Intervention of Health Informatics in Medicine, Nursing, Pharmacy, and Dentistry

The emergence of public health informatics as a professional specialty is part of a larger development of informatics in related health fields, such as medicine, nursing, pharmacy, and dentistry. Interest in informatics as a specialty in these areas reflects the importance that information collection, analysis, evaluation, and utilization now play in the health care division. One of the primary inventions of clinical medicine is the patient medical record. Practitioners use the record to capture their findings and conclusions for each clinical encounter and to guide future care of the patient. As medical care gets more and more complex and new information is already overwhelming physician‘s capacity to treat patients with the latest information, physicians need new technologies to help them cope. There is great need for a digital record to allow capture of patient data that can then be processed and mined for insights into better treatment for patients. The electronic health record (EHR) is the tool that promises to provide the platform from which new functionality and new services can be provided for patients.
Hospitals hope to reduce medical errors, such as ordering and administering the wrong dose of a medication. Providers hope to access and share patient information more easily, thereby improving care. Governments and businesses hope to save money by improving efficiency. But for a variety of reasons, health care providers have not fully embraced these technologies. Some professionals comment that high implementation costs deter providers, especially those in small group practices, from adopting new technologies. Other studies suggest that implementing health IT systems might even hinder patient care, at least initially. In either case, the question remains: how should policymakers help facilitate the adoption EMR/EHR (Electronic Medical Records and Personalized Medicine)?
Health Information Technology a broad array of new technologies designed to manage and share health-related information. The most basic type of health information technology is a system that electronically collects, stores and organizes health information about patients. When properly implemented, such a system can help coordinate patient care, reduce medical errors and improve administrative effectiveness. Some call the information collected an electronic health record (EHR); others call it an electronic medical record (EMR). Though some health informatics professionals make a distinction between EHRs and EMRs, these terms are often used interchangeably in the media. Efforts are underway to develop consensus definitions for these terms and others.
Electronic record systems come in a variety of shapes and sizes. Some collect and share patient information only within a certain institution or within a certain provider group, while others are integrated into larger information networks. The capabilities of EHR systems and the extent to which they are integrated into provider practices also vary. "Fully functional" EHR systems collect and store patient data, supply patient data to providers on request, permit physicians to enter patient care orders, and assist providers in making evidence-based clinical decisions.
Another technology is known as computerized physician order entry (CPOE), an important part of a fully functional EHR system. This allows physicians to order prescription drugs and laboratory tests digitally, thereby eliminating errors associated with illegible hand-written prescriptions. CPOE systems check for the accuracy of prescription orders, flagging any orders that appear extreme. One study concluded that CPOE systems for prescriptions could reduce preventable medication errors by as much as 55 percent because they ensure, at a minimum, that orders are complete and legible. Despite this potential, adoption of health information technology has been slow. Much clinical information in the U.S. remains on paper rather than on computers. Recent studies have shown that only about 10 percent of hospitals and providers have fully implemented EHR systems and even fewer have adopted CPOE systems (Electronic Medical Records and Personalized Medicine).
Knowledge of an individual’s physiologic patterns is a great advantage in safeguarding his/her health. Over time, the patient medical record has evolved due in part to medical advances, liability risks, and changing administrative requirements for care reimbursement. Relatively unchanged though have been the means and media for recording and storage of these notes. Until recently, medical records have been captured on paper, largely by hand, and have been the property of the recording provider. Over the last twenty years most other industries have transitioned to digital record keeping while medicine continues to embrace a dated inescapable paper system. Physicians are expected to document encounters they have with patients to ensure crucial information for decision-making is recorded and actions taken are also recorded. Documentation is also required as an archival record of what happened in cases of dispute. To a great extent, physicians resent the task of documentation, as it detracts from their primary task: taking care of patients. Physicians also resent the duplication of effort required with documentation, as every medication that is written on a prescription pad, every lab test ordered, every x-ray ordered has to be re-written in the chart to maintain a good record. Communication between practitioners is difficult as in many cases the information collected is fragmented, frequently redundant and voluminous. Finally, physicians are constantly inundated with new information and have no tools to help them incorporate new techniques and treatments into their day-to-day activities, other than using their memories or having to lug around large textbooks.
In addition to physicians, health care systems (e.g., HMOs, Regional Health Authorities, and Ministries of Health) also need information technology to meet their management and administration needs. Their performance criteria include timely reporting of data, reduction of duplicate tests, reduction of medical errors, and improvement of care and cost management. There has been an on-going tension in the health care marketplace between the needs of physicians and healthcare systems –their needs have not always been aligned. Additional performance criteria include use of standards for data exchange, billing, diagnosis, medications and laboratory data (Percentage of U.S. Physicians using Electronic Health Records).
EHRs have been available for well over a decade and yet they are utilized by only a quarter of practicing physicians. Is there a compelling reason to transition from paper to an electronic system? EHRs are, at their simplest, digital (computerized) versions of patients' paper charts. But EHRs, when fully up and running, are so much more than that. EHRs are real-time, patient-centered records. They make information available instantly, "whenever and wherever it is needed". And they bring together in one place everything about a patient's health. EHRs can: Contain information about a patient's medical history, diagnoses, medications, immunization dates, allergies, radiology images, and lab and test results. Offer access to evidence-based tools that providers can use in making decisions about a patient's care. Automate and streamline providers' workflow. Increase organization and accuracy of patient information. Support key market changes in payer requirements and consumer expectations.
One of the key features of an EHR is that it can be created, managed, and consulted by authorized providers and staff across more than one health care organization. A single EHR can bring together information from current and past doctors, emergency facilities, school and workplace clinics, pharmacies, laboratories, and medical imaging facilities. I find converting to a digital record keeping system is the promise of improved quality and anticipated cost reductions. The U.S. healthcare system is by far the worlds’ most expensive. EHRs that can efficiently allow sharing of patient record information with authorized doctors, health care administrators, and public health professionals should reduce redundant medical testing and administrative costs, and improve cost avoiding prevention efforts. These greater efficiencies at the local level should reduce costs of the nation’s healthcare system overall. A major way that electronic health records would reduce our nation’s healthcare expenditures is by eliminating unnecessary procedures. Clearly this would not financially benefit outpatient clinics. It is unlikely that aiding public health efforts will inspire a conversion to electronic health records. Historically poor participation in reporting to registries and even mandated infectious disease reporting illustrates the separation between doctors and our public health system. Although most providers acknowledge that the medical system is error prone, there is a lack of urgency to enact change in their own practice as it is unlikely they feel they are practicing unsafely.
As we know, our world has been radically transformed by digital technology – smart phones, tablets, and web-enabled devices have transformed our daily lives and the way we communicate. Medicine is an information-rich enterprise. A greater and more seamless flow of information within a digital health care infrastructure, created by electronic health records (EHRs), encompasses and leverages digital progress and can transform the way care is delivered and compensated. With EHRs, information is available whenever and wherever it is needed.
The Health Information Technology for Economic and Clinical Health (HITECH) Act, a component of the American Recovery and Reinvestment Act of 2009, represents the Nation’s first substantial commitment of Federal resources to support the widespread adoption of EHRs. As of August 2012, 54 percent of the Medicare- and Medicaid-eligible professionals had registered for the meaningful use incentive program. When fully functional and exchangeable, the benefits of EHRs offer far more than a paper record can. EHRs: Improve quality and convenience of patient care. Increase patient participation in their care. Improve accuracy of diagnoses and health outcomes. Improve care coordination. Increase practice efficiencies and cost savings. Despite its sluggish pace, the United States is in the midst of a conversion from paper to digital records. President Bush set a goal for the conversion to electronic health records by 2014. To encourage adoption of an EHR the Department of Health and Human Services’ quality incentives (Physician Quality Reporting Initiative) program financially incentivized use of an electronic health record by adding a bonus of an extra 1.5% to federal reimbursement of care provided with an HER (Percentage of U.S. Physicians using Electronic Health Records). Likely to sweeten the pot, President Obama’s American Recovery and Reinvestment Act of 2009 will provide $20 billion for the development of health informatics targeting electronic health records adoption. These efforts will likely move a critical mass of health care facilities to EHR use. Ultimately it seems likely that a mandate or financial penalties will be used to move technology laggards accepting payment from a federal government source to EHR conversion. Most medical practices cannot live without the federal payer so federal leverage will likely drive conversion.
About $19.2 billion of the $787 billion American Recovery and Reinvestment Act that President Obama signed in 2009 is directed as an electronic medical records stimulus. The administration is working to complete the movement to EMR integration because it believes there are many benefits of electronic medical records use, including streamlining patient care and providing long-term savings in the health field. The electronic medical records stimulus also provides incentives to help physicians convert to the paperless electronic medical record systems, but reports have found that even without the incentives, there are real benefits of electronic medical records and electronic health records integration (Electronic Medical Records; Partnership to make Electronic Health Record).
The changing expectation of both new doctors and patients regarding the use of technology in the office is aiding the move to electronic records. Expectations of practice will not involve paper charting for this cohort. Patients increasingly conduct their financial transactions electronically, shop online, and even discuss their car trouble with a computer wielding mechanic. As time goes on the use of paper and pen will seem more outdated in a world where all other information transactions are conducted digitally. Medical practices sticking to the old ways will be at a marketing disadvantage.
EHRs are important to public health because the conversion of patient data to a digital format allows for greater coordination and data sharing. EHRs store their information in a database. With the use of secure networks and standardized categorization of information, this data could be sent for use to other doctors, public health professionals, public health departments, the CDC, researchers, etc. By storing health information electronically through electronic medical record systems, health care providers are able to finish their patient charting quicker, allowing for the scheduling of more patients. This heightened efficiency of this type of medical records storage fosters a more effective medical practice. Having instant access to electronic health records allows providers to chart during their patient encounters as opposed to several hours later. In theory, this enhances accuracy of the patient’s health record.
The very nature of recording information on a computer has certain advantages over recording medical data on paper. Traditional paper charts are not interactive. Although the record may have printed reminders or cautions, these are easily ignored or overlooked. Physicians are notorious for poor handwriting. Studies have shown that as little as 65% of written medical charts are fully legible. The written record, even if shared outside the practice, may be useless to anyone other than its creator. (Assuming he or she can decipher their own notes!) Written records exist solely in their file jacket in the provider’s office. Disorganization, the dissolution of a practice, or a disaster in the office can easily result in the irretrievable loss of patient data. Both electronic and paper records record health information, but an EHR has added capabilities. Proponents of EMR/EHRs also argue that digital medical record storage helps prevent filing errors. Most paper patient records are not backed up in a secondary location. Medical records storage through digital means eliminates any threats of losing the patient health information in an emergency. Many electronic medical record systems are backed up every day automatically and are accessible almost anywhere in the world.
Ensuring privacy and security of health information, including information in electronic health records (EHR), is a key component to building the trust required to realize the potential benefits of electronic health information exchange. If individuals and other participants in a network lack trust in electronic exchange of information due to perceived or actual risks to electronic health information or the accuracy and completeness of such information, it may affect their willingness to disclose necessary health information and could have life-threatening consequences. The HIPAA Privacy and Security Rules protect the privacy and security of individually identifiable health information. HIPAA Rules have detailed requirements regarding both privacy and security (www.healthcarepathway.com/HCD/Health-Informatics.html). The HIPAA Privacy Rule covers protected health information (PHI) in any medium, while the HIPAA Security Rule covers electronic protected health information (ePHI). In addition to HIPAA, you must comply with all other applicable federal, state, and local laws. Privacy concerns in healthcare apply to both paper and electronic records. According to the Los Angeles Times, roughly 150 people (from doctors and nurses to technicians and billing clerks) have access to at least part of a patient's records during a hospitalization, and 600,000 payers, providers and other entities that handle providers' billing data have some access also. Recent revelations of "secure" data breaches at centralized data repositories, in banking and other financial institutions, in the retail industry, and from government databases, have caused concern about storing electronic medical records in a central location (www.healthcarepathway.com/HCD/Health-Informatics.html). Records that are exchanged over the Internet are subject to the same security concerns as any other type of data transaction over the Internet.
The Health Insurance Portability and Accountability Act (HIPAA) were passed in the US in 1996 to establish rules for access, authentications, storage and auditing, and transmittal of electronic medical records. This standard made restrictions for electronic records more stringent than those for paper records. However, there are concerns as to the adequacy of these standards. Threats to health care information can be categorized under three headings: Human threats, such as employees or hackers; Natural and environmental threats, such as earthquakes, hurricanes and fires and technology failures, such as a system crashing. These threats can either be internal, external, intentional and unintentional (www.nlm.nih.gov › Health Services Research & Public Health). Therefore, one will find health information systems professionals having these particular threats in mind when discussing ways to protect the health information of patients. The Health Insurance Portability and Accountability Act (HIPAA) has developed a framework to mitigate the harm of these threats that is comprehensive but not so specific as to limit the options of healthcare professionals who may have access to different technology (www.nlm.nih.gov › Health Services Research & Public Health).
While there is no argument that electronic documentation of patient visits and data brings improved patient care, there is increasing concern that such documentation could open physicians to an increased incidence of malpractice suits. Disabling physician alerts, selecting from dropdown menus, and the use of templates can encourage physicians to skip a complete review of past patient history and medications, and thus miss important data.
Another potential problem is electronic time stamps. Many physicians are unaware that EHR systems produce an electronic time stamp every time the patient record is updated. If a malpractice claim goes to court, through the process of discovery, the prosecution can request a detailed record of all entries made in a patient's electronic record. Waiting to chart patient notes until the end of the day and making addendums to records well after the patient visit can be problematic, in that this practice could result in less than accurate patient data or indicate possible intent to illegally alter the patient's record. In some communities, hospitals attempt to standardize EHR systems by providing discounted versions of the hospital's software to local healthcare providers. A challenge to this practice has been raised as being a violation of Stark rules that prohibit hospitals from preferentially assisting community healthcare providers. In 2006, however, exceptions to the Stark rule were enacted to allow hospitals to furnish software and training to community providers, mostly removing this legal obstacle.
EMR technology has been around for a long time and has not taken off in the market place. This technology is very dependent on innovations and breakthroughs that occur outside of the health care space. The dominant design paradigm does not appear to hold for core health care applications in the EMR, even though it does hold for many parts of the EMR because the EMR depends on the general information technology marketplace for many of its components. It appears that the Modularization of Design paradigm explains developments in the area better than the Dominant Design paradigm. There do not appear to be any increasing returns or lock-ins from standards, as standards are increasingly determined through consensus processes in the industry. There are few patents for EMRs and the few that do exist are extremely weak and general. There are many Open Source EMRs freely available. All the above leads us to conclude that this marketplace has a weak appropriability regime and that having and wielding specialized complementary assets is likely to be a major determinant of competitive advantage. Besides improving care for patients, another advantage of EMR integration is that it can reduce costs for physicians. Unnecessary staff expenses and storage costs are eliminated with electronic medical records storage because they take up less space and are more easily accessible than paper versions. Additionally, the cost of medical record chart materials are replaced by inexpensive maintenance costs, which helps pay for the investment over time.
Finally, we conclude that there is only one major obstacle to widespread EMR uptake: the high total cost of ownership. If this can be brought down, either through subsidies or through technological breakthroughs, then we will see EMR uptake at a relatively rapid pace. However, if the cost cannot be brought down, then, even if other major problems are resolved, we should not expect that the market place would take off quickly.