The role of medical informatics in health promotion and disease prevention

Although not all older people have medical problems and functional impairments, the percentages of adults with illness and functional concerns dearly increase with age. In addition, the epidemiologic risk of illness, even among currently well elderly, produces a need to monitor several biomedical and psychosocial indicators. Comprehensive healthcare of older persons, therefore, can entail a major task of information management. This task can be compounded by the need to see not only a general internist but also specialists. Access to up-to-date information is a key to continuity of care. In this article we have decided to give a more theoretical account of the potential role of medical informatics in the support of strategies for promoting health at all stages of life. Whereas it might be interesting and informative to review the variety of existing computerized approaches that support clinical activity and research, we felt that since the discipline of medical informatics is in such rapid evolution, it would be useful to discuss a conceptual framework and give a vision of future possibilities. Medical informatics is a relatively young discipline that, in essence, concerns the management of information in medicine (Shortdiffe, 1990). This apparently vast area, however, has certain characteristics that should prove increasingly useful. The increasing application of computing and information technology has created the need for precision of information, including terminology classification and the modeling of information both statically (i.e., defining the structural elements) and dynamically (i.e., showing the processing of information and its change with respect to time). When a computing application is in its planning phase, the exercise following the definition of the user requirement is the development of a conceptual model that identifies exactly which elements of the available information will actually be used and processed by the system (Sowa, 1984). Much energy has been spent in discussions about the "human/computer interface," that is, the human factors that determine whether the user can understand the computing system and is willing to use it (Kass and Finin, 1989). One of the reasons that most medical computing systems are used much more often for administration purposes rather than for patient care still relates to the human factors requirement (Grant et al., 1991). Much has to do with screen design and system speed, but also involved is an understanding of how information is processed in the working environment. This understanding needs to be formed by consensus, that is, by all the different persons who are implicated; doctors, nurses, secretaries need to understand their role in relation to a new information system and how this role might have changed with respect to the previously existing system. The client or patient also does not necessarily have to be a passive participant. This currently underexploited aspect should permit patients to add data into the system, to interrogate the system to understand not only general principles but the current status of their own health, and, together with their doctor, to make use of computer-generated information like graphs, so that their doctor's advice can be better understood. In a recent survey, we determined that the patient-doctor relationship is considered by far the most important factor in the practice of preventive medicine. For some patients, computers can have a negative, even a "big brother" aspect--a reaction that worries some practitioners. We find, however, that about 50 percent of general practitioners are happy to use a computer in the presence of their patients. This discussion will deal less with the complicated issues of introducing an information system into the busy medical environment and more with the organization of information. It should be expected that where information is highly organized and well managed, a relatively coherent environment for decision making, as well as a good structure for supporting practice-based research, might be achieved. We do not undervalue the importance of human factors or good clinical judgment. Indeed the goal of medical informatics should always be to assist, as best it can, the exercise of good clinical judgment.