Early in my training, I was ushered into the emergency department with a telling of its history. It went like this:
A long time ago, there was no such thing as an emergency department. Doctors went to people’s homes when trouble occurred. As hospitals evolved and the habit of coming to the facility for care formed, people started to show up in the hospital with urgent issues. This necessitated having health professionals prepared to receive them. At first, this was just a room, hence the origin of the phrase ‘emergency room,’ but it quickly grew into a much larger area that required significant infrastructure and budgetary support. Now we are a department, a specialty, and an indispensable one.
Knowing this history gave me a sense of context, pride, and belonging. I no longer practice as an emergency physician. I have evolved into a clinical informaticist and, much as an emergency room doctor may have experienced in the early 1900s, my friends and family have no idea what I do. When I try to explain that I help clinicians use technology to enable better care, they often respond with, “So, you’re like, part of the IT crowd,” combined with wrinkled noses and twisted mouths. I do understand their confusion. Our preconceived notions of a typical IT department limits our understanding of today’s reality. It’s time to tell the story of how the hospital IT crowd emerged from behind their monitors and became true partners in care.
History of hospital IT
In the 1960s, hospitals began using computers for administrative tasks, which necessitated people to support servers, workstations, and networks. There was no place to put these new employees, so they were literally shoved in the basement. In a closet. Probably with a sign on the door that said, “Here there be dragons.” As computer capabilities expanded, applications were developed for clinical tasks as well. This meant more functions could be supported, which in turn required new departments, new skill sets, and new employees. Often these new people were hired into a specific department, making the trip up and down the stairs to visit those infrastructure-supporting IT staff who had by now grown out of their closets.
The rise of electronic health records (EHRs) created another surge of growth, adding project management, clinical informatics, database administrators, business analysts, integration specialists, trainers, and security specialists to the ever-growing IT department. IT became a central hub of activity for the hospital, which had now been fully released from its depths in the persona of the CIO and supporting functions leads (i.e., CMIOs, CNIOs, etc). Application support housed in other departments often found benefit in uniting with the IT department to form a centralized service.
The current state of digital health
The name “IT department” seems increasingly outdated as the use of technology in healthcare approaches ubiquity. The future promises a slow merging of clinical and IT into one symbiotic entity of digital health. Meanwhile, advances in virtual care, hospital at home, remote patient monitoring, and population health are resulting in the decentralization of patient care. Digital health infrastructure will need to exist beyond the walls of the hospital to support these changing models of care.
Future-state prediction for digital health
The evolution of digital health from a commodity to a partner in service will likely continue, resulting in a shift in focus from the hospital to the community. Although IT infrastructure is also increasingly moving outside of the hospital’s four walls (we are already seeing this happening as more and more services move to the cloud), support services and clinical liaisons are still in the process of navigating the transition. Key hurdles to overcome as healthcare continues on its decentralization journey include: the management of vendors that do not have innate ownership in the service delivered, ensuring clinical makes this journey symbiotically with technology, and equitable funding models that fairly address and distribute costs.
The muddy middle
This evolution of digital health has left us with a mixture of odd-looking beasts (formerly known as IT departments), somewhere in transition from our past to the future. The variety of governance, budgeting, roles, and responsibilities makes benchmarking complex, if not impossible. Key points of variance include:
- Centralized vs. decentralized - Centralized digital health structure involves all application, security, analyst, support, training, data management, and infrastructure services falling under one digital health department. Decentralized is where separate functions remain within individual clinical service departments or other service departments of the organization.
- Point of division between IT and clinical - Sometimes clinical informatics, business analysts, and or training and education responsibilities will lie within the clinical departments leaving application and infrastructure support to IT; however, this line of division can vary within and between organizations.
- Outsourced vs. in-house - Accruing internal expertise to carry out the functions of digital health at each organization can be a challenge and a drain on attention to the other tasks of caregiving. There can be an advantage to outsourcing some or all the digital health functions to companies well versed in a desired skill. As the scope and responsibility of digital health extends beyond the walls of an organization, it may begin to make more sense for IT to exist outside of the hospital.
- Capital vs. operational - Canadian funding models for digital health vary as much as structure. Some organizations have regular capital dollar allotments assigned to digital infrastructure, others have yearly battles to secure funding for maintaining vital digital infrastructure, and still, others have rules limiting the use of capital funds for digital expenses.
Benchmarks for resourcing digital health in the U.S. have been empirically established. In 2008, Hersh and Wright published an analysis of the 2004 HIMSS Analytics Database for an AMIA symposium which examined the number of IT staff per patient bed across a number of hospital systems. They found that the number ranged from 0.082 FTEs per patient bed in the lowest EMRAM stage, up to 0.196 FTEs per patient bed for Stage 6 hospitals. Ten years later, Hersh and colleagues published a follow-up study with 2014 data showing 0.229 FTEs per patient bed for Stage 6 and 0.411 FTEs per patient bed for Stage 7 hospitals. While the applicability to the global market hasn’t yet been studied, these data indicate a positive relationship between the number of IT staff and EMRAM stage. Additional benchmarking, including an in-depth assessment of which services are included and excluded across different healthcare markets or models, would be helpful.
The search for context, pride, belonging, and budgetary support
Digital health continues to grow, and those of us actively engaged in the evolution can be proud of how far we have come and enthusiastic for the continued journey, as messy as it is likely to be. In many instances we have evolved without a re-evaluation of structure, needs, and support. It is time to pause and reflect on the future vision for digital health and to make thoughtful choices around the structure and budgetary support needed to facilitate the value proposition.
 Hersh, W.R., Boone, K.W., Totten, A.M. (2018). Characteristics of the healthcare information technology workforce in the HITECH era: underestimated in size, still growing, and adapting to advanced uses. JAMIA Open, 1(2), 188-194.