To accompany the Healthcare Curriculum.
CTAE Resource Network, Instructional Resources Office, 2010
GEORGIA PERFORMANCE STANDARDS:
HS-AHI 10. Students will demonstrate an understanding of electronic health/medical records applications,
maintenance, and storage.
HS-AHI-2. Students will analyze the role of health information management in healthcare organizations.
See the end of this document for complete GPS listing
Student Information Guide
Use the information in this student information sheet to complete the accompanying student study sheet. Complete all items on the study sheet and turn in to the teacher.
Health Informatics (also referred to as health care informatics and medical informatics) involves the fields of information science, computer science, and health care.
; Information science is an interdisciplinary science primarily concerned with the analysis, collection, classification,
manipulation, storage, retrieval and dissemination of information. Practitioners within the field study the
application and usage of knowledge in organizations, along with the interaction between people, organizations
and any existing information systems, with the aim of creating, replacing, improving or understanding
; Computer science is the study of the theoretical foundations of information and computation, and of practical
techniques for their implementation and application in computer systems. It is frequently described as the
systematic study of algorithmic processes that create, describe, and transform information. According to Peter J.
Denning, the fundamental question underlying computer science is, "What can be (efficiently) automated?"
; Healthcare incorporates several industry sectors that are dedicated to providing services and products dedicated
to improving the health of individuals.
Health informatics is essentially the intersection of people, information and technology. Health informatics deals with the resources, devices, and methods required for the acquisition, storage, retrieval, and use of information in health and biomedicine. Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems. It is applied to the areas of nursing, clinical care, dentistry, pharmacy, public health and (bio)medical research.
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WHY DO WE NEED IT?
To Err is Human: Building a Safer Health System is a report issued in November 1999 by the U.S. Institute of Medicine that resulted in increased awareness of U.S. medical errors. The push for patient safety that followed its release continues. The report was based upon analysis of multiple studies by a variety of organizations and concluded that between 44,000 to 98,000 people die each year as a result of preventable medical errors. The report asserts that the problem in medical errors is not bad people in health care—it is that good people are working in bad systems that need to be made safer.
The report called for a comprehensive effort by health care providers, government, consumers, and others. Claiming knowledge of how to prevent these errors already existed, it set a minimum goal of 50 percent reduction in errors over the next five years. Though not currently quantified, as of 2007 this ambitious goal has yet to be met. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility lead to substantial errors and injuries, according to the Institute of Medicine (1999) report. The follow-up IOM (2004) report, Crossing the quality chasm: A new health system for the 21st century, advised rapid adoption of electronic patient records, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. Paper-based records require a significant amount of storage space compared to digital records. In the US, most states require physical records be held for a minimum of seven years. The costs of storage media, such as paper and film, per unit of information differ dramatically from that of electronic storage media. When paper records are stored in different locations, gathering them to a single location for review by a healthcare provider is time consuming and complicated, whereas the process can be simplified with electronic records. This is particularly true in the case of person-centered records, which are impractical to maintain if not electronic. When paper-based records are required in multiple locations, copying, faxing, and transporting costs are significant compared to duplication and transfer of digital records. Handwritten paper medical records can be associated with poor legibility, which can contribute to medical errors. Pre-printed forms, the standardization of abbreviations, and standards for penmanship were encouraged to improve reliability of paper medical records. Electronic records help with the standardization of forms, terminology and abbreviations, and data input. Digitization of forms facilitates the collection of data for epidemiology and clinical studies. EHRs can be continuously updated. The ability to exchange records between different EHR systems ("interoperability") would facilitate the co-ordination of healthcare delivery in non-affiliated healthcare facilities. Interoperability is a property referring to the ability of diverse systems and organizations to work together (inter-operate). Interoperability is the capability of a product or system -- whose interfaces are fully disclosed -- to interact and function with other products or systems, without any access or implementation restrictions. In addition, data from an electronic system can be used anonymously for statistical reporting in matters such as quality improvement, resource management and public health communicable disease surveillance.
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Medical informatics began to take off in the US in the 1950s with the rise of the microchip and computers. Early names for medical informatics included medical computing, medical computer science, computer medicine, medical electronic data processing, medical automatic data processing, medical information processing, medical information science, medical software engineering, and medical computer technology. Since the 1970s the coordinating body has been the International Medical Informatics Association (IMIA).
HEALTH INFORMATICS IN THE UNITED STATES
The earliest use of computation for medicine was for dental projects in the 1950s at the United States National Bureau of Standards by Robert Ledley.
The next step in the mid 1950s were the development of expert systems such as MYCIN and INTERNIST-I. In 1965, the National Library of Medicine started to use MEDLINE and MEDLARS. At this time, Neil Pappalardo, Curtis Marble, and Robert Greenes developed MUMPS (Massachusetts General Hospital Utility Multi-Programming System) in Octo Barnett's Laboratory of Computer Science at Massachusetts General Hospital in Boston. In the 1970s and 1980s it was the most commonly used programming language for clinical applications. The MUMPS operating system was used to support MUMPS language specifications.
In the 1970s a growing number of commercial vendors began to market practice management and electronic medical records systems. Although many products exist, only a small number of health practitioners use fully featured electronic health care records systems. Homer R. Warner, one of the fathers of medical informatics, founded the Department of Medical Informatics at the University of Utah in 1968, and the American Medical Informatics Association (AMIA) has an award named after him on application of informatics to medicine.
HEALTH INFORMATICS LAW
Health informatics law deals with evolving and sometimes complex legal principles as they apply to information technology in health-related fields. It addresses the privacy, ethical and operational issues that invariably arise when electronic tools, information and media are used in health care delivery. Health Informatics Law also applies to all matters that involve information technology, health care and the interaction of information. It deals with the circumstances under which data and records are shared with other fields or areas that support and enhance patient care.
Clinical Informatics is concerned with use information in health care by clinicians.
Clinical informaticians transform health care by analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen
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the clinician-patient relationship. Clinical informaticians use their knowledge of patient care combined with their understanding of informatics concepts, methods, and tools to:
; assess information and knowledge needs of health care professionals and patients,
; characterize, evaluate, and refine clinical processes,
; develop, implement, and refine clinical decision support systems, and
; lead or participate in the procurement, customization, development, implementation, management, evaluation,
and continuous improvement of clinical information systems.
Physicians who are board-certified in clinical informatics collaborate with other health care and information technology professionals to promote patient care that is safe, efficient, effective, timely, patient-centered, and equitable.
ASPECTS OF THE FIELD
ARCHITECTURES FOR ELECTRONIC HEALTH RECORDS
An electronic health record (EHR) (also electronic patient record, computerized patient record, or electronic medical record) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being
embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and
allergies, immunization status, laboratory test results, radiology images, and billing information. It is important to note that an EHR is generated and maintained within an institution, such as a hospital, integrated delivery network, clinic, or physician office. Its purpose can be understood as a complete record of patient encounters that allows providers to automate and streamline workflow in health care settings and to increase safety through evidence-based decision support, quality management, and outcomes reporting.
EHRs can reduce several types of errors, including those related to prescription drugs, to preventive care, and to tests and procedures. Important features of modern EHR software include automatic drug-drug/drug-food interaction checks and allergy checks, standard drug dosages and patient education information, such as describing common side effects. Recurring alerts remind clinicians of intervals for preventive care and track referrals and test results. Clinical guidelines for
disease management have demonstrated benefits when accessible within the electronic record during the process of treating the patient. Advances in health informatics and widespread adoption of interoperable electronic health records promise access to a patient's records at any health care site. A 2005 report noted that medical practices in the United States are encountering barriers to adopting an EHR system, such as training, costs and complexity, but the adoption rate continues to rise.
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COMPUTERIZED PROVIDER (PHYSICIAN) ORDER ENTRY
Prescribing errors are the largest identified source of preventable errors in hospitals. A 2006 report by the Institute of Medicine estimated that a hospitalized patient is exposed to a medication error each day of his or her stay. Computerized provider order entry (CPOE), formerly called computer physician order entry, can reduce total medication error rates by 80%, and adverse (serious with harm to patient) errors by 55%. A 2004 survey by Leapfrog found that 16% of US clinics, hospitals and medical practices are expected to be utilizing CPOE within 2 years. In addition to electronic prescribing, a standardized bar code system for dispensing drugs could prevent a quarter of drug errors. Consumer information about the risks of the drugs and improved drug packaging (clear labels, avoiding similar drug names and dosage reminders) are other error-proofing measures. Despite ample evidence of the potential to reduce medication errors, competing systems of bar-coding and electronic prescribing have slowed adoption of this technology by doctors and hospitals in the United States, due to concern with interoperability and compliance with future national standards.
CLINICAL DECISION SUPPORT SYSTEM
Clinical Decision Support Systems (CDSS or CDS) are interactive computer programs, which are designed to
assist physicians and other health professionals with decision making tasks. A working definition has been proposed by Dr. Robert Hayward of the Center for Health Evidence; "Clinical Decision Support systems link health observations with health knowledge to influence health choices by clinicians for improved health care". This definition has the advantage of simplifying Clinical Decision Support to a functional concept.
A clinical decision support system has been coined as an “active knowledge systems, which use two or more items of
patient data to generate case-specific advice.” This implies that a CDSS is simply a DSS that is focused on using knowledge
management in such a way to achieve clinical advice for patient care based on some number of items of patient data. The main purpose of modern CDSS is to assist clinicians at the point of care. This means that a clinician would interact with a CDSS to help determine diagnosis, analysis, etc. of patient data. Previous theories of CDSS were to use the CDSS to literally make decisions for the clinician. The clinician would input the information and wait for the CDSS to output the “right” choice and the clinician would simply act on that output. The new methodology of using CDSS to assist forces the clinician to interact with the CDSS utilizing both the clinician’s knowledge and the CDSS to make a better analysis of the patients data than either human or CDSS could make on their own. Typically the CDSS would make suggestions of outputs or a set of outputs for the clinician to look through and the clinician officially picks useful information and removes erroneous CDSS suggestions.
An example of how a CDSS might be used by a clinician comes from the subset of CDSS, DDSS or Diagnosis Decision Support Systems. A DDSS would take the patients data and propose a set of appropriate diagnosis. The doctor then takes the output of the DDSS and figures out which diagnoses are relevant and which are not.
STANDARDS FOR INTEROPERABILITY OF HEALTH INFORMATION TECHNOLOGY
Health informatics involves standards (e.g. DICOM, HL7) and integration profiles to facilitate the exchange of information between healthcare information systems - these specifically define the means to exchange data, not the content. Hospitals and other healthcare provider organizations typically have many different computer systems used for everything from billing records to patient tracking. All of these systems should communicate with each other (or "interface") when they receive new information but not all do so.
For example, Health Level Seven (HL7), is an all-volunteer, non-profit organization involved in development of international healthcare standards. HL7 specifies a number of flexible standards, guidelines, and methodologies by which various healthcare systems can communicate with each other. Such guidelines or data standards are a set of rules that allow information to be shared and processed in a uniform and consistent manner. These data standards are meant to allow healthcare organizations to easily share clinical information. Theoretically, this ability to exchange information should help to minimize the tendency for medical care to be geographically isolated and highly variable. DIGITAL IMAGING AND COMMUNICATIONS IN MEDICINE
Digital Imaging and Communications in Medicine (DICOM) is a standard for handling, storing, printing, and transmitting
information in medical imaging. It includes a file format definition and a network communications protocol. The
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communication protocol is an application protocol that uses TCP/IP to communicate between systems. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The National Electrical Manufacturers Association (NEMA) holds the copyright to this standard. It was developed by the DICOM Standards Committee, whose members are also partly members of NEMA.
DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). DICOM has been widely adopted by hospitals and is making inroads in smaller applications like dentists' and doctors' offices.
CONTROLLED MEDICAL VOCABULARIES
Another aspect of health informatis is controlled medical vocabularies (CMVs) such as the Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT), MEDCIN, Logical Observation Identifiers Names and Codes (LOINC), OpenGALEN Common Reference Model or the highly complex UMLS - used to allow a standard, accurate exchange of data content between systems and providers
Controlled vocabularies provide a way to organize knowledge for subsequent retrieval. They are used in subject indexing schemes, subject headings, thesauri and taxonomies. Controlled vocabulary schemes mandate the use of predefined, authorized terms that have been pre-selected by the designer of the vocabulary, in contrast to natural language vocabularies, where there is no restriction on the vocabulary.
For example, SNOMED CT (Systematized Nomenclature of Medicine -- Clinical Terms), is a systematically organized computer processable collection of medical terminology covering most areas of clinical information such as diseases, findings, procedures, microorganisms, pharmaceuticals etc. It allows a consistent way to index, store, retrieve, and aggregate clinical data across specialties and sites of care. It also helps organizing the content of medical records, reducing the variability in the way data is captured, encoded and used for clinical care of patients and research. The purpose of SNOMED CT is to support the community of practice who are developing electronic health records systems which will allow the appropriate retention, processing and exchange of unambiguous clinical records. The ability for such systems to support patient-centric actions such as fast transfer of records between different healthcare providers is dependent on a number of techniques, collectively referred to as 'semantic interoperability' of which a reference terminology such as SNOMED CT is a fundamental part. Clinicians and organizations use different clinical terms that mean the same thing. For example, the terms heart attack, myocardial infarction, and MI may mean the same thing to a cardiologist, but, to a computer, they are all different. There is a need to exchange clinical information consistently between different health care providers, care settings, researchers and others (semantic interoperability), and because medical information is recorded differently from place to place (on paper or electronically), a comprehensive, unified medical terminology system is needed as part of the information infrastructure.
HEALTH INFORMATICS & POLICY INITIATIVES TODAY
As of 2000, adoption of EHRs and other health information technology (HITs) was minimal in the United States. Fewer than 10% of American hospitals had implemented HIT, while a mere 16% of primary care physicians used EHRs. In 2001-2004 only 18% of ambulatory care encounters utilized an EHR system. In 2005, 25% of office-based physicians reported using fully or partially electronic medical record systems (EMR), an almost one-third increase from the 18.2% reported in
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However, less than one-tenth of these physicians actually had a "complete EMR system" (with computerized orders 2001.
for prescriptions, computerized orders for tests, reporting of test results, and physician notes). In 2004 the U.S. Department of Health and Human Services (HHS) formed the Office of the National Coordinator for Health Information Technology (ONCHIT). The mission of this office is widespread adoption of interoperable electronic health records (EHRs) in the US within 10 years.
The Certification Commission for Healthcare Information Technology (CCHIT), a private nonprofit group, was funded in 2005 by the U.S. Department of Health and Human Services to develop a set of standards for electronic health records (EHR) and supporting networks, and certify vendors who meet them. In July, 2006 CCHIT released its first list of 22 certified ambulatory EHR products, in two different announcements.
FUTURE DIRECTIONS & INCENTIVES
Until recently, with the American Recovery and Reinvestment Act of 2009, providers were expected to take the full risk of investing in healthcare IT. Notably, healthcare payers, such as the government through Medicare, also have potential for significant cost savings if providers adopt EHR systems.
The HITECH Act, part of the 2009 economic stimulus package (ARRA) passed by the US Congress, aims at inducing more physicians to adopt EHR. Title IV of the act promises incentive payments to those who adopt and use "certified EHRs" and, eventually, reducing Medicare payments to those who do not use an EHR. Funding for EHR incentives is also added to the Medicaid system. In order to receive the EHR stimulus money, the HITECH act (ARRA) requires doctors to also show "meaningful use" of an EHR system. The rule-making process for meaningful use and certification are currently being decided upon. The goal for universal EHR adoption is 2014. Health information exchange (HIE) has emerged as a core capability for hospitals and physicians to achieve "meaningful use" and receive stimulus funding. Healthcare vendors are pushing HIE as a way to allow EHR systems to pull disparate data and function on a more interoperable level. In the United States, the development of standards for EHR interoperability is at the forefront of the national health care agenda. The future of health informatics will involve the ability to exchange electronic health records between healthcare systems
GEORGIA PERFORMANCE STANDARDS
HS-AHI 10. Students will demonstrate an understanding of electronic health/medical records applications, maintenance, and storage.
a. Analyze trends in automated office communication systems and medical record maintenance including, but not limited to,
electronic health records, digital signatures, and data capture methods.
HS-AHI-2. Students will analyze the role of health information management in healthcare organizations.
a. Research the history of health information technology and trends in the management of health records.
LICENSE & VERIFICATION
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and the information has been independently verified.
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