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Essentials of Clinical Informatics

1
Essentials of Clinical
Informatics
E D I T E D B Y
M A R K E . F R I S S E , M D , M S , M B A
ACCENTURE PROFESSOR OF BIOMEDICAL INFORMATICS
VICE CHAIR FOR BUSINESS DEVELOPMENT
VANDERBILT UNIVERSITY SCHOOL OF MEDICINE
NASHVILLE, TENNESSEE
K A R L E . M I S U L I S , M D , P H D
PROFESSOR OF CLINICAL NEUROLOGY
PROFESSOR OF CLINICAL BIOMEDICAL INFORMATICS
VANDERBILT UNIVERSITY SCHOOL OF MEDICINE
NASHVILLE, TENNESSEE

1
Oxford University Press is a department of the University of Oxford. It furthers
the University’s objective of excellence in research, scholarship, and education
by publishing worldwide. Oxford is a registered trade mark of Oxford University
Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press
198 Madison Avenue, New York, NY 10016, United States of America.
© Oxford University Press 2019
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted, in any form or by any means, without the
prior permission in writing of Oxford University Press, or as expressly permitted
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rights organization. Inquiries concerning reproduction outside the scope of the
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address above.
You must not circulate this work in any other form
and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Frisse, Mark E., editor. | Misulis, Karl E., editor.
Title: Essentials of clinical informatics /edited by Mark E. Frisse, Karl E. Misulis.
Description: New York, NY : Oxford University Press, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018049155 | ISBN 9780190855574 (alk. paper)
Subjects: | MESH: Medical Informatics | Health Information Systems
Classification: LCC R858 | NLM W 26.5 | DDC 610.285—dc23
LC record available at https://lccn.loc.gov/2018049155
This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information with
respect to the subject matter covered and to be current as of the time it was written, research and
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or incurred as a consequence of the use and/or application of any of the contents of this material.
9 8 7 6 5 4 3 2 1
Printed by WebCom, Inc., Canada

CONTENTS
Contributors ix
PART I Introduction: Areas of Focus
1. The Healthcare System 3
Mark E. Frisse and Karl E. Misulis
2. Healthcare and the Electronic Health Record 7
Karl E. Misulis and Mark E. Frisse
PART II The Framework
3. Data, Information, and Knowledge 17
4. People 23
5. Policies, Laws, Regulations, Contracts, and Procedures 29
6. Process: The Learning Health System 38
PART III The Foundation
7. Representation and Organization of Health Information 45
8. Basics of Computers 53
9. Design of the Core Healthcare Operating System 69
Douglas J. Dickey, Karl E. Misulis, and Mark E. Frisse
10. Data Repositories 89

vi Contents
11. Decision-Making 104
12. Information Systems Strategy and Administration 126
Jeffrey G. Frieling, Karl E. Misulis, and Mark E. Frisse
13. Large-Project Management 132
Jeffrey G. Frieling, Karl E. Misulis, and Mark E. Frisse
14. Clinician Interface and Experience 152
Paul Weaver, Douglas J. Dickey, Karl E. Misulis, and Mark E. Frisse
15. Access and Access Controls 162
16. Analytics 170
17. Decision Support 180
Christoph U. Lehmann, Karl E. Misulis, and Mark E. Frisse
18. Security and Privacy 200
19. Data Science 219
20. Enabling Technologies 224
PART IV Application of Informatics in Healthcare
21. Clinical Teams 231
22. Patients and Families 236
23. Body, Home, and Community 245
24. Specialties 248

Contents vii
25. Health Information Exchange in Practice 264
26. Population Health Management 281
27. Researchers 287
PART V Future Trends
28. On the Horizon 293
29. Staying Current 298
PART VI Appendices
Appendix 1. Case Discussions 307
Karl E. Misulis, Jeffrey G. Frieling, and Mark E. Frisse
Appendix 2. Self-Assessment 317
Appendix 3. Reference Data 329
Notes and References 343
Index 353

CONTRIBUTORS
Douglas J. Dickey, MD
Chief Medical Officer of Physician Strategy
Cerner Corporation
Kanas City, MO (Missouri)
Jeffrey G. Frieling, MBA, FACHE
Vice President and Chief Information Officer
West Tennessee Healthcare
Jackson, TN (Tennessee)
Christoph U. Lehmann, MD, FAAP, FACMI, FIAHSI
Professor of Biomedical Informatics and Pediatrics
Vanderbilt University Medical Center
Nashville, TN
Paul Weaver
Vice President, User Experience and Human Factors
Cerner Corporation
Kanas City, MO (Missouri)

Part I
Introduction
Areas of Focus

1
The Healthcare System
M A R K E . F R I S S E A N D K A R L E . M I S U L I S ■
OVERVIEW
This chapter focuses on people, processes, policies, and technologies aimed
at improving the health and well-
being of individuals, their families, and their
communities.
The US healthcare system is impressive in so many ways, yet it fails to deliver
reliable, consistent, and affordable high-
quality care to every individual. From the
perspective of patients and providers, the system is a complex and opaque laby-
rinth of processes driven by misaligned incentives and a failure to appreciate the
critical role of culture, behavior, human thought, and problem-
solving processes.1
Although the United States is the most expensive (per capita) healthcare system in
the world, it ranks among the lowest in patient access and health outcomes among
Organization for Economic Cooperation and Development (OECD) countries.2
It is a system overburdened with excessive complexity, number of payers, admin-
istrative requirements, regulatory impositions, and hidden costs. In the future, an
aging population, complex comorbidities, family financial distress, changing cul-
tural expectations, and unsustainable healthcare prices will necessitate a radically
broader view of clinical care. Things must change and clinical informatics must be
up to the task.

4 Pa rt I . I n t r oduct io n : A r eas of  F ocus
ROLE OF INFORMATICS PROFESSIONALS
Clinical informatics professionals historically have concentrated on improving care
through more effective use of electronic medical records (EMRs). Often, these EMRs
were localized to large hospitals and clinics and were entirely disconnected from
mobile devices, consumer products, and a range of other technologies. Often, they
were only clumsily associated with operational, administrative, and billing systems
essential for payment and administration. Over the last decade, federal electronic
health record (EHR) certification requirements, health plan changes, and federal
payment regulations have focused the attention of many clinicians on the admin-
istrative aspects of care, at the expense of time with their patients. There was a time
when physicians did not do anything that did not require a medical degree. Now,
clinicians have become clerical workers.3
Our central challenge is to ensure that clinical informatics professionals under-
stand the forces that drive our healthcare system and employ their understanding
to address the most pressing needs of clinical practice. From this perspective, a mas-
tery of healthcare delivery in hospitals and clinics is necessary but not sufficient.
One heavily cited analysis claimed that clinical care accounts for only 20% of overall
health status. According to this analysis, health behaviors account for 30%, physical
environment (e.g., air, water, housing, transit) accounts for 10%, and social and eco-
nomicfactorsaccountforafull40%(e.g.,socialsupport,financialstatus,education).4
To fix hospitals and clinics, one must look outward and address these other factors.
ROLE OF ADMINISTRATION AND FINANCE
Payment and oversight for clinical services drive much of the day-
to-
day work of
clinicians. Societal expectations, legislation, payment trends, financial constraints,
andmanyotherfactorsdrivetheultimatedesignofourhealthcaredeliverysystemand
thepeople,processes,data,andtechnologiesusedtosupportthissystem.Knowledge
of the nuances of mainstream biomedical informatics—
clinical systems—
simply
will not be sufficient to advance healthcare systems increasingly dominated by finan-
cial imperatives. To excel, one must interpret clinical informatics through the lens
of details of federal programs (e.g., Medicare, Medicaid, disability services, Veterans
Affairs [VA], Department of Defense [DoD], Indian Health Service); state programs
(e.g., Medicaid, public health); private insurers (both employer-
sponsored health
plans and pharmacy benefits managers); accrediting bodies; quality improvement
organizations; and certification initiatives. Every clinical informatics professional
must understand how participation in management, support, and delivery can col-
lectively deliver more effective care, improve quality of care, and support research.
THE CUSTOMER: ROLE OF PATIENTS AND FAMILIES
Patients and their families are central. Every individual patient is supported by
an often-
hidden network where many family members, friends, and others work

Chapter 1. The Healthcare System 5
in collaboration to assist with a full range of care activities, including shopping or
transportation, household tasks, finances, personal care and nursing, and indoor
ambulation. The overall composition of these informal patient-centered care teams
and the roles individuals play are generally not known to providers. To provide ef-
fective care, providers must be aware of both formal and informal caregivers, their
tasks, available devices and technologies in the home, and the broader physical and
cultural environment in which patients live. Clinical informatics professionals must
find means of collecting this information and making it available to improve care
delivery.
The patient perspective is that care is often highly fragmented. Studies showed
that the average elderly patient sees seven doctors across four practices, and that
the average elderly surgery patient is seen by 27 different healthcare providers.5
Providers pay the consequences of this care fragmentation; they sometimes do not
even know who a patient’s other providers are. One study found that the typical
primary care physician must coordinate with 229 other physicians working in 117
practices.6
Hence, in most instances, for a single patient, different individuals will
have different roles reliant on different data sets collected and presented through
multiple technical systems. The EHR of the past must continue to evolve to accom-
modate these realities.
Thecarefragmentationexperiencedbypatientsandprovidersalikedemonstrates
that the EHR would likely best be served by evolving from a database of orders, re-
sult, and documents toward a platform supporting true communication and collab-
oration. Presently, steps are incremental, care quality is uneven, and coordination
is limited.
ROLE OF TECHNOLOGY
Technology’s rapid advancement has not yet led to a mature healthcare technology
infrastructure. Indeed, the rapid evolution of technologies often overwhelm our ca-
pacitytograsptheirpotentialandtoincorporatethemintoourhealthcaresystem.As
a result, some consumers are taking commercial technologies into their own hands
to maintain and monitor health, to monitor chronic disease status, and to commu-
nicate with one another. Data collected through these technologies are seldom in-
corporated into the EHR. Informatics professionals must understand technology
trends and make decisions today that will prepare them for future developments.
ROLE OF ANALYTICS
Providers are faced with a growing and increasingly complex array of quality and fi-
nancial metrics and are increasingly reliant on analytics technologies for their com-
pensation. Researchers, armed with advanced machine learning methods applied to
large data sets, are adding insights to relationships between genetics, behaviors, and
phenotypes derived from EHR and medical claims data. The vast majority of these
more complex analytic approaches are not yet applicable to healthcare delivery and

payment; a focus on fundamental, simple techniques is more cost effective. One
must always remember that new innovations often take several years before their
use and value are widely realized.
Every clinical informatics professional must remain knowledgeable about inno-
vativetechnologies,yetbeadvisednottoadoptexpensiveandunstabletechnologies
while more pressing clinical and financial issues are already apparent.
CLINICAL INFORMATICS PROFESSIONAL SKILL SETS
Clinicians who seek to practice informatics within complex care delivery settings
must be particularly aware of the techniques and skills required to translate their
clinical aspirations into meaningful organizational actions. Informatics is practiced
in the context of teams and organizations united toward common goals. Success
often depends far more on organizational capabilities and immediate needs than on
one’s own knowledge and capabilities. One’s organizational fit is a major determi-
nant of career success.
Mastery of traditional clinical informatics approaches is only the starting point
for a lifetime of effective clinical informatics practice. Much work lies ahead.
KEY POINTS
• Clinical care is only one determinant of health; behavior, social and
economic circumstance, and physical environment play vital roles. Clinical
care requires deep understanding of patients, families, policies, behaviors,
and many other factors.
• Healthcare is delivered by both formal and informal teams composed
of individuals pursuing common goals but playing different roles and
performing different tasks.
• Understanding roles, tasks, and goals is critical both to traditional care
delivery teams and to the informal support care network supporting
patients in their homes.
• Because of demographic trends, care fragmentation, technology
acceleration, and payment methods, EHRs will increasingly be
incorporated into a larger network of systems supporting care
communication, coordination, and accountability.
• New technologies and data sources have the long-term potential of
transforming clinical care to a dramatic extent but will take time to mature
into actionable programs.

2
Healthcare and the Electronic
Health Record
K A R L E . M I S U L I S A N D M A R K E . F R I S S E ■
OVERVIEW OF THE ELECTRONIC HEALTH RECORD
IN THE TWENTY-FIRST CENTURY
The electronic health record (EHR) is the present preferred term for the digital sys-
tems that coordinate healthcare information. The term electronic medical record
(EMR) was used more prominently in the past and has largely been replaced by
current terminology. These terms are not interchangeable. We tend to think of the
EMR as the record an individual facility or provider would use to accomplish what
they previously accomplished with paper records. We think of EHRs as more of a
continuum of records, extending beyond one provider or group of providers and
even beyond the enterprise. Ideally, the EHR would be able to access all medical in-
formation for a particular patient and be able to execute orders across the spectrum
of healthcare services. We aspire to that functional level, but we are not there yet.
Looking to the future, the next step is the personal health record (PHR), for
which healthcare data are governed not by the healthcare institutions but rather
by the patient. As providers, we will interact with the patient’s records using our
electronic tools.
The importance of these conceptual and functional transitions cannot be
underestimated. As authors of this book, we have clinical responsibilities in on-
cology (M.F.) and hospital neurology (K.M.) in addition to our Biomedical
Informatics appointments. These specialties, or almost any other, practiced with

incomplete information results in life-
and-
death decisions that are difficult and
dangerous.
BASICS OF EHR TECHNOLOGY
There are many functions of the modern EHR, but some key core elements include
• Data storage
• Clinical documentation
• Orders
• Results
Some additional expected functions of a modern EHR include
• Patient list management
• Communication with other providers
• Results inbox with check-off
• Decision support
These functions are detailed further in this chapter as well as elsewhere in this book.
The beginnings of EHRs included individual applications that performed orders,
provided results, or archived documents. Ultimately, the EHR evolved into a system
that could perform most or all of these tasks.
Presently, the EHR is pervasive in hospitals and most clinics. Estimates are that
more than 95% of hospitals use certified EHR technologies and have achieved
some level of Meaningful Use qualification.1
As of August 2018, the proportion of
hospitals meeting Meaningful Use levels 1 or 2 were as follows2
:
• Large hospitals = 99%
• Medium hospitals = 98%
• Small rural hospitals = 98%
• Small urban hospitals = 84%
• Critical access hospitals = 96%
• Children’s hospitals = 78%
Proportions of EHR use by outpatient clinics are somewhat lower, but still substan-
tial. The Centers for Disease Control and Prevention estimated that 87% of outpa-
tient physicians use an EHR in their practice.3
Children’s hospitals were quick to begin the journey to EHR adoption, but in re-
cent years, they have lagged behind adult hospitals and behind children’s hospitals
that are part of adult hospital facilities.4
As a result, they have lagged in Meaningful
Use achievement.5
Among the reasons implicated in this disparity is the greater
inefficiencies of EHRs for pediatric workflow and the challenging finances of many
children’s hospitals.

Chapter 2. Healthcare and the Electronic Health Record 9
Similarly,EHRadoptionislessintheoutpatientthaninpatientarenas.Partofthis
is functionality; not all EHRs are equally facile at acute and ambulatory workflows.
Some EHRs are better in outpatient space and some in inpatient space. Part of the
reason for lower adoption is also because, in the ambulatory market, the decision-
makers for resource utilization are usually the physicians, and they are less likely to
make a substantial investment for a modest incentive payment return.
There are multiple EHR vendors, but there are fewer major players in the market
than there were years ago. Part of this contraction is due to consolidation from
mergers and acquisitions. Part is from sunset of applications that could not keep up
with demands for functionality by users or regulatory agencies. The Office of the
National Coordinator for Health Information Technology (ONC) expects certified
EHRs to have specified functionality, and many vendors without significant market
share have abandoned their segment of the market, not expecting revenues to meet
development costs.
Because of the sunset of some applications, healthcare systems have had to re-
place them with current applications, with the hope that the new apps will not
themselves be sunset. Also, some healthcare systems replace working EHR systems
or subsystems because of hospital or clinic mergers and acquisitions, so that most or
all units of a healthcare system use the same EHR.
Most healthcare systems have more than one functioning EHR, often because
of lags in conversion to an enterprise-
wide EHR. Also, some specialties prefer
their niche information system. Until a comprehensive EHR can perform the
essentials of the niche systems, the specialty systems will be slow to be replaced.
Examples of where niche systems have significant market penetrance include
radiology’s picture archiving and communication system (PACS) and radi-
ology information system (RIS); oncology EHR (for chemotherapy and radia-
tion therapy); cardiology EHR; and gastroenterology EHR. These systems are
particularly image and procedure based, with complex and unique workflows.
The niche systems accommodate this complexity by generally well-
designed
scripting and workflows, automating many of the tasks required for orders, doc-
umentation, and billing.
Future directions of the EHR will likely be the following:
• Further consolidation of the EHR vendor market
• Transition of enterprises to use fewer and, it is hoped, one principal EHR
• Improved interoperability as part of core functionality
• Transition from niche specialty apps to functionality embedded in
comprehensive system-wide EHRs
• Focus on user efficiency and productivity
• Connection of EHRs with other EHRs to facilitate point-of-care
information exchange and care coordination
• Improvement of clinical decision support function to improve quality of
care, reduce gaps, and control costs
• Improved use of patient-entered information and facilitation of the move
to the PHR

Advantages of EHRs over paper records include legible notes and orders, access
from multiple locations, and automation of some previously manual processes, such
as order execution. However, composing a note in the EHR is often slower than
writing a note by hand and much slower than straight dictation. So, while almost no
one advocates returning to paper records, we should understand that efficiency is
affected by use of the EHR. Dealing with that inefficiency is discussed in Chapter 4.
In the future, our goal should be a single health record that spans all service
locations, incorporates patient data entry, and provides decision support not only
to the providers but also to the patient. Quality of care would be better. Costs
would be less.
CLINICAL NEEDS
Clinical needs can be divided into the following general categories:
• Point-of-care data
• Decision support
• Analytics
• Billing
• Communication
Point-
of-
care data management is the principal core function of the EHR. This
function not only consists of creation, storage, and manipulation of local data but
also extends to include data sharing with other systems.
Decision support is the growing role of the EHR in improving quality of care and
reducing costs. This is discussed in detail in Chapter 17. Some of the components
include disorder-specific order sets, alerts, and reminders.
Analytics is manifest in a broad spectrum of methods, as detailed in Chapter 16.
Among the analytics arenas are both clinical and business performance. Reports are
generated at almost every level of the healthcare system.
Billing requires access to clinical data for justification and authorization of appro-
priate charges and for creation of claims. This includes functions that are dependent
on financial arrangements with individual patients, payer contract management,
and regulatory requirements.
Communication includes messaging from within the EHR in regard to patients;
sending reports and other documents to other providers via exchanges, direct mes-
saging, or electronic fax functions; and secure messaging. Not all of these commu-
nication tasks are widely functioning.
CLINICAL APPLICATIONS
Let us explore some of the user-facing functions of a core EHR system. The minimal
functions are

• Clinical documentation
• Orders
• Results of laboratory and radiological studies
We focus mainly on these with mention of some of the additional functions that are
becoming pervasive but are not yet standard equipment:
• PACS for radiological image viewing
• Secure messaging for provider communication
• Assistance with coding and billing
• Electronic prescribing of medications for outpatient care
• Health information exchange data query and viewing
• Viewing/editing of data from interfaced applications, especially
procedural applications
These functions may be illustrated by a use case. Consider a patient who is in our
emergency department (ED) with fever and delirium. We assess the patient and
review the record. We discover that the patient has a high fever, appears pale, and is
hypotensive (has low blood pressure). A general medical examination shows that
the patient had previous lower abdominal surgery and bilateral mastectomy.
Our interaction with information systems is as follows:
• Vital signs have already been entered, and the fever and hypotension
are noted.
• Review of a discharge summary from an admission 3 months ago shows
the patient had a bilateral mastectomy. Pathology shows high-grade
adenocarcinoma. There are no other records in the EHR.
• Query of the regional health information exchange identifies documents
from a freestanding cancer center. These documents reveal aggressive
chemotherapy with neutropenia appropriately treated, with the last
documented chemotherapy 2 days prior to this ED visit.
• The ED physician electronically orders laboratory tests, including a
comprehensive metabolic panel (CMP), complete blood cell count
(CBC), and blood cultures to check for infection. The physician selects
Stat as the priority of the studies.
• Soon, the EHR displays laboratory results showing the patient is severely
anemic, with a very low white blood cell (WBC) count.
• The ED physician electronically orders antibiotics using an order set for
Febrile Neutropenia; the order set includes typical weight-adjusted doses
of medications and the antibiotics most commonly used in this clinical
scenario. The order set also has a section for transfusion, but the ED
doctor does not believe the patient requires transfusion at this time, so
this order is not selected. The ED doctor orders a CBC to be drawn in the
morning.
• The ED physician uses secure messaging to notify the internal medicine
hospitalist and on-call oncologist about the admission.

• The ED physician uses the documentation module to create the ED note
and then clicks the links to send the document by direct messaging to the
patient’s outpatient oncologist and primary care provider.
• The admitting hospitalist arrives and places an admission order set, which
includes entries for level of service, admitting provider identification,
admitting diagnosis, resuscitation status, and basic orders.
• As providers complete their notes, they are forwarded to administrative
personnel for coding and billing.
• As the patient has tests performed and interpreted, the results are sent to
the EHR inbox of the providers for review.
• As the patient receives treatments, details are sent to administration to
create the bills and for ordering replacement supplies for inventory.
Thepatientisadmittedtothefloor,andtheordersareexecuted.Amongtheseorders
are parameters for administering certain medications as needed and instructions re-
garding notification of the hospitalist of important events.
• Overnight, the patient becomes hypotensive. The nurse calls the
hospitalist because of the patient’s sudden loss of consciousness
and hypotension. The hospitalist gives a verbal order for fluids and
medications to increase blood pressure.
• The hospitalist soon arrives at the bedside, assesses the patient, then
places an intensive care unit admit order set, with selections tailored to
this clinical scenario. The hospitalist also looks at the early morning CBC
results and orders a blood transfusion. The hospitalist then electronically
signs the verbal orders that he had given on the phone.
A few aspects deserve comment. First, whether an ED doctor has time to review
the chart prior to evaluating the patient depends on whether the identity of the pa-
tient is known before arrival and the acuteness of the presentation: A patient who
is in cardiorespiratory distress and is not known to be arriving will be evaluated
emergently, with historical information reviewed later. It is hoped there will be a
computerintheroomsothatthedatacanbereviewedinthepresenceofthepatient.
When the patient was in acute distress, the hospitalist did not take the time to
go to a computer but rather gave verbal orders, which would be executed as fast as
the nurse and pharmacist could do them. We strive for efficient use of the EHR by
providers, but we do not slow down management when verbal orders can be faster
in times of emergency.
OVERVIEW OF CLINICAL INFORMATICS
Theremainderofthisbookpresentsourvisionsofwhereappliedclinicalinformatics
is and should be in the healthcare system. We discuss the framework of healthcare
information systems from hardware to applications and to policies and regulations.

We discuss how the infrastructure and tools are used to foster better healthcare and
reduced costs, thereby improving value.
There have been many criticisms of modern clinical informatics in that the EHRs
have not resulted in the improved outcomes and reduced costs anticipated. We be-
lieve we are transitioning to the next stage of informatics, which has the potential to
produce these results. But, this potential will only be realized with appropriate and
focused work.
KEY POINTS
• We are migrating from the EMR to the EHR with a goal of the PHR.
• Electronic methods are a crucial tool but not a replacement for personal
interaction between providers and between the patient and providers.
• The functionality of EHRs is expanding rapidly as demands for better
outcomes and better value insist on advancements of our technology.
• The role of the clinical informatics professional is to leverage the people
and processes as well as the technology to provide the best possible care.

3
Data, Information, and Knowledge
OVERVIEW
Data, information, and knowledge (DIKW) are fundamental concepts that have been
described in a variety of ways. Among the most common is the DIKW pyramid.
We prefer a nonpyramidal diagram, adding wisdom and understanding at the top
because these are not ensured steps and are not always acquired either sequentially
or simultaneously. The reason for abandoning the pyramid structure is because
the amount or importance of the level does not necessarily narrow at successively
higher levels.
The lowest three layers of our diagram are most relevant to healthcare infor-
matics (Figure 3.1). While the exact structure can be debated, the layered concept
is valuable.
• Data are values, and a datum is one of these. A creatinine of 3.71 mg/dL is
a datum.
• Information is data combined to allow for meaningful interpretation.
A creatinine of 3.7 mg/dL in a patient with previously normal renal
function is cause for urgent action, whereas the same data in a patient
with known renal failure on dialysis would be expected. Context of data is
important.
• Knowledge is a bit more difficult to define. In the context of healthcare,
knowledge is a structured compilation of information that can be used

18 Pa rt I I . T h e F r a m e w o r k
to guide decision-making. International guidelines (Kidney Disease
Improving Global Outcomes [KDIGO]1
) for management of renal disease
are knowledge.
• Wisdom is difficult to define, but most agree that judgment is a key part of
this layer. Computers are not able to have wisdom presently. We do not
understand the algorithms our brains use to be wise, and we are unable to
program our computers to be so.
• Understanding is sometimes interjected as a layer between knowledge
and wisdom, but we have it parallel. Developing understanding of any
complex clinical situation does not lead to development of good judgment
and wisdom regarding the issue. Similarly, it is possible to use good
judgment and make wise decisions without completely understanding the
conceptual framework.
For the remainder of this chapter and the remainder of this book, we focus on data,
information, and knowledge and leave understanding and wisdom to others to
debate.
DATA
Among the types of data stored and used in healthcare, the most common are nu-
meric, string, and Boolean.
Numeric data are measurable by a number in one form or another. The number
can be an integer, floating point, or fixed point. An integer has no decimal point; it
is a whole number. The floating point and fixed point numbers have digits to the
right of the decimal point, with either an indeterminate or fixed number of digits,
respectively. However, many fixed-
point numbers are really represented in the
databases as floating points but with a fixed-
point display. We are generally inter-
ested in three significant digits. I may be interested in knowing that the creatinine
Wisdom Understanding
Knowledge
Information
Data
Figure 3.1 Knowledge layers. Elements of the knowledge framework, starting from the
bottom with Data and being combined in context to produce Information. When this is
used to create guidelines, Knowledge is created. Wisdom and Understanding are more
difficult to define and represent higher levels dependent on judgment and comprehension.

Chapter 3. Data, Information, and Knowledge 19
was 3.71, but providing me with a number of 3.7147234 does not change my clin-
ical decision-making.
Strings are composed of characters, termed alphanumeric, meaning that both
alphabetic and numeric components can comprise the string. Text data are
represented as strings.
Boolean data are true or false and can be represented by the elemental bits of
1 or 0, where 1 would represent true and 0 would represent false. If the question
is asked whether a particular patient is currently an inpatient, the status is either
yes or no; there is no middle ground. Not all apparent binary data are actually
binary, however. Gender can be male or female, but it also can be unknown, un-
specified, patient refuses to answer, or transgender. A Boolean data point cannot
encode this.
Arrays are used to represent complex data. Arrays are series of data elements,
usually numeric, where the positions of the data in the array have meaning. For ex-
ample, images are stored as numeric arrays where the numbers can represent color
and intensity for each pixel. The computer keeps track of where on the screen the
pixel color for each datum belongs.
Data representation and storage are discussed in depth in Chapter 7. Our
databases store all of these types in an organized format, which becomes extremely
complex.
Healthcare Data
Healthcare data are of multiple types. Some of these are as follows:
• Provider documentation
• Nursing documentation
• Hospital ancillary staff records (e.g., for physical therapy [PT],
occupational therapy [OT], case management)
• Laboratory and pathology data
• Radiology images and reports
• Business information
The applications handling these data include the
• EHR
• Laboratory information system (LIS)
• Radiology information system (RIS)
• Picture archiving and communication system (PACS)
• Business/financial information system
The applications can be part of the same application suite or independent.
Suites of programs typically have data connections as part of the suite architecture.
Independent programs must be interfaced.

Data Problems
Data can be corrupted in a variety of ways. Some of the issues are as follows:
• Error in data entry
• Misunderstanding the patient
• Incorrect information from the patient
• Data entered in the wrong field
• Delay in data entry
• Inaccurate data association
Anerrorindataentrycanbefromsimplemistyping.Ifthedataarestring,surrounding
characters can resolve the error. “Never soked” is likely to be interpreted as “Never
smoked.” However, if the year field in a date-
of-
birth entry is in error, “2016” rather
than “2006” can have implications in decision support for antibiotic selection, dose
recommendations, and even patient matching for a health information exchange.
Misunderstanding the patient is common. Considering the amount of data
a medical assistant, nurse, or provider acquires from the patient in an encounter,
errors in understanding are expected.
Incorrect information from the patient is common and can be unintentional
(e.g., misspeaking) or intentional, to hide sensitive or embarrassing information or
sometimes to protect personal details the patient does not wish to share.2
Entering data in the wrong field is common at every level of the encounter be-
cause forms are so commonly used. Fields are designed to recognize some data
entry errors, but this does not identify all errors. For example, a patient’s weight
of 206 entered into the field for birth year would easily be flagged for the user as an
error because it is out of bounds.
Delay in data entry is a crucial and usually avoidable cause of error with great pa-
tient safety implications. Some providers delay documentation until hours or per-
haps even days after an encounter. A busy clinician is incapable of recalling the same
level of detail after a significant time interval, and confusing data from different
patients becomes a more significant issue. Enterprise regulations or incentives
should promote documentation and orders to be completed in a timely fashion;
merely encouraging timeliness is usually not successful.
Inaccurate data association is linking of data incorrectly. For example, two
patients with nearly identical names and addresses may be assumed by an informa-
tion exchange to be a single individual, so that the healthcare and financial data are
blended. The converse is more common, where a patient has multiple records in
the same information system because of variations in how they registered through
shifting personal preferences or change in name due to marital status.
INFORMATION
Data are made useful by context. What we typically consider data in clinical practice
are really information. We consider a laboratory value in the context of the normals

Chapter 3. Data, Information, and Knowledge 21
for age and comorbid conditions. We consider a laboratory value as part of a trend
for that particular patient. A digital image is information by definition: The pixels
are data, but the displayed image and interpretation are information. Information is
data presented in a useful form.
Information is created by association of data with norms or expected values.
A computed tomographic scan of a 90-
year-
old patient may be normal for age,
but the same appearance in a 40-
year-
old would be interpreted as premature
atrophy.
Information is inaccurate if the data are incorrect for any reason, whether artifac-
tual, wrong data entry, or incomplete. Incorrect information is often propagated, so
when a datum is corrected, that fix may not correct the downstream copied datum
and may not reach the decision-maker to alter the clinical plan.
KNOWLEDGE
Knowledge is organization of the data and information in way that can be helpful
for future decision-
making. The decisions we make on the basis of information
are guided by our knowledge, whether acquired in school, continuing education,
reading, or personal clinical experience. Among the knowledge sources are
• Basic clinical training
• Continuing education from speakers, publications, and colleagues
• Published guidelines for specific presentations or disorders
• Personal clinical experience
• Embedded knowledge base in our workflow
Knowledge Management
Knowledge management is a large academic field, with real-
world implications.
Ideally,thebestknowledgesourceswouldconsiderallofthedatasourcesmentioned
plus local data, such as a local antibiogram.
We recommend that knowledge management in the healthcare arena consist of
the following components:
• Online knowledge resources (e.g., UpToDate)
• Context-sensitive information on demand (e.g., drug or laboratory details
on hover or click of an orderable)
• Order sets for specific diagnoses designed to adhere to best practices and
evidence-based medicine (EBM) principles
• Templated notes to guide complete evaluation and documentation,
adhering to best practices and regulatory requirements
• Analytics to determine site-specific factors in management
• Analytics to determine the practice and educational needs for providers
and staff

An embedded knowledge base is a principal focus of this book.
Online knowledge resources are commonly subscription services or links to a
hospital’s online library. The days of physically going to a library have ended. For
medical care, we generally favor availability of both book (physical or e-
book) and
Internet-
based access (e.g., PubMed, UpToDate). Many providers have preferred
texts that they consult for specific cases. The Internet-
based reference material is
generally easier to search, partly because the search engine is more robust than a
book index and because of more extensive tagging of information with online data.
Also, the online reference material is more likely to be updated than that in books,
especially the print versions.
Knowledge management has multiple potential pitfalls. Errant and obsolete data
are the most common issues. Guidelines change, and for a busy clinician, it is hard
to keep track of the new changes. New indications for medications and procedures
may be found. This new knowledge ultimately triggers changes to protocols and
order sets, and these changes have to be made with appropriate speed as well as cau-
tion. During build and review of our order sets, there will undoubtedly be errors,
and with each update and review, we repair many, but we are unlikely to be totally
free from inaccuracies. We make every decision on the basis of the best and most
accurate information we have at the time. In knowledge management, we need to
keep up.
KEY POINTS
• Data are values, and a datum is one of these.
• Information is data in combination and context for meaningful
interpretation.
• Knowledge is a structured compilation of information that can be used to
guide decision-making.
• Data types are multiple, but most include numeric, string, or Boolean data.
• Errors in data entry are common, and our systems must be able to
deal with missing and conflicting data and perform reconciliation of
errant data.
• Knowledge management is a principal task of the applied clinical
informatics professional.

4
People
OVERVIEW
The patient is the central focus of health care. The range of individuals employing
clinical systems to support the care of patients is vast. Effective clinical support
requires sophisticated care coordination and technology skills. Introduction of
poorly-
designed systems and processes has consequences. Inefficiencies cost
money. Errors cost lives.
In this chapter, we review the involvement of a spectrum of people in clinical in-
formatics, with a focus on some of the pivotal roles in healthcare systems.
PATIENTS AND FAMILIES
Family members and other caregivers are reliant on informatics because they
are central to care coordination and patient support. The individuals playing
supporting roles vary significantly in their capabilities, health literacy skills, formal
training, finances, and ability to manage social resources. They need assistance.
Each caregiver bears a personal burden of medical and social issues. For example,
a deteriorating elderly patient may in turn be cared for by an elderly spouse who is
also deteriorating. These behavioral capabilities are often far more important than
technology. Often on-
site visits or virtual visits through a range of technologies
can ease the burden. Similarly, investing in a technology to document medication

adherence is not sufficient unless documentation can lead to behaviors leading to
better adherence. Information alone will not magically make people act more effec-
tively to address problems they already know they face.
Challenges faced by patients and families that pertain to informatics include
• lack of a clear plan shared by all parties involved in care;
• variance in how providers are contacted;
• lack of communication between providers; and
• difficulty accessing clinical reports, and when accessed, the med-
speak descriptions are difficult to understand and sometimes easy to
misunderstand.
Providers and healthcare systems do not “connect” effectively. Often they rely on
different technical platforms, have varying degrees of technical maturity, and dif-
ferent workflows. For example, one provider may offer a patient portal, but not
use the portal effectively for communication, relying instead on the telephone.
Another provider may rely on primarily portal messages and not receive updates via
telephones. Each provider may have a different approach. To receive the care they
need, patients and their families are forced to adapt to inconsistent communication
methods.
Patients generally believe providers communicate with one another far more
than what really takes place. Patients may arrive for a clinic appointment after
a prolonged hospitalization only to discover that his or her trusted provider was
not aware of the hospitalization. Even if discharge summary is present in the elec-
tronic health record (EHR), the trusted provider may not be aware of it and hence
is unprepared for the post-discharge visit. Clinical informatics professionals cannot
ensure that all busy providers “close the loop,” but they can and should seek to im-
prove notification and communication. Improvements may be as simple as having
an up-to-date directory of phone numbers electronically distributed to providers. It
may be having secure messaging for all providers in a healthcare system (whether
employed or not) and ensure that inbound messages reach the attention of desig-
nated providers. The quality of communication must be adequate for clinical care.
It often is not.
Patientsmustunderstandwhatportalcommunicationsmean.Healthcaresystems
often include laboratory and radiology reports in their portals. The implications of
these numbers must be clear. For example, serum sodium levels of 134 mEq/dL and
135 mEq/
dL are not significantly different, but portal user will observe that one
value is “abnormal” and the other is not. Similarly, inconsequential abnormalities
on a magnetic resonance imaging (MRI) report may create anxiety. Providers must
address potential anxiety through simple notes. The patient seeing a report with
inconsequential results will be relieved to have the personal note: “You have some
small abnormalities on your studies that do not indicate any serious disease. We will
discuss further when we meet again, but if you want to chat with us earlier, message
us back.”

Chapter 4. People 25
CLINICAL STAFF
Clinicians, staff, and teams performing direct care in hospitals and clinics and at
home are formal care providers equally affected by the quality of clinical informatics
work. The ability of clinical systems to provide timely information and decision
support within effective workflows impacts quality and cost of care.
Besides direct patient providers, there are others in the healthcare system with
immediate or long-term dependence on informatics. Clinical actions drive logistics
tasks, including patient scheduling, supply procurement, medication management,
medical billing, quality reporting, patient/family communication, and care coordi-
nation. The quality and efficiency with which these tasks are enabled by data, pro-
cess, and technology have a significant long-term impact.
Among the pain points for providers pertaining to clinical informatics, some of
principal concern are
• Time required to create documents
• Burden of transmitting documents to appropriate individuals
• Medicine reconciliation
• Decision support alert fatigue
• Diagnosis and problem management
The amount of time needed to create clinical documents has increased. Part of this
is that entering data in the EHR is not as fast as dictation, but a significant compo-
nent is new requirements for documentation. We need to make providers as effi-
cient as possible, and streamlining document creation is a priority.
Now that we have these shiny new technical tools and providers can do a lot of
the clerical work themselves, we ask them to do so. One of us spent 12 minutes
ordering an MRI and doing all of the computer work required to schedule an ap-
pointment with a specific surgeon. This is not a good use of our time. We need to
have users work at the height of their licenses and capabilities.
Medicine reconciliation is the process of comparing medicine lists, usually at an
office visit or a transition of care, such as a discharge or a move to a long-
term care
facility. This is time intensive and often cumbersome, and we need to improve this
process.
Decision support is discussed at length in Chapter 17 and is a process of using
stored information and algorithms to remind providers of gaps in care or potential
errors. These algorithms are imperfect and may aggravate the user to the point that
they ignore important notifications.
Diagnosis and problem lists need to be updated and reconciled, just as medica-
tion lists are. This is time consuming and sometimes clumsy. Some patients will end
up with a lengthy list of redundant and sometimes errant entries, and with so much
information to review, the next user may review none of it. We must help the users
with maintenance of these lists.

THE INFORMATICS TEAM
We often refer to an “informatics team” and their work. Who, exactly, is on this team
and who leads the team? In this chapter, we describe team members of pivotal im-
portance. We describe leadership further in Chapter 12.
Chief Medical Informatics Officer
The chief medical informatics officer (CMIO; an alternative is chief medical in-
formation officer) usually has an MD, DO, MBBS, or equivalent degree. Some
highly effective CMIOs carry other clinical credentials. Most are trained and
experienced clinicians, but many have surrendered some or all direct clinical
responsibilities to focus on their informatics. Many CMIOs in academic med-
ical centers also have a doctoral (PhD) degree in informatics. In non-
academic
settings, many CMIOs have a master’s degree in informatics, but some have less
formal informatics training. Many CMIOs also have an MBA degree or manage-
rial experience.
Most enterprises of any size have a CMIO with one or more associate CMIOs
with fewer formal credentials. Many are generalists, but specialists in surgery, cardi-
ology, or other clinical areas are often found in larger organizations. Many associate
CMIOs advance to CMIO positions.
Nothing is more satisfying to clinicians than to know that their CMIO performs
clinical work in their own system. Clinicians become alienated by leaders who em-
phasize promises, present informatics only through demos, and do not actually “eat
what they cook.” At the same time, CMIOs—
especially those in primary care—
cannot be effective if their informatics work is continually interrupted by care
responsibilities. We recommend that CMIOs pursue balanced clinical activities for
a host of reasons, including:
• Ongoing direct interaction with patients, families, and other caregivers.
• Strengthened credibility with other clinicians.
• Hands-on regular experience using the organization’s clinical systems
Whether one remains clinically active or not, CMIOs must retain and develop their
clinical mindset as they oversee their wide range of responsibilities that include:
• Working with senior enterprise leaders on issues facing information
systems and providers involving informatics and enterprise strategy.
• Maintaining effective knowledge management by ensuring order sets
incorporate best practice guidelines.
• Providing leadership for decision support efforts for providers.
• Coordinating provider education programs.
• Working closely with nursing, pharmacy, medical specialties and other
groups ensure that needs are being met.

Chapter 4. People 27
• Collaborating closely with the chief information officer (CIO) and other
information systems leadership to coordinate enhancements, updates,
upgrades, new clinical systems’ needs, and information systems strategy.
• Participating in and directing analytics efforts in both clinical and financial
domains.
Chief Nursing Informatics Officer
The chief nursing informatics officer (CNIO) may also be called a chief nursing in-
formation officer. In hospitals, nurses spend more time on direct patient care than
physicians. Often, an overemphasis on physician needs comes at the expense of
nursing support that can have tremendous impact on care efficiency, care quality,
and clinical morale. The CNIO works closely with the chief nursing officer, CMIO,
and other leadership as needed to ensure the most efficient and error-
free nursing
practice, issue identification, and coordination with providers.
The CNIO typically has a nursing degree and additional education leading to a
master’s degree or other significant training in informatics or management.
Nurse Informaticists
Healthcare systems have nurse informaticists who are responsible for a wide range
of tasks, from assistance with design decisions and rollout to education and opti-
mization. Backgrounds are varied, with some having BSN, master’s, or even DNP
degrees and others having associate degrees as registered nurses (RNs). Most of
these individuals learned informatics on the job.
Specialty Informaticists
Large facilities usually have select specialty informaticists. These informaticists can
include those practicing in pharmacy, radiology, emergency services, operating
room/
anesthesia, cardiology, ambulatory clinic, and other specialty operations.
Individualhealthcaresystemswilldifferinneedsinthisregard.Theseinformaticians
are usually practitioners or administrators in these areas who are familiar with their
needs, workflows, and challenges.
ROLE OF THE INFORMATICS TEAM
When seeking solutions, clinical informatics professionals must consider the needs
of each of the stakeholder groups and understand how informatics decisions can
affect both immediate care and long-
term administrative, public health, policy,
and research needs. Needs and priorities among these efforts will not always align.
Teams working on these projects must respect one another as equals; simply giving

orders will not work. Balance requires effective communication, cooperation, and
collaboration. The importance of team-building, management, and communication
skills cannot be overemphasized.
KEY POINTS
• Individuals may differ in their needs, their values, their ability to
understand and communicate, and their incentives to change their
behavior.
• Groups of individuals, working together as members of formal or informal
teams united by a common purpose, differ in their ability to communicate,
coordinate, and effect desired change.
• Organizations have different roles that may include service delivery,
administration and payment, regulation, public health, research, advocacy,
and governance. Their needs differ, and often benefits accrued to one
organization may come at the expense of another organization; incentives
among organizations are not aligned.
• Few individuals or organizations have the time and resources to address
and reconcile all needs. These struggles are often played out in clinical
settings and come at the expense of clinicians providing care.

5
Policies, Laws, Regulations,
Contracts, and Procedures
OVERVIEW
The adoption and use of clinical systems are driven and constrained by laws,
regulations, contracts, and operational procedures. Often, the creation of institu-
tional procedures is influenced by differences in how leaders within an institution
interpret the laws, policies, and contracts governing healthcare delivery.
POLICIES
Policies are explicit combinations of decisions, plans, and expected actions. Policies
are created to realize specific economic or healthcare goals. According to the World
Health Organization, an explicit health policy can achieve several goals:
• Define a vision for the future that helps to establish targets and points of
reference for the short and medium terms
• Outline priorities and the expected roles of different groups
• Build consensus and inform people1
Because of the breadth of society’s health issues; the diversity of personal, reli-
gious, philosophical, or societal goals; and the conflicts that arise among concerned

stakeholders, policies or their execution through procedures are almost always
controversial.
Policies are positions, statements, and courses of action that reflect an
organization’s goals and values.2
Policies are the products of government, business,
or other authorities. Policies can be expressed as high-
level aims or with granular
specificity. When simply expressed through position papers or other media, they
seek to develop a consensus for action. When expressed through legislation and
regulations, they lead to mandates. Policies describe what must be done. Policies
are not laws but often are the byproduct of legislation or regulatory action. At both
the state and federal levels, laws provide directives to government agencies, which
in turn, often through a process called rule-
making, create policies that articulate
detailed and specific actions a healthcare organization must take to comply with the
law or directive.
LAWS
Laws impacting clinical informatics are created at all levels of government. Most of
the most important laws are products of federal legislation, but states have a consti-
tutional right to create laws that complement or modify federal legislation. States
play significant roles in privacy, public health, and the financing of federal programs
like Medicare.
Atthefederallevel,someofthemostimportantlegislationincludesthefollowing:
• HIPAA. The Health Insurance Portability and Accountability Act of 1996
(HIPAA)3
has become the legislative basis for healthcare transaction code
sets, privacy rules, security rules, and a national provider identifier system.
Some of these rules have been modified in other legislation, but HIPAA is
the foundational element.
• HITECH. The Health Information Technology for Economic and Clinical
Health (HITECH)4
Act of 2009 established a number of offices and
processes to enhance the adoption and effective use of electronic health
records. HITECH was enacted as part of the American Recovery and
Reinvestment Act of 2009. It was not part of later healthcare reform acts.
As part of broad economic stimulus legislation, HITECH was required
to move quickly and, critics say, led to the imposition of the current
generation of electronic health record (EHR) implementations without
adequate understanding of healthcare workflow and future needs.
• Stark Law. The Stark law is actually a number of separate legislative
elements established in the early 1990s.5
Their goal was to prohibit
physician self-referrals and kickbacks: referring patients for specific
tests to facilities in which the physician received additional financial
compensation. As collaboration requirements necessitated shared
health information systems and data, hospitals sought to expand clinical
technologies to referring physicians, which could have been construed as

Chapter 5. Policies, Laws, Regulations, Contracts, and Procedures 31
a violation of Stark laws. These concerns were alleviated when most uses
were granted safe harbor6
status from regulatory agencies.
• Antitrust. Section 1 of the Sherman Act7
prohibits actions that
unreasonably restrain competition. This issue is raised when provider
groups or health plans merge or when collusion on pricing is alleged.
Antitrust concerns are often raised when price information is shared
in the course of broader clinical data-sharing initiatives. Antitrust
is also raised when dominant providers or payers create contracts
that exclusively prohibit physicians from referring patients to out-of-
network specialists.
• FDASIA. The Food and Drug Administration Safety and Innovation Act8
(FDASIA) Act of 2012 expanded the Food and Drug Administration’s
(FDA’s) authority to regulate medical devices and software. In
collaboration with the Federal Communications Commission (FCC) and
FDA, advisory panels recommended a risk-based framework for regulating
software. EHRs, decision support, mobile devices, and health information
exchange may all be subject to some regulation. Established EHRs and
other clinical systems are considered relatively low risk and have largely
avoided FDASIA scrutiny.9
• ACA. The Patient Protection and Affordable Care Act10
(ACA) of 2010
was created to correct inadequacies in healthcare delivery and payment.
Although most attention is given to Medicaid expansions, it included
removal of preexisting illness coverage exclusions and initiated incentives
or penalties to require every adult to have healthcare coverage with certain
minimal criteria. The ACA also had mechanisms to study the cost-benefit
value of various treatments and to establish a Patient-Centered Outcomes
Research Institute (PCORI). PCORI’s Patient-Centered Clinical Research
Network (PCORNet) is a shared data network of healthcare institutions
supporting comparative effectiveness research using routine healthcare
translated to meet a PCORNet common data model. Electoral changes
and judicial decisions since the Act’s passage have eliminated mandatory
coverage and weakened other key provisions, but public sentiment,
changing demographics, and financial constraints suggest that many of
technology and payment approaches stimulated by the Act will continue.
In particular, care management across a continuum of care, greater
exchange of healthcare information among providers and patients, and
value-based reimbursement will remain a primary focus for new clinical
informatics initiatives.
• 21st Century Cures Act.11
This bipartisan 2016 law builds on prior
legislation and requires federal agencies to promote greater patient and
provider access to biomedical data for care and for research. It has fostered
significant new data interoperability efforts and standardized application
program interfaces (APIs) to EHRs. This more open and accessible data
infrastructure in turn necessitated new regulations granting additional safe
harbor status for many clinical initiatives.

REGULATIONS
Laws at the federal or state level mandate one or more executive agencies to act on
the laws by specific times. Laws often issue directives at relatively high levels and
require agencies to translate legislative intent into actionable conduct. In response
to legislation, agencies must engage in what is called the rule-making process. When
tasked by Congress, agencies are required to issue one or more notices of proposed
rule-making (NPRM) to inform the public of the proposed rules before they take
effect. The public rule-making record must include the data and analyses supporting
the proposed rule.
The public can then comment on the proposed rules and provide additional data.
The issuing agency must respond to public comments. In some instances, agencies
may publish a second draft proposed rule for an additional cycle of commentary.
Ultimately, the agency publishes a final rule that establishes policy; these are the
regulations. These rules often are modified over time through the same rule-making
process.
CONTRACTS
Contracts are required if organizations work together to accomplish a policy goal.
Contracts designate the responsibilities of participating parties and set metrics
and penalties if obligations are not met. Most contracts have significant financial
implications. Often, failing to read the fine print or not communicating with others
under similar contractual relationships can be very costly. Medicare Advantage
Plan contracts, for example, define relationships among providers and payers; these
contracts often define what quality metrics must be collected and how quality met-
rics will influence payment.
Information technology vendor contracts define obligations and penalties asso-
ciated with installation and operation. These contracts are complex and usually in-
volve many different parties.
HIPAA’s business associate agreement (BAA) establishes a relationship between
a provider, health plan, or claims clearinghouse (covered entities) and any vendor
that works with a covered entity. BAAs both state what the business associate can
do with personal health information and obligate the business associate to comply
withallotherrelevantHIPAArequirements.ThisisdiscussedfurtherinChapter18.
PROCEDURES
Procedures form a bridge between both policy and contractual requirements and
specific actions at the organizational level. At the local level, procedures define the
series of actions and actors necessary to ensure the requirements of a policy or con-
tract are met. Some procedures become routinely embedded into care processes
(e.g., medication administration, patient registration, granting access rights to per-
sonal health information). Other procedures more resemble fire drills in that they

are only invoked in extraordinary circumstances (e.g., adverse event reporting, mass
casualty management, data breaches). These must be kept available and periodi-
cally reviewed and rehearsed so that every individual in the organization is aware
of their role.
Effective local procedures derived from clear local policies can mean the differ-
ence between success and failure. The introduction of EHRs required organiza-
tions to formalize procedure statements that described exactly how an organization
would incorporate EHRs into clinical workflow and how it would ensure that data
were managed effectively. Where HITECH was concerned, the why of the legisla-
tion and the what of the policies were uniform. The success or failure of an EHR
implementation was due largely to the extent to which they clearly conceived and
executed procedures. Success was about the how.
The difference between successful and failed implementations can be explained
by how organizations chose their technologies, developed their teams, and
redesigned their workflows. The right procedures, when combined with effective
execution and ongoing oversight, had significant financial consequences to health-
care delivery organizations. As is the case in every policy, successful outcomes re-
quire organizational procedures that are clear, actionable, and managed.
Many procedures arise from policies that do not originate from government but
instead come through contractual relationships between and among healthcare
providers, plans, regulatory agencies, and other groups. These contracts may restrict
or expand coverage and services, may specify mandatory quality metric reports, and
may employ different rules for care reimbursement. This may include how a health
plan will reimburse clinical work or how delivery organizations must collect and
report data on the quality of care. Medicare Advantage programs are an example;
these are private health plans approved by the Centers for Medicare and Medicaid
Services (CMS) that charge additional premiums but offer additional services, such
as vision, hearing, dental, and wellness programs. Most plans also have prescrip-
tion drug coverage (Medicare Part D). Over a third of Medicare beneficiaries are
enrolled in Medicare Advantage plans.12
MedicareAdvantageplansandotherpayercontractsinvokeproceduresthatoften
alter network referral patterns, therapy options, prior authorization practices, and
quality reporting requirements. These plans are growing in popularity and may be
a model for more aggressive Medicare changes in the future. Coding requirements
mayalsodifferfromtraditionalMedicare.HealthplansofferingMedicareAdvantage
are revising their client-
facing and administrative process to create comprehensive
plan-
branded consumer engagement platforms that simplify enrollment, increase
customer services support, and support clinical care management. From the pro-
vider perspective, Medicare Advantage contracts primarily accelerate emerging
trends: tighter integration with health plan systems, clinical and administrative
decision support addressing both medical and financial issues, and more patient-
oriented care management supporting teams working both in institutions and in the
home. Provider service administrators must also rely on various analytics methods
to understand risk under capitation models. For example, the CMS Hierarchical
Condition Categories13
(CMS-HCC) model is used to adjust capitation payments
to Medicare Advantage plans.

CONSEQUENCES OF POLICIES, LAWS,
AND CONTRACTS
Policies, laws, and contracts have many consequences on clinical practice.
Minimizing complexity and mitigating administrative time require a thoughtful re-
view of clinical workflows and of the design and use of clinical information systems.
Several issues are particularly relevant to clinical informatics:
Cost. Even in an ideal world, great costs are incurred in creating or
interpreting policies, on disseminating policies, on creating subsequent
procedures that aid in uniform policy compliance, on measuring policy
compliance, and on enforcing compliance. At the federal level, HIPAA
and subsequent health information exchange policies often are associated
with regulatory impact statements created when the policy is put in place.
For example, agencies must assess “all costs and benefits of available
regulatory alternatives” if a law is expected to impact the economy by
over $100 million a year. Unfortunately, these statements are often gross
simplifications and tend to underestimate the enormous burdens placed
on healthcare professionals and organizations. In the original HIPAA
regulatory impact statement,14
Health and Human Services (HHS)
stated that a regulatory impact statement was not necessary because the
“aggregate economic impact of this final rule is minimal and will have
no effect of the economy,” and that the law would not have a “significant
impact on a substantial number of small entities.”15
But, the true costs are
much higher because of the enormous efforts every hospital had to make
to understand the regulation, change workflows, train their personnel,
and enforce compliance to avoid costly penalties. More realistic estimates
suggested that costs to hospitals alone would range from $670,000 to
$3.7 million per hospital. HITECH and subsequent expansions of health
information exchange requirements also suggested rosy outcomes that
have never been realized. When combining direct institutional costs with
the productivity impact of these regulations, the costs are much higher
and represent a major administrative challenge to this very day.
Policy Variation. Many health plans have different metrics and policies for
reporting clinical activity and quality metrics. These wide variations have
enormous consequences on clinical information systems vendors and
on providers. System designers must model each complex requirement
and providers must spend inordinate amounts of time addressing these
requirements in the course of care. For example, providers are confronted
with a dizzying array of formularies, each with minor differences
in covered drugs and patient payments. Collectively these changes
place enormous cognitive as well as financial burdens on patients and
clinicians.
Policy Requirement Growth and Complexity. Quality metrics
exemplify how regulations and contractual requirements are increasing

in number and complexity. When combined with other administrative
tasks, these requirements place additional burdens on clinicians
and threaten to smother their clinical patient care. In turn, this shift
from clinical to administrative work contributes to growing provider
dissatisfaction. Vendors have other concerns. Faced with widespread
provider backlash, regulatory groups often give the provider a choice
of metrics to collect and report. A provider may be required only to
address any one of three items: A or B or C. But, the vendor must
design its systems for all of the three items: A and B and C. These
complexities drive up costs to vendors and, arguably, impede vendor
abilities to create EHR environments more conducive to clinical
practice and knowledge management.
Rationale. Controversy arises over the extent that cumbersome reporting
metrics actually measure care quality. Legitimate arguments can be made
about the efficacy of quality metrics with respect to both their sheer
number and large variation. A broader national discussion on the validity
of metrics would be beneficial. Much is spoken about evidence-based
medicine. Where is the dialogue about evidence-based administration?
Along the same lines, in complex areas such as risk-adjustment metrics,
it is possible that discrepancies between the provider calculations and
payer calculations are the result of payer error, not provider error. Where
analytics and implementation of complex algorithms are concerned, no
organization is infallible.
Certification. Certification is the process of ensuring that an individual,
process, technology, or professional service can do the job it was designed
to do. The HITECH Act is an example of a law that created numerous
and highly complex certification policies.16
Its overall goal was to create a
nationwide, standardized healthcare technology infrastructure to ensure
safer and more effective care in a manner aligned with the spirit of the
broader economic stimulus legislation. This is the why of HITECH. The
authors of HITECH specified in great detail the what through a number of
specific measures. For example, HITECH authorized the secretary of HHS
to create a set of data standards that would ensure effective deployment and
interoperable use of EHRs in most American hospitals and ambulatory care
settings. The policies were created by the Office of the National Coordinator
for Health Information Technology (ONC) and, true to the legislative
intent, came with both financial incentives and, later, possible financial
penalties. These policies expressed in detail what measures had to be taken
by healthcare organizations to receive incentives and avoid penalties.
Overall, the legislative ambition was to see that EHR technologies were used
in meaningful ways. This intent was converted via policies into three stages
of Meaningful Use. Initial phases required only that an institution seeking
financial incentives demonstrated the capability of performing a number of
specific tasks, including selected clinical decision support and transmission
of prescriptions and other reports in digital format.

WHAT CLINICAL INFORMATICS PROFESSIONALS
SHOULD DO
Clinical informatics professionals must be aware and informed of the process
of creating legislation, deriving policies, and execution through procedures.
Understanding the context helps a clinical informatics professional explain the ra-
tionale behind a procedure when practiced at the local level. Individuals are often
less motivated to conform to procedures if they do not understand the context and
consequences.
Often, professional groups, technology firms, and others strive to simplify
procedures before they are formalized. This occurs typically with notification
through an NPRM, as discussed previously in this chapter.17
Each party has a sepa-
rate agenda in seeking to modify policies. Although some agents seek obfuscation
and self-
interest, most agents seek to create simpler policies that are easier to im-
plement and reinforce. Despite the complexity and confusion, the public is at least
theoretically aware of new policies as they emerge.
One’sinfluenceisgreatestwhenfocusingonorganizationpoliciesandprocedures.
Informatics professionals play a critical role on the ground. At the institutional level,
the process is often far more complex for many reasons:
• First, policies often originate from relatively isolated management groups,
and the clinical informatics professional must ensure that all legitimate
concerns of those affected by the policies are incorporated.
• Second, policy and procedure creation efforts are often inadequately
governed. At times, leaders fail to establish clear project governance,
convene a sequential series of meetings leading to a goal, and ultimately
state explicitly responsible parties for each task. When in a large meeting,
statements like “we will do this” may sometimes translate into “no one will
do this.”
• Third, institutional processes are often inefficient. Rather than establish
clear project governance and convene a sequential series of meetings,
organizations often wander in circles and incorporate people in meetings
whose interest and trust can be more efficiently gained through individual
dialogue and constant communication.
• Fourth, meetings can be expensive. Value is realized through the impact
of policies and procedures; frequent and ineffective meetings merely add
to the cost. Time spent by colleagues in meetings necessarily comes at the
expense of other tasks. Often, people participate in meetings because they
are concerned they will not be informed of the process otherwise; this is a
failure of leadership and communication.
• Fifth, legal counsel and external consultants, while often essential, may
be invoked prematurely. At times, meeting with stakeholders and clearly
understanding their needs will minimize legal and consulting costs. The
more stakeholders understand the intended purposes of policies and
procedures, the easier it will be for leaders to lower costs by providing
legal and consulting professionals with clear guidance. One common and

very expensive example concerns creation of policies and procedures
around protection of personal health information. Even the experts in
an organization often have different interpretations of what is required.
Gaining a consensus internally then draws focus onto legal support. One
cannot expect counsel to sort it out if key parties disagree. The clinical
informatics professional, with an awareness of the impact on most
stakeholders, must play a vital role.
KEY POINTS
• We should understand the intent of legislation and the policymaking
process.
• We should understand the why or the context motivating a policy,
contract, or procedure.
• We need to set priorities and focus on the important policies and
procedures first.
• We should gain a clear understanding of stakeholder needs and concerns
as early as possible so that we can understand the impact on individuals
responsible for carrying out required tasks.
• We focus on solving the problem, and to do this we maximize
communication but minimize the number of individuals assigned to any
task or meeting.
• Within the meeting group, we seek a consensus early so that one can be
assured that everyone seeks to solve the same problem.
• We strive for simplicity. Remember that positive consequences only
emerge if everyone knows what to do. The simpler the message and the
fewer the moving parts, the more effective will be the outcomes.
• We should develop a simple message. No matter how complex the policy
or procedure is, we work with our colleagues to develop a simple pitch that
can explain to everyone in the organization the why, who, what, and how.

6
Process
The Learning Health System
HISTORY AND THEORY OF THE LEARNING
HEALTH SYSTEM
Scientific research has been performed for hundreds of years, but much of medical
care has been guided mainly by the personal experience of the providers and their
professors. This was challenged especially in the past 25 years: Study after study
have refuted processes that had become accepted medical practice. Also, there has
been a cultural change among many providers. We came to appreciate that each of
us is not the single source of truth for best practices for our patients. Yet, even today,
some clinicians cling tenaciously to their archaic methods of medical and surgical
practice. This indicates a serious flaw in knowledge management. When some of us
finish training, we stop learning.
The Institute of Medicine (IOM) released To Err Is Human in 2000; it reported
that as many as 98,000 deaths in the United States can be attributed to medical
errors.1
Subsequent work has emphasized the need for development and practice of
evidence-based medicine (EBM).
The learning health system (LHS) is a logical extension of EBM in the context of
our advances in electronic health record (EHR) technology.2
The LHS is an itera-
tive approach to healthcare improvement: The data in our EHRs is combined with
data from other sources and known knowledge bases to produce improvement.
The LHS tries to break the closed circuit of provider and patient interaction and
connect to local and regional data sources. These data sources would be used to

Chapter 6. Process: The Learning Health System 39
engage patients, providers, administration, and all knowledge holders in the im-
provement of care.
Connected partners in the LHS are
• Providers
• Patients
• Local EHR data, including warehoused data for analytics
• Regional and state reporting agencies
• Knowledge bases, including the National Library of Medicine (NLM),
universities, medical societies, and other sources
The culture of the providers and patients must be amenable to assessing information
from these connections. In some of our facilities, certain providers are not participa-
tory in quality improvement, let alone helping to facilitate an LHS. Moving the cul-
turemaybeamongthemostchallengingaspectsofdevelopmentanduseofthe LHS.
Data elements of the LHS are voluminous; some of these are
• Patient demographic information
• Clinical history
• Clinical events
• Laboratory results
• Imaging
• Genomics
• Published knowledge base data
• Repositories of study data
• Evidence-based guidelines
• Received data from clinical practice
Charles Friedman described a cycle that consists of the following steps3
:
• Decide to study an issue
• Assemble the relevant data
• Analyze the data
• Interpret the results
• Deliver a tailored message
• Take action to change practice
• Assess outcome
• Restart the process
This is similar to the iterative cycles discussed in business school for almost every
project, and the take-
home lessons are similar. We do not assume we know the
reason for an event; we perform careful analysis. We design an intervention that is
likely to solve the problem. We implement the intervention. We assess the outcome
to ensure that the anticipated improvement is obtained, and if not, we assess poten-
tial reasons for the failure. Similarly, we watch for adverse unintended consequences
of our changes.

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different content

fell on the floor with a crash. I was so impressed with the dream
that I became prejudiced in no slight degree against my host, and
when the latter, a few days later, tried to persuade me to invest
money in a mining enterprise in Cornwall, I refused; and it was very
fortunate I did so, for the mine which had been opened with so
much show and flourish failed, and nearly all the shareholders were
ruined.
Many years ago I visited the State of B——, and shortly after my
arrival at a farm, situated some distance from any settlement, I
made the acquaintance of a neighbouring farmer and his wife, of the
name of Coney. The Coneys, perceiving that I did not like my
present surroundings, suggested that they should take me to the
next Province in their waggon. I was to pay them one and a half
dollars a day, in return for which I was to receive such sleeping
accommodation as the waggon could afford and full board. The
route, they took very good care to assure me, was both beautiful
and interesting. Crossing the C—— Mountains, and passing within
sight of a famous crater lake and Lake D——, they would go through
mile after mile of forest, teeming with big game and lovely scenery.
As I was young (I was comparatively fresh from a Public School) and
very fond of adventure, the prospect of seeing so much new country
and of doing a little shooting appealed to me very strongly.
Consequently, though I was by no means favourably impressed with
the looks either of the farmer (a squat, beetle-browed man) or of his
wife (a dark, saturnine woman with sly brown eyes and a cruel
mouth), I was on the whole inclined to accept their offer. For the
rest of the day after their visit I deliberated what I should do, and
that night I had a very vivid dream. I saw myself lying asleep in a
waggon which was standing close to the edge of a tremendous
abyss. The horses, which had been taken from the shafts, were
tethered to the trunks of two lofty fir trees, and close to them,
engaged in earnest confabulation, were the farmer and his wife. The
moonbeams, falling direct on their faces, rendered both features and
expressions clearly visible, and as I gazed into their eyes and
recognised the intensity of their evil natures, my soul sickened—they

were plotting to murder me. Gliding over the red-brown soil with
noiseless feet, they crept up to the waggon, and seizing the
individual I identified as myself by the head and feet, they hurled
him into the chasm. There was the sound of a splash in the far
distance—and—I awoke. My mind was now made up. I would
remain where I was for the present, at least. And very thankful I am
for the warning, since I afterwards learned that the Coneys bore a
very sinister reputation, and that had I gone with them there is but
little doubt they would have robbed and murdered me.
A friend of mine, who is an officer in the —— Regiment, dreamed
three times that he was descending a road, at the bottom of which
was a bridge overhead. When he came to the bridge, a man who
was in hiding there rushed out and shot him. The scene was so real
and the details so graphic that my friend was greatly impressed. One
day, when he was walking in the South of Spain, he came to a dip in
the road, and there, before him, lay the scene he had seen so often
in his dreams. He was now in some doubt as to whether he should
go on, as he felt sure the person he had dreamed of would dash out
on him. After some hesitation, however, he proceeded, and
eventually arrived at the bridge. There was no one there, nor did he
suffer any molestation whatsoever on his way home. It is impossible
to explain why the dream should only have been verified in part.
I have many times dreamed I have been fishing in a wood by a
waterfall, and so vividly has the scenery been portrayed that I have
got to know every stick and stone in the place. So far, however, I
have never come across the objective counterpart of that cascade.
In other instances I have found myself visiting the actual spots I
have seen in my visions. For instance, I constantly dreamed of a
curious-looking red and white ship with two funnels, side by side,
three masts and a hull, very high out of the water. Something always
told me the vessel was for some peculiar use, but I could never
discover what, neither could I make out the name which was written
on her bows. I could read the first three letters, but no more. On
arriving at a seaside town in the West of England shortly after one of

these vivid nocturnal visions, I saw a steamer in the bay which I
instantly identified as that of my dreams, whilst to make me still
more certain, the letters on her bows corresponded with those I had
seen in my sleep. She had been specially designed as an Atlantic
Cable boat!
Before going to America I distinctly recollect dreaming that I was
standing by myself in the corridor of an enormous hotel. I saw no
other visitors, only one or two porters in very faded uniforms, and
instinctively felt that I was the only guest in the place. This feeling
filled me with awe, and I was dreading the idea of spending a night
on one of the deserted landings, when I awoke. On arriving in San
Francisco some months later, I was conducted by a passenger agent
to an hotel, which I at once recognised as the hotel of my dreams.
There was the same tier upon tier of empty galleries, the same
almost interminable succession of gloomy, deserted corridors and
row upon row of gaping doors leading into silent, tenantless rooms,
whilst to complete the likeness the hall porters wore exactly similar
uniforms. From a variety of causes I was, so the clerk at the
booking-office informed me, the only visitor in the building.
If dreams of present-day places have their objective counterparts,
and dreams of future scenes are fulfilled, is it not feasible that
dreams of the past should be equally veritable? I see no reason why
it should not be so. I have often dreamed of ancient cities teeming
with people clad in loose, flowing drapery and turbans, or tight hose
and armour. I have rubbed shoulders with red-crossed knights, and
followed in the wake of bare-headed monks and light-footed priests.
I have gazed admiringly into the faces of fair ladies whose shining
hair was surmounted with lofty, conical hats, and I have moved
aside to make way for great dames on milk-white palfreys.
In my dreams I have lived in all ages, breathed all kinds of
atmospheres, seen all kinds of events. One or two of these dreams
haunt me now. I remember, for example, dreaming that I was in a
very quaint old town covered with cobblestones. I had a lady with

me who was very near and dear to me, and my object was to
protect her from the crowds of hustling, jostling merrymakers who
crowded the thoroughfares. From the style of dress I saw on all
sides, and which both I and my companion wore, I knew we were in
the Middle Ages. But where we were and what was going on I could
not tell. After threading our way through endless narrow streets,
lined with gabled wooden houses, whose upper storeys projected far
over their entrances, we at length arrived at a big square in which a
vast number of people were watching a show. There were three
actors—a devil in a tight-fitting black costume and mask, and two
imps in red, whilst the show consisted of the acrobatic performance
of a number of tricks played by the imps on the devil, who
apparently tried his level best to catch his tormentors, but always
failed. Though my companion and I thought it extremely stupid, the
crowd enjoyed it thoroughly, and I saw one or two stout red-faced
women and several burly men-at-arms convulsed with laughter.
Suddenly, however, when the performance was at its height, there
was an abrupt pause—two priests, with knit brows and glittering
eyes, glided up to a girl, and, placing a hand on each of her arms,
led her despairingly away, the crowd showing their approval of the
act by shaking their fists in the poor wretch's face. Seized with a
terrible fear lest my companion should likewise be taken, I hurried
her away, and as we hastened along I heard the most fearful
screams of agony. On and on we went, until we came to an open
space in the town, void of people, and surrounded by dark,
forbidding-looking houses. I halted, and was deliberating which
direction to take, when my companion clutched me by the elbow. I
turned round, and saw, a few yards behind us, three priests, who,
fixing their eyes malevolently on us, darted forward. Catching my
companion by the hand, I was preparing to drag her into one of the
houses opposite, when my foot slipped, and the next moment I saw
her struggling in the hands of her relentless captors. There was a
long, despairing cry—and I awoke. I have had this same dream,
detail by detail, five times, and I know the faces of all the principals
in it now as well as I know my own.

Curiously enough, I have dreamed of the same place, but at a
different period. I have found myself walking along the quaint
streets with a girl, whom I instinctively knew was my wife, past
crowds of laughing, frolicing people dressed in the costume of the
French Revolutionary period. We have come to the open space with
the dark, forbidding houses, when I have slipped just as two savage-
looking men in red caps have dashed out on us. My companion has
attempted to escape; they have pursued her, and with the wails of
her death-agony in my ears I have awakened. Can it be that these
dreams are reminiscences of a former existence, of scenes with
which I was once familiar? Or have they been vividly portrayed to
me by an Elemental? I fancy the latter to be the more likely.
Occasionally I have a peculiarly phantastic dream, in which I find
myself in the depths of a dark forest, standing by a rocky pool, the
sides of which are covered with all kinds of beautiful lichens. As I am
gazing meditatively at the water, a slight noise from behind makes
me look round, when I perceive the tall figure of a man in grey
hunting costume, à la Robin Hood, with a bow in one of his hands
and a quiver of arrows by his side. His face is grey, and his eyes long
and dark and glittering. He points to the root of a tree, where I
perceive a huge green wooden wheel, that suddenly commences to
roll. In an instant the forest is alive with grey archers, who fire a
volley of arrows at the wheel, and endeavour to stop it. An arm is
thrown round me, I am swung off the ground, and when I alight on
the earth again it is to find myself on a flight of winding stone steps,
in what I suppose is a very lofty tower. The walls on either side of
me are of rough-hewn stone, and on peering through a small grated
window, I can see, many feet beneath me, the silvery surface of a
broad river and a wide expanse of emerald grass. I ascend up, up,
up, until I arrive in a large room, brilliantly illuminated with
sunbeams. Hanging on a wall is a picture representing a woman
gazing at a grey door, which is slowly opening. On the door
something is written, which I feel is the keynote to Life and Death,
and I am endeavouring to interpret it when a hand falls on my
shoulder. I look round, and standing beside me is the grey

huntsman. I awake with his subtle, baffling smile vividly before me.
A moment more and I might have been initiated into the great
mystery I have long been endeavouring to solve.
I have little faith in dreams of marriages and deaths. They so
seldom portend what they were once supposed to do. In my opinion,
they are the suggestions of mischievous Elementals.
In concluding this chapter, I will describe a dream I had
comparatively recently. I fancied it was late at night, and that I was
on the Thames Embankment. The only person in sight was a well-
dressed man in a frock-coat and silk hat, who was leaning over the
parapet. Feeling certain from his attitude that he was contemplating
suicide, I yielded to impulse, and, walking up to him, said, "You
seem to be very unhappy! Can I do anything for you?" Raising his
head, he looked at me, when to my astonishment I at once
recognised the grey huntsman I had seen in the dream which I have
previously narrated. Complexion, hair, eyes, mouth, were the same—
the expression alone differed. On this occasion he was sad. "You
need not be afraid," he said. "I cannot put an end to my existence. I
wish I could." "Why can't you?" I enquired with interest. And I have
never forgotten the emphasis of his reply. "Because," he responded,
"I am an Evil Force, a Vice Elemental."
Some months after this, when I was travelling one night from
Victoria to Gipsy Hill, I had as my sole companion a well-dressed
man in a soft Panama hat, who appeared to be occupied in a novel.
I did not pay the slightest attention to him till the train stopped at
Wandsworth Common, when he proceeded to get out. As he glided
by me on his way to the door, he stooped down and, smiling
sardonically, passed out into the darkness of the night. It was the
man of my dreams, the huntsman and the would-be suicide!

PART II.
Phenomena Witnessed by Other People.
CHAPTER III.
"ELEMENTALS."
The reticence people in general show towards having their names
and houses mentioned in print has led me to substitute fictitious
names in most of the cases referred to in this chapter.
In one of my former works I alluded to a phantasm with a pig's
head I saw standing outside an old burial ground in Guilsborough,
Northampton. Some years after the occurrence I was discussing the
occult with my father-in-law, Henry Williams, M.D. (late of Chapel
Place, Cavendish Square), and was very much surprised when he
told me that he, too, had witnessed the same or a similar
phenomena in Guilsborough. I append the statement he made with
regard to it:—
"Guilsborough,
"Northampton,
"January
23, 1909.

"I well remember many years ago, when a boy, running upstairs into the top
room of a certain house in Guilsborough and seeing a tall, thin figure of a man
with an animal's head crouching on the bed. I was so frightened when I saw it
that I ran out of the room as fast as I could.
"Henry W. Williams,
M.D."
My father-in-law had certainly made no mention of what he had
seen to me before he heard my experience, neither had I the
slightest idea that such a phantasm had been encountered in the
village by any one but myself. Close to the house where he saw the
phenomena I believe an ancient sacrificial stone was once found,
whilst in the same neighbourhood there are the remains of a barrow
and numerous other evidences of the Stone Age; hence the pig-
faced phantasm may have been either a Vice Elemental attracted to
Guilsborough by the human blood once spilt on the sacrificial stone,
or by certain crimes committed in and around the village in modern
times, or by the thoughts of some peculiarly bestial-minded person,
or people, buried in the now disused cemetery; or, again, the
phantasm may have been the actual earth-bound spirit of some very
vicious person, whose appearance would be in accordance with the
life he or she led when on earth. Which of the two it is I cannot, of
course, say: that is—for the present, at least—beyond human
knowledge.
I have recorded another haunting of a similar nature.
Writing to me from Devizes on May 15th, 1910, Mr. "I. Walton"
says:—
"Dear Sir,
"I have just been reading your book, 'Haunted Houses of London.' It recalls to
my mind a hideous apparition which I witnessed about ten days ago, and which
made such an impression on my mind that I send you particulars of it.

"I was on a visit to my two sons, who live at No. 37, M—— Square, Chelsea. On
the first night of my visit I slept in a room on the third floor facing the Square. I
have no knowledge of the science you profess, and no personal faith in
supernatural apparition, but the spectacle I witnessed was so extraordinary that,
by the light of your thrilling narratives, it looks as though I may have been
sleeping in a room that has been the scene of a tragedy.
"The room was not utterly dark, and some light penetrated from the lamps in
the Square, but as I lay with my face to the wall, all in front of me was dark.
"I fell asleep, and remained so for an hour or more, when I suddenly awoke
with a great jerk, and found confronting me the most awful apparition you can
imagine. It was a dwarfed, tubby figure with a face like a pig, perfectly naked, in a
strong bright light. The whole figure resembled in appearance the scalded body of
a pig of average size, but the legs and arms were those of a human being
brutalised, male or female I could not say. In ten or fifteen seconds it vanished,
leaving me in a profuse perspiration and trembling, from which I did not recover
for some time. But I slept off the rest of the night.
"When the landlady came to call me (she slept on the third floor back) she
pointed out that a picture on the connecting door had fallen down between my
bed and the next room. Doubtless it was the fall of the picture that waked me up
with a start. But what about the apparition? I can only assign it to some occult
cause.
"I remain, dear Sir,
"Yours faithfully,
"'I. Walton.'"
In this instance it is, of course, very difficult to tell whether the
phenomena is Subjective or Objective. Presuming it to be Objective,
which I am inclined to believe it was, then it was either the earth-
bound spirit of some particularly vicious person who was in some
way connected with the house, or else it was a Vice Elemental
attracted to the house either by the foul thoughts of some occupant
or by some murder formerly committed there.
Writing to me again on June 13th, 1910, Mr. "I. Walton" says:—
"Dear Sir,

"I am quite willing that you should find a place for my experience in your
forthcoming book. I think I omitted one detail of the spectre: it had bright yellow
hair worn in ringlets extending barely as far as the shoulders.
"Yours faithfully,
"'I. Walton.'"
Another case in which there is little or no doubt of the apparition
being a Vice Elemental was related to me by Mrs. Bruce, whose
husband was recently stationed in India. Her narrative is as follows:
—
"We once lived in a bungalow that had been built on the site of a
house whose inhabitants had been barbarously murdered by the
Sepoys during the Indian Mutiny, and we had not occupied it many
days before we were disturbed by hearing a curious, crooning noise
coming from various parts of the building. The moment we entered
a room, whence the noise seemed to proceed, there was silence,
while the instant our backs were turned it recommenced. We never
saw anything, however, until one day when my husband, hearing the
sounds, hurriedly entered the room in which he fancied he could
locate them. He then saw the blurred outlines of something—he
could only describe as semi-human—suddenly rise from one of the
corners and dart past him. The disturbances were so worrying that
we eventually left the house."
In this case the amount of blood spilt on the site of the bungalow
would in itself be a sufficient cause for the hauntings, and my only
surprise is that it did not attract many more Elementals of this
species.
Miss Frances Sinclair had an uncanny experience whilst travelling
by rail between Chester and London last autumn.
On entering a tunnel, at about six in the evening, Miss Sinclair was
quite positive there was no one in the compartment saving herself
and her dog. Judge then her astonishment and dismay, when she

suddenly saw, seated opposite her, the huddled-up figure of what
she took to be a man with his throat cut! He had two protruding
fishy eyes, which met hers in a glassy stare. He was dressed in
mustard-coloured clothes, and had a black bag by his side. Miss
Sinclair was at once seized with a violent impulse to destroy herself,
and whilst her dog was burying its nose in the folds of her dress and
exhibiting every indication of terror, Miss Sinclair was doing all she
could to prevent herself jumping out of the carriage. Just when she
thought she must succumb and was on the verge of opening the
door, the tunnel ended, the phantasm vanished, and her longing for
self-destruction abruptly ceased. She had never before, she assures
me, experienced any such sensations.
Here, of course, it is impossible to say whether what she
witnessed was Subjective or Objective, but assuming the latter, then
I am inclined to think that the apparition, judging by its appearance
and the desires it generated, was a Vice Elemental, and not a
Phantasm of the Dead. It need not necessarily have been attached
to the compartment in which she happened to see it, but may have
haunted the tunnel itself, manifesting itself in various ways.
An author, whom I will designate Mr. Reed, told me a few weeks
ago, that he and his brother, on going upstairs one evening, had
seen the figure of a man with a cone-shaped head suddenly stalk
past them, and, bounding up the stairs, vanish in the gloom. Though
naturally very surprised, neither Mr. Reed nor his brother were in the
least degree frightened. On the contrary, they were greatly
interested, as the phantasm answered so well to their ideas of a
bogey! As both brothers saw it, and neither of them were in the
least degree nervous, I am inclined to think that this phantom was a
Vagrarian, and that its presence in the house was due either to some
prehistoric relic that lay buried near at hand, or to the loneliness and
isolation of the place.
Mrs. H. Dodd had a strange experience with an Elemental.
"Waking up one night many years ago," she tells me, "I saw a tall

figure standing by my bedside. It appeared to have a light inside it,
and gave the same impression that a hand does when held in front
of a candle. I could see the red of the flesh and dark-blue lines of
the ribs—dash;the whole was luminous. What the face was like I do
not know, as I never got so far, being much too frightened to look. It
bent over me, and I hid my head in the bedclothes with fright. When
I told my parents about it at breakfast, to my surprise no one
laughed at me; why, I do not know, unless the house was haunted
and they knew it. My brother said he had seen a tall figure disappear
into the wall of his room in the night."
As Mrs. Dodd adds that a near relative of hers died about that
time, it is, of course, possible that the phantasm was that of the
latter, although from the possibilities of grotesqueness suggested by
what she saw of the ghost, as well as from the fact that the house
was newly built in a neighbourhood peculiarly favourable to
Elementals, I am inclined to assign it to that class of apparitions.
Some months ago I received from the Baroness Von A—— the
following account of a haunting experienced by her family:—
"Dear Mr. O'Donnell" (she writes),
"I should be much obliged if you would tell me the meaning of the things
witnessed by my grandmother, Lady W——, widow of General Sir B. W——. I must
first tell you that she was always a most truthful, sensible and unimaginative
woman, that I am quite sure she would not have invented or added to anything
she told so often. The story is thus:—
"During the fifties or sixties, she and my grandfather, then Colonel W——, went
to stay with some very old friends of theirs, Colonel and Mrs. V——, at their place
in the country: I forget the name, but think it was near Worcester. Neither of my
grand-parents had ever heard of anything supernatural in connection with the V
——'s house, yet my grandmother told me she felt a sense of the most acute
discomfort the minute she entered her friends' house. This, however, passed off
until, having occasion to go upstairs to her room after dinner to fetch her
needlework, she felt it again on crossing the hall. Scarcely had she started to
mount the stairs than she distinctly heard footsteps behind her. She stopped, so

did they; so, thinking it a trick of imagination, she went on, when the footsteps
went on, too. They could not possibly be the echo of hers, as she heard the sound
of her own, and the others were quite different, lighter and shorter. They followed
her to the door of her bedroom, the door of which she quickly shut and bolted, as
she was feeling very frightened, but all the time she felt the footsteps were
waiting for her outside. At last she made up her mind to go down again, but
scarcely had she emerged from her room and started to go down the corridor,
when the footsteps recommenced. Thoroughly frightened, she ran to the drawing-
room, never stopping till she was in the midst of her friends, but hearing all the
while the light steps flying after her. They stopped only when she entered the
drawing-room. On Mrs. V—— remarking on her pale face, my grandmother told
her what had happened. Mrs. V—— then announced that the footsteps were a
common occurrence, that nearly every one in the house had heard them, and that
a thorough investigation had been made without result—there was no explanation.
My grandmother heard the footsteps on several other occasions.
"The other manifestations occurred during her stay in the same house. It was
some days after the last occurrence, that my grandfather had occasion to go up to
town with Colonel V——, leaving my grandmother alone. Quite contrary to her
usual habit, when bedtime came she felt unaccountably nervous, and therefore
asked a friend, Miss R——, who was also a guest at the V——'s, to stay with her
for the night. They went to bed and to sleep, but not for long. They were both
awakened by the clock on the landing outside striking twelve, when they both sat
up in bed simultaneously, owing to their hearing the most unaccountable knocking
over their heads, although, otherwise, the house was absolutely silent. They
listened, and heard it again and again, and my grandmother said it sounded to
them both as if nails were being driven into a coffin. The knocking continued for
some time, until, unable to bear it any longer, Miss R—— jumped out of bed and
said, 'Well! I'm going to see what it is; it is evidently coming from the room on the
floor above, just over us, and I must find out.' My grandmother volunteered to go
with her, and they crept up to the second storey, the knocking getting louder each
step they took. On arriving at the door whence the sounds—which were very
distinct now—proceeded, they found the door was locked, and as they turned the
handle for the second time the knocking ceased, to be replaced by the most
gruesome and hellish laughter. Too frightened to go on with their investigations,
they fled downstairs, the laughter continuing as they ran. Immediately they
entered their room the knocking recommenced, and went on for a considerable
time, and when it stopped, being both too frightened to sleep, they lit a lamp and
talked till the morning. When the housemaid brought them their tea, she remarked
on their worn looks, and on being told the reason, said, 'Oh, dear! That's Mr.
Harry's room, and it's always kept locked when he is away. If only nothing has
happened to him!'

"During the day a telegram came to say that the eldest boy, Harry, who was
then in London, had died during the night; they did not even know he was ill.
"One thing I ought to mention is that a large cage of doves stood outside on the
second floor landing. As a rule, these birds are frightened at the smallest sound,
but my grandmother says she noticed that they never moved, although the noise
of the knocking and laughter was enough to waken any one."
The Baroness Von A—— goes on to ask if I think the disturbances
were due to Phantasms of the Dead or to Elementals. I told her that,
in my opinion, the knockings and laughter were due to one and the
same agency, namely, that of an Elemental which had attached itself
to the house in the same way as other Elementals—commonly
known as Family Ghosts—attach themselves to families. Very
probably the Elemental was attracted to the house in the first
instance by some crime committed there, or it may even have been
attracted to the soil prior to the building of the house. Such spirits
vary in their attitude to Man. "The Yellow Boy," for instance, that
haunted a certain room at Knebworth, appearing periodically to
whoever was sleeping there, and by gestures describing the manner
of their approaching death, did not, when giving the warning, exhibit
any glee or malice: his actions were perfectly mechanical and his
expression neutral. For example, when the apparition appeared to
Lord Castlereagh, it merely drew its hand three times across its
throat, thus predicting the way his lordship would die. (Lord
Castlereagh shortly afterwards committed suicide by cutting his
throat.)
Other cases of death-warning in which there is no apparent malice
are "The Radiant Boy" at Corby Castle, when the apparition is
benevolent rather than otherwise, and the "Drummer" at Cortachy
Castle, when the phenomenon appears to be mischievous rather
than malicious.
On the other hand, that there is evil design and intention on the
part of some death-warning phenomena is quite evident, to my
mind, from the case of the clock to which I have alluded in Chapter

I.; a case which also proves, I think, that the fates of some, if not
indeed of all of us, are pre-ordained, and that there are certain
orders of Elementals that not only have the power to warn us of
these fates, but that can also be instrumental in accomplishing
them. For instance, re the clock that struck thirteen, and the lady
who was killed in the taxi-cab accident, it will be remembered that
the latter was of a very extraordinary nature—so extraordinary, in
fact, that it really seems as if the Elemental was the actual contriver
of it—that it deliberately plotted the disaster, and that it was present
at the time, predominating the thoughts and guiding the hands of
the two drivers as they collided with one another. Why it did so is
difficult to conceive, unless, preferring solitude for its domain, it
regarded Mrs. Wright as an obstacle in its way, and an intruder
where it had the sole privilege of haunting. Possibly, too, the house
in which Mrs. Wright lived may be under some curse or ban, which
necessitates those having the temerity to occupy it, paying the
penalty of so doing with their lives, the time and nature of their
deaths being decided by the phenomenon in charge.
This supposition—namely, that Elementals can be instrumental in
working evil—coincides with my theory that diseases are primarily
due to powers or spirits antagonistic to the human race, and that
such powers or spirits exist in multitudinous forms; but whereas
Morbas have the widest range possible, the other two species of
Elementals, i.e., Vice Elementals and Clanogrians, or Family Ghosts,
are confined to certain families and houses.
Miss Rolands, a friend of mine, who is an artist, gives me an
experience that once happened to her.
"I am afraid I will tell this story very badly," she begins, "but I will
do my little best. I remember it all so well, though I was little more
than a child at the time. I lived with my grandparents, aunts, and
sister in an old house in Birkenhead. The house was a very high one.
It had both attics and cellars, and in one of the attics there was a
bloodstain, due, so I was told, to a murder of a particularly horrible

nature, that had once been perpetrated there, and on account of
which the house was reputed to be haunted. Rumour said that in
bygone days the house had been inhabited by priests, and that it
was one of them who had been killed, his body being taken away in
a barrel! In spite, however, of the bloodstain and the grim tales in
connection with it, my sisters and I, at the commencement of our
tenancy of the house, used to play in the attic, and nothing
happened. But at last there came a night when we awoke to the fact
that there was a ghastly amount of truth in what we had heard.
Some time after we had all gone to bed, we were all aroused (even
my practical old grandfather) by three loud knocks on one of the
doors which each of us fancied was our own. Then there was
silence, and then, from the very top of the house where the attic
was situated, a barrel was rolled down the stairs!—bump! bump!
bump! When it reached each separate landing, there was a short
interval as if the barrel was settling itself before beginning its next
journey, and then again, bump! bump! fainter and fainter, until it
reached the cellar, when the sounds ceased.
When this stage was reached, we used to light tapers and all look
out of our respective doors with white scared faces and hair that
literally felt as if it were standing on end, and then, after a few
seconds of breathless silence we flew with one accord to one room,
where we remained, packed like herrings, till the morning.
This strange, mysterious occurrence happened at least three times
to my knowledge, and I can vouch for its absolute truth, as can my
aunts and sister, and as could my grandparents, if they were alive.
Without any accurate details with regard to the murder, it is
impossible to say definitely to what class of phantasms this haunting
was due. One might attribute it entirely to the work of Impersonating
Elementals, entirely to phantasms of the Dead, or to both
Impersonating Elementals and Phantasms of the Dead.

I have recently been seeking for information concerning Pixies,
and as the result of my enquiries have received replies from several
people (whose social position and consequent sense of honour are a
guarantee of their veracity) declaring they have seen this species of
Elemental.
One of my informants, Miss White, who lives in West Cornwall,
tells me that on one occasion, when she was crossing some very
lonely fields, almost within sight of Castle-on-Dinas, she suddenly
saw a number of little people rise from among the boulders of
granite on the top of a hill facing her; they were all armed with
spears and engaged in a kind of mimic battle, but, on Miss White
approaching them, they instantly vanished, nor did she ever see
them again.
I can quite imagine that the hill, where Miss White alleges she saw
these little phantasms, is haunted, as the whole of that
neighbourhood (with which I have been acquainted for some years)
is most suggestive of every kind of Elemental. There are, for
example, on Castle-on-Dinas, the remains of an ancient Celtic
village, and I have no doubt the locality has experienced many
violent deaths, and that many prehistoric people lie buried there.
Another of my correspondents, Mrs. Bellew, says:—"In the winter
of 1888-89 I was suffering from delicate lungs, and was advised to
have a fire in my bedroom night and morning. One night, between
eleven and twelve, I was awakened suddenly by a coal falling into
the fender, and heard a small voice, resembling the squeaking of a
mouse, say, 'We did that! you didn't know it,' then there followed
shrill laughter. I sat up in bed so as to command a view of the
fireplace, and saw sitting on a live coal two little beings about six
inches high, with human faces and limbs and white skins.
"Quite naturally I answered, 'I knew perfectly well it was you.' At
the sound of my voice they vanished at once, and I, only then,

realised how strange an experience I had had. The whole incident
only occupied a minute or two."
Of course, it is very difficult to think that this was not entirely
subjective, and were it not for the fact that Mrs. Bellew is so positive
that the phenomena were objective, I should be inclined to believe
otherwise. Still, it is very delightful to think there may be such a
pleasant type of Elemental.
An interesting incident occurred to the Rev. G. Chichester, with
whom I had some correspondence two years ago. It was the only
psychic experience he had had, and took place at a Druid's Circle in
the North of England. As he was examining the stones of the Circle,
he suddenly became aware of a "death-like smell" (to quote his own
words) and the sense of some approaching presence. Retreating
hastily to a distance, he then perceived a figure clad in white or light
grey glide from the adjoining wood and vanish near the largest stone
of the cromlech. The Circle was in a pine wood, and under one of
the stones which had been dug up in the late seventies of the last
century an urn had been found, which urn is now in a museum. The
Rev. G. Chichester informed me that manifestations of an unpleasant
nature had also followed the lifting of a stone in a celebrated
cromlech in Cumberland, so that he was inclined to think psychic
phenomena invariably followed the disturbance of any of the stones.
Though Mr. Chichester did not give me any very definite idea of what
he saw, it seems to me highly probable that it was a Barrowvian, or
the phantasm of a prehistoric man; the latter, being thoroughly
animal, would possess no soul, and his spirit would doubtless remain
earth-bound ad infinitum. On the other hand, of course, it might
have been a Vagrarian.
Of the appearance of spirit lights I have had abundant evidence.
Mrs. W——, of Guilsborough, with whom I am well acquainted,
informs me that on awaking one night she found the room full of the
most beautiful coloured lights, that floated in mid-air round the bed.
They were so pretty that she was not in the least alarmed, but

continued to watch them till they suddenly vanished. The darkness
of the night, the inclemency of the weather, and the situation of the
room precluded the probability of the lights being produced by any
one outside the house.
In the memoirs of a famous lady artist I have just been editing, I
have given an account of blue lights seen by her and her husband in
their bedroom. On this occasion the manifestations filled the eye-
witnesses with horror, and the husband, in his endeavours to ward
them off the bed, struck at them with his hand, when they divided,
re-uniting again immediately afterwards.
I am inclined to think that in both instances the lights were due to
the presence of some form of Elemental in the initial stage of
materialisation; but whereas the beauty of the lights and the
absence of fear in the first case suggests that the phantasms
belonged to some agreeable type of Elemental, very likely of the
order of Pixies, the uniform blueness and the presence of fear in the
latter case suggests that the lights were due to some terrifying and
vicious form of Elemental, that was in all probability permanently
attached to the house.
These lights seem to resemble in some respects those seen from
time to time in Wales, though in the latter case the phenomena
appear with the purpose of predicting death. A description is given
of them in "Frazer's Magazine." They would seem to be closely allied
with the corpse candles, or Canhyllan Cyrth, also seen in Wales, an
account of which is given in "News from the Invisible World," a work
by T. Charley, who collected his information (so I understand from
an announcement on the title-page) from the works of Baxter,
Wesley, Simpson, and other writers. These candles are so called
because their light resembles in shape that of a candle; in colour it is
sometimes white, sometimes of various shades of blue. If it is pale
blue and small, it predicts the death of an infant; if big, an adult.
The writer then narrates several cases relative to the appearance of
these lights, the concluding one running thus: "About thirty-four or

thirty-five years since, one Jane Wyatt, my wife's sister, being nurse
to Baronet Rud's three eldest children and (the lady being deceased)
the lady controller of that house, going late into a chamber where
the maidservants lay, saw there no less than five of these lights
together. It happened a while after, the chamber being newly
plastered and a grate of coal fire therein kindled to hasten the drying
up of the plastering, that five of the maidservants went there to bed,
as they were wont; but in the morning they were all dead, being
suffocated in their sleep with the steam of the newly tempered lime
and coal. This was at Langathen, in Carmarthenshire."
These lights do not appear to have ever reached any further stage
of materialisation, though I imagine they possess that capability and
that they are in reality some peculiarly grim form of Elemental—as
grim, maybe, as the drummers and pipers of Scotland, and other
Clanogrians or Family Ghosts, with which they would seem to be
closely connected.
Of Noises, that are popularly attributed to Poltergeists, but which I
think are due either to Phantasms of the Dead or to Vagrarian,
Impersonating or Vice Elementals, I have received many accounts.
Miss Dulcie Vincent, sister to the Society beauty (whose
experience I shall give later on), and herself a well-known beauty,
says:—
"When I was staying with my uncle some years ago in his house in
Norfolk, we used to hear the most remarkable noises at night, which
no one could in any way explain. For example, there were
tremendous crashes as if all the crockery in the house was being
dashed to pieces on the kitchen tiles, whilst at other times we heard
heavy thuds and bumps as if furniture were being moved about
wholesale from one room to another. One night, the noises were so
great that my uncle took his gun and went downstairs, making sure
that there were burglars in the house; but the moment he opened
the door of the room whence the sounds proceeded, there was an

intense hush, and nothing was to be seen. A few nights after this
incident, I was awakened by hearing my bedroom door slowly open.
I looked, but saw no one. Seized with ungovernable terror, I then
buried my head under the bedclothes, when I distinctly heard soft
footsteps approach the bed. There was then a silence, during which
I instinctively felt some antagonistic presence close beside me.
Then, to my indescribable terror, the bedclothes were gently pulled
from my face, and I felt something—I knew not what—was peering
down at me and trying to make me look. Exerting all my will power,
however, I am thankful to say I kept my eyes tightly closed, and the
Thing at length stealthily withdrew, nor did I ever experience it
again.
"My uncle's house was built on the site of some old cottages, in
one of which lived a mad woman, but whether the disturbances
were due to her phantasm or not, I cannot, of course, say."
Neither can I! though I should think it not at all improbable, as
many hauntings of a similar nature are undoubtedly caused by the
earth-bound spirits of the mad, which accounts for the senseless
crashings and thumpings!
Miss Featherstone, a lady residing in Hampshire, has also had an
experience with similar phenomena. "About six years ago," she
informs me, "after my sister's death, I had a very unpleasant form of
Psychism" (I quote her own words), "which has only lately ceased.
Things used to disappear and reappear in a very strange way.
Though it was apparently uncanny, it was, of course, difficult to
prove absolutely they had not been moved by physical means. The
first time the phenomena took place was during the visit of a very
practical friend. She had been writing, and had put her materials
together, and was walking out of the room, when her pen was
whisked out of her hand. She looked about everywhere, she shook
her dress (which was quite a new one), but the pen had vanished—it
was nowhere to be seen. Then she went upstairs, put on her
walking shoes, hat, and gloves, and went to the railway station,

came straight home, and, on taking off her outdoor things,
discovered the missing pen inside a tailor's stitching across the front
of her dress! She could not find any opening where it could have got
in, and was obliged to unpick part of the dress to get it out. I
wanted her to send an account of the incident to the S.P.R., but as
she had a strong aversion to anything in the nature of publicity, I
could not persuade her to do so. After this things constantly
disappeared, and reappeared in a prominent position after every one
had searched the place. I think, and hope, however, that this has
now ceased, as it procured me a very bad reputation with several
servants, who emphatically declared I was in league with the Evil
One."
In a subsequent letter she writes:—"The house in which my
Poltergeist experiences took place was in Dawlish, but the
annoyances followed me to London. I had been sitting at friendly
séances with one or two friends at that time. At the beginning the
phenomena seemed in some way associated with an old cupboard
which I had bought second-hand, and which I still possess."
If the disturbances were not brought about by human agency,
then I think it highly probable that both the séances at which Miss
Featherstone had been attending and the oak chest may have been
responsible for them. I am quite sure that whenever a genuine spirit
manifestation takes place at a séance, that that manifestation is due
either to the earth-bound spirits of people who were merely silly
when in the body (and of these there have been, still are, and
always will be a superabundance), to the earth-bound spirits of
people who were bestial and lustful, or simply due to mischievous
Impersonating and other kinds of Elementals. These latter, when
once encouraged, are extremely difficult to shake off. They attach
themselves to certain of the sitters, whom they follow to their
homes, which they subsequently haunt. I have known many such
instances; hence, I think it very probable that a mischievous
Elemental attached itself to Miss Featherstone at one of the séances
she attended, and, following her from place to place, pestered her

with its unpleasant attentions. On the other hand, it is quite possible
that the oak chest was haunted by some species of Elemental, as is
often the case with pieces of furniture, either old in themselves or
constructed of antique wood—wood, for instance, that comes from a
bog, an ancient forest, a mountain top, or any other spot frequented
by Vagrarians.
Miss Featherstone gives me another experience she once had, and
which is not without interest.
"About seven years ago," she says, "my two sisters and I were
staying at a farmhouse near Chagford, on Dartmoor, between Thridly
and Gidleigh. We started one day to walk to the latter place, and
went through the village and up a lane beyond, on to the open
moor, where we found ourselves on a level piece of ground, with Kes
Tor close by to our left, whilst on our right were three new-looking
houses, with little gardens and wicket gates leading to them. I went
into one to enquire if there were any rooms to let for the following
year, and was shown over it, while my sisters waited on the moor for
me. Strange to say, I forgot to ask the name and address of the
place, but it seemed on a perfectly straight road from Gidleigh.
When we got back to Chagford, we asked our landlady where we
had been, and she said the name of the place was Berry Down; so
the next year we wrote there for rooms, but on arriving were
astonished to find quite a different place—not on the open moor at
all. We then set about looking for the three houses we had seen. We
walked round Gidleigh in every direction, enquiring of the postman,
clergymen, farmers, and villagers, but none knew of any such
houses, nor could we ever find the remotest traces of them. The day
on which we saw them was bright and sunny, so that we could not
possibly have been mistaken, and, moreover, we rested on the moor
opposite them for some time, so that had they been mere optical
illusions, we should have eventually become aware of the fact.
Several old Gidleigh cottagers to whom we narrated the incident
were of the opinion we had been 'Pixie led.' Is such a thing
possible?"

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