, devices, and system redesign to make health care processes work more efficiently while maintaining high quality patient care and safety. The discipline of clinical informatics is rapidly growing and evolving, in part aided by government mandates for universal adoption of EHR systems.

How is informatics relevant to surgery?

Historically, few surgeons have been involved in informatics, which is problematic because the interactions that surgeons have with HIT and EHR systems are different from that of other clinicians. Any time change is taking place within the health care system, surgeons need to be a part of the process to help maximize the benefit of these changes on surgical care. The following five areas are where applied clinical informatics have far-reaching implications for surgeons:

Workflow

Informatics can improve workflow with respect to patient care throughout preoperative, perioperative, and postoperative settings by optimization of scheduling and allocation of operating room resources, electronic order sets, outpatient and inpatient records, and integration of evidence-based guidelines with patient information. Numerous studies have shown that human factors, including human error, have the greatest influence on complications in surgery. Patient outcomes have improved considerably with increased surgeon compliance to implemented measures such as early feeding, optimal pain control, thromboembolic disease prophylaxis, glucose control, and use of perioperative beta-blockers. These are all examples of informatics working to minimize (or eliminate) human error!

Quality Improvement & Research

Traditional clinical research requires manual extraction of data from patient charts. These reviews are time consuming, costly, and typically involve single institutional datasets. Research that relies on coding can help researchers ask questions on a large scale but at the cost of relying on often error-prone claims data. Thanks to early informaticians, initiatives such as National Surgical Quality Improvement Project (NSQIP) have been implemented. NSQIP is standardized, nationally validated, and risk-adjusted and has been universally lauded as high quality, allowing surgeon scientists to conduct reliable large-scale population studies. Moving forward, with so much genetic data tied to clinical charts, surgeon scientists have the ability to ask clinical questions that dig deep into the DNA level. Furthermore, the use of artificial intelligence such as machine learning can make data extraction can take place in a high throughput manner.

Precision Medicine

Informatics has brought bench to bedside by introducing clinical genomics and proteomics to the practice of medicine. We are confronted with technically and statistically complex data sets like never before and are faced with the challenge of trying to tailor this information to fit each patient’s unique clinical situation. Informatics transforms this cumbersome task into something manageable, so that personalized medicine can be provided without exception to all patients. This has tremendous implications in the way surgeons can counsel and treat patients with a variety of disease processes, most notably cancer. Our understanding of other heterogeneous diseases, such as inflammatory bowel disease, have also been significantly advanced due to precision medicine. For example, we know so much more about the microbiome of the GI tract due to informatics.

Security

Cyber security is extraordinarily lax in medicine, far more than in many other professions, in large part due to the complexity of our EHR and HIT systems. Unfortunately, this means that patient information is highly susceptible to being used as ransomware if it falls into the wrong hands. Recent hospitals made headlines due to these types of attacks. All clinicians—and especially surgeons—need to be aware of the potential of the medical environment to be hacked. Anything that relies on coded data and a wired or wireless connection is susceptible to attack—meaning anything from the EHR to the supply tracker to the operating room scheduling system to patient vitals monitors to surgical implants—so surgeons need to be aware of and able to adapt to these situations, particularly if one occurs in the middle of an operation.

Simulation, Surgical Education, & Emerging Technology

Informatics is neat because it deals with the acquisition and interpretation of large quantities of data, which means that the principles of informatics can apply to just about anything the mind can think up. This makes informatics a wonderful tool for surgeon and patient education. For example, informatics can help us track information about the stress levels of the operating staff at specific time points during cases and analyze emerging patterns. This information can then be used for team building and patient safety by identifying which parts of the operation a surgeon feels least comfortable and may benefit from more practice via simulation, when noise levels should be lowered during critical parts of the surgery, and even when team members consistently want to speak up but do not and why. After surgery, informatics can be used to track the status of a patient’s recuperation with the use of fitness trackers to monitor post-operative ambulatory, pain, and nutrition status. Easy-to-use patient portals can facilitate patient-surgeon communication to avoid the unnecessary travel and wait time associated with a dedicated clinic visit.

There you have it. Clinical Informatics and how it is relevant to surgery in a nutshell. I am enjoying every moment of my fellowship so far and encourage surgeons to think about all the ways informatics can be used to shape and enrich their clinical practice.

I highly recommend checking out the profiles of two amazing women surgeon-informaticians Gretchen Purcell Jackson, M.D, Ph.D., a pediatric surgeon at Vanderbilt University, and Genevieve B. Melton-Meaux, M.D., Ph.D., a colorectal surgeon at the University of Minnesota. Both are pioneers and were visionary way ahead of their time, paving the way for other surgeons interested in clinical informatics.

For surgical residents interested in pursuing a clinical informatics fellowship, the Clinical Informatics Fellowship at the University at Buffalo, State University of New York is a fully accredited two-year program through the ACGME. Funding is available for two spots annually. For more information, please visit the official website.

References

Chung CH, Levy S, Chaurand P, Carbone DP. Genomics and proteomics: Emerging technologies in clinical cancer research.  Critical Reviews in Oncology/Hematology 2007;61(1):1-25.

Elkin, PL. Human Factors Engineering in HI: So What? Who Cares? And What’s in It for You?  Healthc Inform Res 2012;18(4):237-41.

FitzHenry F, Murff HJ, Matheny ME, Gentry N, Fielstein EM, Brown SH, Reeves RM, Aronsky D, Elkin P, Messina VP, Speroff T. Exploring the Frontier of Electronic Health Record Surveillance: The Case of Post-Operative Complications.  Med Care 2013;51(6):509-16.

Melton GB. Biomedical and Health Informatics for Surgery.  Advances in Surgery 2010;44:117-130.

Many thanks to Drs. Peter Elkin and Steven Schwaitzberg for their feedback in the early drafts of this blogpost.  

Jane Zhao, M.D. is a general surgery resident and clinical informatics fellow at the University at Buffalo, State University at New York. She received her medical degree with a scholarly concentration in Clinical Quality, Safety, and Evidence-based Medicine from McGovern Medical School, the University of Texas Health Science Center at Houston and her bachelor’s degree from Vanderbilt University where she majored in Medicine, Health and Society. She was the 2012 recipient of the Shohrae Hajibashi Memorial Leadership Award and was the founder and chair of the AWS Blog Subcommittee from 2013 to 2014.

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author, and are not necessarily the opinion of the Association of Women Surgeons.