CHAPTER 6

Informatics

Alan Tomines, MD

To make optimum clinical decisions, physicians must have information about their patients’ health that is current, accurate, reliable, and complete. The physician should be able to access this information wherever and whenever necessary. To the extent possible, the physician should be presented with information that fosters an evidence-based approach to decision making, and the decisions made should be communicated to other health professionals in a manner that is clear and error-free. The physician should be able to review measures of the quality of care provided. Health information technology (HIT) holds the promise of increased access to patient health information, improved patient safety, reporting of desired health outcomes, and improved health care efficiency with the potential for decreased health care expenditures. The implementation and acceptance of HIT is not without challenges, however.

Basic Concepts

Although the terms “data,” “information,” and “knowledge” are sometimes used interchangeably, these are distinct concepts. Data are mere observations or facts (eg, hemoglobin equal to 9 g/dL). Information is data placed in meaningful context (eg, hemoglobin equal to 9 g/dL in a 3-month-old who is breastfed). Knowledge is the understanding of information, including an assessment of its completeness (eg, hemoglobin equal to 9 g/dL in a 3-month-old infant who is breastfed may represent a physiologic nadir but may also represent blood loss, increased destruction of red blood cells, or decreased production of red blood cells).

Information technology refers to any hardware or software that supports the management of data, including how the data are acquired, stored, retrieved, transformed, interpreted, and dissem-inated. For example, a database is an organized collection of data that facilitates the storage and retrieval of those data. An information system is the sum of the people, work processes, and information technology that supports an activity. Depending on the degree to which technology is applied, the processes of an information system may be automated, manual, or a combination of both.

Informatics Defined

Medical informatics is the science of the appropriate application of information technology to health care work processes. Specialists in informatics (referred to as informaticians or informaticists) serve as liaisons between clinical and technology staff to ensure that HIT is optimally applied to address clinical information and workflow needs. Medical informatics places great emphasis on nontechnologic considerations that can affect the successful implementation and acceptance of health information systems, including information science, cognitive psychology, project management, organizational and change management, health care policy, and ethics.

The field of medical informatics can itself be subdivided into specific clinical domains, such as nursing, pharmacy, veterinary medicine, dentistry, and imaging. Biomedical informatics is a term of broader scope that encompasses medical informatics; bioinformatics, in which the primary domain is genomics and bioengineering; and public health informatics.

Electronic Health Information Systems

All electronic health information systems ultimately are used in managing some aspect of patient care, and for ease of discussion in this chapter these systems are presented in 4 broad categories: electronic records of patient care, ancillary clinical systems, administrative systems, and telemedicine. Table 6.1 lists several common abbreviations used in electronic health information systems and informatics.

Electronic Records of Patient Care

A medical record serves as the legal record of care provided to a patient by a health professional or health care organization. An electronic medical record (EMR) is an information technology that supports the traditional role of the medical record, including serving as an archive for clinical documentation, such as physician orders, progress notes, and laboratory and imaging results. A full-fledged EMR is more than an electronic version of the traditional paper-based record, however. It provides capabilities that support the enhanced delivery of care.

Important components of an EMR include a clinical data repository, a clinical decision support system, and computerized physician order entry. A clinical data repository (CDR) is a real-time database containing the clinically relevant patient data of an institution. It supports timely access of patient information for physician decision making and provides information used by other EMR components. A clinical decision support system (CDSS) is a special computer program that applies medical knowledge to data from a CDR to produce patient-specific care recommendations. A computerized physician order entry (CPOE) is a specialized computer program that allows health professionals to write electronic orders that are directed to the appropriate clinical staff or ancillary department. A CPOE can decrease errors resulting from illegible handwriting, decrease delays in the receipt and execution of orders, and allow entry of orders away from the care setting. Additionally, a CPOE paired with a CDSS can leverage patient- specific information in a CDR to prevent harm resulting from drug-drug interactions, drug-allergy interactions, or errors in age- or weight-based dosing.

Although an EMR generally operates within the functional boundary of a hospital or practice, the history of a patient’s health care is not limited to these settings. The personal health record (PHR) is a summary of an individual’s health history—usually self- maintained—that contains information collected from encounters with different health professionals, medicolegal documents (eg, living wills, advance directives), and other health information that may be relevant to patients (eg, regimens for nontraditional remedies, logs of home testing for blood pressure or glucose). The concept of a PHR is not new; patients with multiple medical problems have long maintained paper-based PHRs out of necessity to ensure they have at least 1 reliable and portable source containing a complete medical history. The electronic PHR is an evolving entity, ranging from scanned paper documents stored on portable devices to web-based applications that connect with EMRs and capture data from medical devices. The PHR is not considered a legal record of care.

The next stage in the evolution of the EMR is the electronic health record (EHR), which has the functionality of a full-fledged EMR with the additional capability for exchanging data among multiple different EMRs to provide the entire longitudinal history of the patient. With this data exchange capability, an EHR may also support the needs of population health, such as identification of patient-applicable clinical trials, mandatory reporting of notifiable disease, and provision of anonymized clinical data to support clinical and public health research. (The term EHR has been used interchangeably with and has largely supplanted the term EMR.)

A health information exchange (HIE) is an enabling technology that acts as a hub for the secure exchange of data between EHRs. Via an interface (a program that allows 1 information system to communicate with another), an EHR can connect to an HIE and exchange health information with other EHRs that are connected to that HIE. Although an HIE generally serves a specific geographic region, in future the interconnection of HIEs may allow an EHR in 1 region to share data with an EHR in another region, thereby providing nationwide or worldwide access to a patient’s entire history of episodic care.

Ancillary Clinical Systems

Ancillary clinical systems provide information management and automation for specific health care services or domains, including pharmacy, laboratory, imaging, and immunizations.

A pharmacy information system tracks patients’ prescription and payment information and can improve patient safety by checking for medication interactions and appropriate dosing. A related concept is electronic prescribing (e-prescribing or eRx), which is a specialized type of CPOE that allows physicians to prepare and transmit prescriptions electronically to a pharmacy information system. When connected to an EHR, a pharmacy information system can receive and process prescriptions, and send back dispensing information to support medication reconciliation.

Laboratory information systems (LISs) are used to manage the receipt of laboratory orders, track specimens, capture data from automated analyzers, and present laboratory results to the ordering health professional via direct access to the LIS, or via an interface that transfers the results to an EHR. An LIS can support patient safety through timelier access to laboratory results and data for use in making individualized patient care decisions.

A picture archiving and communication system manages the storage and distribution of patients’ electronic medical images, which often are captured directly from computerized or digital radiography devices, as well as other imaging modalities (eg, computed tomography, magnetic resonance imaging, ultrasonography). A radiology information system incorporates the functionality of a picture archiving and communication system while managing other service activities, such as reporting, scheduling, and billing.

An immunization information system (IIS, also referred to as an immunization registry) is used to document and track patient vaccinations. An IIS can send reminder or recall notices, as appropriate, to physicians and parents or guardians when vaccinations are due or when administered vaccines are determined to be ineffective or unsafe. An IIS usually is maintained regionally by public health entities; thus, it also collects reports on adverse vaccine events and provides summaries of regional vaccination prevalence. These systems usually have the capability to exchange data with capable EHRs.

Administrative Systems

A hospital information system comprises all the clinical and nonclinical information systems of an institution. A hospital information system may be a single integrated information system or may represent multiple interconnected information systems. Hospitals and large practices often have separate information systems to manage individual administrative functions, such as appointment scheduling, insurance eligibility, and billing and payment. A practice management system is an information system designed to manage administrative tasks for small- and medium-sized clinical practices.

Telemedicine

Telemedicine is not an information system per se but a related concept of interest in informatics. Telemedicine is the use of information and communication technologies to deliver health care over a distance, often to support patient care in rural or underserved areas. Many specialties exist within telemedicine, and they roughly correspond to distinct medical specialties, such as teleradiology (ie, the transmission of radiologic images electronically for interpretation) and telesurgery (ie, the use of video and robotic technology to perform surgery). The use of email and websites to consult with patients is also a form of telemedicine.

Key Drivers for Adoption of Informatics

The key drivers for the adoption of HIT are improved patient safety, the ability to measure health care outcomes, increased efficiency of work flow in the patient care setting, and reduced health care expenditures.

Improved patient safety through the reduction of preventable errors is the primary driver of information technology adoption in many health care organizations. In the report To Err Is Human: Building a Safer Health System, the Institute of Medicine (now known as the Health and Medicine division of the National Academies) estimated that up to 98,000 deaths annually in the United States are attributable to medical errors. Most errors were noted to be preventable and caused by systems and processes that increase or fail to prevent human errors. Computerized physician order entry is an EHR technology with the potential to improve patient safety by alerting a physician to errors before an order is submitted in an EHR.

Changes in the health care marketplace are driving the measurement of health care outcomes. Pay for performance, which relates payment to measures of quality of care provided; medical “report cards” that permit comparison of health care plans and professionals; and accountable care organizations are examples of market drivers. Electronic health records are critical to collecting and analyzing data to calculate these measures. Additionally, the decision support system of an EHR may improve health care outcomes through guideline adherence, such as by reminding both physicians and patients about care options that may have been overlooked.

Improvements in efficiency are another driver in the adoption of information technology. For example, efficiency can be gained by automating highly repetitive, data-intensive activities such as billing and scheduling. The introduction of information technology into a clinical setting without thorough consideration of effects on work flow, however, may introduce unanticipated workflow consequences that decrease efficiency or result in the creation of workarounds that reduce the effectiveness of the newly implemented technology.

In 2016, health care spending represented nearly 18% of the gross domestic product of the United States and increased at a rate nearly twice that of inflation. Information technology is considered to be a possible source of cost savings because its use has the potential to reduce duplication of diagnostic studies as well as the time spent on administrative tasks. As predicted in the 2001 report Crossing the Quality Chasm: A New Health System for the 21st Century, the use of email has served to meet the needs of patients more quickly and at lower cost than a traditional visit.

Challenges

Despite the existence of significant health care drivers for the adoption of informatics, several challenges prevent the easy implementation and acceptance of HIT, including information security, technology costs, organizational change, system usability, and the effect on physician-patient interaction.

The ease with which information systems can exchange data should not belie the care required to protect electronic patient data. Protected health information (PHI) is any information about a patient (eg, name, medical record number) that may be used to identify that patient. Patients have the expectation that their PHI will be kept private; health professionals’ assurance that private information will not be revealed is referred to as confidentiality; the policies and technologies that support confidentiality are called security. The Health Insurance Portability and Accountability Act of 1996 defines the measures that must be taken to ensure that PHI is kept secure and is made available only to authorized individuals or organizations participating in a patient’s health care. Although health information systems often use sophisticated technical barriers to protect patient data, recent instances have occurred in which hospitals’ EHRs have been accessed and control of them gained by unauthorized parties who sought ransoms to restore control of the EHR. Generally, such data breaches are the result of failure to adhere to security safeguards, such as sharing passwords or failing to update security software. Educating health professionals is critical to ensuring the confidentiality of patient data.

The cost of implementing health information systems can be prohibitive for health care delivery organizations, particularly small practices. To address this barrier, the Health Information Technology for Economic and Clinical Health (HITECH) Act was included in the American Recovery and Reinvestment Act of 2009. The HITECH Act authorized the provision of Medicare and Medicaid incentives to physicians and hospitals that adopt EHRs and demonstrate “meaningful use” of EHRs by meeting specific objectives toward improved health care delivery and outcomes. These objectives include using EHRs for basic activities, such as recording patient demographics and vital signs; maintaining active problem, medication, and allergy lists; providing patients with summaries of outpatient visits and inpatient discharge instructions; electronic prescriptions and CPOE; and providing drug-drug and drug-allergy checks. The objectives also include more complex functions, such as providing data to public health agencies for disease surveillance as well as immunization and cancer registries; generating lists of patients with specific conditions for quality improvement and research; identifying and providing patient-specific education resources; and supporting medication reconciliation and care summaries across health care settings. To assure physicians and hospitals that they are adopting EHRs that allow them to meet meaningful use regulations, the US Department of Health and Human Services developed criteria for certifying EHRs. By 2016, more than 95% of eligible hospitals and 60% of office-based physicians had demonstrated meaningful use of certified EHRs.

Management of organizational change is an important part of successful information system implementations. Introduction of technology inevitably results in workflow changes for physicians and nurses and may result in repurposing of administrative staff. Resistance to these changes should be anticipated, and strategies to mitigate resistance should be instituted, including involvement of health professionals in the selection and ongoing enhancement or optimization of EHRs.

It is also important to consider the effect of technology on the patient-physician interaction. Physicians increasingly engage in electronic documentation and ordering during patient visits. Although some patients have a favorable opinion on the use of HIT, physicians should be sensitive to patients who feel that technology is intrusive; as appropriate, physicians should acknowledge the intrusion and identify potential benefits to the patient, including efficiency of access to information and more efficient communication of prescriptions to pharmacies or orders to ancillary services. Additionally, physicians should remain vigilant and not allow the EHR to detract attention from their patients during the office visit.

Human-computer interaction is the study of the interactions between people and information technology. It is important for users to perceive that the technology is both useful (ie, supports the work being done) and usable (ie, readily learned, efficient, helps in avoiding and correcting errors). Perception by the physician that an EHR is difficult to use or interferes with patient care or patient interaction may impede the acceptance of EHRs as supportive tools. The topic of usability of HIT is an emerging area of research in the field of informatics.

Pediatric Considerations

Although certified EHRs are present in more than 95% of hospitals, only 3 in 4 children’s hospitals have successfully demonstrated their meaningful use; similarly, pediatricians trail other primary care specialists in demonstrating the meaningful use of EHRs. Although pediatric patients represent approximately 25% of the US population, pediatric EHR functionality often is underdeveloped. When considering these systems for pediatric settings, particular attention should be focused on the highly specific data, task, and policy needs of pediatric practice.

The presence of functionality to support clinical tasks that are generally, if not uniquely, related to pediatrics should always be examined. Immunization management, including the ability to assess a patient’s status or exchange data with an IIS, is highly desirable. Weight-based dosing and tracking of specialized growth parameters (eg, for Down syndrome, for preterm infants) are other functions that are often overlooked. Age-specific documentation and educational materials may be lacking or may require customization.

The data and terminology of an information system should suit the highly specific needs of pediatric practice. For example, units of measure should reflect the requisite data precision needs of pediatric patients. Options to display patient age in hours rather than years, months, or even days and weight in grams is critical to appropriate care in the neonatal period. Laboratory values should be accompanied by normative ranges for age. Patient identification must account for the frequent changes in names and numeric identifiers that may occur in infancy or during change of custody. Pediatric terminology, such as developmental milestones, type of cry, or characterization of stool, are often overlooked in information systems designed for adults.

Pediatric policy issues should also be reflected in the design of an information system. Authorization for the child or the child’s parent(s), guardian(s), or other legal authority to view all, none, or portions of a child’s medical record should be enforced electronically as it would be for the paper medical record. This is particularly true for adolescent records, in which the need for granular awareness of EHR data elements by the pediatrician as well as privacy controls to restrict what a parent, guardian, or other legal authority may see, should be consistent with the relevant statute. Likewise, secondary use of patient data for public health, research, or commercial purposes should be allowed or restricted as appropriate.

Currently, no electronic medical home for the care of children exists. The electronic history of a child’s care may be distributed across EHR systems, immunization registries, school health information systems, and specialty registries for rare conditions, trauma, or foster care. With the promise of HIEs as a conduit for data exchange, it may be possible to create a virtual medical home in the future. It is important that pediatricians work toward reducing the legislative, technologic, and cultural barriers to linking child health information systems without compromising the security or confidentiality of PHI.

Pediatricians should be actively involved in the acquisition and development of information technology to ensure that child- specific data and policy needs are addressed. Pediatricians should also be involved in national policy initiatives to ensure that health information systems are certified for pediatric use and integrated to support care that is child-centered.

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