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The IMIA Yearbook editorial team asked five internationally renowned biomedical informaticians to respond to Prof. Haux's editorial. This paper summarizes their thoughts and responses. Contributions are ordered alphabetically by the contributor's last name. All authors provided an equal contribution to this manuscript.

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OBJECTIVE: To discuss interdisciplinary research and education in the context of informatics and medicine by commenting on the paper of Kuhn et al. "Informatics and Medicine: From Molecules to Populations". METHOD: Inviting an international group of experts in biomedical and health informatics and related disciplines to comment on this paper. RESULTS AND CONCLUSIONS: The commentaries include a wide range of reasoned arguments and original position statements which, while strongly endorsing the educational needs identified by Kuhn et al., also point out fundamental challenges that are very specific to the unusual combination of scientific, technological, personal and social problems characterizing biomedical informatics. They point to the ultimate objectives of managing difficult human health problems, which are unlikely to yield to technological solutions alone. The psychological, societal, and environmental components of health and disease are emphasized by several of the commentators, setting the stage for further debate and constructive suggestions.

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The levels of resistance to a new informatics system can vary widely both between and among specific groups. The relevance to today's behavioral medicine area is obvious. The aim of effective change management techniques is not to eliminate all resistance. This is typically impossible when a group of any size is involved. The aims are (1) to keep initial general resistance at reasonable levels, (2) to pre-vent that initial resistance from growing to serious levels, and (3) to identify and deal with any pockets of serious resistance that do occur despite the previous efforts. His article outlines areas of resistance to behavioral informatics and offers suggestions for overcoming the resistance.

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All of us realize that these are times of high change in virtually every health care system, regardless of size or location. As part of this change process, many health care systems are taking a serious look at the area that has evolved as knowledge management. While change may be mandatory, progress is definitely optional.

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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.

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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.

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In 1993 the International Medical Informatics Association approved a working group whose purpose focused on the people and organizational issues surrounding the use of computers in health care. This article outlines two key concepts that act as the guiding principles for the working group's efforts. The concepts are: applying the knowledge of human behaviors toward the use of information or information technology within a health care environment and effectively incorporating human factors, culture, change, and organizational and human engineering in the medical informatics processes. These concepts are further supported by functional statements and a strategy to ensure the principles are effectively diffused in the medical informatics community. The concepts, functional statements and process were adopted by the working group and are outlined in this article.

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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.

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Positive outcomes come to health care organizations that are doing the right things well, that is, their organizational strategies are aligned with their environments and they are executing those strategies well. Likewise, the informatics strategies must also be aligned with the organization's strategies. Without this congruence, informatics does not have the potential to have a substantial positive impact on the overall organizational outcomes. The execution of the informatics strategies must also be exemplary; however, the change processes required for achieving the desired informatics and organizational outcome goals are demanding and complicated. Implementing them in extremely complex organizations that operate on a 7-day by 24 hour basis is not easy. However, we are constantly learning more about complex change processes and the ways we can better manage them to improve our needed informatics outcomes. The challenge is to build upon the existing research base to more us even further ahead.

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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.

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In response to demands to enhance the efficiency and accountability of health systems, a range of different information technologies are being promoted. These technologies include integrated hospital systems, community health information networks and data repositories. However, the record of such technologies inside and outside the health industry suggest that such technologies cannot necessarily be relied on. The reason identified is that information systems are inherently logical and rational systems, and often come into conflict with the less rational social systems of organizations. Health information is identified in terms of three basic dimensions of information; that associated with managers; with professionals; and, with patients. The information of these dimensions are focused on very different objectives, have different structures and functions and are controlled by very different social processes. The information is also very complex and diverse within the dimensions. In the clinical encounter the clinician draws on specialist expertise, satisfies administrative requirements, and provides a clinical record. Thus, these dimensions converge at that point. However, collecting information is costly, and an efficient service demands economy in data collection. However, the technologies being promoted demand 'complete' data acquisition based on consistent and stable data definitions and data structures. The article argues that there is, thus, a conflict between the requirements of these technologies, and the realities of providing efficient services within a changing organizational, professional and social environment.

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What are the keys to implementing a new information system within a physician environment? How can resistance to the technology be circumvented? Should physicians be brought in on the front end of system development, to help design information technology that can meet their needs? The authors give some timely advice for the information-driven industry.

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