- Health information technology
Health information technology (HIT) provides the umbrella framework to describe the comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers. Health information technology (HIT) in general are increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system (Chaudhry et al., 2006). Broad and consistent utilization of HIT will:
*Improve health care quality;
*Prevent medical errors;
*Reduce health care costs;
*Increase administrative efficiencies;
*Decrease paperwork; and
*Expand access to affordable care.Interoperable health IT will improve individual patient care, but it will also bring many public health benefits including:
*Early detection of infectious disease outbreaks around the country;
*Improved tracking of chronic disease management; and
*Evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared.
Concepts and Definitions
Health information technology (HIT) is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making” (Brailer, & Thompson, 2004).
Technologyis a broad concept that deals with a species' usage and knowledge of tools and crafts, and how it affects a species' ability to control and adapt to its environment. However, a strict definition is elusive; "technology" can refer to material objects of use to humanity, such as machines, hardware or utensils, but can also encompass broader themes, including systems, methods of organization, and techniques. For HIT, technology represents computers and communications attributes that can be networked to build systems for moving health information. Informatics is yet another integral aspect of HIT. Informaticsis the science of information, the practice of information processing, and the engineering of information systems. Informatics underlies the academic investigation and practitioner application of computing and communications technology to healthcare, health education, and biomedical research. Health informaticsis intersection of information science, computer science, and health care. Health informatics describes the use and sharing of information within the healthcare industry with contributions from computer science, mathematics, and psychology. It deals with the resources, devices, and methods required for optimizing the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. Medical informatics, nursing informatics, and pharmacy informaticsare subdisciplines that inform health informatics from different disciplinary perspectives. The processes and people of concern or study are the main variables.
Implementation of HIT
The Institute of Medicine’s (2001) call for the use of electronic prescribing systems in all healthcare organizations by 2010 heightened the urgency to accelerate United States hospitals’ adoption of CPOE systems. In 2004, President Bush signed an Executive Order titled the President’s Health Information Technology Plan, established a ten-year plan as this technology is essential to put the needs and the values of the patients first and gives patients information they need to make clinical and economic decisions. According to a study by RAND Health, the US healthcare system could save more than $81 billion annually, reduce adverse healthcare events and improve the quality of care if it were to widely adopt health information technology. [RAND Healthcare: [http://www.rand.org/pubs/research_briefs/RB9136/index1.html Health Information Technology: Can HIT Lower Costs and Improve Quality?] Retrieved on July 8, 2006] The most immediate barrier to widespread adoption of technology is cost: patients benefit from better health, and payers benefit from lower costs; however, hospitals pay in both higher costs for implementation and lower revenues due to reduced patient length of stay.
Types of technology
In a recent study about the adoption of technology in the United States, Furukawa, and colleagues (2008) classified applications for prescribing to include electronic medical records (EMR), clinical decision support (CDS), and computerized physician order entry (CPOE). They further defined applications for dispensing to include bar-coding at medication dispensing (BarD), robot for medication dispensing (ROBOT), and automated dispensing machines (ADM). And, they defined applications for administration to include electronic medication administration records (EMAR) and bar-coding at medication administration (BarA).
Electronic Health Record (EHR)
Although frequently cited in the literature the
Electronic health record(EHR), previously known as the Electronic medical record(EMR), there is no consensus about the definition (Jha et al., 2008). However, there is consensus that EMRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures. [American College of Physicians Observer: [http://www.acponline.org/journals/news/sep04/emr.htm How EMR software can help prevent medical mistakes] by Jerome H. Carter (September 2004)] Important features of modern EHR software include automatic drug-drug/drug-food interaction checks and allergy checks, standard drug dosages and patient education information, such as describing common side effects. Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for disease management have a demonstrated benefit when accessible within the electronic record during the process of treating the patient. [cite journal | author = Kensaku Kawamoto, fellow1, Caitlin A Houlihan, E Andrew Balas, David F Lobach | year = 2005 | title = Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success | journal = British Medical Journal | volume = 330 | pages = 765–768 | url = http://bmj.bmjjournals.com/cgi/content/full/330/7494/765 | accessdate = 2006-06-29 | doi = 10.1136/bmj.38398.500764.8F] Advances in health informaticsand widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise (see chart to right). [cite journal | author = Gans D, Kralewski J, Hammons T, Dowd B | year = 2005 | title = Medical groups' adoption of electronic health records and information systems | journal = Health affairs (Project Hope) | volume = 24 | issue = 5 | pages = 1323–1333 | url = http://content.healthaffairs.org/cgi/content/abstract/24/5/1323 | accessdate = 2006-07-04 | doi = 10.1377/hlthaff.24.5.1323 ] Since 2002, the National Health Serviceof the United Kingdom has placed emphasis on introducing computers into healthcare. As of 2005, one of the largest projects for a national EHR is by the National Health Service(NHS) in the United Kingdom. The goal of the NHS is to have 60,000,000 patients with a centralized electronic health record by 2010. The plan involves a gradual roll-out commencing May 2006, providing general practices in England access to the National Programme for IT(NPfIT), the NHS component of which is known as the "Connecting for Health Programme". [NHS Connecting for Health: [http://www.connectingforhealth.nhs.uk/delivery/ Delivering the National Programme for IT] Retrieved August 4, 2006] However, recent surveys have shown physicians' deficiencies in understanding the patient safety features of the NPfIT-approved software. [cite journal | author = C J Morris, B S P Savelyich, A J Avery, J A Cantrill and A Sheikh | year = 2005 | title = Patient safety features of clinical computer systems: questionnaire survey of GP views | journal = Quality and Safety in Health Care | volume = 14 | pages = 164–168 | url = http://qhc.bmjjournals.com/cgi/content/full/14/3/164 | accessdate = 2006-07-08 | doi = 10.1136/qshc.2004.011866 ]
Computerized Provider (Physician) Order Entry (CPOE)
Prescribing errors are the largest identified source of preventable errors in hospitals. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay.cite journal | year = 2006 | title = Preventing Medication Errors | last = The Institute of Medicine | journal = The National Academies Press | url = http://www.nap.edu/catalog/11623.html | accessdate = 2006-07-21 ] Computerized provider order entry (CPOE), formerly called
Computer physician order entry, can reduce total medication error rates by 80%, and adverse (serious with harm to patient) errors by 55%. [cite journal | author = David W. Bates, MD, et al | year = 1998 | title = Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors | journal = JAMA | volume = 280 | pages = 1311–1316 | url = http://jama.ama-assn.org/cgi/content/abstract/280/15/1311 | accessdate = 2006-06-20 | doi = 10.1001/jama.280.15.1311] A 2004 survey by Leapfrog found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOEwithin 2 years. [cite web | title = Hospital Quality & Safety Survey | publisher = The Leapfrog Group | date = 2004 | url = http://www.leapfroggroup.org/media/file/Leapfrog-Survey_Release-11-16-04.pdf | format = PDF | accessdate = 2006-07-08 ] In addition to electronic prescribing, a standardized bar codesystem for dispensing drugs could prevent a quarter of drug errors. Consumer information about the risks of the drugs and improved drug packaging (clear labels, avoiding similar drug names and dosage reminders) are other error-proofing measures. Despite ample evidence of the potential to reduce medication errors, competing systems of barcoding and electronic prescribing have slowed adoption of this technology by doctors and hospitals in the United States, due to concern with interoperability and compliance with future national standards. [cite news | last = Kaufman | first = Marc | title = Medication Errors Harming Millions, Report Says. Extensive National Study Finds Widespread, Costly Mistakes in Giving and Taking Medicine | pages = A08 | publisher = The Washington Post | date = 2005-07-21| url = http://www.washingtonpost.com/wp-dyn/content/article/2006/07/20/AR2006072000754.html | accessdate = 2006-07-21 ] Such concerns are not inconsequential; standards for electronic prescribing for Medicare Part Dconflict with regulations in many US states.
Technological Innovations, Opportunities, and Challenges
Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the Institute of Medicine (2000) report. The follow-up IOM (2004) report, Crossing the quality chasm: A new health system for the 21st century, advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. [cite web | last=Institute of Medicine | first= | year=2001 | url=http://www.nap.edu/books/0309072808/html | title=Crossing the Quality Chasm: A New Health System for the 21st Century | publisher=The National Academies Press | accessdate=2006-06-29] However, many system implementations have experienced costly failures (Ammenwerth et al., 2006). Furthermore, there is evidence that CPOE may actually contribute to some types of adverse events and other medical errors.(Campbell et al., 2007) For example, the period immediately following CPOE implementation resulted in significant increases in reported adverse drug events in at least one study (Bradley, Steltenkamp, & Hite, 2006) and evidence of other errors have been reported.(Bates, 2005a; Bates, Leape, Cullen, & Laird, 1998; Bates; 2005b) Collectively, these reported adverse events describe phenomena related to the disruption of the complex adaptive system resulting from poorly implemented or inadequately planned technological innovation.
Technology may introduce new sources of error [cite journal | author = Ross Koppel, PhD, et al | year = 2005 | title = Role of Computerized Physician Order Entry Systems in Facilitating Medication Errors | journal = JAMA | volume = 293 | pages = 1197–1203 | url = http://jama.ama-assn.org/cgi/content/abstract/293/10/1197 | accessdate = 2006-06-28 | doi = 10.1001/jama.293.10.1197 ] [cite news | last = Lohr | first = Steve | title = Doctors' Journal Says Computing Is No Panacea | publisher = The New York Times | date =
2005-03-09| url = http://www.nytimes.com/2005/03/09/technology/09compute.html?ei=5089&en=402b792e748d99a2&ex=1268110800&adxnnl=1&partner=rssyahoo&adxnnlx=1150474153-xVix1BcYkvTKJpuLyHStrQ | accessdate = 2006-07-15 ] Technologically induced errors are significant and increasingly more evident in care delivery systems. Terms to describe this new area of error production include the label technological iatrogenesis [cite journal | author = Patrick Palmieri, et al | year = 2007 | title = Technological iatrogenesis: New risks force heightened management awareness | journal = Journal of Healthcare Risk Management | volume = 27 | number = 4 | pages 19–24 | url = http://www.hom.ba.ttu.edu/FordPub/Palmieri_JHCRM_2008_Technological%20iatrogenesis.pdf | accessdate 2008-07-02] for the process and e-iatrogenic [ cite journal | author = Weiner, et al | year = 2007 | title =e-Iatrogenesis: The most critical unintended consequence of CPOE and other HIT | journal = Journal of the American Medical Informatics Association | volume = 14 | number = 3 | pages 387-388 | url = http://www.jamia.org/cgi/reprint/14/3/387.pdf | accessdate 2008-08-24] for the individual error. The sources for these errors include:
*Prescriber and staff inexperience may lead to a false sense of security; that when technology suggests a course of action, errors are avoided.
*Shortcut or default selections can override non-standard medication regimens for elderly or underweight patients, resulting in toxic doses.
*CPOE and automated drug dispensing was identified as a cause of error by 84% of over 500 health care facilities participating in a surveillance system by the
United States Pharmacopoeia. [cite web | last=Santell | first=John P | year=2004 | url=http://www.usp.org/pdf/EN/patientSafety/slideShows2004-12-09.pdf | title=Computer Related Errors: What Every Pharmacist Should Know | format = PDF | publisher=United States Pharmacopia | accessdate=2006-06-20]
*Irrelevant or frequent warnings can interrupt work flow.
References and Resources
In process of converting references into citations (in the body).
*Ammenwerth, E., Talmon, J., Ash, J. S., Bates, D. W., Beuscart-Zephir, M. C., Duhamel, A., Elkin, P. L., Gardner, R. M., & Geissbuhler, A. (2006). Impact of CPOE on mortality rates – contradictory findings, important messages.” Methods Inf Med, 45(6): 586-593.
* Ash, J. S., Sittig, D. F., Poon, E. G., Guappone, K., Campbell, E., & Dykstra, R. H. (2007). The extent and importance of unintended consequences related to computerized provider order entry.” Journal of the American Medical Informatics Association, 14(4): 415-423.
* Bates, D. (2005a). Computerized Physician Order entry and medication errors: finding a balance. Journal of Biomedical Informatics, 38(4): 250-261.
* Bates, D.W. (2005b). Physicians and ambulatory electronic health records. Health Affairs, 24(5): 1180-1189.
* Bates, D. W., Leape, L. L., Cullen, D. J., & Laird, N. (1998). Effect of computerized physician order entry and a team intervention on prevention of serious medical errors. Journal of the American Medical Association, 280: 1311-1316.
*Bradley, V. M., Steltenkamp, C. L., & Hite, K. B. (2006). Evaluation of reported medication errors before and after implementation of computerized practitioner order entry. Journal Healthc Inf Manag, 20(4): 46-53.
*Brailer, D., & Thompson, T. (2004). Health IT strategic framework. Washington, DC: Department of Health and Human Services.
*Chaudhry, B. Wang , J., & Wu, S. et al., (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care, Annals of Internal Medicine, 144(10), 742–752.
*Campbell, E. M., Sittig, D. F., Ash, J. S., Guappone, K. P., & Dykstra, R. H. (2007). In reply to: “e-Iatrogenesis: The most critical consequence of CPOE and other HIT. Journal of the American Medical Informatics Association.
*Furukawa, M. F., Raghu, T. S., Spaulding, T. J., & Vinze, A. (2008). Health Affairs, 27, (3), 865-875.
* Institute of Medicine (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, D.C: National Academies Press.
*Jha, A. K., Doolan, D., Grandt, D., Scott, T. & Bates, D. W. (2008). The use of health information technology in seven nations. International Journal of Medical Informatics, corrected proof in-press.
*Kawamoto, K. H., Caitlin, A., Balas, E. A., & Lobach, D. F. (2005). “Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success.” British Journal of Medicine, 330(7494): 765-774.
*Sidrov, J. (2006). It ain’t necessarily so: The electronic health record and the unlikely prospect of reducing healthcare costs. Health Affairs, 25(4): 1079-1085.
;Governmental –United States
*Agency for Healthcare Research and Quality (AHRQ) Health Information Technology site located at: http://healthit.ahrq.gov/
*Health Resources and Services Administration (HRSA) Health Information Technology site located at: http://www.hrsa.gov/healthit/
*United States Department of Health & Human Services (HHS), Health Information Technology (HIT) Site located at: http://www.hhs.gov/healthit/
*United States White House, Transforming Health Care: The President’s Health Information Technology Plan located at: http://www.whitehouse.gov/infocus/technology/economic_policy200404/chap3.html
;Standards and Regulation
*American Health Information Community (AHIC) Successor organization site located at: http://www.ahicsuccessor.org/hhs/ahic.nsf/index.htm
*American National Standards Institute (ANSI) Healthcare Information Technology (HIT) site located at: http://www.ansi.org/standards_activities/standards_boards_panels/hisb/hitsp.aspx?menuid=3
*Certification Commission for Healthcare Information Technology (CCHIT) site located at: http://www.cchit.org/
*American Medical Informatics Association site located at http://www.amia.org/
*National Alliance for Health Information Technology for senior leadership site located at: http://www.nahit.org/
*American Academy of Family Practitioners, Center for Health Information Technology located at: http://www.centerforhit.org/
Subdomains of (bio)medical or
health care informaticsinclude: clinical informatics, nursing informatics, imaging informatics, consumer health informatics, public health informatics, dental informatics, clinical research informatics, bioinformatics, veterinary informatics, pharmacy informaticsand nursing informatics.
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