HCML876– 2105C
UNIT 1 IP
DUE DATE: Wednesday, 12/ 22/ 2021
Assignment Details
Discuss how the development of integrated health care systems has affected the installation of computer networks. Synthesize the opportunities and challenges associated with computer networking in the health care sector.
Discuss how the development of integrated health care systems has affected the installation of computer networks.
Advanced networks and computing in healthcare
Michael Ackerman and Craig Locatis
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See “Biomedical informatics: how we got here and where we are headed” in volume 18 on page 351.
This article has been cited by other articles in PMC.
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Abstract
As computing and network capabilities continue to rise, it becomes increasingly important to understand the varied applications for using them to provide healthcare. The objective of this review is to identify key characteristics and attributes of healthcare applications involving the use of advanced computing and communication technologies, drawing upon 45 research and development projects in telemedicine and other aspects of healthcare funded by the National Library of Medicine over the past 12 years. Only projects publishing in the professional literature were included in the review. Four projects did not publish beyond their final reports. In addition, the authors drew on their first-hand experience as project officers, reviewers and monitors of the work. Major themes in the corpus of work were identified, characterizing key attributes of advanced computing and network applications in healthcare. Advanced computing and network applications are relevant to a range of healthcare settings and specialties, but they are most appropriate for solving a narrower range of problems in each. Healthcare projects undertaken primarily to explore potential have also demonstrated effectiveness and depend on the quality of network service as much as bandwidth. Many applications are enabling, making it possible to provide service or conduct research that previously was not possible or to achieve outcomes in addition to those for which projects were undertaken. Most notable are advances in imaging and visualization, collaboration and sense of presence, and mobility in communication and information-resource use.
Keywords: Research, visualization of data and knowledge, supporting practice at a distance (telehealth), processing, portable, establishment of digital multimedia or image libraries, developing/using wireless, information storage and retrieval (text and images), image representation, machine learning
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Introduction
Key themes or characteristics of advanced network and computing applications in healthcare are described in this article. They were identified through a retrospective review of National Library of Medicine (NLM) sponsored application research in three initiatives the NLM undertook as the lead government agency for high-performance computing in healthcare. Some applications were proofs of concept, while others examined costs, effectiveness, and other outcomes related to healthcare practice, education, and research. Nineteen projects were funded in the 1996–1999 Telemedicine Initiative, 15 in the 1998–2002 Next Generation Internet Initiative, and 11 in the 2003–2007 Scalable Information Infrastructure Initiative. Most entailed building communications infrastructure and required additional time to complete. Some received extended funding. They included a range of academic and clinical specialties and programs in telemedicine, scientific collaboration, medical education, and disaster management. Many of the cutting-edge applications in the earliest initiatives are now commonplace, while some of the latest ones, only recently concluded, still test technology limits.
The National Research Council Report,1 Networking Health: Prescriptions for the Internet, underscored the potential of networks in health this way:
Although health-related web sites garner considerable media attention, they represent only a small sampling of the ways in which the internet can be used in health, itself a large sector embracing healthcare, public health, health education, and biomedical research. Because the internet, in theory, can link all participants in the health community, it can be used to improve consumer access to health information and healthcare, to enhance clinical decision-making and improve health outcomes …. to improve the education of medical professionals, enhance public health surveillance, and facilitate biomedical research. In each of these domains, specific applications can be envisioned in which the internet is used to transfer text, graphics and video files … control remote medical or experimental equipment; search for needed information; and support collaboration, in real time, among members of the health community. (p. 3)
Networking Health: Prescriptions for the Internet was very influential in spawning NLM’s Next Generation Internet and Scalable Information Infrastructure Initiatives, just as NLM’s earlier Telemedicine Initiative grew partially from earlier reports by the National Research Council and Institute of Medicine.2 3 These NLM-sponsored reports raised questions about the technical network capabilities health applications demand, how they differ from those in other sectors, and what experiments and demonstrations are needed to learn about the requirements and benefits of health applications that the initiatives addressed. Ten themes concerning the use of advanced networks identified in project reviews are presented that provide a landscape view of network applications in healthcare today.
Diversity theme
One of the most striking aspects of NLM funded projects is their diversity. The numbers of health specialties and applications represented exceed the number of projects because of the work’s interdisciplinary nature and because many projects developed multiple applications. Varied applications were anticipated in Networking Health: Prescriptions for the Internet, but the projects could have turned out otherwise. Their variety suggests that most areas of healthcare could benefit from using advanced networks.
Applications ranged from multimedia websites for providing and interlinking consumer health, personal health records, patient education, and clinical guidelines,4–18 to the use of two-way interactive video, 3D imaging, and haptic (tactile) tools for telemedicine, surgical education, and implant modeling.19–33 They included projects linking physicians to patients at the bedside34–39; connecting families from their homes to their babies and professional staff in neonatal intensive care units40–43; developing electronic medical record systems with multimedia capabilities, clinical decision support and patient monitoring and education facilities44–50; leveraging existing videoconferencing telemedicine infrastructure for continuing medical education51; deploying wireless technologies for disaster management45 52–63; and transmitting video of patients and other data from ambulances en route to emergency rooms.64 65 Projects demonstrated the feasibility of a distributed database enabling medical records and imaging studies to be portable when patients relocate66 67; determined the viability of telemedicine network applications to reach underserved rural68–78 and urban populations79–81; and established collaboratories allowing clinicians at diverse sites to conduct tumor boards,82–84 collaboratively research rare diseases,85 86 and work together in real time and to jointly control applications for developing databases and learning objects on human development.87–89 They involved experimentation with acquiring, archiving, and sharing radiologic images,90–96 using expert systems to generate alerts of drug interactions,97 98 and testing real time 3D video’s potential for providing remote consultation to paramedics.99–101
Projects included the medical specialties of anatomy and surgery,19–33 cardiology,68 69 102 dermatology,72 73 76 embryology,87 89 emergency medicine,52–65 77 80 99–101 family practice medicine,49 50 74 75 103 104 genomics,105 geriatrics,36 39 neonatology,40–43 nephrology,34 35 neurology,85–88 92 105 oncology,82–84 ophthalmology,79 80 otolaryngology,102 pediatrics,68 69 pharmacology,97 98 psychiatry,70 71 and radiology.9 31–33 66 67 90–96
Specificity theme
Many aspects of healthcare do not need advanced networks. This theme does not contradict the first, since many routine health applications work over standard networks. But there are special healthcare problems where advanced networks become paramount. In one project, for instance, physicians were connected from their clinic and homes to a nursing facility to provide 24×7 coverage by videoconference. The technology was not needed for reporting usual medications and vital signs,37 but became essential when patients’ conditions changed dramatically or they fell.36
As image quality increases and technologies are used representing data in three dimensions, more advanced networks are required for asynchronous data transport and manipulation of large files.28 90 Moreover, certain areas of remote routine care, such as echocardiography,68 69 neurologic exams, and gait analysis require sufficient network capacity for real-time motion. Real-time video also is important in telepsychiatry,70 emergency medicine,99 100 and disaster management.53 62 Video transmissions from ambulances allow physicians to assess patients and begin interventions immediately,64 65 while those from disaster sites enable commanders to obtain accurate real-time data on the unfolding conditions.53 62
Quality theme
Network quality of service (QoS) is as important as bandwidth in healthcare. Although greater bandwidth reduces the probability of congestion, network capacity and QoS are not synonymous, since data still can be lost or corrupted. Bandwidth management is vital, however, even in disaster situations where mobile, low-capacity network technology with reduced power requirements is deployed57 61 and where land lines may be down and cellular systems overwhelmed.57 Codecs, methods of compressing video, can lower bandwidth requirements, but excessive compression reduces quality and introduces latency and jitter. Neurologic exams and echocardiogram interpretation68 69 are examples where smooth motion is needed, and when haptic feedback is required for remote surgery, even less latency can be tolerated.21 Quality of service also is important in non-life-threatening situations. Workflow interruptions and delayed communication can frustrate scientists and clinicians collaborating online.82 83 Students observing surgeons doing virtual operations and feeling movement with haptic devices will not learn much if movement is delayed or erratic.21
Effectiveness theme
A sampling of project outcomes shows that advanced network applications in healthcare can be highly effective.
Baby CareLink, a project connecting a neonatal intensive care unit by video to parent’s homes and using a patient centric web interface with educational materials, demonstrated shorter stays, greater satisfaction, and earlier discharges. All babies in the project were discharged directly home, while 20% in a no-video control condition had to be discharged to community hospitals first.40–42
A teledermatology project in rural areas where referral rates by primary care providers to dermatologists were inappropriately low because local specialists were lacking found that video and store and forward technologies to access distant specialists reversed the trend, improving care while reducing the number of in-person visits.72
A project sending patient data, including real-time video transmission, while patients were in transport to the hospital demonstrated that the data were sufficient for physicians to identify patients having strokes and to begin interventions immediately upon arrival, halving treatment time.64 65
A project developing technology for real-time 3D views of patients found that first responders made fewer errors and had greater confidence when physicians gave them advice in a 3D proxy condition than when it was given by 2D videoconferencing.99 100
A project developing applications for disaster management demonstrated computer-based, mobile communication systems captured data just as well as paper-based systems with superior ability to monitor and track victims.60
An ophthalmology telemedicine study demonstrated that digital imaging combined with remote consultation by video could be used for initial screening of eye disease.79 80
Controlled studies of telepsychiatric counseling, tele-echocardiography, and telemedicine consultation of children with neuromuscular disorders demonstrated that outcomes were equivalent when these services were delivered in person or by telemedicine.68–71 Moreover, there were significant reductions in time to render service and in costs.
Studies involving the use of networks for immersive 3D imaging found that students who had successfully completed a standard anatomy lesson made further dramatic knowledge gains that continued over time because 3D visualizations enabled them to understand concepts that were only partially learned initially.32
3D embryo image data and animations showing development of organs over time were used to determine how certain organs develop and to clarify what constitutes normal and abnormal development.87–89
Advanced network applications have had additional indirect and unanticipated benefits. For example, a remote dermatology project found that patients felt they had a physician’s undivided attention more in telemedicine consultations than those in person.76 The project assessing videoconferencing for remote consultation with dialysis patients found they felt they had greater access to physicians who would otherwise visit the dialysis center less frequently.35 A tumor board project found that distributing conference sessions over multiple sites allowed more staff attendence.83 Some telemedicine studies also demonstrated time and cost savings for providers, patients, or both, and high levels of utilization and patient satisfaction due to increased access and convenience.68 76
Enabling theme
The network infrastructure established in most projects produced applications enabling other outcomes. For example, network connectivity enabled multicenter and multinational clinical trials for rare diseases where there usually are insufficient patients to study at any given location,85 86 making it easier to pool data to increase reliability, confidence, and probability of clinical conclusions about the diseases. Advanced networking enabled physician access to archives of previous medical records and mammogram imaging studies carried out in cities from which patients had moved. The archives contributed to continuity of care and served as a teaching resource.66 Networks also provided a way for embryology experts to collaborate across institutions to develop and annotate databases, create educational objects, and provide instruction to students at universities lacking faculty.87
NLM-funded telemedicine projects enabled entrée to previously underused healthcare services72 that often required great effort and expense to access.76 Some involved utilizing large statewide telemedicine networks and multiple services,68–70 76–78 while others involved local53 57 82 83 national,20 66 87 and even international partnerships.82 85 86 The varied projects funded in Iowa and Missouri demonstrated how advanced networks could extend access to healthcare in rural underserved areas,68–70 76–78 and one project demonstrated how the technology could be used to extend healthcare to underserved urban populations.79 80
Many projects developed products or techniques that could be adopted elsewhere. For example, the Baby CareLink application could be replicated today using Skype or other free, low-bandwidth videoconferencing software. Three-dimensional anatomical viewers created for Visible Human and other data sets are online or exist as independent applications that can be adopted by others.19 25 The open-source personal electronic-medical-record system,18 real-time prescription-checking technology,97 98 online annotation tools for digital mammography,67 methods for electronically tagging and monitoring disaster victims,60 61 creating colorized three-dimensional images from radiologic data for teaching and surgical planning,28 and animations depicting embryo development88 are other examples.
Imaging and visualization theme
Technologies for high-resolution image capture for diagnosis and volume rendering of 3D images from 2D scans have been available for a while, but advanced networks allow sharing and interacting with the data in real time from remote sites. Seamless, reliable image sharing over advanced networks was demonstrated in the project assembling cases from various sources for multisite tumor boards,82 the project for multinational clinical trials enabling pooling data from around the world for meaningful analysis,85 86 and the projects leveraging the Visible Human datasets of complete human male and female anatomy.19 27 Other projects developed a large visual databases of human embryology87 and radiology images.90–94 Advanced networks made it possible to distribute and federate databases at different sites, eliminating the need for large, central repositories.29 66
Collaboration and sharing theme
Advanced networks can foster collaboration. Many projects were inherently collaborative, given the nature of the work and varied expertise required, and some were cross-institutional, not just interdepartmental. For example, Stanford University developed 3D anatomy and surgical simulation resources working with the University of Wisconsin at La Crosse19–21 and later with schools in Canada and Australia. George Mason University’s effort to develop an embryology visual database and related teaching resources included faculty and staff from the University of Illinois at Chicago, the Johns Hopkins University, the Oregon Health Sciences University, the Armed Forces Institute of Pathology, the Lawrence Livermore National Laboratory, and Eolas Technologies.87 88 All projects concerning disaster management required working with first responders and public health departments.55 58 Some projects supported existing collaborations, such as tumor boards, to eliminate travel time and cost,83 while others were new collaborations to develop information resources or applications.87 96 Projects created new collaboration tools and adapted existing ones.31 32 87 88
Presence theme
Sense of presence and telepresence can be dramatically extended by advanced networks, especially in telemedicine where real-time video allows physicians and patients to interact remotely. While patients may rate telemedicine and in-person consultations similarly71 and feel they receive more attention in telemedicine consultations,76 providers and patients may view a sense of presence differently. Providers may believe telemedicine consultations yield ample data, while patients may be concerned they were examined sufficiently.35 Less obvious areas where sense of presence can be important include scientific collaboration,87 distance learning,20 32 and disaster management.53 In many of these contexts, being able to simultaneously share tools and applications augments sense of presence, making interaction at a distance more like in person.
Many projects extended presence. Experts at diverse locations collaborating in real time were able to reach consensus segmenting embryo structures using mark-up tools that they could hand off virtually.87 Similarly, surgeons and physicians can interact with 3D radiologic datasets in real time to reach consensus on appropriate treatments when visualization applications are combined with interactive video.31 3D visualizations created from 2D clinical data can also be streamed as video creating immersive environments for surgical planning and teaching,32 and 3D video streams with head tracking allow physicians to move in relation to the screen and view patients from varied perspectives.101 Video from cameras situated at disaster sites can be stitched together to provide operations managers more realistic views.53 Haptic devices provide tactile feedback enabling medical modelers to fashion cranial implants with precise fit using stereolithography machines, by-passing the expensive, time-consuming steps of physical sculpting and mould making.33
Mobility theme
Several projects investigated nomadic network applications and the deployment of ad hoc networks, especially those researching emergency medicine and disaster management. An early telemedicine project multiplexed analog cell phones to send video of patients from ambulances to emergency rooms,64 and disaster projects tested deployment of mini wireless ad hoc networks upon arrival at disaster scenes.60 61 The latter also demonstrated video transmission from remote-controlled drones, transmission of information from monitoring devices placed on patients in the field,61 62 and use of global positioning systems to identify locations of victims and first responders.52 62 Mobility was a factor in projects monitoring unattended ambulatory patients in emergency rooms and those sending video wirelessly from handheld devices in clinics or from videoconferencing devices that could be wheeled into patient’s rooms.37 45 96
Integration/accommodation theme
Devices for monitoring vital signs, triaging patients, and for providing haptic feedback had to be integrated into the developed applications.32 60 61 Wireless networks and devices had to be integrated with wired ones,37 and the capabilities and range of standard wireless networks sometimes had to be extended.60 61 64 Software often had to be integrated instead of hardware, especially in projects linking multimedia information into medical records44 46 and electronic medical records to online libraries.103 Finally, integration had to be addressed at a social and organizational level so that the applications developed would fit into the normal workflow of health professionals.55 83
Many integration issues remain that are barriers to widespread adoption of many of the innovations developed and researched. Some are technology-related, but others are exogenous to the technology itself.80 81 The so-called ‘last mile’ problem remains a factor in many contexts where network bandwidth and quality of service are available nearby but not at the point where it is needed. This problem is prevalent in rural and underserved areas that can especially benefit from networked delivery of healthcare and related information and education services, but it also occurs in settings relatively rich with network resources. Another technology problem is that many of the applications are still platform-dependent, requiring specific hardware, operating systems and levels of technology expertise. Further work is needed to make some applications turnkey systems.
Security is a problem that is, partially, technological but also due to policy and those administering it. All the telemedicine projects and those using databases and electronic medical records had to address security which was the focal point for several projects.15–17 38 74 There were antagonisms between applications involving collaboration and security, since the former give access to networks the latter are intended to block. Investigators mentioned firewall problems and differing mindsets of those involved with collaboration and security, but these were usually not publicized, with some exceptions.80 81 Collaboration tools need to be more secure, and network security tools need to better accommodate access, since security features can make applications more difficult and discourage use.14
Workflow integration is another problem with technology and non-technology aspects. Applications can disrupt work, especially if new and experimental. Refining applications to make them less platform-dependent, easier to use, and more turnkey will help, but the fact remains that any technology application, even when integrated into the work environment, will still require work to be done differently. Users should be involved in the refinement and workflow integration process, and trained appropriately. Similarly, interoperability is a hybrid technology/non-technology integration problem, especially in projects that employed electronic medical records. The varied systems have to have mechanisms for exchanging and sharing data, but users and developers need to agree on standards and have incentives for complying with them.
Perhaps the greatest non-technology barrier to adoption of network applications involves trust. For example, clinicians have issues concerning data integrity and transparency when distributed patient record systems are integrated.104 Staff working with collaboration tools may dismiss or have relaxed attitudes about security, but those working with security may be too rigid. They need to work together to enable collaboration and outside network access in secure ways. Finally, there are legal, social, and economic concerns about telemedicine licensure, privacy, and reimbursement.18 73 80 If a patient going out of state to receive care is not a problem, why is a physician coming virtually to a patient from out of state an issue? These problems are political, requiring various constituencies to agree on policy. They are not resolved by research.
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Conclusion
Although many routine aspects of healthcare do not require advance networks, there are special problems in a range of healthcare specialties that require their use. Advanced network applications can directly and indirectly affect health outcomes. They improve ways the healthcare community can share resources and interact with patients, students, and each other by providing ways to distribute information, collaborate, and operate in a more mobile environment. They also present challenges to developers, end users, and network administrators because they often change how networks are managed and healthcare is provided. Advanced networks are not static, and neither are the needs of healthcare. Some of the cutting-edge applications funded under NLM’s first Telemedicine Initiative are now commonplace, and improvements in wireless networks, optical networking, and tools for allocating bandwidth offer new research opportunities.
Advanced networks and computing in healthcare
J Am Med Inform Assoc. 2011 Jul-Aug; 18(4): 523–528.
Published online 2011 Apr 12. doi: 10.1136/amiajnl-2010-000054
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128395/
Michael Ackerman and Craig Locatis
Healthcare IT: Challenges and Opportunities
The Superior Care Health Group (SCHG) is a group of healthcare providers, with 10 general practitioners (GPs) who also function as family physicians for many in their town of about 50,000 people. As GPs, the group functions as primary care physicians, which means they are the first point of contact for many in the community. SCHG accepts all patients who carry health insurance, including Medicare and Medicaid.
SCHG has been in operation for over 25 years. Drs. Smith and Jones founded the group, but since then have hired the balance of the medical staff. Aside from Drs. Smith and Jones, the medical staff is relatively young, and well oriented to modern medicine and its management and organization.
The office staff at SCHG is composed of several job positions. These include a receptionist, several secretaries, several medical coders/billers, several transcriptionists, nine medical assistants, two laboratory technicians, and an office manager.
Because SCHG was established before the Internet revolution, use of computers is limited. The front desk uses four terminals to schedule patients and to complete billing tasks. The terminals are connected to two central personal computers that run an old version of the Linux operating system. They are also connected to several dot-matrix printers used to print billing forms and other pertinent financial information.
All patient information including the medical record is maintained by paper files. When a doctor examines a patient, all of the pertinent chart information is recorded either by the doctor writing directly in the paper chart, or by voice dictation, which is then later transcribed into the chart.
Drs. Smith and Jones developed SCHG to be as vertically integrated as possible, so they own and manage some of their medical equipment. Therefore, they have a small laboratory where routine blood tests and urinalysis can be completed on-site. As laboratory equipment becomes obsolete quickly, all the lab equipment is less than one year old. They also have a small x-ray suite for chest x-rays, broken bones, and so on. Unfortunately, x-ray equipment is very large, expensive, and hasn’t really changed much for simpler examinations like those conducted by SCHG. Thus, all of the x-ray equipment is original. For cardiac concerns, they have their own EKG equipment, but only half of the machines are current; the other half are original to the group.
Drs. Smith and Jones recently learned of something new from the government called the HITECH Act. They are concerned that new government regulations will constrain their business without significant improvement in their ability to deliver quality health care.
While governments debate how to balance their budgets, these facts are clear:
• Health costs keep rising.
• Technology continues to improve while becoming less expensive.
• Information technology adoption by the healthcare industry is slower than in other industries.
The question is often raised, “Why hasn’t the healthcare industry embraced information technology?” There are many reasons. Some healthcare professionals are concerned that they will not be able to recoup their investment in time and money spent to convert existing manual systems to electronic systems. Another problem is the way in which the healthcare system is fragmented. Patients are frequently required to see doctors from several different groups for the same diagnosis. This makes automation much more difficult because each group can have its own separate system. However, perhaps one of the most important obstacles is the shortage of trained healthcare technology professionals needed to implement the new technologies. As reported by the U.S. Federal Government, the need for such professionals could grow as much as 20 percent by 2018, with employment projected to grow faster than average. Even now, health information professional jobs are among the 20 fastest growing occupations in the U.S., which has driven some salaries beyond $50,000 per year.1
Given the demand and compensation levels for healthcare information technology professionals, it is unlikely that the need can be met using existing information technology experts. Although healthcare information technology is similar in some respects to information technology in other industries (for example, the same types of computers are used in health care as in education and manufacturing), it has many aspects that are unique. For example, healthcare providers must adhere to scores of governmental and accreditation regulations to which other industries are immune. Technologists who are employed in the implementation and maintenance of healthcare information technology must be aware of these regulations.
This chapter introduces the field of healthcare information technology. It begins by defining healthcare information technology, noting some of its benefits, and reviewing CompTIA’s response to the shortage of trained healthcare information technology professionals. Then the chapter examines various regulatory agencies and regulations applicable to healthcare information technology, and finishes with an overview of legal documents that healthcare information technology professionals encounter on a regular basis.
The words healthcare and health care are not the same. When used as one word, healthcare describes an entity such as a system (as in healthcare system) or information technology (as in healthcare information technology). When used as two words, health care is a thing (as in providing health care).
What Is Healthcare Information Technology?
Healthcare information technology has been described in many ways: as a framework for managing health information, as a mechanism to improve patient care, and as an enabler of patient care coordination. All of these descriptions convey the results of using healthcare information technology, but fundamentally, healthcare information technology is the application of information technology to the healthcare industry.
When defining HIT, some sources use “healthcare information technology,” while others use “health information technology.” They may be considered synonymous.
At the conceptual level, information technology (IT), or the use of hardware and software in an effort to manage and manipulate data and information, consists of devices that input, process, and output data and information. At the physical level, these devices could include keyboards, computers, printers, and network devices, which are collectively known as hardware. In addition to hardware, IT consists of software. Software contains the logic that makes computers do what they do. Software is like a set of instructions that helps hardware process data into information. Together, hardware and software are used to manage and manipulate both data and information. Therefore, a more precise definition of healthcare information technology (HIT) is the use of hardware and software in an effort to manage and manipulate health data and information.
IT is composed of hardware and software
Data can be considered raw facts that have little or no meaning, while information is data with meaning. For example, hospital patient census reports are data unless they address a specific need, such as determining length-of-stay trends.
Benefits of HIT
As countries face ever-more-challenging budget crises, healthcare costs continue to be at the forefront. Headlines such as “Baby boomers worry about finances and health costs,” “State employees get freeze in healthcare costs,” and “Rise in healthcare costs doubles that of inflation” are common. The data behind these rising costs include the following:2
• In 1960, the United States spent approximately 5.2 percent of all its goods and services (also known as gross domestic product, or GDP) on healthcare. In 2007, that number had increased to 17 percent.
• The greatest share of each dollar spent (about 30 percent) goes to hospital care, while only 6 percent is allocated to nursing homes.
• The United States spent over $7400 per person for health care in 2007, up from $7026 the previous year. This represents an increase of over 5 percent, compared to the year’s average inflation rate of 2.85 percent.
According to the Congressional Budget Office (CBO), advances in technology can be attributed to about half of healthcare spending increases.3 It is clear from these statistics that the cost of health care in the United States has continued to increase over time. Although some individuals claim that the federal health care statute known as the Patient Protection and Affordable Care Act (PPACA) enacted in 2010 by President Barack Obama will reduce healthcare costs over time, others have proposed specific recommendations that focus on specific systemic problems.
A report from the CBO called “Evidence on the Costs and Benefits of Health Information Technology”4 states that the use of an electronic medical record (EMR) for patient care would have several efficiency benefits. These include:
• Eliminating the use of medical transcription
• Reducing the need to physically retrieve patient’s charts or files
• Reminding prescribers to prescribe less costly drugs
• Reducing the number of duplicated diagnostic tests
These are only a few of the benefits of using computers and other electronic technologies to manage healthcare information.
Medical transcription is the conversion of handwritten/verbal doctor’s orders and/or notes into typed or electronic format.
In order for the healthcare industry to embrace HIT, it needs professionals that understand both aspects of the industry: healthcare and information technology. As in other industries, one way professionals can differentiate themselves is by obtaining a certification.
The CompTIA Healthcare IT Technician Certificate
CompTIA is a nonprofit trade organization and advocate for the IT industry. With a 25-year history, the organization has grown to over 2000 members and 1000 business partners. This allows it to promote IT globally using a four-pronged approach:
• CompTIA provides education through various resources including webinars, forums, events, and market research.
• CompTIA provides multiple technology- and vendor-neutral certification programs for IT workers.
•
Ciampa, M., & Revels, M. (2012). Introduction to Healthcare Information Technology. Cengage Limited. https://coloradotech.vitalsource.com/books/9781285412436
Synthesize the opportunities and challenges associated with computer networking in the health care sector.
J Gen Intern Med. 2006 Feb; 21(Suppl 2): S50–S57.
doi: 10.1111/j.1525-1497.2006.00363.x
PMCID: PMC2557136
PMID: 16637961
Priorities and Strategies for the Implementation of Integrated Informatics and Communications Technology to Improve Evidence-Based Practice
Bradley N Doebbeling, MD, MSc,1,2,3 Ann F Chou, PhD, MPH,1,4 and William M Tierney, MD1,2,3
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Abstract
The U.S. health care system is one of the world’s most advanced systems. Yet, the health care system suffers from unexplained practice variations, major gaps between evidence and practice, and suboptimal quality. Although information processing, communication, and management are key to health care delivery and considerable evidence links information/communication technology (IT) to improvements in patient safety and quality of care, the health care system has a longstanding gap in its investment. In the Crossing the Quality Chasm and Building a Better Delivery System reports, The Institute of Medicine and National Academy of Engineering identified IT integration as critical to improving health care delivery systems. This paper reviews the state of IT use in the U.S. health care system, its role in facilitating evidence-based practices, and identifies key attributes of an ideal IT infrastructure and issues surrounding IT implementation. We also examine structural, financial, policy-related, cultural, and organizational barriers to IT implementation for evidence-based practice and strategies to overcome them.
Keywords: information technology, implementation, evidence-based practices
The U.S. health care system is a $1.6-trillion industry that is undergoing rapid changes, facing increasing market pressure and competition for scarce resources.1 The industry involves multiple private and public stakeholders, including provider associations, health care delivery organizations, insurers, consumers, community networks, and local, state, and federal agencies. It is an information intensive industry,2 and yet it has lagged behind other industries in its investments and use of communication and information technology (IT).3–5
The acquisition and implementation of IT have great implications for the operations of health care organizations because of: (1) rapidly rising health care costs; (2) escalating concerns surrounding issues of patient safety and medical errors; (3) call for improving the provision of evidence-based care; and (4) increasing regulatory requirements.2,6 In particular, the Institute of Medicine (IOM) and the National Academy of Engineering have identified IT as crucial for building an improved health care delivery system that achieves the 6 health system 21st century attributes of being safe, effective, patient-centered, timely, efficient, and equitable.3 Industry groups outside of health care, such as the Leapfrog Group, as well as the U.S. government, have encouraged IT investments as a solution to reduce medication errors and patient safety problems.7–9 IT use has been shown to yield significant improvements in quality, cost containment, and patient safety in several empirical studies.10–12 However, relatively little research has focused on identifying effective approaches for IT implementation and applications in evidence-based practices (EBPs). Evidence-based practice is the process of using current best evidence from well-designed research conscientiously and judiciously, in conjunction with patient values and clinical expertise, to guide health care decisions.
To explore these issues, Veterans Health Administration (VHA) convened a State-of-the-Art Conference (SOTA) on “Implementing the Evidence: Transforming Practices, Systems, and Organizations” in December 2004. This synthesis of literature was undertaken as background to the SOTA conference. Given the limited amount of information in this area, evidence for this project came from: (1) MEDLINE search and review of published literature; (2) general world wide web search; and (3) expert opinions from discussions of the paper at the SOTA workshop. Our objectives in this paper are to: (1) provide a summary of current IT implementation efforts and its role in facilitating EBPs; (2) identify key stakeholder issues and barriers surrounding IT implementation to support EBPs; and (3) outline strategies for IT implementation and management to support EBPs as part of a better delivery system. Although other nations have also launched IT implementation efforts,13,14 our literature synthesis will focus exclusively on the U.S. health care system.
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DEFINITION AND CURRENT APPLICATIONS OF IT
Information technology is defined as the development, installation, and implementation of computer systems and applications, including hardware, software, networking, and communication tools. In the past decade, IT development activities within the health care industry have increased as executives and providers recognized the urgent need for strategic information management and inadequacies of traditional information storage, retrieval, and analysis tools.15,16 However, most IT investments in health care have focused on administration rather than care delivery.
Current IT applications in the health care industry can be divided into 3 categories: (1) infrastructure, such as electronic health records (EHRs) as storage and retrieval systems, automated mechanisms for capturing data, and an electronic library of medical literature; (2) performance enhancement, such as computer-based clinical decision support (CDS) systems, continuing medical and patient education; and (3) performance evaluation, such as demonstration and measurement of the cost, effectiveness, and outcomes of different systems.15,16 All 3 applications can support the delivery of EBPs. In general, most health care information systems are composed of automated billing and financial management, patient admission, discharge, transfers and registration, coordination of communications infrastructure, claims processing, customer service, and electronic data sharing.2
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CURRENT IT IMPLEMENTATION TRENDS
The establishment of a national health information infrastructure is considered a top priority. During fiscal year 2004, the president requested $50 million for IT projects related to patient safety and $12 million to develop IT standards. The Agency for Healthcare Research and Quality allocated $60 million in 2004 to promote research and demonstrations to advance IT use for care improvement.6,17 Similarly, the Food and Drug Administration proposed new regulations for bar coding medications to potentially reduce medication errors.
From a financial perspective, the implementation of a national health information infrastructure could yield as much as $142–371 billion in savings for the health care system.6 From a human perspective, improved IT use in care delivery may help prevent the multiple deaths that are expected to occur because of medical errors.18 Efforts in IT use may intensify as requirements to address administrative simplification emanated from the Health Insurance Portability and Accountability Act impel the health care industry to use more efficient and standardized electronic communications.2,6 More efficient coordination of information and communication could better support the delivery of EBPs. However, important technical, cost, organizational, social, and policy issues remain to be resolved before IT systems could be widely adopted and implemented. Table 1 outlines priorities according to expert opinion in IT implementation, and identifies barriers and strategies to promote EBPs.
Table 1
Priorities, Barriers, and Strategies to Effective Implementation of Information Technology (IT) Applications Supporting Evidence-Based Practice and Management
Priority
Barriers
Strategies
Priority 1:
Support knowledge-based decisions
Information and provider overload
Research on prioritization Research to include data on added value in terms of mortality and morbidity
Lack of integration
National patient data record Patient ownership of patient data, guidelines, and reminders Common patient identifier Common provider identifier Integration across systems Research on what information users need
Operationalizing evidence
Basic research in managing information complexity Alignment of research priorities with clinical management Performance measures focused on how much evidence informs practice Regular presentation of significant translation research findings to senior leadership
Priority 2:
Reporting/evaluation functions
Threats to provider autonomy
Flexibility in decision support with required feedback about reasons for non-compliance and barriers to compliance Local review of compliance with local solutions (tailored training)Add autonomy in other areas: e.g., guideline input, self-review, link to reference materials
Data issues
More data automation (e.g., link diagnosis to test)Review and monitoring of data quality Linkages to other information in electronic health record to eliminate duplicate entry
Reporting complexity
Move reports off system—put analytical tools on a system separate from patient care system
System resources
Simplify user generation of report
Priority 3:
Information system needs to evolve with health care system
Emphasis on provider-level activities and provider-entered data
Develop patient-centered data collection methods, core data elements, and system capacity for patient-based health data sets Encourage basic research on capturing home care data for all stakeholders
Emphasis on workload rather than care received by patient
Focus on outcomes (maintaining/improving functional status of the patient), not workload Encourage “just in time” rather than “just in case” visits, collect interim data remotely
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Adapted from discussion of the white paper by attendees at the Department of Veterans Affairs State-of-the-Art Conference in August 2004.
Currently, the VA medical system has the most broadly implemented federal health IT system. The VA also launched the Quality Enhancement Research Initiative (QUERI) in the late 1990s, designed to integrate care delivery, quality improvement (QI), and health services research to identify and implement EBPs in routine care settings for individuals with chronic illness.19,20 The VA has successfully used IT within its health care system to improve quality through the use of clinical reminders,21 EHRs, and other innovative approaches.20 However, the VA’s information system currently lacks rigorous data standards, which limits the sharing and usability of data across health information systems and in QI.22,23
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IT AND THE IMPLEMENTATION OF NEW EVIDENCE
Major efforts are warranted to reengineer health care in the United States to improve quality, safety, and bridge the gap between evidence and practice.8,24,25 The President’s Information Technology Advisory Committee (PITAC) attributes the gap between evidence and practice to a number of problems inherent in care delivery.22 On an individual level, providers cannot maintain or consider all details of patients’ medical history, or all best medical practices needed in order to deliver optimal care.26 Moreover, ready access to patient data for medical decision-making is often unavailable at the point of care. On a system level, there is urgent need for change in how health care is organized and delivered to make it more evidence based.
Synthesizing recommendations from the IOM’s Quality Chasm report, 5 priority areas have been identified to bridge this gap, including building organizational support for change, applying evidence to health care delivery, developing IT, aligning payment policies with QI, and preparing the workforce.27 In addition to enhancing information access and supporting decision making, IT may help meet other objectives, particularly the delivery of EBPs.3 The informatics infrastructure needed for EBP includes data acquisition methods, health care standards including standardized terminologies, data repositories, clinical event monitors, data-mining techniques, digital sources of evidence, and communication technologies.28,29Table 2 identifies attributes of an ideal IT system to support EBP and health care delivery.
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Adapted from discussion of the white paper by attendees at the Department of Veterans Affairs State-of-the-Art Conference in August 2004.
The President’s Information Technology Advisory Committee has proposed a framework for a 21st century health care IT infrastructure with 4 key elements: (1) readily available EHRs to equip patients and providers to share the decision-making in making health care decisions; (2) CDS to use state of the art knowledge in making treatment decisions; (3) computerized provider order entry (CPOE) for tests, medicine, and procedures; and (4) secure, private, interoperable, electronic health information exchange.22 Additional IT applications supporting the implementation of EBP include population-based care systems, and functional baseline estimates against which future information system enhancements can be measured.30 All of these tools coordinate information dissemination and sharing from various databases to equip the provider in providing patient-specific, appropriate, timely, and evidence-based care.3,22Table 3 provides examples of how potential IT applications can support EBPs.
Table 3
Information Technology (IT) Applications Supporting Evidence-based Practice and Management
Application
Utility
Support for EBPs
Population-based health care systems
These systems support creation of large, integrated databases of patient-specific information that allow real-time management of populations of similar patients
These databases may facilitate evaluation of new implementation strategies and provide insights into new associations between management approaches and health states
Computer-based decision support
Clinical decision support (CDS) may help health care providers utilize state-of-the-art medical knowledge in treatment decisions
CDS provides information management tools for the acquisition, manipulation, application, distribution, and display of appropriate patient- and task-specific clinical data to providers and patients that is conducive to correct, timely, and evidence-based clinical decision-making
Computerized provider order entry
Computerized provider order entry (CPOE) can help the tracking and analysis of health care processes
CPOE for tests, medicine, and procedures has the potential to decrease medical error, improve quality. It can help provider coordinate and collect patient-specific information
Electronic health records
Electronic health records (EHRs) would equip patients with personal health data, reliable patient-specific tools and resources
EHRs provide every patient and their caregivers with the necessary information required for optimal care. They can help patients to better understand the complexity of medical care and more readily participate in clinical decision-making and preventive health behaviors
Electronic health information exchange
This exchange ensures security, privacy, and system compatibility
The exchange between organizations would facilitate sharing patient information at the point of the care delivery to eliminate unnecessary testing, improve safety, and facilitate efforts to improve quality
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Adapted from the Kaiser Permanente’s Agenda for Clinical Information System Research.30
Nevertheless, evidence describing IT’s impact on EBPs has been mixed. Shea et al.’s metaanalyses reported that improvement in preventive care such as vaccinations and cancer screenings can be attributed to the use of clinical reminders.31–33 On the other hand, the evidence on the effect of CDS on practice is quite variable. Hunt et al.’s analysis noted that while a number of studies showed a correlation between CDS and improved clinical performance, some did not find any benefit.32,34 Further evaluation and more evidence are needed to assess the utility of these IT tools and determine how best to design and implement them to support EBPs.
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ISSUES IN IT IMPLEMENTATION
Tan and Modrow have advocated for overall industry performance standards or measures, in order to define accountability expectations for IT.35,36 As IT becomes more integrated into the care delivery system, IT implementation is likely to expand to include other participants in the health care setting. The IT system needs to interface with, and be responsive to, patients, managers, providers, researchers, and the public. Key stakeholder groups, including managers, providers, and other clinicians, patients, and health care organizations, have identified different barriers and facilitators to IT use in improving EBPs. Therefore, any IT implementation plans should address concerns of the stakeholders in order to build a better system.35
Clinician/Provider Issues
The utilization of IT in health care delivery systems depends upon IT availability and acceptance by health care providers. In the next few years, the most important IT clinical applications are likely to include CPOE, clinical information systems, CDS, and improved medication management.2 Providers, other clinicians, and managers share many concerns regarding the use of IT in implementing EBPs.33,35
An example of an important clinician issue is that outpatient laboratory test results are often not reviewed and acted upon within reasonable time frames.37 Clinicians desire a system that allows them to review and act upon test results safely and efficiently. Clinical decision support for laboratory test results might be used to classify the extent of abnormality for given results, provide context-appropriate advice to help manage abnormal results, generate letters to patients using templates, and help set reminders for follow-up testing.37
Taking full advantage of IT may require a team approach, where active involvement of interdisciplinary groups of providers and users is important. For example, to achieve maximum medication safety, introducing a CPOE system with advanced CDS, as well as involving both clinical pharmacists and other providers, may be particularly effective.38
Patient Issues
Patient-centered care, defined as care that elicits, respects, and incorporates patients’ wishes and maximizes patients’ subjective outcomes, is increasingly recognized as an important dimension of health care quality. In promoting patient-centered care, IT provides opportunities to enhance patient-provider interactions and patients’ use of their own health data. Information technology use may empower patients in their exchange with providers and promotes the alignment of care between hospital/clinics and patients’ home.39 Furthermore, IT tools may facilitate patient education and activation in enhancing the patient’s role as an active participant in the care process.
Information technology provides patients with chronic conditions new tools to manage their illness. For example, a “Home Telecare System” that integrates clinical signs monitoring, automated scheduling, and medication reminders, access to health education, and daily logs, can help patients self-manage their chronic disease.40 There are also a number of examples of systems that facilitate patient-EHR interactions and studies have shown a benefit to having patients view their medical data.40–42
As IT development accelerates, and access to information and interface capability increases, there is increasing opportunity to engage patients in further IT use. Information technology resources that are currently available to patients range from general information to personalized tools. For example, static web sites (e.g., WebMD, American Diabetes Association, etc.) can disseminate disease-specific information to a broad audience. Interactive web sites (e.g., Care Wise, Caresteps, E-Diets) can create community platforms for information sharing between providers and patients as well as for the dissemination of educational information to targeted patient cohorts.
New devices are being developed and tested to enhance individually tailored disease management. For example, biometric devices, which are home-based measurement devices that monitor and collect daily readings and symptom information, are increasingly used in care delivery.42 Handheld devices (e.g., personal digital assistants) allow patients to track daily progress such as weight and medications. Connectivity-facilitated workflow management, which deploys clinical and administrative workflow support through web-based connectivity among health plans, physician offices, and hospitals, gives patients customized, real-time delivery of alerts, guidelines, reminders, and other targeted information at the point of care.42
Emerging technology has the potential to increase patient participation in IT-facilitated, evidence-based, patient-centered care. Obtaining regular patient input in the design of health care IT systems can facilitate making the EHR responsive to patients needs.41
Organizational Issues
Within the health care industry, over one half of health care executives identified the top IT priority as implementation.2 However, most health care organizations are still at the stages ranging from considering adoption through early implementation.43,44 The lack of financial support for widespread IT applications is considered a primary barrier to its implementation by both managers and clinicians.2,45 The financial burden of implementation, including acquisition and implementation costs, slow and uncertain financial payoffs, and disruption to clinical practices, is directly related to both the size of organization and its readiness for conversion.46,47
The complexity of IT implementation not only requires significant resource investment by the organization, but it also involves many levels of personnel and system interaction and management, representing a major organizational change effort. Case studies in hospitals that have implemented advanced clinical information systems with extensive CDS provide important lessons. Implementation of some systems have been well accepted by providers and managers and have improved clinical processes, whereas there have also been significant and costly failures. Successful implementation requires leadership, a long-term commitment to improving and documenting health care processes, and efforts to involve clinicians and sustain productivity.48
In health care organizations, using IT for clinical documentation and order entry may provide an opportunity to improve processes of care and capture QI efforts into data warehouses to support better care delivery systems.49 Using IT systems to document and generate performance measures may make the accreditation processes with agencies such as the Joint Commission on Accreditation of Healthcare Organizations, Centers for Medicare & Medicaid Services, the National Center for Quality Assurance, and the National Quality Forum, more efficient.49 In addition, the use of IT tools has the potential to facilitate networking and benchmarking among collaborating health care organizations.50 However, health care organizations need to adopt these applications with caution as unexpected inaccuracies or problems with data collection, entry, and processing may arise.
Human Factors Issues
Human factors such as product usability, process complexity, and user-engagement methods routinely influence IT uptake.51 Prior experience with an IT application, different implementation approaches, and differential utility of structured data entry, can also influence user satisfaction.52 Notably, significant concerns remain regarding liability, patient electronic communication, and reimbursement.53
New IT solutions are often not adequately piloted, tested, and revised for usability in care prior to deployment. It is crucial to regularly observe user-IT interactions, particularly in the development phase. For example, in evaluating clinical reminders use, ease of use, access to workstations, perceived value, and relative benefits to administrators versus clinicians all impact their uptake.21,54,55 Similarly, in using a CDS system to set the dosage of anticoagulant and time interval to the next appointment, nurses found it stressful to override program-generated recommendations.56
Priorities and Strategies for the Implementation of Integrated Informatics and Communications Technology to Improve Evidence-Based Practice
Bradley N Doebbeling, MD, MSc,1,2,3 Ann F Chou, PhD, MPH,1,4 and William M Tierney, MD1,2,3
Author information Copyright and License information Disclaimer
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2557136/
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