All around us, we see a rapidly growing explosion of computers and related technologies appearing in our lives. Electronic pagers, educational CD-ROMs, and databases on the Internet's World Wide Web are only a small selection of examples. Many of these technologies are information technologies: they alter how we gather, create, organize, and disseminate information. They influence how we practice psychiatry as well as how others expect us to practice it. Their impact will only continue to grow with time, becoming an essential part of psychiatric work (1).
Many forces are contributing to making knowledge of these technologies an essential part of practicing psychiatry. The ever-increasing volume of medical knowledge is too vast to be taught in a time-limited medical curriculum (2,3), requiring access to tools that can assist in obtaining and organizing that expanse of information. A related increase in the amount of specialization and in the distribution of care demands effective communications and database tools for psychiatrists who must contact consultants and manage the various components of a dispersed treatment team. Most significantly, the enormous pressure to manage care has created large enterprises that demand information about the services that psychiatrists and other physicians provide (4). These groups have instituted the use of computers for most medical tasks in an attempt to obtain risk-adjusted data for comparing the outcomes of treatment in different hospitals and managed care plans (5—7).
In this environment, we need to train psychiatrists to use the technologies they will face in their daily practice. Even more than this, we need to help them to learn to introduce information technology into their understanding of how they practice so that information technology can serve as a useful tool, rather than an outside demand. It will not be enough for psychiatrists simply to learn to operate computer equipment or particular idiosyncratic software. We will need to be familiar with the concepts and potential that guide the operation and implementation of these devices.
The study of the application of information technologies to medical tasks is part of the science of medical informatics. Medical informatics has been defined as the "scientific field that deals with the storage, retrieval, and optimal use of biomedical information, data, and knowledge for problem solving and decision making" (8). This paper will briefly review the development of medical informatics before presenting some guidelines about the necessary content of informatics training in a psychiatric context. Finally, the article ends with a detailed exploration of possible strategies and barriers to the implementation of an informatics component into a training program.
Historically, information has always been a large part of work in medicine. Whether approaching the four humours or the 16 types of serotonin receptors, physicians have always had to contend with learning extensive nomenclatures, as well as medical theory, diagnosis, and treatment. Computers began to play a larger role in organizing this information in the 1960s (9). Medical informatics started as the study of such computer applications, formally recognized as an academic field in the 1970s. At that time, organizations like the IMIA (International Medical Informatics Association) or meetings like the SCAMC (Symposium for Computer Applications in Medical Care) gathered together physicians of similar interest and encouraged research into making information tools that would accomplish common medical tasks. Today, after astronomical growth in the power of computers, this research has produced easily available systems, shifting the emphasis from creating computer tools for physicians to the problem of implementing their use in physician offices, hospitals, and other health care organizations (10,11). Time has seen an especially successful application of medical informatics to solving the information challenges of particular fields of medicine, such as radiology and pathology. Such work is only beginning in the field of psychiatry (12).
We believe that an informatics curriculum needs to be developed in psychiatry. Although programs exist for specific training in medical informatics (13,14), they generally focus more on producing technically skilled information professionals rather than informed clinicians (15). Informatics training in medical schools is limited, though it should improve in the near future (16). It continues to have a bias toward teaching "computer literacy" rather than clinical use of the computer (17). Residency training programs have begun to implement and study the effects of specific training curricula (18,19), although this is more prominent in nonpsychiatric training programs than psychiatric ones (20). These curricula also tend to emphasize mastery of technology instead of the information process of clinical practice.
This section describes what we feel are the four essential areas of knowledge where psychiatrists must be able to apply an informatics approach to their clinical work. These are patient care, communications, education, and practice management (see T1A and T1B). The focus of the first section will be on the learning objectives of training in these areas. The subsequent section will describe in greater detail how instruction in these areas might be accomplished and how such a curriculum might be implemented in an academic setting.
The primary learning task of this area is to define and learn to execute the information tasks of clinical patient care. Instruction on these processes should include analysis of how we interact with the patient and others to collect history and mental status information, deciding how that data should be organized and prioritized, and theorizing or implementing ways to efficiently effect such processes. Information technology has been applied to these tasks in the form of computer software that automates standardized interviews, computer applications for electronically maintaining patient records, and software that aids in the formulation of diagnoses. Gathering ancillary lab data has also become computer based due to the development of electronic clinical support systems for communicating pathology or radiology results.
With these changes, an informatics curriculum should encourage discussion and exploration of issues of interface. Important questions to raise include the following:
Communication and Networking
The learning tasks of this area cover communication with others, whether patient or physician. Instruction on these tasks should include study of how we communicate with patients; how the timing and the space in which we meet affect the message; what we relate using nonverbal cues; and what types of information we provide and how we provide it. We should examine how in consultation we communicate the basic information describing a patient's difficulties as well as the ineffable qualities of interpersonal interaction. Such aspects of communications will be affected as the Internet and other computer networks are used more and more in forms ranging from plain text e-mail to large-screen videoconferencing for telemedicine-type evaluations and consultation (21). Psychiatric informatics curricula should explore several issues in this area:
Such issues will become significant as new communications options create new expectations of how psychiatry should be practiced, introducing changes into the doctor—patient relationship (22).
The learning task of this category is to discover how we obtain and disseminate the information needed to practice the art and science of psychiatry. As new kinds of teaching occur through the use of multimedia programs on videodisc, CD-ROM, or the World Wide Web and as the research base and list of publications and new sources of information continue to swell, residents must master the ability to critically look at the information they acquire and the process by which they obtain and organize it. New information sources such as the Internet pose a challenge to learning because of the quantity and diversity of opinions expressed (21). Relevant questions for study include the following:
This final area covers the study of managing information related to maintaining a clinical practice. Typical management tasks include scheduling patients, tracking their treatment and bills, monitoring outcomes of treatment, and handling quality assurance. Informatics instruction should include discussion and evaluation of what these tasks are and how they are best organized.
New information systems are beginning to automate some of these tasks, but we need to first define and ponder the goals that such systems should strive to accomplish. Such an emphasis can help trainees prepare themselves and maintain an appropriate focus as they attempt to forge a practice in the future information age.
To achieve the learning objectives described earlier, direct experience with technology is important to help instill an understanding of the challenges it brings. Just as the breadth of a psychiatry curriculum ranges from basic science in molecular genetics and neuroscience to clinical studies of many forms of psychopathology, the breadth of a complete informatics curriculum ranges from basic studies of computer operations to theoretical consideration of the application of computers in different tasks. Problem-based learning (PBL) has been suggested as an appropriate means to bridge the breadth of behavioral science training (23) and has been applied to learning informatics (24). We suggest that specific tasks be devised to ensure experience and thought about the information skills useful for psychiatric work. Although the ability to operate a computer is important, an informatics curricula for residents should focus on using computers to accomplish psychiatric information tasks instead of specific didactics on computer functioning. Such a focus has been described as learning with computers instead of learning about them (3). As in the PBL model, learning is accomplished through solving a problem related to the learning objectives, then supplemented with relevant discussion of underlying theory and related issues.
Implementation of any part of this curriculum is challenging, and complete implementation is likely to be beyond the resources of any training institution. Much of this training can be accomplished, however, if available resources and support are appropriately acquired and organized. We have divided the types of assets that require assessment and organization into three broad categories: physical assets, personnel assets, and cultural/political assets. Physical assets include available computers, networking equipment, and software. Personnel assets are the different people who can serve as instructors or provide support in using the physical resources. Cultural/political assets are the positive and negative environmental factors that will affect an informatics effort driven by particular political or personal motivations. We will cover the assessment of each category in turn and follow with a discussion of how this assessment can guide program design and the expansion of further resources and instruction.
Assessing Physical Assets
Assessment of physical assets can be simply divided into assessment of available hardware and software (see T2A and T2B). Assessment of hardware starts with determining what types of computers are available for resident use. Many hospitals, especially older ones, rely on terminals connected to a mainframe computer. For such systems, one needs to discover what types of software and information delivery the mainframe or system administrator supports. Other clinical facilities use desktop computers, in which case one needs to find out the available disk space, RAM, operating system, and processor type of these machines. This list of parameters define the computer capacity and, consequently, the types of software that can be used. Assessment of associated hardware such as type of networking card, availability of CD-ROM or scanner, etc., allows one to determine the ability to use more specialized software such as Internet browsers or optical character-recognition software.
Assessment of software starts with discovering what is currently available for both desktop computers and hospital-wide mainframe systems. Personal computers will usually have word-processing, spreadsheet, and perhaps some type of communications software. Specialized programs for database, education, or practice management may be present. Determine if licensing agreements are present for these individualized packages, remaining alert for site licenses that may have been obtained for the entire organization. Larger mainframe or other hospital-wide servers will provide lab information and testing data to an entire institution. Determine how access to this information is made available (through terminals, terminal emulators, or database systems). Other hospital-wide services may be made through subscription, such as to bibliographic services like MEDLINE or Grateful MED, in conjunction with the use of particular software.
Assessing Personnel Assets
The assessment of physical assets goes hand-in-hand with the assessment of personnel assets. There are many groups of individuals who can contribute to establishing an informatics curriculum (see T3A and T3B). Discovering who among these groups is capable and interested in providing help will not only identify potential instructors, but will also identify people who own or are aware of other physical information assets that might be accessible.
Looking within one's own department is the first step in identifying potential personnel resources. Find out who has interest or experience in dealing with informatics or computer systems. The scope of informatics is broad, ranging from high-level understanding of knowledge synthesis and generation to the nuts and bolts of making a computer perform seemingly banal tasks. No single person can maintain expertise in such a large range of topics, making it essential to build a team of informatics leaders and instructors within the department.
Looking outside one's department can yield a variety of talented individuals who may be willing to contribute to an informatics effort. Depending on how computer support, librarian services, and informatics studies are organized, different groups will have different skills and different computer resources available. Most academic institutions, for example, have a dedicated Information Service (or Information Technology) group. Such a group is responsible for installing and maintaining all computer hardware and software necessary for supporting clinical work. Often, these groups also provide instruction in how to use the hardware and software they install. Thus, Information Service people may be able to teach technical information to residents or provide some of their teaching materials.
Librarian services can be an excellent source of personnel as well. Medical libraries are usually responsible for providing bibliographic tools (like MEDLINE or Grateful MED) and access to medical teaching resources such as CD-ROM. In a given medical institution, librarians often spearhead the effort of discovering potential Internet resources and may offer classes or instruction on using the Web or other information resources.
Finally, other medical departments and even nonmedical departments may have informatics expertise they are willing to share. Departments of radiology and pathology have a tradition of informatics involvement, as much of the information they gather and disseminate is processed using computers. Nonmedical departments, such as biomedical engineering, computer science, library science, or even art, should also be examined as potential sources of help and information. If a formal Medical Informatics program exists at a given institution, it will often be tied to such a department. Such programs provide a reservoir of expertise about the subject of informatics as well as experience in the practical difficulties of implementing technology in the local environment.
Assessing Political Assets
Evaluation of the cultural and political environment proceeds with the assessment of personnel (see T4A and T4B). Looking at one's own department, it is important to have a sense of the degree of support from fellow faculty as well as administrators who control resources. An informatics program requires both financial and personnel resources, which inevitably makes it the target of political struggles. Ideally, an informatics effort would be something supported by all faculty. Residents would be encouraged to understand and use information technology in all of their clinical and learning settings, moving instruction beyond the limits of a didactic series.
It is also important to assess the degree of support that can be provided by extradepartmental groups. Information Systems/Information Technology groups bear a responsibility to institutional technology as a whole and may have other agendas for encouraging psychiatry to use the same technologies as other departments. Their recommendations and instructions will be biased toward institutional solutions instead of the broader range of information tools that are available, possibly missing effective and simple areas that are still useful for the clinician. Medical library groups, on the other hand, can be less biased, since their goal as librarians is simply to make information more available to the physician.
Other medical departments and nonmedical departments are generally subject to the more obvious bias of self-interest. Whether associated with a formal medical informatics program, or not, such groups will be looking for help and resources themselves. It is important to try to understand what their specific needs and goals may be, so that synergistic relationships might be encouraged. Our experience is that many of these groups are interested in working with others, but that psychiatry has rarely pursued involvement.
Once resources are assessed, one can proceed to program design. This should start by targeting areas of competency to be covered by particular learning tasks that use present hardware, software, and instructor expertise. Some tasks might be delegated to medical librarians and the computer systems they possess. Others might require the acquisition of new hardware, software, or training that allows someone to become an instructor on a particular task and subject.
Looking at the example of our own program, we find it under constant revision. There are still areas in which we have little expertise available. As we discover new resources or as we learn more about the subject of informatics ourselves, we devise new learning tasks that can be assigned or demonstrated for residents. It is always possible to find alternatives for teaching particular competency areas where resources are scarce. If we lacked the benefit of our local computer network, for example, we could still demonstrate Internet principles by using a computer hooked up to a modem and a subscription to a local Internet service provider.
As our time in the overall curriculum is limited, we emphasize issues of how to continue learning and how we learned this information ourselves. Our goal is not to teach every detail of how to use e-mail or database software or MEDLINE, but to give residents an overall framework for organizing their computer knowledge and what questions they should be asking. The examples we use are the ones that we find easily available in our own environment. These are used to promote discussion and the critical evaluation of the limits and potential of technology and modern information management. We want to encourage not only familiarity with the tools but also understanding of the types of resources available, the social structure of information generation, and the factors to consider in judging the value and impact of technology. These are the factors that make a person truly "well rounded" in their understanding of information technology (25).
As a corollary to this principle of emphasizing a broader process of learning, we also emphasize the use of systems that are already in place in the department and hospital. All computer hardware and software is continuously outdated, and it makes little sense to try to keep everyone constantly updated with a limited education budget. When we do obtain hardware or software, it is generally made available through a shared workstation. Most of our communications software is free or discounted because we are an educational institution. We attempt to teach the use of information technology while remaining within the limitations of our resources.
The basic components of the curriculum will shift as well. Our suggested curriculum outlines what we consider minimum standards based on how psychiatry is currently practiced and the technologies we feel will become so ubiquitous that they cannot be avoided and must be learned. With time, even more aspects of information technology will likely become unavoidable parts of psychiatric practice and thus essential components of the curriculum. As an example, one could imagine a future where psychiatric practice involves frequent, short, intensive outpatient visits by videophone. The information demands and the application of technology would shift, requiring informatics instruction to explore if trainees should simply talk into the screen, or if it would be more effective in some cases to combine speech with instructional slides.
Information technology is playing an increasingly important role in psychiatric work. Psychiatric training needs to include not only experiences teaching psychiatric treatment and diagnosis but also experiences that teach how information technology is employed in the daily tasks of the psychiatrist. Basic familiarity with a computer or a computer program will not be enough. Increased information demands from patients, managed care, and other physicians will require us to be able to understand how to apply these technologies to our usual habits of work (26).
Other authors have found that psychiatric residency training directors have hesitated in implementing computer training because of a lack of funds, lack of resident time, lack of knowledgeable instructors, and lack of a nationally accepted curriculum (20). We hope that this description of a curriculum and discussion of implementation will help generate ideas and a discourse as to important aspects of informatics in psychiatry and how we can increase our efforts to incorporate these aspects into our training.