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the power of technology
It’s 7:51 a.m. A doctor steps out of Foggy Bottom Metro station
in Washington, DC, personal digital assistant (PDA) in hand. She puts down
her briefcase and reviews an e-mail from a rural clinic in Virginia for which
she is a radiology consultant. A set of digital X-rays is attached. She reviews
them and then speaks into a small microphone on her PDA. Her spoken comments
are translated into a text message using speech recognition software, which
she attaches to the e-mail and forwards to a colleague for review.
Also in
her in-box: a prescription renewal request. With a few clicks, she authorizes
the prescription, which is sent electronically to the patient’s
neighborhood pharmacy to be filled. It’s now 7:58 and she’s already
served two patients before even stepping into her office—with time to
spare to pick up coffee at the café down the block.
HIT or Miss
This scenario is not far-fetched. All over the country, technology
is helping clinicians treat patients more efficiently and effectively. The
health information technology (HIT) available today offers many possibilities
for storing, computing, analyzing, and sharing health data. It could have many
other advantages as well.
In 2004, the national health care bill was estimated to be $1.79 trillion.1 Of
that total, an estimated 31 percent ($555 billion) was spent on administration
alone.2 Estimates are that HIT-like electronic
medical records (EMRs) could save the American health industry approximately
$162 billion a year.3,4
If widely adopted,
HIT also could reduce the occurrence of serious medication errors by 55 percent.5 This
effect is no trifling matter: The Institute of Medicine estimates that hospital
health errors lead to a staggering 44,000 to 98,000 lives lost each year.6 “The
only way that computers make errors is if they’ve been programmed wrong,” affirms
David Stockwell, assistant professor of pediatrics and critical care at the
National Children’s
Medical Center in Washington, DC.
Opportunities to use information technology
(IT) to achieve better health outcomes, fewer medical errors, and greater administrative
efficiency are being pursued by just about everyone in the health care field.
This interest extends to the Federal Government, which is pushing for the increased
use of EMRs and the establishment of a nationwide health information network
(NHIN) by 2014.7 When implemented, the NHIN would provide a secure, nationwide,
interoperable health information infrastructure to connect providers, consumers,
and others involved in supporting health and health care.8 Moreover, the network
would enable EMRs to be easily transported and shared among a host of diverse
parties.
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What is HIT?
HIT comes in many forms and provides many functions. As a result,
it can be hard to define and understand. The U.S. Department of Health and
Human Services (HHS) defines HIT as technology that “allows comprehensive
management of medical information and its secure exchange between health care
consumers and providers.” 9 Ultimately, understanding what HIT is means
understanding what HIT can do (Table 1).
Type |
Definition |
Audio computer-assisted
survey interview (ACASI) |
An application by which patients can complete a touch-screen questionnaire
that screens for various behaviors; the ACASI system helps clinicians
initiate and prioritize areas for intervention by providing synthesized
information for treatment reinforcement.10 |
Computerized physician
order entry (CPOE) Systems |
Electronic applications that allow
doctors to enter orders for medications, diagnostic tests, referrals,
and other services through an automated computer system.11,12 CPOEs
also can issue electronic reminders and alerts that can improve clinician
adherence to specific practice guidelines.13,14
|
Electronic medical
record (EMR) |
A computer-based electronic health
record containing a wide range of documentation, including multimedia
elements (e.g., EKG output, heart and lung sounds) and digitized photographs
(e.g., rashes, retina changes). EMRs are more likely than paper-based
records to be fully understandable, to be fully legible, and to have
at least one diagnosis recorded. They also improve the documentation
of services, referrals, and the drug dosage of prescribed treatment.15 Doctors using EMRs have been shown to recall advice given to patients
better than doctors using paper-based records.16
|
Electronic prescription
software |
Enables a physician to transmit a
prescription electronically to a patient’s pharmacy of choice.
|
Nationwide health
information network |
A secure, nationwide, interoperable
health information infrastructure that will connect providers, consumers,
and others involved in supporting health and health care.17
|
Personal digital
assistant (PDA) |
A hand-held computer, often pen-based,
that provides organizational software (e.g., appointment calendar,
billing software) and communications hardware (e.g., cell phone, modem).18 The PDA software also can include digital drug databases, drug interaction
checkers, and medical books and references.19
|
Smartphone |
A PDA that includes a mobile telephone.
|
Speech recognition
software (SRS) |
Enables a machine or program to recognize
and carry out voice commands or take dictation and incorporate the
voice data into an EMR. The technology can match a voice pattern against
vocabulary that has been preprogrammed or acquired when the user records
additional words. SRS reduces or eliminates the need to enter or correct
data after taking clinical notes. The most up-to-date technology, SRS
has the ability to accept natural speech (i.e., speech as it is naturally
spoken rather than carefully enunciated). 20 |
D
Seeing the Big Picture
Using HIT is, in many ways, like putting together a
jigsaw puzzle—it
allows the many pieces of a patient’s or a population’s health
profile to be viewed as a whole. EMRs, for example, allow text like X-ray reports
and clinical notes to be imported. Using a scanner and an optical character
recognition program, text on the pages is converted to a format compatible
with the EMR. This process saves a great deal of physical storage space and
allows information to be accessed and organized more efficiently.21 With an
EMR system, a doctor or nurse ideally would have a computer or PDA available
in the examination room and would record findings by typing them into the computer
rather than writing them down. Some blood pressure cuffs and thermometers automatically
send their readings to computers.22
Electronically stored data also facilitate
the creation of summary information, which can be used to create summaries
and graphs of test results over time and aid providers in the preparation of
data summaries like the Ryan White Program Data Report.*
The Personal Touch
Providers and administrators aren’t the only ones using HIT.
Now that consumers can electronically manage everything from their bank accounts
to their dating lives, managing personal electronic health information is a
natural next step. Personal electronic health records can help patients store
all of their health information in one secure place. They also allow patients
to share their data with their providers, leading to better health data management
and, ultimately, better health.
PDAs can help patients manage and organize
health-related information. A study by the University of Maryland School of
Medicine investigated using PDAs to help adolescents with their HIV medication
regimens.23 The PDAs were used to issue reminders and assist with self-reporting
of medications taken, thereby facilitating reporting of medication adherence
and allowing the young people living with HIV/AIDS (PLWHA) to better manage
their disease.24
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Opening the Patient-Provider Dialogue
In 2003, the Ryan White HIV/AIDS Program established an IT initiative
under the Special Projects of National Significance (SPNS) program to determine
how HIT can contribute to measurable and sustainable improvements in the delivery,
quality, and cost-effectiveness of HIV/AIDS care for PLWHA. (For more information,
see http://hab.hrsa.gov/special/it_index.htm.)
Two of the six grantees, Cornell
University and Johns Hopkins University (JHU), are evaluating whether audio
computer-assisted survey interviews (ACASI) can improve patient involvement
in—and adherence to—HIV care. Prior
studies have documented that patients disclose information about health-related
behaviors more readily when responding privately to electronic surveys than
when speaking with interviewers. ACASI’s audio feature also prevents
low literacy from being a barrier to a patient’s ability to use the technology.25
Cornell’s project tested whether ACASI screening in hospital community
HIV clinics could improve patient-provider communication while improving patient
satisfaction and health outcomes, including medication adherence, lab values
(HIV RNA), depression symptoms and treatment, and condom use. Computer workstations
were set up in private settings, and patients completed ACASI questionnaires
(in English or Spanish) that were immediately transmitted to their providers.
At JHU, ACASI was used to evaluate patient adherence to treatment regimens
and identify risk-taking behaviors that could interfere with adherence. Despite
the sensitive nature of the assessment, “We received an overwhelmingly
good response not just from our providers but from our patients,” says
Beulah Sabundayo, research associate at the JHU School of Medicine. “And
that’s ultimately who this technology is about.” The final results
of the Cornell and JHU projects are forthcoming.
Safety First
If knowledge is power, PDAs pack a mighty punch. “You can have
volumes and volumes of references in your PDA that you can take anywhere,” says
Stockwell. PDAs can contain drug databases and drug interaction alert systems
and store entire medical references. They offer a combination of portability
and depth of information unrivaled by traditional paper information sources.26
PDAs also enable electronic prescribing (EP), which helps physicians avoid
potentially harmful drug interactions or allergies. HIV medications, in particular, “are
notorious for interacting with other drugs,” says Stockwell. “Electronic
prescribing is great for determining if there are interactions with other drugs
the patient is taking.”
EP can reduce pharmacy phone calls (which often
result from doctors’ hard-to-read
handwriting) and allows greater access to patient medication history. EP also
enables an easier prescription renewal process and formulary status* on each
medication prescribed.
EP is not a stand-alone service—it can work with EMRs, PDAs, and nearly
any other form of technology from the alphabet soup of HIT. “I can take
my smartphone anywhere it can get cellular service,” says Stockwell. “I
could get a call for a prescription and send one to any pharmacy the patient
wants. And I can do it even if I’m in the middle of the woods somewhere.”
Bridging the Divide
Today, patients and providers increasingly meet in a virtual landscape.
Take the example of an HIV-positive patient who is due for a checkup and labwork
but lives hundreds of miles from the nearest primary care doctor’s office,
let alone an HIV clinic. Specialty HIV clinics are a luxury that many rural
areas cannot afford given scant resources and limited patient volume. Even
if the nearest primary care doctor can refer the patient to a specialist in
a nearby city, the visit may require the patient to drive an hour or more and
lose time from work. This scenario is a common complication of rural living
that can cause patients with chronic diseases to postpone making appointments
with distant specialists. As a result, their conditions worsen.
The situation
may sound discouraging, but it does not have to be. The State of Georgia has
made great strides in using HIT to narrow the gap in service to its rural residents,
establishing one of the largest integrated telemedicine programs in the country.27 Across 39 rural counties, patients and their doctors can visit a local teleconference
center and meet remotely with one of 75 specialists at 11 urban sites.28
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If knowledge is power, PDAs pack
a mighty punch. “You can have volumes and volumes of references
in your PDA that you can take anywhere...” |
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Hurdles
to HIT
Experts identify four major hurdles to HIT: inertia, cost, the patient’s
perception of provider competence, and lack of standards.
Inertia
Despite evidence of the benefits of HIT, only 10 to 15 percent of
hospitals use computerized physician order entry (CPOE) systems.29 These systems
can serve as an electronic platform for physicians to enter a variety of clinical
orders (e.g., prescriptions, lab tests) that are then integrated with background
information about the patient being treated. CPOE systems can automatically
check for and intercept possible errors, such as harmful medication interactions,
at the time of the order.30
But of the hospitals that use CPOE systems, only
1 in 10 store all necessary data, offer clinical reminders, and permit electronic
test orders in their systems, according to HHS.31 In fact, just 5 percent of
6,000 U.S. hospitals have systems that support computerized ordering of drugs
and tests.32
The number
of hospitals that have adopted CPOE is small, in part, because HIT is no different
from any other tool—it requires human influence to accomplish
its ends. Unfortunately, resistance to change can be a greater influence.
A
2004 study interviewed top management at 72 U.S. hospitals to identify the
barriers to adopting CPOE systems. Management cited various reasons including:
- the belief that CPOE would create more work
and be slower to use than traditional, paper-based ordering methods;
- low computer
literacy among some physicians;
- a lack of user involvement in the implementation
process; and
- fear that new mistakes would occur.33
“There’s always going to be a spectrum of acceptance in any health
care environment,” observes Stockwell. “There are people who can’t
wait to try new technology. There are people in the middle who want you to
prove that it works before they start thinking of using it. Then there are
people on the other end of the spectrum who say, ‘I’m fine! I don’t
need to use this.’”
Bridging the spectrum of acceptance requires
providing consistent support and encouragement to users. It requires establishing
administrative leadership to manage change and addressing workflow concerns
by providing HIT training. It also may require that clinicians comfortable
with a technology tout its benefits to colleagues not yet “on board.”
Cost
The health care industry spends only 2 percent of gross revenues on
IT;34 in contrast, other information-intensive industries, such as finance,
spend 10 percent of their gross revenues on IT. Nevertheless, cost is a factor
that few, if any, health care providers have the luxury to ignore. The initial
investment in EMRs alone can range from a few million dollars to upwards
of $60 million, according to Pat Wise, an executive with the Healthcare Information
and Management Systems Society.35
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EMRs are being implemented in a radically new way
by New York City’s Department of Health and Mental Hygiene (DHMH).
The department recently announced that it will provide free EMR software
to more than half of all high-volume Medicaid providers in the city
(medical practices in which more than 30 percent of patients are covered
by Medicaid or are uninsured).38 Software will be distributed to about
1,500 practices over the next 2 years, including small neighborhood
doctors’ offices, large clinics, and the medical offices at the
Rikers Island jail.39
“As a doctor, I’m likely to pay attention to the patient’s
acute complaint and not notice, “Oh, my goodness, she hasn’t
had a mammogram,” says Farad Mostashari, the assistant city health
commissioner overseeing the EMR project for the DHMH, echoing the concerns
of many overtaxed health professionals. “But the computer never
forgets, and it will remind me.”40
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Although it is true that progress has a price,
sometimes it comes at a discount. HIT can streamline service delivery, improve
quality of care, and make care delivery more cost-effective in the long run.36 Organizations that have kept their benefits in mind have found the following
ways to circumvent financial challenges:
- Using differential reimbursements from payers that could be passed on
to physicians;
- Encouraging malpractice insurers to discount rates for physicians
who use advanced HIT; and
- Issuing government or commercial grants or loans
to assist providers with implementation.37
Patient Confidence in Provider Competence
Some providers may feel as though
patients will think they are uncertain or uninformed if they use IT to identify
symptoms or reference drug interactions. “Physicians
were initially worried about using PDAs because they were worried about showing
the patient that they have to look something up,” remarks Stockwell.
Over time, however, experience has taught otherwise. “People are starting
to realize that patients like knowing that the care they are receiving is
as accurate as possible,” he adds.
According to Frank Lombard, project director at the Duke SPNS IT project, “There’s
always a large fear among providers that patients are going to be very resistant
to having their information collected electronically. But we’ve found
that actually isn’t a significant issue.” He adds, “One of
our case managers says that when he encounters clients suspicious of how the
information will be used, they complete the form together so the patient can
see everything that goes on the screen. They see exactly what’s happening
and that it’s only going to be shared with their doctors.”
Lack of Standards
A nationwide health information infrastructure is still a
dream, but the need for it is rooted in reality. Health information networks
have been successfully implemented by various regional health care systems
across the country. But with disparate systems come disparate standards of
operation.
According to the HHS National Coordinator of Health Information
Technology Robert Kolodner, “determining the appropriate standards to
use to forward the national agenda” is among the biggest challenges to
developing a nationwide system. “That’s why we have a panel that
serves not as a standards developer but to harmonize standards, identifying
which to use for which purpose, all within the context of accomplishing health
goals,” he
explains. Kolodner’s office is well on its way to accomplishing its goal,
having researched and established several “use cases,” or best
practices, to guide the adoption of a set of national standards for HIT. (For
more information, see www.hhs.gov/healthit/usecases/).
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The Next Horizon
HIT is full of imaginative applications to real health challenges, and an
ever-expanding selection of technologies is available to health care providers
and consumers. It is up to us to use them, because when we push the limits—which
may be self-imposed—on how knowledge is managed and optimized, we deliver
better care. And better care means better health and better lives.
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- Lohr, S. Building a medical data network. New
York Times. November 22, 2004. Available at: www.nytimes.com/2004/11/22/technology/22newecon.html?ei.
Accessed May 2, 2007.
- Lohr, 2004.
- Brown D. VA takes the lead in paperless
care. Washington Post. April 10, 2007. HE01. Available at: www.washingtonpost.com/wp-dyn/content/article/2007/04/06/AR2007040601911.html.
Accessed April 10, 2007.
- Brown, 2007.
- Poon EG, Blumenthal D, Jaggi, T et
al. Overcoming barriers to adopting and implementing computerized physician
order entry systems in U.S. hospitals. Health Affairs. 2004;23(4):184-90.
Available at: http://content.healthaffairs.org/cgi/content/full/23/4/184.
Accessed August 15, 2007.
- Institute of Medicine, 2000. To err is human:
Building a safer health system. 2000. Available at: http://books.nap.edu/openbook.php?record_id=9728&page=26.
Accessed July 16, 2007.
- U.S.
Department of Health and Human Services (HHS). (n.d.) Nationwide
health information network (NHIN): Background. Available at: www.hhs.gov/healthit/healthnetwork/background/.
Accessed August 28, 2007.
- HHS, 2007.
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technology.
Available at: www.hhs.gov/healthit/. Accessed August 27, 2007.
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Resources and Services Administration, HIV/AIDS Bureau (HAB). (n.d.)
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Available at http://hab.hrsa.gov/reports/spnsreport_it.htm.
Accessed August 28, 2007.
- Poon et al., 2004.
- HAB, 2007.
- Safran C, Rind DM, Davis RB, et al.
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- Lobach DR, Hammond WE. Computerized decision support
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or progression? A cross-sectional study. BMJ 2003;326:1439-43 (28 June).
Available at: www.bmj.com/cgi/content/full/326/7404/1439. Accessed
May 14, 2007.
- Hippisley-Cox et al., 2007.
- HHS, 2007.
- Personal digital assistant. (n.d.) Dictionary.com
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Retrieved August 6, 2007.
- American Medical
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- Peralta L, Metcalf M, LaGrange R, et al. Innovative
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Accessed August 28, 2007.
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In the HIV/AIDS field, we constantly strive to
change health outcomes and change perceptions—all in an effort
to effect the biggest change of all: the eradication of a deadly disease.
But change comes in waves, and we know that we can’t just wait
for the waves to crash onto the shore before we make our next move.
We have a history of ensuring that we stay ahead of the waves when
it comes to delivering HIV/AIDS care.
Over time, one of the biggest
changes in the HIV/AIDS field has been a rise in technologies that
continually expand our capacity to deliver HIV/AIDS care. HRSA has
invested in the Special Projects of National Significance (SPNS) Information
Technology (IT) Initiative to explore new ways of using IT to improve
HIV care delivery and health outcomes, because one thing that we’ve
experienced as health care providers is that the increasing amount
of information that we need to manage sometimes feels like it is managing
us. IT helps us take back control by allowing us not only to manage
information effectively, but also to share it and learn from it better
than ever before.
Deborah Parham Hopson
HRSA Associate Administrator for HIV/AIDS
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