Clinical informatics is not about the technology

I have asked the same question in a lot of hospitals, and I have never once received a good answer.

Name the three largest technology investments your organization made in the last five years. Now say what clinical outcome each one was meant to change, whether it changed, and whether anyone even checked.

The room usually goes completely quiet. Not because the leadership are careless. Most of them are serious, and many are exhausted from the work of installing the growing technology stack aimed at nothing. The room also goes quiet because the question was never asked at the beginning, and no one has thought to ask it since.

Consider where a decision to build something in your EHR or purchase something typically originates. A vendor demonstrated a capability. A project had a deadline and needed a quick response. A regulation threatened a penalty. An executive came back from a conference. A competitor announced something and the board read about it. Those are the five doors, and I have watched major builds, with major expense, and even more disruption come through all of them. Not one of those doors contains a clinical question.

So the build proceeds, aimed at nothing in particular, and we call the result a solution.

What follows is the part physicians experience and rarely get to name specifically. The clinical encounter, which is the reason the whole enterprise exists, gets a little worse. Not always catastrophically. A template that asks about things that did not happen. An alert that fires on a patient it didn’t fit. A value that matters is buried under five that do not. Each is survivable on its own, and that is exactly why it accumulates.

I call the rest of it the symptom cascade, because it behaves like one. Documentation burden does not stay documentation burden. It becomes cognitive load, then work taken home, then disengagement, then a resignation, then a vacancy, then agency coverage, then a ratio that makes the next resignation likelier. Somewhere in that chain the cost becomes visible, usually as a labor problem on an executive’s desk two years later and three departments away from the configuration decision that started it. This is the chief complaint, and health care has spent twenty years treating everything except it.

I want to be careful about where the fault sits, because the conventional answer is both wrong and expensive. The conventional answer is that clinicians need more resilience. Physicians rate their EHR record quality at 45.9 out of 100 on a standard usability scale, which is a grade of F, and that score tracks burnout in a dose-response relationship. Ambulatory physicians spend roughly two hours in the record for every hour of patient contact. The National Academies classified poorly designed health information technology as an organization-level driver of burnout, which is a statement about the system rather than about the people working inside it. In clinical pharmacology, a dose-response curve like that one prompts a dose reduction. In health care we order a refill.

It is also rarely about a technology failure; the software largely works as advertised. Nearly every hospital in America runs a certified record, and the variation in what those records deliver between organizations is enormous, including between organizations running the same platform from the same vendor under the same contract. The variable is not the tool. The variable is whether anyone in the building is accountable for the relationship between the tool and the clinical work it was bought to serve.

That is a role, and most organizations do not have it, in a form that can make a difference. Many have a title on a badge (a name). Fewer have given that title a seat where decisions happen, a budget, a team, and the standing to stop a deployment (a workable form). Very few have the important informatics work itself occurring, which is a different thing from having someone responsible for it (the function).

Clinical informatics was never about the technology. It is the clinical discipline that makes the technology serve the clinical work and answers for it when it does not. Where it is present and genuinely resourced, override rates fall because someone pruned the library on purpose, notes get signed before dinner because someone redesigned the template alongside the people using it, and the numbers on the dashboard start to resemble the shift the charge nurse actually worked. None of that required new software, just the work.

So, I will leave you with the question I opened with, which is a diagnostic question and not a rhetorical one. Three investments. What was each meant to change and did it?

If your room goes quiet, you have found the chief complaint. The first step in recovery from a disease is the recognition that you have one.

Thomas Powell is a physician executive, a career chief medical information officer (CMIO), and the founder of CMIO, LLC, which provides interim physician informatics leadership and advisory work to health systems. He has held the CMIO seat in academic, community, pediatric, and integrated delivery systems, and in most of them he was the first.

At the University of Arkansas for Medical Sciences (UAMS), he was CMIO and associate vice chancellor and led the move to Epic across the hospital and 43 clinical groups. At Aspirus Health, he was vice president and CMIO of an 18-hospital system with 1,300 employed physicians and advanced practice clinicians, and at Miami Children’s Hospital, now Nicklaus Children’s, he took 38 pediatric subspecialties from paper to Cerner. He served the State of Arkansas as medical and executive officer of the Office of Health Information Technology and the state health information exchange.

He trained at Duke University as a National Library of Medicine fellow in clinical informatics under Ed Hammond, and at UAMS he created Arkansas’s first clinical informatics master’s and doctoral program and helped build the state’s only clinical informatics board fellowship. He writes and speaks on applied clinical informatics, the governance of clinical AI, electronic health record usability, and the physician executive role.

He is the author of The Diagnostician: American Healthcare Is Sick, Misdiagnosed, and Getting Worse; It’s Time to Call the Doctor, forthcoming November 3, 2026, which applies the clinical diagnostic method to the health care organization itself. He shares updates on X.