REFLECTIONS

For me, Northwestern University was the natural choice. I am familiar with the
University. I have earned a Bachelor's degree in Philosophy at Northwestern and I am
already aware of the superior education at this nationally recognized research institution
offers. At Northwestern, the MMI program offered me access to established leaders,
clinicians and physicians who are successful early adopters of ambulatory medical
records. I have always wanted to work in a hospital or clinical setting and this program
was a natural fit for me. It has always been my desire to improve the overall quality of
health care. I have learned how we can improve this through the use of clinical decision
support and quality reporting. I am excited that as a graduate of the MMI program, I
now have the skills to fill many positions in health care information technology. I have
attained skills for consulting with physicians and hospitals in order to implement and
maintain their electronic health records as well as improve or implement integrated
delivery systems. Through the curriculum provided in this program, I have acquired
the skills necessary to enter the growing field of health information exchange, which
includes provider-centric regional health information organizations (RHIOs) and patient-
centric models based on the emerging personal health records systems.
The Medical Informatics Program at Northwestern University has taught me
about the American Health Care System and its components. I was fascinated with how
the United States compares to international health care systems as well as other
industrialized nations. The focus of American Healthcare Delivery was how to assess
health care and the major challenges of the delivery of health care. I gained an
understanding of health care in America. I learned about where health care is provided
and what the characteristics of those institutions which provide health care are. In
addition, we discussed how changes in health care provisions are affecting the health of
the population, the cost of care, as well as access to care. This course also covered
many facets of the health care system in the United States. Many topics included legal
and regulatory issues, managed care, non-profit versus profit care, the role of the
federal government in health care, technology assessment, as well as costs and
reimbursement. We also studied how the United States compares with other health care
systems internationally.
I learned that healthcare in America is multi-faceted and very complicated and
the status of our nation’s health is in jeopardy. The U.S. has many financial and legal
barriers to care. The nursing, physician and pharmacist shortage is a problem that truly
needs to be addressed. I like the fact that we were was challenged to think about
solutions to the nursing shortage that we face today. Our elder generation is living
longer and will require the aid of nurses. There are many financial resources available
for nursing education and our Professor shared this information with the class. We also
learned about health status, workforce structures and issues, public health’s role in
health care and costs.
Introduction to Clinical Thinking taught me problem solving techniques for

clinicians, clinical environments, medical terminology, and standard issues and

processes in the clinical setting. I was introduced to the complexity of clinical thinking

and decision making. I learned how doctors interact with patients, key terms related to

clinical thinking, methods for reaching a clinical diagnosis, and current tools in the

market today. I was amazed at the process, knowledge level and skill required for

physicians. Intro to clinical thinking provided me with a foundation on how physicians

handle a clinical encounter, arrive at a diagnosis, develop a treatment plan and use

evidence based medicine into their workflow.

I was introduced to the complexity of the decisions and factors that doctors use

to evaluate in a short patient visit. Very often, the correct diagnosis is reached by the

time the physician is only 2 minutes into the patient's history. From that, they form a

hypothesis - a presumptive diagnosis that the problem solver thinks may be the

explanation for the patient's complaints. I remember such questions as: What is the

patient's chief complaint? What is a problem list? I reflect that the answer is that it is the

data base that one acquires and processes into a list of problems that tells what is

wrong with the patient. This list can contain the diagnosis, syndrome, patho-physiologic

state, cluster of clues, isolated abnormality and psycho-socioeconomic issue.

 I learned about Prevalence and Probability - the prevalence of a particular

disease is represented by the number of cases of the disease per population unit at any

particular time and the probability that a disease exists in a particular patient is a

decimal or percentage estimate based on available data. Both the prevalence

and probability of disease are expressed by the Bayesian symbol P(D). Also important,

was pattern recognition, a method that allows one to make a diagnosis with a single

glance. I ask myself: What is the key clue? It is what you must look for when various

clues do not form a definite cluster, do not seem to relate or are nonspecific. The key

clue is known to occur in a specific variety of clinical situations and can be used to track

and seek further information. I learned that there is a lot that medical informatics

students can do to help them clinicians work more efficiently.

Introduction to Databases covers the fundamentals of database management

and design. The curriculum included the principles and methodologies of database

design, database application development, normalization, transitivity, referential

integrity, security, relational database models, and database language. This was one of

my most challenging classes. I had no previous database classes or experience. I

learned about functional dependencies, SQL, relational models and normalization,

candidate keys and composite keys, transitivity and data modeling with entity

relationship models. I learned to use Microsoft Access and I created a database as well.

Another challenging class for me, was Telecommunications and Computer

Networks. This course provided an overview of telecommunications and computer

networks. The curriculum included the study of signals and bandwidth concepts,

spectra, basics of electronics, information and coding, modulation, multiplexing,

transmission systems, transmission media, analog and digital communications,

computer networks, and switching techniques. I learned about LAN, WAN, VPN and
cloud networking. I learned that a Local Area Network (LAN) delivers applications to

local users, and provides the infrastructure for group collaboration, file sharing and

transfer as well as printing. A Wide Area Network (WAN) definition might be a network

that commonly connects Local Area Networks (LANs) in geographically dispersed

locations together using a variety of technologies not normally used to form a LAN.

VPNs are now a common part of many corporate networks. These encrypted links

across the Internet are formed either between two firewalls or VPN appliances, or

between a remote computer and a firewall VPN appliance.

In Introduction to Medical Informatics, I was provided a foundation for the medical

informatics field. This was the first class where I began to really understand and things

started to make more sense. Because I did not have any clinical or technical

background, I was required to take both the clinical as well as the technical tracks prior

to taking Introduction to Medical Informatics. I agree that the two tracks were necessary
and am glad that I took them. I believe that a solid foundation was laid and that

contributed to my success in the program. This class, along with HIT Integration,

Interoperability and Standards, ensured an understanding of coding and classification

systems. This was key to health information exchange. I learned the purpose of

standardized coding and classification systems. I learned that standardized coding

describes the reason for the patient’s visit, the services rendered to the patient and

allows for the uniform exchange of data among healthcare providers. The group project

for these two classes required the development of proposed HIT systems. I worked on

a research project with a group regarding personal health records (PHR), where we

defined a PHR, its availability, CCHIT certification and future roles of PHR in improving

the quality of care.

Enterprise Operations taught me about hospital workflows and high level

processes, as well as how technology can enhance the workflow. This class also

provided me an understanding of how national rankings and ratings are composed via

the use of dashboards. I now have a thorough understanding of interoperability issues

that healthcare systems, as well as, private practice physicians encounter on a daily

basis. One huge lesson that I remember is learning how to describe the methodology

for calculating a Diagnostic or Testing area’s utilization and understanding the standard

utilization rate. The D & T Area is calculated by taking the total hours for all procedures

and dividing them by the total hours that the area or unit is open. This can be calculated

to include holiday hours or taking the holidays hours out to account for holiday hours off,

depending on the operational facility. The methodology for calculating a Diagnostic or

Testing area’s utilization is detailed. An area or unit group must be realistic in its

expectations regarding utilization rates. A 100-percent efficiency level is not achievable.

A range of 75 percent to 85 percent is considered to be the standard utilization rate.

In addition, this course provided a view into the operational aspects of healthcare

institutions and involved an individual paper as well as a group project. Our group

worked on a Picture Archiving Communication System (PACS) and I learned a great

deal about PACS and how we can improve healthcare and how, where and how much

data is stored.

The Clinical Decision Support course taught a variety of decision support

applications relevant to the healthcare industry. Throughout the course we explored the
history and current uses of clinical decision support (CDS) and how it applies to medical
decision making and various techniques that can improve the process. This course
provided an introduction to decision analysis with an emphasis on medical decision-
making. Topics for the course included structuring decision problems and developing
creative decision options, quantifying uncertainty and preferences, and combining them
to arrive at optimal decisions. The course also provided the foundation needed to apply
the methods of decision analysis in decision support systems and intelligent systems.
Students become familiar with the graphical display of medical information, decision
analysis and modeling, evidence-based medicine, Bayes' theorem, knowledge-based
systems, learning systems, lexicons, coding and structured data entry, and data mining
techniques.

The following is an approach to decision making known as PROACTIVE:

Problem: Define the problem - Is there a problem? What is the problem?

Reframe: Reframe the multiple perspectives - Whose perspective do I represent?
Objective: Focus on the objective - What is the goal of an intervention?
Alternative: Consider all relevant alternatives - Do I know all of the reasonable
alternatives?
Consequences and Chance: Model the consequences and estimate the chances -
What events may occur over time? What are the chances?
Trade-offs: Identify and estimate the value trade-offs - How do the benefits and harms
compare for each possible outcome?
Integrate: Integrate the evidence and values - If there are uncertainties, what is the
overall expected value of each alternative?
Value: Optimize expected value - How do I optimize the decision?
Explore and Evaluate: Explore the assumptions and evaluate uncertainties - What if I
have a different patient consult me?
We used this framework to analyze case studies. My group project was regarding Acute
Myocardial Infarction (AMI) Treatment and the Promise of Clinical Decision Support
(CDS).
In the Legal, Ethical and Social Issues class, we learned how these concepts
apply to medical informatics and healthcare information technology. We worked on
issue spotting exercises and learned how to help protect ourselves and our
organizations. We spent a lot of time learning about HIPAA and patient privacy. We
discussed potential legal, ethical and social issues. The Legal, Ethical and Social
course presented students with legal, ethical, and social issues in health care
informatics and provided students with the knowledge and analytic tools needed to
spot key issues. This enabled students to understand and empowered them to protect
themselves as well as their employers in the medical informatics field. The health care
industry is highly regulated. This course covered regulatory informatics requirements as
they apply to work with health care data and information management systems. The
course also covered topics such as privacy and security, fraud and abuse,
confidentiality, antitrust law, intellectual property, the Joint Commission, disclosure, and
compliance programs I wrote a paper that critiqued an article by Regina Herzlinger
"Why Innovation in Healthcare is so Hard." Although I agree with Herzlinger that there
are many barriers to innovation, I believe that we can make healthcare easy, not hard.

My final paper, was regarding legal and ethical issues arising from human implantable
RFID chips. I addressed how patients should have a right to choose whether they are
implanted with these chips, what disclosures should take place and what rights will be
violated as well as potential changes to current laws.
Medical Informatics Technology Acquisition and Assessment introduced me to
the process of acquiring medical informatics technology products. I learned how to so a
Statement of Work, Request for Purchase, evaluate potential vendors, read and
understand contract and negotiate. Our group project entailed a hospital needing a new
website, in order to compete in their market area. The old website lacked the
capabilities to take the hospital to the next level. We provided potential vendors our
Statement of Work with the hospital’s requirements. After we reviewed the bids, we
developed a Request for Proposals, after which we selected our vendor during the
vendor selection process. We had a blast during the negotiation process because our
group was unexpectedly split up for this part of the assignment (after we had worked for
the entire semester together). This unexpected change made the negation process
quite interesting and a lot of fun.
After a 14 month scare prior to taking the Biostatistics course, I discovered that
the class was not so bad. It was demanding, but not as bad as I was led to believe. I am
sure that my prior exposure to Statistics did not harm me and I am sure that I had more
trouble with Introduction to Databases. Biostatistics helped me to understand the
application of statistics to biology and medicine. I learned more about descriptive
statistics, hypothesis testing, t-tests, chi-squared tests, analysis of variance, linear
regression, and correlation.
Remember the Six Sources of Influence? In Foundations of Leadership, I had to
develop a leadership strategy to affect organizational change. In our project, we
identified physicians and nurses as stakeholders. We linked vital behaviors to metrics,
as well as identified challenges and recovery behaviors. In this case, prior to strategy
implementation these physicians did not communicate and were quite autonomous.
Their cultural belief was that an EMR would impinge on quality care and decrease
income. Site visits (positive deviance), extensive training (deliberate practice) and
consultant(s) along with stories of successful implementations in similar cultures create
new basic assumptions that link with vital behaviors and key value drivers.

I believe that people should be involved with change and therefore, influenced to
change. Change must not be imposed upon people. My personal influence and style is
democratic in nature. As a democratic leader in my organization, I make the final
decisions. However, I invite other members of the team to contribute to the decision-
making process. This not only increases job satisfaction by involving team members,
but it also helps to develop other people's skills. Team members feel in control of their
own destiny, so they're motivated to work hard, outside of financial rewards.
Participation takes time in this approach, but often the end result is better. This
approach can be most suitable when working as a team is essential and quality is
important.

I believe that employees do not have the responsibility to manage change. It is

employees’ responsibility to do their best, which is different for every person and
depends on a wide variety of factors (health, maturity, stability, experience, personality,
motivation, etc). The organization has the responsibility for managing change.
Management and executives of the organization must manage the change in a way that
employees can cope with. The manager has a responsibility to facilitate and enable
change. I believe that management needs to objectively understand, show empathy,
and be non-judgmental. Management is responsible for sharing the goals and core
company values and to help the team understand the reasons, aims, and ways of
responding positively according to employees' own situations and capabilities.
In conclusion, I entered the Medical Informatics Program with very little clinical and
no technical knowledge. I have had a wonderful time and great learning experience. I
can now make informed decisions and contribute meaningful dialog, theories and
interpretations about topics such as universal healthcare. I understand the business
aspect of health care as well as the dynamics that go into care of the patient, disease
diagnosis, probability, specificity and sensitivity of medical test, as well as the
governance for healthcare information. I am also aware of support systems and
technologies that will improve the quality of care that is given to patients, as we strive
for error free health care. I understand interoperability and why it is necessary. I was
introduced to HIMSS (and proud to be a member). I know what the Joint Commission,
the Institute of Medicine, the Centers for Disease Control and Prevention (CDC) and the
Veterans Administration are and the roles that they play in healthcare. I understand
Health Information Exchange, Regional Health Information Organization, Electronic
Medical Records and Personal Health Records are. I wouldn’t have any of this
knowledge without Northwestern University and my Medical Informatics colleagues. I
am very grateful. It has been a wonderful learning experience.