Moving forward
The last two months have been rough. Aside from keeping up with residency projects, I had the fine pleasure of searching for a job. The good news is I am no longer prospectively unemployed. In fact, I have patiently waded through the process and found a position which I think will be a great fit for me.
Along the way, I had the chance to contemplate the current state of clinical informatics and how I (as a pharmacist) can make an impact. Towards the end, it came down to a decision between a clinical informatics position and a clinical position. I have no doubts that I would have found a satisying and fruitful career with either choice, albeit their paths being different.
In the end, I chose the clinical informatics position. The decision was hard- much harder than I would have guessed. Although this year has been incredible and I have learned a lot about informatics, I also saw the challenges associated with this field. The truth of the matter is, the field is largely governed and led by non-pharmacists. While our professional organizations have done a ton to promote pharmacist involvement, the current state is that pharmacists are largely underrepresented at meetings where critical decisions are being made. It is a seemingly insurmountable challenge, not unlike the one clinical pharmacy services face. It is, however, a challenge I have now accepted to undertake.
I am extremely inspired that there are pharmacists among us that are paving a new path towards making an impact on clinical information systems. I have also gained a understanding of some of the potential roles a pharmacist can function in regards to informatics.
As for my future role, it will be a hybrid analyst/developer position. Analysis is important as it encompasses both project managment and business analysis. This aspect includes determining structure, policies and operations of an organization and coming up with solutions that balance timelines, cost, and functionality along with system integration points and limitations. Once the solution has been established, the developer aspect will deal with requirements gathering from clinicians and translating those requirements for the full time programmers on the team. These requirements will typically be for new implementations of various types of clinical decision support for the hospital.
Technical Concepts
I'm currently in a 'technical concepts' rotation which gives me the opportunity to work with various development and IT infrastructure teams at the medical center. It has given me a more detailed perspective into the transparent yet crucial infrastructure that supports all of the clinical information systems.
Some notable highlights regarding various topics and questions I asked about:
Server and database infrastructure:
The director of application support runs a team whose job is to provision platforms (eg., databases & servers) so they are ready for apps. The first question he typically asks is whether it is 'chocolate' or 'vanilla.' Essentially, all applications that use a database either run on Windows or *nix (eg., Linux Red Hat). As a clinical application owner (the pharmacy information system & CPOE) and customer, I work out an operational-level agreement (OLA) with his team. The OLA determines the support turnaround time, availability, and maintenance I receive from them. Just as it is important to determine a service level agreement (SLA) with an outside vendor, it is paramount to define an OLA with your internal infrastruture service. Disaster recovery (DR) is also crucial; plan to test the DR failover at least once per year.
What innovations in the market has changed the way you do business?
Storage area networks (SAN) is a big game changer. By having a central network of storage devices, it simplifies administration and flexibility. For disaster recovery, SAN offers modularity so you can replace individual components. In addition, fiber optics introduces the ability to have long distance transmission to another distant location.
What is an important current trend you see developing?
Virtualization. By using virtualization, you can set up hundreds of virtual servers with different setting using a central group of commodity boxes. These commodity boxes are basically physical servers with identical configurations that emulate the server environment you need. This decreases cost and increases efficiency. Virtualization also allows you to run thin clients as a UI for users while maintaining everything in a central location on the back end. A typical clinical work computer will run software with all its data and settings stored in the 'cloud.'
Speaking of the 'cloud', how does software as a service (SaaS) play a role?
SaaS is a competitor to traditional data infrastructures, but that is where the market is headed towards. Small to medium hospitals cannot afford the personnel to maintain and administer server farms. SaaS is attractive because the entire infrastructure is handled by the vendor. However, traditional models still offer advantages. Since the team is internal, you get the face to face interaction and maybe faster turnaround times. Also, an internal team will not 'nickle and dime' you for every single service. One key challenge to SaaS is not storing the data remotely, but transmitting the data in an efficient manner. When talking about petabytes worth of information, the bandwidth from point A to B must be able to keep up with the data (eg., the internet is a series of tubes).
The elusiveness of drug interactions
One of the seemingly insurmountable challenges that face CPOE and e-Prescribing is alert fatigue. Alert fatigue results when something like drug drug interactions (DDIs) are highly insensitive or have a high rate of false positives. When a clinical information system imports DDIs from a commerical provider like FirstDataBank (FDB), you get every single possible interaction that may occur. This paradoxically results in a situation where noisy alerting may impede clinical decision support rather than facilitate it. In Greenberg and Ridgely's JAMIA commentary, Clinical Decision Support and Malpractice Risk, they poignantly highlight:
"CDS represents a situation in which malpractice and products liability can too easily lead to a perverse equilibrium in which the law has a detrimental effect on technology and in which patients, physicians, institutions, and the government are all made worse off as a result."
Challenges in e-prescribing
JAMIA's article "Transmitting and processing electronic prescriptions:experiences of physician practices and pharmacies" by Grossman et al. talks about the challenges pharmacies and physician practices face regarding e-prescribing. From my experience in retail pharmacy, it is pretty accurate in highlighting the current state of the art.
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