OBJECTIVE: Clarify disciplinary foundations and internal structure of biomedical informatics. METHODS: We analyze BMI's emergence at disciplinary intersections and map its internal structure across 4 domains: theory and practice of knowledge discovery, knowledge representation and reasoning, knowledge architecture, and knowledge-driven transformation. We compare BMI with mathematics, computer science, biostatistics, and biomedical engineering, and illustrate emergent characteristics through a precision medicine example. RESULTS: BMI's distinctive contribution-elucidating the structure of biomedical knowledge and developing methods to discover, preserve, and make knowledge actionable-requires strength across all 4 domains. BMI developed these domains pragmatically: building systems, extracting principles, and formalizing theories. The discipline must now complement empirical approaches with rigorous theoretical work: assessing adequacy of existing theories, identifying gaps, and orchestrating collaborative development. CONCLUSIONS: BMI creates emergent capabilities across disciplines. As biomedicine becomes increasingly complex, BMI must strengthen its theoretical foundations while demonstrating transformative potential of knowledge spanning biological scales and time.

Eta S. Berner, EdD, FACMI, FIAHSI, died on December 11, 2023, only a month after interacting with many colleagues at the American Medical Informatics Association (AMIA) Annual Symposium in New Orleans. As co-workers, collaborators, and friends we each have personal memories that we hold near and dear. With this editorial, we celebrate her professional contributions. Dr Berner was an author of 20 papers published in Journal of the American Medical Informatics Association (JAMIA),1–20 the most recent in the February 2024 issue. Her 1994 New England Journal of Medicine paper on evaluation of diagnostic decision support systems set the standard for rigorous evaluation of such systems.21 Several of her early JAMIA papers reflected her expertise in decision support,1,4,5 while others represented Dr Berner’s commitment to competency-based informatics education through her own work11,12 as well as her substantial contributions to efforts within AMIA.14 A third area of important contribution published in JAMIA was in the area of professional ethics for the field.8,13,16,17 In addition to her authorship contributions, Dr Berner served multiple terms on the JAMIA Editorial Board providing thoughtful peer-reviews on hundreds of manuscripts.

OBJECTIVE: The characteristics of clinician activities while interacting with electronic health record (EHR) systems can influence the time spent in EHRs and workload. This study aims to characterize EHR activities as tasks and define novel, data-driven metrics. MATERIALS AND METHODS: We leveraged unsupervised learning approaches to learn tasks from sequences of events in EHR audit logs. We developed metrics characterizing the prevalence of unique events and event repetition and applied them to categorize tasks into 4 complexity profiles. Between these profiles, Mann-Whitney U tests were applied to measure the differences in performance time, event type, and clinician prevalence, or the number of unique clinicians who were observed performing these tasks. In addition, we apply process mining frameworks paired with clinical annotations to support the validity of a sample of our identified tasks. We apply our approaches to learn tasks performed by nurses in the Vanderbilt University Medical Center neonatal intensive care unit. RESULTS: We examined EHR audit logs generated by 33 neonatal intensive care unit nurses resulting in 57 234 sessions and 81 tasks. Our results indicated significant differences in performance time for each observed task complexity profile. There were no significant differences in clinician prevalence or in the frequency of viewing and modifying event types between tasks of different complexities. We presented a sample of expert-reviewed, annotated task workflows supporting the interpretation of their clinical meaningfulness. CONCLUSIONS: The use of the audit log provides an opportunity to assist hospitals in further investigating clinician activities to optimize EHR workflows.

OBJECTIVE: Successful technological implementations frequently involve individuals who serve as mediators between end users, management, and technology developers. The goal for this project was to evaluate the structure and activities of such mediators in a large-scale electronic health record implementation. MATERIALS AND METHODS: Field notes from observations taken during implementation beginning in November 2017 were analyzed qualitatively using a thematic analysis framework to examine the relationship between specific types of mediators and the type and level of support to end users. RESULTS: We found that support personnel possessing both contextual knowledge of the institution's workflow and training in the new technology were the most successful in mediation of adoption and use. Those that lacked context of either technology or institutional workflow often displayed barriers in communication, trust, and active problem solving. CONCLUSIONS: These findings suggest that institutional investment in technology training and explicit programs to foster skills in mediation, including roles for professionals with career development opportunities, prior to implementation can be beneficial in easing the pain of system transition.

OBJECTIVE: The goal of this investigation was to determine whether automated approaches can learn patient-oriented care teams via utilization of an electronic medical record (EMR) system. MATERIALS AND METHODS: To perform this investigation, we designed a data-mining framework that relies on a combination of latent topic modeling and network analysis to infer patterns of collaborative teams. We applied the framework to the EMR utilization records of over 10 000 employees and 17 000 inpatients at a large academic medical center during a 4-month window in 2010. Next, we conducted an extrinsic evaluation of the patterns to determine the plausibility of the inferred care teams via surveys with knowledgeable experts. Finally, we conducted an intrinsic evaluation to contextualize each team in terms of collaboration strength (via a cluster coefficient) and clinical credibility (via associations between teams and patient comorbidities). RESULTS: The framework discovered 34 collaborative care teams, 27 (79.4%) of which were confirmed as administratively plausible. Of those, 26 teams depicted strong collaborations, with a cluster coefficient > 0.5. There were 119 diagnostic conditions associated with 34 care teams. Additionally, to provide clarity on how the survey respondents arrived at their determinations, we worked with several oncologists to develop an illustrative example of how a certain team functions in cancer care. DISCUSSION: Inferred collaborative teams are plausible; translating such patterns into optimized collaborative care will require administrative review and integration with management practices. CONCLUSIONS: EMR utilization records can be mined for collaborative care patterns in large complex medical centers.

In today’s society, most people are both consumers of information technology and of health care. Virtually every person has consumed health care and will consume more as one ages. Moreover, 84% of US households own a computer, 1 and 64% of adults own a smartphone. 2 We carry pocket-sized devices that connect us to people around the world and vast stores of information. With these technologies, we manage our lives from mundane activities like reading, checking the weather, making to-do lists, and buying books and clothes, to more complex tasks such as learning, managing finances, shopping for houses, and maintaining ties with friends and family around the world. With such diverse and powerful technologies at our fingertips and myriad societal-level health care challenges in cost, quality, and outcome, it is tantalizing to imagine all of the ways that health information technologies (health IT) can be used to enhance people’s health and societies’ health care delivery. Patient-centered care respects and responds to individual differences in patient preferences, needs, and values. 3 To respond to such differences and achieve patient-centered care, patients and health care professionals must engage in constant communication. In recent years, researchers have examined a number of ostensibly patient-oriented technologies that could enhance such communication, including patient portals, personal health records (PHRs), and mobile health (mHealth) applications. Furthermore, it is not difficult to conceptualize pathways through which such information systems might improve communication between patients and clinicians, create more patient-centered care, and help achieve the triple aim of better experiences of care, better population health, and lower health care costs. 3 Yet, practically, these enticing tools and outcomes are far from reality. There is scant evidence that patients frequently or effectively access and use information systems that engage them and improve patient-centered care delivery. For example, patients generally have positive attitudes toward using patient portals, but studies have not shown portals to have positive impacts on patient empowerment, 4,5 health outcomes, or costs. 6,7 Also, racial and ethnic differences may impede widespread portal adoption and use, 6 and this threatens to compound already-existing disparities in health care access and communication. Another often-studied system type, the PHR, has been shown to infrequently contain patient-oriented features, which is also likely to limit patient-clinician communication. 6 Next, as smartphone adoption has increased, mHealth technologies have emerged as another set of tools that may enhance patient-clinician communication. Yet despite the existence of many applications, including hundreds for cancer alone, 8 we lack strong research evidence on how to design and use mHealth applications to consistently achieve patient-centered care. 3 Finally, the study of patient-facing systems to improve patient-centered care cannot be disentangled from the study of electronic health records (EHRs). EHRs are nearing ubiquity in the US health care system, meaning that patient engagement, communication, and attainment of patient-centered care is also inexorably tied to the design and use of EHRs. This special focus issue follows from the 2014 annual Workshop on Interactive Systems in Healthcare (WISH). The WISH workshop aims to promote deeper and more profound connections among the biomedical informatics, human-computer interaction, medical sociology, and anthropology communities. WISH 2014 focused on the challenge that information systems often fall short in adequately engaging patients and ensuring that clinical decisions are patient-centered. This may be attributed to a disconnect between system designers’ understanding of clinical work and care processes, a lack of clear protocols defining how patient-engaged technologies should be adopted and used, or an insufficient understanding of people’s information needs, preferences, and values. Therefore, the articles in this special focus issue reflect discipline-spanning research teams, methodologies, and perspectives while highlighting new approaches to designing, developing, and evaluating interactive information systems to support patient-centered care and patient engagement. We have organized the articles in this special focus issue into four themes: health IT for patient-centered heath care delivery and management, patient–provider interactions mediated by health IT, pervasive and mobile technologies to promote patient engagement, and designing for underserved patient populations. The first theme includes studies that focus on improving EHR and PHR effectiveness and patient-centered care outcome. The studies range from designing a scaffolding system to existing EHR, customizing a commercial EHR system, identifying strategies of using EHR during patient consultation, re-examining the role of EHR in primary clinical workflows, and designing an experiment to determine the PHR impact on patient engagement. For instance, to improve patient engagement and EHR effectiveness, researchers implemented a scaffolding system to include patient-reported outcomes integrated into the existing EHR and identified both facilitators (e.g., high degree of process automation, good interface usability, capability of targeting the right patients at the right time) and barriers (e.g., uncertain clinical benefits and constraints on time, workflows, and efforts). 9 Similarly, researchers from Texas Children’s Hospital customized a commercial EHR to include the design of a new work element for a cross-functional team to prioritize the outcome measurement in EHR optimization, which significantly improved the outcome status tracking and number of patients involved. 10 Moreover, researchers continue to investigate workflow issues 11 and the tensions of using EHR while interacting with patients face to face 12 in primary care settings, which helps inform commercial vendors about how to improve the design of EHR for accommodating the dynamic needs of frontline clinicians. Furthermore, an observational study on the use of PHR indicated significant improvement in the HbA1c levels of the active and super user groups while no other health outcomes improved. There was also no statistically significant improvement observed in patient engagement during the study. While the research context is limited in coronary artery disease patients, we hope this study could shed light on the current debates of PHR usefulness and effectiveness, and invite additional efforts in examining the effectiveness of patient-centered systems, including patient portals, on improving patient engagement and health outcomes. The second theme focuses on the design of health IT to improve the quality of patient–provider interaction. Studies included the development of a web-based toolkit to improve patient education and involvement in the care plan during hospitalization, 13 the design of a dashboard to facilitate data collection and efficient use of patient-reported outcomes, 14 and design recommendations for a web-based tool to satisfy the caregivers’ information needs in the context of inpatient pediatric hematopoietic stem cell transplant. 15 As there is a paucity of research in designing IT tools to support patients and caregivers in an inpatient setting, we hope that these studies will provide readers with valuable insights and practical design experiences for approaching the problem, including ways to engage patients, caregivers, and providers in the iterative user-centered design process. The third theme involves the use of pervasive and mobile technologies to promote patient engagement, such as. 16 Many mHealth technologies were found to be useful for patients to manage their care and improve health outcomes. However, certain patient factors must be considered when designing mHealth technologies, as they play a pivotal role in patient engagement. For example, patient factors like ethnicity, health literacy, and age were found to impact the use of mHealth applications for managing medication adherence 17 and service members’ background characteristics were reported to impact their engagement with an mHealth application for managing their post-trauma issues. 18 On the other hand, one size does not fit all. It is therefore important to customize mHealth tools for patients with special needs to ensure patient engagement. For instance, an mHealth tool designed for diabetic patients from economically disadvantaged communities and ethnic minorities was found to help patients self-monitor and reflect, 19 and a PHR application customized for post-cardiothoracic surgery patients was useful to support their medication management and tracking in a hospital setting. 20 The last theme that we identified is centered around designing for underserved patient populations, e.g. 21 It is well-known in the health informatics community that studying underserved patient populations is challenging. Thus, most previous research focused on a single case study. While a single case study offers valuable knowledge, cross-case analysis of diverse case studies offers exceptionally important insights to the success factors, barriers, and common patterns identified across multiple cases. 22 In addition, research targeted at underserved populations offers lessons particularly instrumental in the design of health IT to meet the specific needs of individual underserved populations. For example, a large-scale national program succeeded in promoting health and well-being in older adults using a suite of accessible computing, 23 a longitudinal participatory design approach supported the design of mHealth applications for overcoming perinatal depression of women from vulnerable populations after their pregnancies, 24 and the use of daily questionnaires helped to identify the association between service members’ background characteristics and their engagement with an mHealth application for managing their post-trauma issues/conditions. 18 In conclusion, researchers in this growing, vibrant health informatics community have been diligently exploring a range of relevant topics in the design, implementation, and evaluation of interactive, patient-centered health IT systems for enhancing patient engagement, as evidenced in the sample research included in this special focus issue. While challenges remain and future work abounds, we believe that our effort has led us a step closer to achieving a high level of health care quality and outcomes.

Public interest in the quality and safety of health care has spurred examination of specific organizational routines believed to yield risk in health care work. Medication administration routines, in particular, have been the subject of numerous improvement projects involving information technology development, and other forms of research and regulation. This study draws from ethnographic observation to examine how the common routine of medication administration intersects with other organizational routines, and why understanding such intersections is important. We present three cases describing intersections between medication administration and other routines, including a pharmacy routine, medication administration on the next shift and management reporting. We found that each intersection had ostensive and performative dimensions; and furthermore, that IT-enabled changes to one routine led to unintended consequences in its intersection with others, resulting in misalignment of ostensive and performative aspects of the intersection. Our analysis focused on the activities of a group of nurses who provide technology use mediation (TUM) before and after the rollout of a new health IT system. This research offers new insights on the intersection of organizational routines, demonstrates the value of analyzing TUM activities to better understand the relationship between IT introduction and changes in routines, and has practical implications for the implementation of technology in complex practice settings.

OBJECTIVE: Without careful attention to the work of users, implementation of health IT can produce new risks and inefficiencies in care. This paper uses the technology use mediation framework to examine the work of a group of nurses who serve as mediators of the adoption and use of a barcode medication administration (BCMA) system in an inpatient setting. MATERIALS AND METHODS: The study uses ethnographic methods to explore the mediators' work. Data included field notes from observations, documents, and email communications. This variety of sources enabled triangulation of findings between activities observed, discussed in meetings, and reported in emails. RESULTS: Mediation work integrated the BCMA tool with nursing practice, anticipating and solving implementation problems. Three themes of mediation work include: resolving challenges related to coordination, integrating the physical aspects of BCMA into everyday practice, and advocacy work. DISCUSSION: Previous work suggests the following factors impact mediation effectiveness: proximity to the context of use, understanding of users' practices and norms, credibility with users, and knowledge of the technology and users' technical abilities. We describe three additional factors observed in this case: 'influence on system developers,' 'influence on institutional authorities,' and 'understanding the network of organizational relationships that shape the users' work.' CONCLUSION: Institutionally supported clinicians who facilitate adoption and use of health IT systems can improve the safety and effectiveness of implementation through the management of unintended consequences. Additional research on technology use mediation can advance the science of implementation by providing decision-makers with theoretically durable, empirically grounded evidence for designing implementations.

OBJECTIVE: The goal of this study was to develop an in-depth understanding of how a health information exchange (HIE) fits into clinical workflow at multiple clinical sites. MATERIALS AND METHODS: The ethnographic qualitative study was conducted over a 9-month period in six emergency departments (ED) and eight ambulatory clinics in Memphis, Tennessee, USA. Data were collected using direct observation, informal interviews during observation, and formal semi-structured interviews. The authors observed for over 180 h, during which providers used the exchange 130 times. RESULTS: HIE-related workflow was modeled for each ED site and ambulatory clinic group and substantial site-to-site workflow differences were identified. Common patterns in HIE-related workflow were also identified across all sites, leading to the development of two role-based workflow models: nurse based and physician based. The workflow elements framework was applied to the two role-based patterns. An in-depth description was developed of how providers integrated HIE into existing clinical workflow, including prompts for HIE use. DISCUSSION: Workflow differed substantially among sites, but two general role-based HIE usage models were identified. Although providers used HIE to improve continuity of patient care, patient-provider trust played a significant role. Types of information retrieved related to roles, with nurses seeking to retrieve recent hospitalization data and more open-ended usage by nurse practitioners and physicians. User and role-specific customization to accommodate differences in workflow and information needs may increase the adoption and use of HIE. CONCLUSION: Understanding end users' perspectives towards HIE technology is crucial to the long-term success of HIE. By applying qualitative methods, an in-depth understanding of HIE usage was developed.

Federal legislation (Health Information Technology for Economic and Clinical Health (HITECH) Act) has provided funds to support an unprecedented increase in health information technology (HIT) adoption for healthcare provider organizations and professionals throughout the U.S. While recognizing the promise that widespread HIT adoption and meaningful use can bring to efforts to improve the quality, safety, and efficiency of healthcare, the American Medical Informatics Association devoted its 2009 Annual Health Policy Meeting to consideration of unanticipated consequences that could result with the increased implementation of HIT. Conference participants focused on possible unintended and unanticipated, as well as undesirable, consequences of HIT implementation. They employed an input-output model to guide discussion on occurrence of these consequences in four domains: technical, human/cognitive, organizational, and fiscal/policy and regulation. The authors outline the conference's recommendations: (1) an enhanced research agenda to guide study into the causes, manifestations, and mitigation of unintended consequences resulting from HIT implementations; (2) creation of a framework to promote sharing of HIT implementation experiences and the development of best practices that minimize unintended consequences; and (3) recognition of the key role of the Federal Government in providing leadership and oversight in analyzing the effects of HIT-related implementations and policies.

OBJECTIVE: To determine characteristics and effects of nurse dosing over-rides of a clinical decision support system (CDSS) for intensive insulin therapy (IIT) in critical care units. DESIGN: Retrospective analysis of patient database records and ethnographic study of nurses using IIT CDSS. MEASUREMENTS: The authors determined the frequency, direction-greater than recommended (GTR) and less than recommended (LTR)- and magnitude of over-rides, and then compared recommended and over-ride doses' blood glucose (BG) variability and insulin resistance, two measures of IIT CDSS associated with mortality. The authors hypothesized that rates of hypoglycemia and hyperglycemia would be greater for recommended than over-ride doses. Finally, the authors observed and interviewed nurse users. RESULTS: 5.1% (9075) of 179,452 IIT CDSS doses were over-rides. 83.4% of over-ride doses were LTR, and 45.5% of these were ≥ 50% lower than recommended. In contrast, 78.9% of GTR doses were ≤ 25% higher than recommended. When recommended doses were administered, the rate of hypoglycemia was higher than the rate for GTR (p = 0.257) and LTR (p = 0.033) doses. When recommended doses were administered, the rate of hyperglycemia was lower than the rate for GTR (p = 0.003) and LTR (p < 0.001) doses. Estimates of patients' insulin requirements were higher for LTR doses than recommended and GTR doses. Nurses reported trusting IIT CDSS overall but appeared concerned about recommendations when administering LTR doses. CONCLUSION: When over-riding IIT CDSS recommendations, nurses overwhelmingly administered LTR doses, which emphasized prevention of hypoglycemia but interfered with hyperglycemia control, especially when BG was >150 mg/dl. Nurses appeared to consider the amount of a recommended insulin dose, not a patient's trend of insulin resistance, when administering LTR doses overall. Over-rides affected IIT CDSS protocol performance.

OBJECTIVE: Health information exchange (HIE) systems are being developed across the nation. Understanding approaches taken by existing successful exchanges can help new exchange efforts determine goals and plan implementations. The goal of this study was to explore characteristics of use and users of a successful regional HIE. DESIGN: We used a mixed-method analysis, consisting of cross-sectional audit log data, semi-structured interviews, and direct observation in a sample of emergency departments and ambulatory safety net clinics actively using HIE. For each site, we measured overall usage trends, user logon statistics, and data types accessed by users. We also assessed reasons for use and outcomes of use. RESULTS: Overall, users accessed HIE for 6.8% of all encounters, with higher rates of access for repeat visits, for patients with comorbidities, for patients known to have data in the exchange, and at sites providing HIE access to both nurses and physicians. Discharge summaries and test reports were the most frequently accessed data in the exchange. Providers consistently noted retrieving additional history, preventing repeat tests, comparing new results to retrieved results, and avoiding hospitalizations as a consequence of HIE access. CONCLUSION: HIE use in emergency departments and ambulatory clinics was focused on patients where missing information was believed to be present in the exchange and was related to factors including the roles of people with access, the setting, and other site-specific issues that impacted the overall breadth of routine system use. These data should form an important foundation as other sites embark upon HIE implementation.

It is an honor to serve as the Chair of the Board of Directors of such a vibrant and member-focused organization. Before beginning my term as chair, I met with the AMIA staff. One of the questions I was asked was “What is your vision for AMIA and what do you want your legacy to be?” As I learned during my 1-year term as chair-elect, it is nearly impossible for one person to understand the sheer volume and depth of our programs and activities. AMIA's board, committees, working groups and individual volunteers have accomplished an incredible amount in the past 20 years. As I thought about that fateful question, I looked at our extensive strategic plan and began to talk to hundreds of you about AMIA. I thank each one of you for your dedication to AMIA. You are the reason that we launched new approaches to branding and messaging, an updated logo, and a realigned strategic plan. We are collectively—Informatics Professionals. Leading the Way.

Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs. When reusable data are needed from notes, providers can use structured documentation or rely on post-hoc text processing to produce structured data, as appropriate.

Rapid technological change has affected many aspects of our society, but perhaps none more profoundly than the world of publishing. Scientific journals largely have moved to primary publication online. Clinicians and researchers first learn of, and then read articles on the Internet—and print them locally when required. Thus, as all publishers, whether commercial or non-profit, have attempted to address online communities, they have had to reconsider their business models and track new opportunities. The end of the current five-year Journal of the American Medical Informatics Association (JAMIA) publisher's contract in 2009 afforded the American Medical Informatics Association (AMIA) the opportunity to reconsider seriously its plans for the future of the journal. Thus, in May 2008, following an invited presentation by the Editor-in-Chief regarding the current status, perceived opportunities, and important decisions to be made for JAMIA, the AMIA Board of Directors began work on the renewal of the publishing contract for its flagship journal. The AMIA Board charged a task force comprising representatives from the Board of Directors, the AMIA Publications Committee, AMIA Staff, the JAMIA Editor, and a seasoned scholarly publishing consultant to assess future publishing options and to then issue a request for proposals. The task force convened frequently (electronically) during the first few months of its work, to examine the overarching principles of the process, to study the current publishing model, and to explore alternative approaches to publishing the association's scholarly journal. As their first order of business, the task force conducted a survey of all AMIA members to solicit comments on a variety of possible approaches. The survey asked members to indicate their personal preferences for five different publishing models, which included combinations of various options of print, online, and open-access versions of JAMIA. The survey results indicated that AMIA members' most favored (70%) overall model was the combined availability of print and online JAMIA versions. The ‘open-access only’ model was rated least desirable, due to the high per-article publication costs that all authors would have to pay. In the autumn of 2008, the task force developed a request for proposals (RFP), heavily influenced by an analysis of the data from the member survey. The RFP was released in December 2008 and sent to 11 publishers. Five bidders submitted proposals in early 2009. The task force analyzed the proposals, taking into account those solutions that would advance JAMIA's leadership position in the field of biomedical informatics, and those that would implement best practices and best evolving technologies. The task force ranked proposals based on criteria covering vision, innovation, quality, cost, marketing, and support. It considered the ability of the publisher to provide extraordinary service to authors and to the Editorial Office, to deliver an exceptional product, and to assure diversification of publication revenues. Three publishers were ultimately selected as finalists to make presentations to the task force in early May 2009 in Bethesda, MD. In a series of sessions held on the same day, the three finalists presented overviews of their proposals and entertained clarifying questions from Publisher Selection Task Force members. Immediately after the candidate publishers' presentations, the task force met to select which publisher it would recommend to the AMIA Board of Directors as the next publisher of JAMIA. In order to make the best selection, the task force focused on 14 evaluation criteria (as developed by Morna Conway, AMIA's consultant) and the weighting that each would carry. The task force members each assigned scores to each candidate publisher based on the evaluation criteria, and considering the written proposals, the oral presentations, and the responses to task force member questions, and intangible aspects. In the end, the task force voted unanimously to recommend the BMJ Group as the next JAMIA publisher. All task force members agreed that while there was higher risk for this strategy, due to the distance of London from the USA and various other factors, there was also the potential for a much higher reward for JAMIA both in recognition and impact (eg, close association with a highly regarded and widely circulated clinical journal), and in the potential for significantly enhanced financial returns to AMIA. The BMJ Group has been at the leading edge of innovation in electronic publishing and in promoting evidence-based medicine in the clinical arena. After receiving the final report and recommendation from the task force, the AMIA Board of Directors voted to invite the BMJ Group to serve as the next publisher of JAMIA, beginning with the January 2010 issue. The BMJ Group is a wholly owned subsidiary of the British Medical Association. It is based in BMA House on Tavistock Square in London. They have over 310 staff worldwide with 20 staff in the USA, including six physicians. They publish the British Medical Journal (BMJ) plus 30 specialty journals, for which the BMJ Group has 10 editors-in-chief based in North America. The AMIA Board decided that the BMJ Group would be more likely to extend JAMIA's (and AMIA's) brand, prestige, and impact through its high-profile presence and innovative publishing practices, as well as its market strength in the healthcare arena. The Board believed that JAMIA would thrive intellectually, enhance its electronic publishing functionality, and increase its relevance under the BMJ Group. The reviewers found several key points attractive in the BMJ Group's proposal, including: guaranteed income to AMIA for 2009 and beyond (with the potential for significant increases), direct association with the BMJ brand, change of access policies to maximize revenues, development of new revenue streams, transition costs covered by BMJ Group, plans to introduce a range of dynamic interactive features, and the opportunity to interact and share best practices with other international journal editors. The BMJ Group proposed a major focus on the journal's revenue growth, including enhanced direct marketing, streamlined management of the renewals process, the introduction of Web 2.0 features to build usage, and the nurturing of more extensive media contacts. The BMJ Group's proposal envisioned dynamic online JAMIA features. Potential examples included regular blogs, podcasts, and video features. Other online features might include topic collections, e-letters, and a JAMIA online community, as well as the bolstering of JAMIA's existing RSS feeds and data supplements. For authors and reviewers, the most prominent JAMIA enhancement will likely be the addition of Bench>Press, an online manuscript submission system developed by HighWire Press at Stanford University, in conjunction with BMJ Group. Compared with past JAMIA practices, Bench>Press offers a more accessible, available, and reliable method to submit manuscripts. Previously, authors were asked to submit their manuscript files via an FTP server, and to then correspond with the JAMIA Editorial Office by email. While this process provided a secure and relatively fast way to transmit files, a majority of JAMIA authors found the FTP process somewhat difficult. With Bench>Press, however, only an internet connection is needed and the submission instructions are very straightforward and easy to understand. The Bench>Press system, most importantly, will provide an online mechanism for authors to track the progress of submitted manuscripts through the JAMIA peer review process—something Editorial Office email did not support well. Another change authors will appreciate is the elimination of the PDF file requirement for submission. Bench>Press, as part of the submission process, will create a PDF version of the manuscript from the submitted text file. Authors will be responsible for checking the resulting PDF to make sure the conversion was successful. Authors will also be responsible for providing print-worthy figures before the manuscript enters the review process as opposed to after the manuscript has been accepted. Now, instead of including figures at the end of the manuscript file, each figure must be submitted as a separate file. The figure files will be uploaded along with the main manuscript file and checked for printability as part of the PDF conversion. If a figure is deemed not fit for print, the paper's corresponding author will receive notification along with a request to submit a figure file with better resolution. The submission will not enter the review process until authors have uploaded an image with better resolution. As part of the transition to the new publisher, and after much deliberation regarding the tradeoffs involved, AMIA is adjusting its policy regarding deposition of published articles from JAMIA into PubMed Central. As in the past, AMIA will retain exclusive rights to publish those submissions that can be copyrighted, but we will adopt a policy already pioneered by the BMJ Group whereby authors retain copyright on their articles (if copyrightable), and assign exclusive rights to publish and distribute the article to BMJ Group and to AMIA. This will allow authors, for example, to make copies of their work for non-commercial purposes (eg, for distribution to students in courses) without asking permission. The BMJ Group will provide assistance to assure that the final versions of all articles will be available in PubMed Central. The new publication process will continue to be compliant with all NIH (and certain other government or foundation funding agencies) requirements for open access 12 months after publication. Per the new publisher contract, those articles not covered under the NIH policy (or its equivalent) will not appear in PubMed Central until 36 months after initial JAMIA publication. To ensure a smooth and appropriate transition for authors, all accepted JAMIA articles that were initially submitted before January 1, 2010—that is, prior to the announcement of this change in policy—will be deposited in PubMed Central after 12 months (consistent with the prior policy). Of course, all articles will be available to AMIA members and to institutional and individual subscribers immediately via the JAMIA web site. The BMJ Group and AMIA will also provide an ‘unlocked’ option, whereby authors may pay a fee prior to publication to have their paper freely available, both in PubMed Central and on the JAMIA site, immediately upon first publication under a Creative Commons license. Details of the PubMed Central arrangements, as well as the ‘unlocked’ fee for 2010, and other ‘instructions to authors’, will be regularly updated on the new JAMIA website. This will include further details on authors' new rights with regard to the sharing of their accepted manuscripts on personal or institutional websites. Although these changes in policy will delay the release of certain JAMIA materials for free access, we will be working to attract more readers to JAMIA's own website, where we will be introducing new features and opportunities not available either in the print journal or on PubMed Central. We will be working closely with BMJ Group to monitor both the impact on revenues and the numbers of downloads, as well as JAMIA's impact factor. We are excited to share with readers some of the detailed plans for JAMIA's transition to a new and dynamic publisher, BMJ Group. The authors and the AMIA Board all believe that this is an important step forward to a better future for the journal. We will share more details with readers in the months ahead. We trust that AMIA's members, and all JAMIA readers and authors, will be pleased to see the evolution to a more timely and dynamic publication model that suitably leverages the new technologies, while continuing to provide the kind of quality articles and rigorous science that you have all come to expect of JAMIA. Comments to the AMIA leadership and to the JAMIA Editor are welcome as we move forward into the new world that lies ahead. AMIA would like to thank those individuals who served as members of the Publisher Selection Task Force: Dominik Aronsky, Morna Conway, Don Detmer, Sherrilynne Fuller, Karen Greenwood, Brian Haynes, Nancy Lorenzi, Randolph Miller, and William Tierney. None.

The objective of this review was to describe methods used to study and model workflow. The authors included studies set in a variety of industries using qualitative, quantitative and mixed methods. Of the 6221 matching abstracts, 127 articles were included in the final corpus. The authors collected data from each article on researcher perspective, study type, methods type, specific methods, approaches to evaluating quality of results, definition of workflow and dependent variables. Ethnographic observation and interviews were the most frequently used methods. Long study durations revealed the large time commitment required for descriptive workflow research. The most frequently discussed technique for evaluating quality of study results was triangulation. The definition of the term "workflow" and choice of methods for studying workflow varied widely across research areas and researcher perspectives. The authors developed a conceptual framework of workflow-related terminology for use in future research and present this model for use by other researchers.

OBJECTIVES: The goal of the study was to develop an in-depth understanding of work practices, workflow, and information flow in chronic disease care, to facilitate development of context-appropriate informatics tools. DESIGN: The study was conducted over a 10-month period in three ambulatory clinics providing chronic disease care. The authors iteratively collected data using direct observation and semi-structured interviews. MEASUREMENTS: The authors observed all aspects of care in three different chronic disease clinics for over 150 hours, including 157 patient-provider interactions. Observation focused on interactions among people, processes, and technology. Observation data were analyzed through an open coding approach. The authors then developed models of workflow and information flow using Hierarchical Task Analysis and Soft Systems Methodology. The authors also conducted nine semi-structured interviews to confirm and refine the models. RESULTS: The study had three primary outcomes: models of workflow for each clinic, models of information flow for each clinic, and an in-depth description of work practices and the role of health information technology (HIT) in the clinics. The authors identified gaps between the existing HIT functionality and the needs of chronic disease providers. CONCLUSIONS: In response to the analysis of workflow and information flow, the authors developed ten guidelines for design of HIT to support chronic disease care, including recommendations to pursue modular approaches to design that would support disease-specific needs. The study demonstrates the importance of evaluating workflow and information flow in HIT design and implementation.

BACKGROUND: The authors define a DNA biobank as a repository of genetic information correlated with patient medical records. DNA biobanks may assist in the research and identification of genetic factors influencing disease and drug interactions, but may raise ethical issues. How healthcare providers perceive DNA biobanks is unknown. OBJECTIVES: To determine how useful healthcare professionals believe DNA biobanks will be and whether these attitudes differ between private and socialized healthcare systems. DESIGN: The authors surveyed 200 healthcare professionals, including research and non-research focused doctors, nurses and other staff from medical centers and independent practice in both the United States and Scotland. The survey included fifteen items evaluated for general receptiveness toward biobanks, presumed usefulness of biobanks and perceived attitudes in recruiting patients for a biobank. MEASUREMENTS: A total of 81 (45%) of 179 eligible participants responded: 41 from the U.S. and 40 from Scotland. Of these respondents, most (70%) were from academic centers. RESULTS: Results indicate that there is a broadly favorable attitude in both locations toward the creation of a DNA biobank (83%) and its perceived benefit (75%). This enthusiasm is tempered in Scotland when respondents evaluated their comfort in consenting patients for entry into a biobank; 16 of 40 respondents (40%) were uncomfortable doing so, representing a significant difference from those in the U.S. (p=0.001). CONCLUSIONS: Despite systematic differences in healthcare practice between the U.S. and Scotland, health care professionals in both nations believe DNA biobanks will be useful in curing disease. This finding appears to support further development of such a research tool.

As health care organizations dramatically increase investment in information technology (IT) and the scope of their IT projects, implementation failures become critical events. Implementation failures cause stress on clinical units, increase risk to patients, and result in massive costs that are often not recoverable. At an estimated 28% success rate, the current level of investment defies management logic. This paper asserts that there are "chasms" in IT implementations that represent risky stages in the process. Contributors to the chasms are classified into four categories: design, management, organization, and assessment. The American College of Medical Informatics symposium participants recommend bold action to better understand problems and challenges in implementation and to improve the ability of organizations to bridge these implementation chasms. The bold action includes the creation of a Team Science for Implementation strategy that allows for participation from multiple institutions to address the long standing and costly implementation issues. The outcomes of this endeavor will include a new focus on interdisciplinary research and an inter-organizational knowledge base of strategies and methods to optimize implementations and subsequent achievement of organizational objectives.

The changes in the health care system over the next decade are goint to make the last 20 years seem like good old days of relative stability. We will continue to see new drugs, new devices, and new techniques; however, the true megachanges of the next decade will center on gathering, managing, and using clinical information. This prediction will prove true for all the health care areas—administrative, clinical, teaching, and research. In health care today, we see pressures for improved access, demands for greater economic efficiency, the development of vertically and horizontally integrated delivery systems, heightened emphasis on wellness, and the transition to medicine based on an understanding of the human genome. All these will continue to create dramatic change in roles and responsibilities in the system. Yet true re-engineering of the health care information management infrastructure has hardly begun. Although information system consultants and vendors are flocking to offer solutions, these solutions still tend to follow old paradigms. Money is being wasted on information systems that are barely adequate for the present and that offer little or nothing for the future. The development of a new, robust information management paradigm is the critical challenge facing the health care industry.1,2 Four cornerstones of medical informatics form the basis for developing a new information management paradigm for health care.3 These four cornerstones of knowledge and expertise extend well beyond the skills associated with traditional data processing and information systems. Producing structures to represent data and knowledge so that complex relationships may be visualized Developing methods for acquisition and presentation of data so that overload can be avoided Managing change among people, process, and information technology so that the use of information is optimized Integrating information from diverse sources to provide more than the sum of the parts, and integrating information into work processes so that it can be acted on when it can have the largest effect. The 1999 AMIA Annual Symposium featured a state-of-the-art session for each of these cornerstones. The presenters have recast their thoughts into written papers. These papers, together with edited comments from the discussion at the sessions, appear in the Mar–Apr and May–Jun issues of the Journal. The 1999 Symposium's Cornerstone presentations demonstrated that significant informatics implementations rest on a four-legged base, with all four legs being essential to success. These cornerstones must come together in an integrated fashion to deliver the types of knowledge that informatics is capable of delivering to support our future health care systems.

As increasingly powerful informatics systems are designed, developed, and implemented, they inevitably affect larger, more heterogeneous groups of people and more organizational areas. In turn, the major challenges to system success are often more behavioral than technical. Successfully introducing such systems into complex health care organizations requires an effective blend of good technical and good organizational skills. People who have low psychological ownership in a system and who vigorously resist its implementation can bring a "technically best" system to its knees. However, effective leadership can sharply reduce the behavioral resistance to change-including to new technologies-to achieve a more rapid and productive introduction of informatics technology. This paper looks at four major areas-why information system failures occur, the core theories supporting change management, the practical applications of change management, and the change management efforts in informatics.

Informatics and information technology do not appear to be valued by the health industry to the degree that they are in other industries. The agenda for health informatics should be presented so that value to the health system is linked directly to required investment. The agenda should acknowledge the foundation provided by the current health system and the role of financial issues, system impediments, policy, and knowledge in effecting change. The desired outcomes should be compelling, such as improved public health, improved quality as perceived by consumers, and lower costs. Strategies to achieve these outcomes should derive from the differentia of health, opportunities to leverage other efforts, and lessons from successes inside and outside the health industry. Examples might include using logistics to improve quality, mass customization to adapt to individual values, and system thinking to change the game to one that can be won. The justification for the informatics infrastructure of a virtual health care data bank, a national health care knowledge base, and a personal clinical health record flows naturally from these strategies.

The 1998 Scientific Symposium of the American College of Medical Informatics (ACMI) was devoted to developing visions for the future of health care and biomedicine and a strategic agenda for health and biomedical informatics in support of those visions. This symposium focus was prompted by the many major changes currently underway in health care delivery, education, and research, as well as in our health and biomedical enterprises, and by the constantly increasing role of information technology in both shaping and enabling these changes. The three audacious goals developed for 2008 are a virtual health care databank, a national health care knowledge base, and a personal clinical health record.

People and organizational issues are critical in both implementing medical informatics systems and in dealing with the altered organizations that new systems often create. The people and organizational issues area--like medical informatics itself--is a blend of many disciplines. The academic disciplines of psychology, sociology, social psychology, social anthropology, organizational behavior and organizational development, management, and cognitive sciences are rich with research with significant potential to ease the introduction and on-going use of information technology in today's complex health systems. These academic areas contribute research data and core information for better understanding of such issues as the importance of and processes for creating future direction; managing a complex change process; effective strategies for involving individuals and groups in the informatics effort; and effectively managing the altered organization. This article reviews the behavioral and business referent disciplines that can potentially contribute to improved implementations and on-going management of change in the medical informatics arena.

Nancy M. Lorenzi, PhD, Reed M. Gardner, PhD, T. Allan Pryor, PhD, William W. Stead, MD; Medical Informatics: The Key to an Organization's Place in the New Healt