6.1 Health Information Technology
Sections:
6.1.1 Background & Terminology
I. Background
Various health information technology (HIT) initiatives have emerged as part of the strategy to assist healthcare professionals in their daily duties and reduce the cost of care. High-income countries, as well as low- and middle-income countries, are working to provide their healthcare systems with HIT. Beyond these efforts, researchers are working on innovative HIT to assist patients in managing their health conditions, accessing healthcare services, and assisting general physicians in their daily duties (Edoh & Teege, 2011; Shire & Leimeister, 2012; Yang et al., 2015).
Low and middle-income countries, and rural regions in high-income countries, are typically medically underserved and thus face poor access to healthcare services primarily because patients live far from care units (World Health Organization, 2017). In addition, rural regions in high-income countries mostly suffer from a low rate of physicians providing medical services in these regions (Edoh, 2018).
Overall, the primary healthcare sector is increasingly being provided with modern information systems that assist medical doctors in their daily duties by supporting them in decision-making, diagnosing, prescribing, and remote delivery of care to patients.
eHealth, mHealth, telehealth, and telemedicine are modern HIT-enabled tools aiming to provide better, more efficient, and more effective care services to the patient. Telehealth and telemedicine enable care service delivery regardless of the time zone, the geographic residence place of the patient, and his or her medical doctor(s). Rural regions (i.e., medically underserved), in particular, have taken advantage of these tools supporting remote care (Edoh et al., 2016).
HIT systems collect and provide medical information to medical doctors and the patient for self-management of his or her health conditions (e.g., glucometer for glucose testing and tensiometer for blood pressure monitoring). HIT also processes collected data to assist in decision-making. These data are stored in the electronic health record or electronic medical record. Evidence has shown the benefits of electronic medical records include reducing prescription errors and enabling inter- and extra-organizational information sharing (Adjerid et al., 2018; Hydari et al., 2019). Beyond decreasing the rate of prescription errors, the EHR could also be used to support accurate diagnosis-making and thus impact the patient’s health outcomes.
II. Terminology
Digital health. Digital health is a broad, overarching term that includes categories such as eHealth, mHealth, HIT, wearable devices, telehealth and telemedicine, and personalized medicine (U.S. Food & Drug Administration, 2020). Digital health technologies use computing platforms, connectivity, software, and sensors for health care and related uses. These technologies span a wide range of uses, from applications in general wellness to applications as a medical device. They include technologies intended for use as a medical product, in a medical product, as companion diagnostics, or as an adjunct to other medical products (devices, drugs, and biologics). They may also be used to develop or study medical products (U.S. Food & Drug Administration, 2020).
eHealth (electronic health). The term ehealth is defined as “a set of technologies applied with the help of the internet, in which healthcare services are provided to improve quality of life and facilitate healthcare delivery” (da Fonseca et al., 2021). eHealth mostly focuses on medical informatics and deals with data. An electronic medical record (EMR) system is an eHealth system that records patients’ medical data. A hospital information system is also an eHealth system that collects, processes, and stores any data related to a hospital.
mHealth (mobile health). According to the (2011), mHealth is a component of eHealth. The Global Observatory for eHealth defines mHealth as medical and public health practice supported by mobile applications, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices (Martinez-Pérez et al., 2013). Health and fitness apps are generally intended for daily individual use and are related to monitoring or informing about a variety of healthy activities such as calorie counting or exercise (Aungst et al., 2014; Martinez-Pérez et al., 2013). Medical apps focus more on healthcare practices and may assist in communication or visual representation of a medical condition or may help to record blood pressure or blood sugars in clients with hypertension or diabetes.
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- However, the use of m-Health technology may have potential security issues. Many health apps currently available require the client to input personal health information (Cummings et al., 2013). The developer informs the user of the terms of use (including the use of personal health information) by requiring a confirmation agreement before the app can be used. If the client agrees to the terms of use, users must be informed of who has access to any personal information placed within the app. Clients also need to be informed if their healthcare provider will monitor this information or if someone else outside the circle of care will have access to this health information, such as the app developer. All healthcare providers must follow the Health Insurance Portability and Accountability Act (HIPAA) when using apps with multiple clients so that any personal information is de-identified. Suppose more than one client is accessing a mobile device during a hospital stay or health consult. In that case, it is also important to develop privacy policies to prevent clients from accessing another client’s health information entered into the app.
(Note: Whereas eHealth refers primarily to systems that create infrastructure, mHealth refers to the mobile applications that provide data to providers and patients.)
Health information technology (HIT). The processing, storage, and exchange of health information in an electronic environment. Widespread use of health IT within the health care industry will improve the quality of health care, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork, and expand access to affordable health care. It is imperative that the privacy and security of electronic health information be ensured as this information is maintained and transmitted electronically (U.S. Department of Health and Human Services, 2022a). HIT includes electronic health records (EHRs), personal health records (PHRs), electronic prescribing (e-prescribing), as well as privacy and security systems (Office of the National Coordinator for Health Information Technology, n.d.). Review fact sheet (Office of the National Coordinator for Health Information Technology, n.d.): Health Information Technology Fact Sheet
6.1.2 General Categories of Health Information Technology Applications
Five (5) categories of health information technology applications include electronic health records, telemedicine/telehealth services, health information networks, decision support tools, and internet-based technologies and services.
I. Electronic Health Records
The electronic health record (EHR) allows access in real-time to patient information to authorized providers since it contains each patient’s medical history, diagnoses, medications, immunizations, and allergies. The certified EHR is a digital system that provides the most up-to-date documented information on the patient’s medical status. EHRs, when integrated with clinical decision support tools, help the provider to interpret the patient data currently available and support the interpretation of that data by the provider. This system can provide clinical reminders or alerts, aggregate the data into a central database for analysis, and provide a means of communication and collaboration with other providers (and with patients) through the patient portal. The EHR is interactive and can support complete documentation of a patient encounter through the use of the Computerized Provider Order Entry (CPOE) templates embedded in the EHR. Access and accuracy of information in the EHR depend upon provider inputs, messaging standards, and terminology standards. The use of patient portals has improved communication between healthcare providers through the use of encrypted emails as well as access to the patient’s medical record, also known as health information exchange.
Standardization overview
Electronic health systems use standardized clinical terminologies so that all healthcare providers can communicate findings and share client information within their specific practice settings. Standardized clinical terminologies refer to a set of common terms that describe health conditions, treatment plans, and necessary interventions. Two examples of commonly used standardized clinical terminologies include the Systematized Nomenclature of Medicine—Clinical Terms (SNOMED CT) and Canadian Health Outcomes for Better Information and Care (C-HOBIC). Standardized clinical terminologies facilitate the measuring and recording of medical care and data, such as monitoring the time it takes to perform a procedure. This recorded data can also describe specific medical activities and their impact on client outcomes, including the client’s progression toward discharge.
Benefits
The accuracy of data used in patient care and treatment is critical as a foundation for better clinical outcomes, accuracy in billing, and timely reimbursements of healthcare services. The EHR design is to provide complete and accurate medical documentation on each patient. This data accessed at the point of care, without the difficulties of reading an illegible paper record, is critical for efficient and effective clinical decision-making. By sharing patient information outside of the healthcare organization or physician practice with other authorized healthcare providers, organizations can reduce the costs of duplicate testing, saving time and money for patients and providers. The coordination of care includes many stakeholders (e.g., care teams, the patient) in the management of the patient’s health. Streamlining administrative and business processes helps improve the value of these systems as well as increase patient safety and satisfaction.
Challenges
There are many challenges when adopting an EHR and CPOE. Some unintentional consequences when adopting these systems can be disrupted workflows that increase the clerical burden on the provider by including clerical documentation responsibilities in addition to the clinical documentation. The frequent changes to systems and user interfaces increase the disruption of work and the learning curve included with each change. Some issues remain with using paper documentation since complex patient orders like Total Parenteral Nutrition (TPN) and Chemotherapy continue on paper orders because of the complexity and uniqueness of each order based on a specific patient’s needs. Although EHR and CPOE technologies change how medications are ordered, they can introduce new medication errors that result from confusing or overly complex graphical user interfaces where CPOE restricts medication orders and protocols that do not allow the clinician to order the appropriate medication because it is not an available selection (Hartzog, 2010).
If the CPOE templates only offer the provider a check-off box, a revision of the templates is indicated to provide more opportunities for specific documentation details. Providers and coders collaborate with the CPOE implementation team to ensure that the templates reflect best practices and billing requirements. Organizations must be aware that correcting one error, such as illegible handwriting, can also lead to alert fatigue. Automating some processes like medication interactions is very valuable as long as the pop-up alerts do not cause alert fatigue. The pop-up alert must be targeted and provide valuable information to the healthcare provider.
If the alerts are frivolous and the provider is overwhelmed by the number of interruptions, they can make errors by overriding all alerts. For example, aspirin causes an alert with almost every drug, and is a common prophylactic medication for stroke and heart attack. Alerts can be modified through the Pharmacy and Therapeutics Committee, where pharmacists, clinicians, and physicians work together to ensure their relevance in the practice setting. The configuration of CPOE templates can present a barrier to billing since accurate documentation is critical. Template configuration must allow the level of detail required to satisfy code requirements for reimbursement of health services provided in patient care (Centers for Medicare & Medicaid Services, 2021a).
Health information exchange
The Health Information Exchange (HIE) supports the sharing of electronic health data between two or more healthcare organizations or providers. The HIE can also be an organization that provides this technology at a local, state, regional, or national level, providing a secure ability to share health data. The STAR (Strengthening the Technical Advancement & Readiness of Public Health via Health Information Exchange) Program expands the ability of HIEs to support public health agencies in response to health emergencies and pandemics such as COVID-19 (HealthIT, 2021a). The HIE is a hub of data pulled from multiple sources, including local communities, regional and state entities that depends on policies to define how data can be used in public health agencies.
One of the challenges of the HIE is the need for a master patient index that provides unique identification so that the patient information is unique to that patient and not merged with a patient who has the same name. The capability of keeping correct patient information is used at an organizational level with medical record numbers associated with unique patients. The danger of incorrect treatments based on incorrect patient information can happen when sharing patient information outside the organization. This danger is one reason that patient engagement in their care and review of the documentation in their medical record is so important.
II. Telemedicine and Telehealth Services
Descriptions
During the COVID-19 pandemic, telemedicine and telehealth were widely adopted to provide healthcare to patients and keep them safe. Telemedicine uses telecommunication technologies such as a computer, tablet, or smartphone over the Internet to let a patient talk to their doctor live either by phone or video chat (Health Resources and Services Administration [HRSA], 2022). Telemedicine uses electronic communications and software to provide clinical services without the need for an in-person visit to the doctor’s office. Telemedicine supports remote monitoring so a patient’s doctor can review any changes they are experiencing from home (HRSA, 2022). Telehealth provides non-clinical services such as provider training and medical education. It also supports the ability to send and receive secure messages and exchange files with a healthcare provider (HRSA, 2022).
Although telemedicine/telehealth may seem to be an entirely new technology, it really is not. NASA pioneered telemetry and telemedical technologies in the space program to monitor the life signs of the astronauts. These emerging communication technologies provide an opportunity for virtual healthcare visits and remote monitoring to support rural populations that are often medically underserved or the need for isolation. For example, the only way that many patients were provided a continuity of care when in-person visits were restricted during the COVID-19 pandemic was through the virtual visit using telehealth platforms (Bird, 2021).
Providing safe and efficient care to patients has always been the goal of healthcare. Pre-COVID-19, the use of telehealth was restricted due to policies governing the specific telehealth services that would be covered and reimbursed. Currently, revisions to state laws and federal regulations are being considered since existing licensing and reimbursement barriers may limit the use of telehealth technologies (Lewis, 2021; Maheu, 2021). During the pandemic, there was a temporary change that removed these restrictions. However, further research is needed to explore the sustainability of telehealth as a treatment option for a wide range of patient groups and its utility as a communication tool (Doraiswamy et al., 2021; Graham et al., 2021; Lieneck et al., 2021; Nicosia et al., 2021; Purnell & Zheng, 2021).
Modalities
Telemedicine/telehealth can take the form of audio and video (synchronous), store-and-forward technologies (asynchronous), and remote patient monitoring (Rangachari et al., 2021).
1. Synchronous
This modality includes real-time telephone or live audio-video interaction, typically with a patient using a smartphone, tablet, or computer. In some cases, a nurse may use peripheral medical equipment (e.g., digital stethoscopes, otoscopes, ultrasounds) physically with the patient, while the consulting medical provider conducts a remote evaluation.
2. Asynchronous
This modality includes “store and forward” technology, where messages, images, or data are collected at one point in time and interpreted or responded to later. Patient portals can facilitate this type of communication between provider and patient through secure messaging.
3. Remote patient monitoring
This modality allows direct transmission of a patient’s clinical measurements to their healthcare provider from a distance (which may or may not be in real-time). It also allows the older adult to age in place with less travel and exposure to COVID-19 and other infectious diseases. Examples of telehealth services include TeleSleep, TeleSurgery, outpatient patient-provider video conferencing, mental health support services, virtual physical exam guidelines, and maternity support (Benziger et al., 2021; Lieneck et al., 2021; Nicosia et al., 2021; Purnell & Zheng, 2021; Westwood, 2021; Zimmerman et al., 2021).
To examine the effectiveness of this modality, Zimmerman et al. (2021) conducted a patient satisfaction survey comparing partial hospital services delivered to 240 patients via telehealth during the COVID-19 pandemic, to in-person treatment provided to 240 patients prior to the pandemic. The results of the patient satisfaction survey revealed that “both groups were highly satisfied with all components of the treatment program and almost all would recommend treatment to a friend or family member” (Zimmerman et al., 2021).
Examples of remote monitoring tools include continuous glucose monitors, anticoagulation testing, electrocardiography devices, heart rate monitors, medical alert systems, maternity care monitoring, pediatric monitoring, pulse oximeter, smart scale, medication monitoring, and patient wearables (Welkin Health, 2020). Devices such as smartphones and computers allow easy access to remote healthcare providers through virtual visits from the comfort of their home. In addition, many new technologies, such as blood pressure cuffs, glucose meters, and pulse oximeters, can upload data for the provider.
III. Health Information Networks
Health Information Networks (HIN) are standards, policies, and services. The objectives of HIN are to secure health information exchange over the Internet. HIN are, therefore, important for medical data, which are sensitive data that need to be protected for reasons such as data integrity prevention. Examples of HIN include:
- National: The Nationwide Health Information Network (NHIN)
- Public: The Public Health Information Network
- State: Michigan Health Information Network
IV. Decision Support Tools
Machine learning and all subsets of artificial intelligence (AI) are now being used with eHealth applications to support decision-making. Decision support tools mostly use patient data for data analytics and can even assist in predicting a medical event.
Electronic clinical decision support (CDS) tools are integrated into some electronic health records (EHR) and other similar systems. Some CDS tools can provide prompts and reminders to assist users, including healthcare professionals, clinical teams, patients, and administrators, in implementing evidence-based clinical guideline recommendations during patient care or service delivery. CDS tools can provide accurate and timely information to help advise clinical decision-making within the patient encounter. The data from the EHR can be used, for example, to analyze organizational practices and progress (Centers for Disease Control and Prevention, 2022a).
V. Internet-Based Technologies and Services
The Internet is the data highway that enables data and information exchange and communication between the different actors within a health system. The Internet of Things (IoT) is defined as user or industrial devices that are connected to the internet including sensors, controllers, and household appliances (National Institute of Standards and Technology [NIST], n.d.). According to the NIST (n.d.), the IoT could revolutionize the American economy by enabling a fully connected world with on-demand access to data, systems, and each other. Of course there are risks that come along with this level of connectivity, especially among so many devices across the globe. We must be able to trust the privacy, security, authenticity, and reliability of these devices, and the advanced networks that support them (NIST, n.d.).
Review video :
NIST. (2018). What is the Internet of Things (IoT) and how do we secure it? https://youtu.be/H_X6IP1-NDc
