What types of technology does hit include?

Health information technology

“Electronic communication will never be a substitute for the face of someone who with their soul encourages another person to be brave and true.”

Charles Dickens

Health informatics has expanded from the medical provider-centered use of EHR to public-wide availability of health information. The widespread consumer use of IT and the Internet has prompted a careful look at how health information can be used and distributed to improve access to health and health outcomes for individuals and populations. Some of the more common ways this is done are by informational websites, patient portals, SMS text messaging, social media, and telemedicine.

Multiple health care entities, both public and private, use websites targeted at disease prevention and health promotion. An Internet search on any disease topic can yield vast amounts of information on the topic and deliver that information in a variety of formats: written, images, audio, and video. Furthermore, a variety of informational websites are specifically designed to effectively communicate with targeted populations to help overcome certain barriers of poor health literacy. Medical offices and providers have taken communication with their patients one step further to include patient education pamphlets/handouts in the patient’s primary language and educational level. This is accomplished through various health information venues.

Websites are also used to create patient portals. The use of portals is an innovative way to enable patients to not only take responsibility for their health by being alerted to health maintenance and preventive services but also engage in shared decision making through interactions with health care providers. This occurs through the ability to retrieve health information via the portal at any given time and at any place in the world with Internet capability. This includes reviewing upcoming health appointments, seeing recent results of labs and other medical diagnostics, and having the ability to request medication refills. A recent narrative literature review on the use of mobile phone and text reminders in health care services revealed some prominent statistics in regards to patient adherence. Approximately threequarters of the studies reported improved outcomes in the following areas:

Adherence to medication or treatment improved by 40%

Appointment attendance increased by 18% and nonattendance decreased by 18%

Decreased amounts of missed medication doses

Improved attitudes toward medication27

Online social network platforms such as blogs, forums, Facebook, and Twitter are other ways for patients and communities to build relationships and share health information. Individuals can tell their stories, relate their progress, and relay resources that others may use to overcome health issues.

22.1 Introduction

Health information technology (HIT) has great potential to increase care quality, efficiency, and safety through its wide adoption and meaningful use. An example of the importance of this goal is that it is the major rationale behind the United States (US) national HIT Initiative, started by President Bush in 2004 and strengthened by President Obama in 2009 with the $19 billion HITECH Act under the American Recovery and Reinvestment Act (ARRA) (see Chapter 1), to have every American’s medical records on computers by 2014. However, there are huge gaps between the status quo and the potential of HIT, mostly due to cognitive, financial, security/privacy, technological, social/cultural, and workforce challenges. Among these, the 2009 National Research Council (NRC) report on “Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions” (Stead and Lin, 2009) identified “cognitive support” as an overarching research grand challenge for HIT.

Cognitive support for HIT is intended to assist clinical problem solving and decision making such that the care for patients can be maximized along the Institute of Medicine’s six dimensions of quality (safe, effective, timely, efficient, equitable, and responsive) (Institute of Medicine, 2001). Thus this chapter is devoted to exploring the methodologies of cognitive science as they are applied to more fully understanding the stresses of the clinical environment to aid in developing clinical decision support (CDS) to meet these needs. Much of the stresses come from the nature of health care itself, the burdens of the information and knowledge explosion, the multiplicity of diagnostic and therapeutic choices available, the time pressures, and the fragmentation of care, which led to the demand for CDS in the first place. The need to better understand cognitive considerations is especially true for more complex care, when the patients themselves are more complicated, multiple participants are involved in the health care team, and often the environments themselves are stressful – such as in the emergency department, operating room, or critical care unit.

The National Center for Cognitive Informatics and Decision Making in Healthcare (http://www.sharpc.org), funded by the Strategic Health Advanced Research Projects (SHARP) grant program under the Office of the National Coordinator for Health IT (ONC), characterizes the cognitive challenges for HIT as the gaps between HIT systems with good and poor cognitive support at three Levels (Figure 22.1). (a) At the work domain level, HIT systems with good cognitive support should have an explicit, unified, accurate, and comprehensive model that reflects the true ontology of the work domain, which provides a clear understanding of the care that is independent of how systems are implemented. What this means for HIT is that the systems should be developed with a work domain ontology for health care that reflects all the goals, needs and challenges of clinical care. Such a model should hold across sites regardless of the implementation (e.g. which electronic health record system is in place, or if providers are physicians or nurse practitioners.) HIT systems with poor cognitive support typically suffer from having models of the work domain that are implicit, multiple, unconnected, disparate, incomplete, and often inaccurate. (b) At the representation and implementation level, HIT systems with good cognitive support are characterized as having clear, comprehensive, easy to navigate information and knowledge models optimized for human users. That is, the systems should be useful, usable, and satisfying for the end users. HIT systems with poor cognitive support usually have representations that are based on hardware and software features, which make them confusing, siloed, task-specific, difficult to use and learn, and hard to navigate, because they do not match human needs and expectations. (c) At the level of task performance, HIT systems with good cognitive support are characterized by having “built-in” safe, timely, effective, efficient, equitable, patient-centered task performance (Institute of Medicine, 2001). HIT systems with poor cognitive support often have disconnected, redundant, tedious, and unclear user models based on business and legal requirements that interfere with task performance. These gaps between good and poor systems highlight some of the issues the ONC named in their call for proposals for the SHARP programs. Strong cognitive support within a well-designed HIT system is built on appropriate models of how clinician make decisions, provides information display and visualization to increase situation awareness, facilitates decision making under stress and time pressure, improves communication among clinicians, patients, and teams, and operates within highly usable systems.

Health Information Technology

Electronic prescribing (e-prescribing) and the use of EHRs are often discussed as being core elements of health information technology (HIT). HIT, as defined by as the Health and Human Services Office of the National Coordinator for Health Information Technology, is “the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making.”44 Although potential benefits of HIT include improvements in health care quality due to medication or medical errors and increasing the efficiency of care due to reducing unnecessary tests and increasing the exchange of information among providers, the full impact of HIT has yet to be realized.45

E-prescribing can help avoid medication errors that stem from difficulties in deciphering handwritten prescriptions, reduce rates of adverse drug events by alerting prescribers of the potential for drug interactions or contraindications at the time of prescription preparation, and improve patient adherence to therapy.44,46 To encourage physicians to adopt the use of e-prescribing, CMS established standards in 2009 for Medicare Part D requiring e-prescribing system compliance with regard to factors such as medication history, fill status notification, and formulary and benefits information.46

Later the same year, to drive the adoption of e-prescribing further, a 5-year program authorized by the Medicare Improvement for Patients and Provider Act of 2008 (MIPPA) introduced incentives for eligible professionals who were successfully using e-prescribing systems. Another incentive program, authorized by Division B of the Tax Relief and Health Care Act of 2006–Medicare Improvements and Extension Act of 2006 (MIEA-TRHCA), known as the PQRI (now PQRS), provided an e-prescribing incentive based on the covered professional services furnished by the eligible professional during the reporting years 2009 through 2013. The MIPPA also required that quality measures used to qualify for the PQRI incentive payment could not include e-prescribing measures.

E-prescribing incentives started at 2.0% during reporting years 2009 to 2010 and decreased to 1.0% and 0.5% for reporting years 2011 to 2012 and reporting year 2013, respectively. Physicians who were eligible for incentives but failed to participate faced penalties of 1.0% and 1.5% in 2012 and 2013, respectively. In 2014, incentive payments were discontinued, and penalties increased to 2.0%.46

Full implementation and use of EHRs have resulted in several important improvements, including the quality and convenience of patient care, patient participation in care, accuracy of diagnoses and health outcomes, care coordination, and practice efficiencies and cost savings.47 In an effort to encourage the use of EHRs, the American Recovery and Reinvestment Act (ARRA) and Health Information Technology for Economic and Clinical Health Act (HITECH), passed in 2009, included a requirement for the adoption of EHR use by 2014 for 70% of the primary care provider population.48 The act also included approval for a CMS EHR Incentive Program, authorizing payments starting in 2011 and continuing through 2014 for physician and hospital providers that successfully become “meaningful users” of EHRs.48 In 2015, providers not actively using an EHR in compliance with the meaningful use definition will be subject to financial penalties under Medicare. Meaningful use under the CMS EHR Incentive Program is determined when eligible professionals, hospitals, and critical access hospitals (CAHs) meet established measurement thresholds.49

Health Information Technologies That Enable and Optimize Patient Engagement

Health information technology (HIT) and consumer e-health tools have become central to promoting patient engagement and empowerment through better communication with providers (Rozenblum et al., 2015b; Grando et al., 2015). Examples of promising patient-facing technology include personal health records, patient portals, mobile health technologies, personal monitoring systems, secure e-mail messaging, Internet-based health information, education and consultation, and social media networking websites. Some tools give patients the opportunity to be more responsible for their care by providing them with the ability to access health information, choose healthcare providers, and manage their health care. Other tools allow patients to communicate directly with their care team, coordinate care across caregivers, and interact with other patients with similar health conditions, creating a broader and more connected healthcare network (see Table 18.1 for examples).

Table 18.1. Patient Engagement Approaches

These tools have the potential to transform care into an active collaboration between providers and patients, with the goal of improving standards of care. Enhancing patient engagement has been shown to directly impact patient behavior that promotes positive health outcomes, patient satisfaction, care delivery efficiency, improved quality of care and patient safety as well as reduce costs (Rozenblum et al., 2015b; Wagner et al., 2012; Zhou et al., 2010; Giardina et al., 2014; Tang et al., 2006; Delbanco et al., 2012). Consistent with this notion, policy trends in the United States and elsewhere are promoting the use of HIT as a vital component to improving patient engagement and outcomes (Bitton et al., 2015). For example, the Office of the National Coordinator for Health Information Technology (ONC) in the United States has identified the adoption and meaningful use of HIT by healthcare providers and patients as a key factor in improving the nation’s health system, with incentive programs designed to promote consumer access to health data (Ricciardi et al., 2013). A similar role, as Chief Clinical Information Officer for the National Health Service (NHS) has been created to drive HIT adoption in England.

Motivated by policy initiatives to accelerate adoption and meaningful use of HIT, healthcare organizations have begun to implement, use, and promote e-health tools (Bitton et al., 2015; Wells et al., 2014). However, the limited adoption data available suggest that ongoing patient usage rates of HIT modalities remain low (Bates and Wells, 2012; Ahern et al., 2011). Some of the challenges related to patient adoption of HIT could be related to lack of patient awareness, limited health literacy, lower socioeconomic status, older age, inadequate computer skills, and unmet technical support needs. Each of these factors have been identified and demonstrated in research literature to negatively affect patients’ use of HIT (Ahern et al., 2011). Nevertheless, HIT tools that enable patient engagement are likely to continue to grow in importance as their potential is further understood and harnessed by policymakers, providers, and patients alike.

The following sections outline the major IT tools to improve patient engagement now being employed by early adopting providers. While this inventory of approaches and tools is not collectively exhaustive, it does represent the principal and most promising strategies to engage patients and their families in the delivery of healthcare services and the ongoing management of patient health.

Abstract

Purpose

Implementation and meaningful use of health information technology (HIT) has been shown to facilitate delivery system transformation, yet implementation is far from universal. This study examined correlates of greater HIT implementation over time among a national cohort of small primary care practices in the United States.

Methods

We used data from a 40-minute telephone panel survey of 566 small primary care practices having 8 or fewer physicians to investigate adoption and use of HIT in 2007-2010 and 2012-2013. We used generalized estimating equations (GEE) to estimate the association of practice characteristics and external incentives with the adoption and use of HIT. We studied 18 measures of HIT functionalities, including record keeping, clinical decision support, patient communication, and health information exchange with hospitals and pharmacies.

Results

Overall, use of 16 HIT functionalities increased significantly over time, whereas use of 2 decreased significantly. On average, compared with physician-owned practices, hospital-owned practices used 1.48 (95% CI, 1.07-1.88;P <.001) more HIT processes. And relative to smaller practices, practices with 3 to 8 physicians used 2.49 (95% CI, 2.26-2.72;P <.001) more HIT processes. Participation in pay-for-performance programs, participation in public reporting of clinical quality data, and a larger proportion of revenue from Medicare were also associated with greater adoption and use of HIT.

Conclusion

The new Medicare Access and CHIP Reauthorization Act (MACRA) will provide payment incentives and technical support to speed HIT adoption and use by small practices. We found that external incentives were, indeed, positively associated with greater adoption and use of HIT. Our findings also support a strategy of targeting assistance to smaller physician practices and those that are physician owned.

Conclusions

HIT will play a crucial role in the provision of coordinated care delivery. While HIT-mediated coordination is often a good thing it can also be a cause of unintended consequences due to conflicts in the care delivery needs across different levels of care. HIT support for one level of care delivery may cause workflow or data collection issues, at the other levels. To address these issues we need to understand HIT implementation across different levels of care delivery.

This chapter presented a multisided market framework for coordinated healthcare delivery. The framework contains three levels (micro, meso, and macro) of healthcare delivery, a coordination space that connects the three levels, and HIT as the platform for supporting coordination. The key contribution from our framework is defining the coordination space across the three levels. The coordination space helps us understand how each of the three levels both enables and constrains the other levels. Enablement occurs because the three levels depend on each other for the healthcare system to work effectively. Individual care processes at the micro level are the basis for team-based collaborative processes at the meso level, as well as for measuring and monitoring care delivery at the macro level. Subsequently the macro level is where much of the policy and funding originates that enables the micro and meso levels to function by empowering patients and providers. In a well-functioning healthcare system the three levels work in harmony by enabling the other levels.

However, such harmony is often not the norm because each of the three levels has different priorities or needs, and therefore they constrain the other levels. Working in collaborative care delivery at the meso level will often put additional workload on individual providers at the micro level, while macro-level policy intended to innovate or standardize healthcare delivery will cause changes for both micro- and meso-level processes. While the HIT that implements these needs (e.g., additional data collection fields, collaborative care plans) is often blamed for workload or process changes, it is in fact a system level issue due to the multimarket manner in which healthcare is delivered. When the various players in the market have different needs there will inevitably be some degree of conflict. In order to reduce the degree of conflict across the three levels we need to define how the coordination space works across the different levels and also to identify the type and extent of trade-offs that need to be made in order for system level coordination to work. These trade-offs then need to inform the design and evaluation of HIT to support coordinated care delivery.

Health Information Technology for Economic and Clinical Health Act

The HITECH Act was enacted under Title XIII of the American Recovery and Reinvestment Act of 2009.20 With a goal of improving health system performance, the HITECH Act program focuses on attaining meaningful use of EHRs and in the process defined the meaningful use of EHRs, thus defining specific criteria for an EHR.

In conjunction with the HITECH Act, the United States Department of Health and Human Services released 45 CFR Part 170 on June 18, 2010 to establish a certification program for Health Information Technology.21 As part of 45 CFR Part 170, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC) established standards and meaningful use criteria for EHRs to be a part of the EHR incentive program. These rules identify the criteria for a certified EHR and the meaningful use of EHRs. Table 40.7 reviews the meaningful use stages, with the third stage focused on improved outcomes, which includes use for population health and clinical research.

Table 40.7. Review of Meaningful Use Stages Provided by Office of the National Coordinator for Health Information Technology22

Table 40.8 reviews an example of meaningful use criteria showing movement to focus on the use of EHRs, the desire to have a complete picture of each patient's care, provide the data to the patients, and share data across organizations.23 These criteria enable a more complete EHR and provide the ability to collect data across EHRs, which in turn enables the ability to use data from the EHR for clinical research.

Table 40.8. Review of Selected Meaningful Use Metrics Stage 223

HIPAA Enforcement

Before the HITECH Act, HIPAA had a reputation for being a “paper tiger” due to its lack of enforcement and relatively low fines and penalties when enforced. The HITECH Act greatly increased the penalties for HIPAA violations (from $100 to $50,000 up to a $1.5 Million cap), which can include jail time [39]. Additionally the HITECH Act empowered State Attorneys General to bring HIPAA enforcement actions [40]. Further, HITECH calls for the sharing of HIPAA violation penalties with individuals harmed by violations (although regulations implementing this provision have not yet been issued) [41]. Lastly, the HITECH Act requires that HHS conduct HIPAA audits of covered entitles and business associates [42]. The combination of these enforcement enhancements under the HITECH Act gives HIPAA the enforcement strength that has been lacking and has made HIPAA compliance a much higher priority at covered entities and business associates.

The HITECH Act

The Health Information Technology Act (HITECH Act) is part of the American Recovery and Reinvestment Act of 2009 (ARRA). The HITECH Act increased the scope of privacy and security protections under the Health Insurance Portability and Accountability Act (HIPAA) and the potential legal liability for noncompliance and enforcement. It provided financial incentives for the adoption of electronic health records. It also imposed breach notification requirements for unauthorized uses and disclosures of unsecured, generally unencrypted, PHI. It requires patient notification and notification of the DHHS if a breach impacts 500 or more patients. It extends certain HIPAA provisions and penalties to the business associates of health care providers.

Utility for Patients

HIT, such as the internet and social media, have become an important source of health information. The utility of social media has been documented in multiple medical disciplines, such as endocrinology [36], dermatology [37], oncology [38], and psychiatry [39]. In the particular case of respiratory disorders, positive outcome has been obtained using HIT for improvement of education on cystic fibrosis [40], asthma [41] and COPD [42].

A systematic review reported that most pregnant women use the internet as a source of information [43]. In 2010, a survey conducted in the United States, found that 15% of social media users (46% of American adults), had obtained health information in social websites [16]. In the EU, in 2014, the European Commission reported that 59% of citizens had used the internet to search for health-related information [44]. A recent study showed that 64% of parents of children with food allergy turned to social media, while only 25% of them did for disease-related purposes [45].

However, there are few studies evaluating the impact of this information in patients. There are indications that it might have a beneficial effect in asthma treatment [46]. Yet, a paradoxical effect seems also possible [47,48], facilitating access to incorrect and potentially harmful information [49]. This effect is known as infoxication, or information overload [50]. At this moment, there are no standardized methods to measure the quality of the information available on the internet [51]. The reliability of videos posted on YouTube has been found to be low for asthma and rhinitis [52,53].

In addition, as previously stated, wearable technologies have demonstrated that they can be useful for promoting healthy habits, by means of gamification, especially in conjunction with social networks [22].