Proposal Review

Chapter 3 Health Care Information Systems

After reading Chapters One and Two, you should have a general understanding of the national health IT landscape and the types and uses of clinical and administrative data captured in provider organizations. In this chapter we build on these fundamental concepts and introduce health care information systems, a broad category that includes clinical and administrative applications. We begin by providing a brief history and overview of information systems used in health care provider organizations. The chapter focuses on the electronic health record (EHR) and personal health record (PHR), including patient portals and the major initiatives that have led to the adoption and use of EHRs in hospitals and physician practices. Included is a discussion on the state of EHR adoption and use in other health care settings, including behavioral health, community health, and long-term care. Applications such as computerized provider order entry and decision support are described in the context of the EHR. (Note: Other health IT systems and applications needed to support population health and value-based payment—such as patient engagement tools, telemedicine, and telehealth—are described in Chapter Four.) Finally, the chapter concludes with a discussion on important key issues in the use of HCIS including usability, interoperability, and health IT safety.

We begin first with a brief review of key terms.

Review of Key Terms An information system (IS) is an arrangement of data (information), processes, people, and information technology that interact to collect, process, store, and provide as output the information needed to support the organization (Whitten & Bentley, 2007). Note that information technology is a component of every information system. Information technology (IT) is a contemporary term that describes the combination of computer technology (hardware and software) with data and telecommunications technology (data, image, and voice networks). Often in current management literature the terms information system (IS) and information technology (IT) are used interchangeably.

Within the health care sector, health care IS and IT include a broad range of applications and products and are used by a wide range of constituent groups such as payers, government, life sciences, and patients, as well as providers and provider organizations. For our purpose, however, we have chosen to focus on health care information systems from the provider organization's perspective. The provider organization is the hospital, health system, physician practice, integrated delivery system, nursing home, or rural health clinic. That is, it is any setting where health-related services are delivered. The organization (namely, the capacity, decisions about how health IT is applied, and incentives) and the external environment (regulations and public opinion) are important elements in how systems are used by clinicians and other users (IOM, 2011). We also examine the use of patient engagement tools such as PHRs and secure patient portals. Yet our focus is from an organization or provider perspective.

Major Health Care Information Systems

There are two primary categories of health care information systems: administrative and clinical. A simple way to distinguish them is by purpose and the type of data they contain. An administrative information system (or an administrative application) contains primarily administrative or financial data and is generally used to support the management functions and general operations of the health care organization. For example, an administrative information system might contain information used to manage personnel, finances, materials, supplies, or equipment. It might be a system for human resource management, materials management, patient accounting or billing, or staff scheduling. Revenue cycle management is increasingly important to health care organizations and generally includes the following: Charge capture Coding and documentation review Managed care contracting Denial management of claims Payment posting Accounts receivable follow-up Patient collections Reporting and benchmarking By contrast, a clinical information system (or clinical application) contains clinical or health-related information used by providers in diagnosing and treating a patient and monitoring that patient's care. Clinical information systems may be departmental systems—such as radiology, pharmacy, or laboratory systems—or clinical decision support, medication administration, computerized provider order entry, or EHR systems, to name a few. They may be limited in their scope to a single area of clinical information (for example, radiology, pharmacy, or laboratory), or they may be comprehensive and cover virtually all aspects of patient care (as an EHR system does, for example). Table 3.1 lists common types of clinical and administrative health care information systems.

Table 3.1. Common types of administrative and clinical information systems Table 3.1. Common types of administrative and clinical information systems

Administrative Applications Clinical Applications Patient administration systems Admission, discharge, transfer (ADT) tracks the patient's movement of care in an inpatient setting Ancillary information systems Laboratory information supports collection, verification, and reporting of laboratory tests Registration may be coupled with ADT system; includes patient demographic and insurance information as well as date of visit(s), provider information Scheduling aids in the scheduling of patient visits; includes information on patients, providers, date and time of visit, rooms, equipment, other resources Patient billing or accounts receivable includes all information needed to submit claims and monitor submission and reimbursement status Utilization management tracks use and appropriateness of care Other administrative and financial systems

Accounts payable monitors money owed to other organizations for purchased products and services General ledger monitors general financial management and reporting Radiology information supports digital image generation (picture archiving and communication systems [PACS]), image analysis, image management Pharmacy information supports medication ordering, dispensing, and inventory control; drug compatibility checks; allergy screening; medication administration Other clinical information systems Nursing documentation facilitates nursing documentation from assessment to evaluation, patient care decision support (care planning, assessment, flow-sheet charting, patient acuity, patient education) Electronic health record (EHR) facilitates electronic capture and reporting of patient's health history, problem lists, treatment and outcomes; allows clinicians to document clinical findings, progress notes, and other patient information; provides decision-support tools and reminders and alerts Personnel management manages human resource information for staff, including salaries, benefits, education, and training Materials management monitors ordering and inventory of supplies, equipment needs, and maintenance Payroll manages information about staff salaries, payroll deductions, tax withholding, and pay status Staff scheduling assists in scheduling and monitoring staffing needs Staff time and attendance tracks employee work schedules and attendance Revenue cycle management monitors the entire flow of revenue generation from charge capture to patient collection; generally relies on integration of a host of administrative and financial applications Computerized provider order entry (CPOE) enables clinicians to directly enter orders electronically and access decision-support tools and clinical care guidelines and protocols Telemedicine and telehealth supports remote delivery of care; common features include image capture and transmission, voice and video conferencing, text messaging Rehabilitation service documentation supports the capturing and reporting of occupational therapy, physical therapy, and speech pathology services Medication administration is typically used by nurses to document medication given, dose, and time Health care organizations, particularly those that have implemented EHR systems, generally provide patients with access to their information electronically through a patient portal. A patient portal is a secure website through which patients may communicate with their provider, request refill on prescriptions, schedule appointments, review test results, or pay bills (Emont, 2011). Another term that is frequently used is personal health record (PHR). Different from an EHR or patient portal, which is managed by the provider or health care organization, the PHR is managed by the consumer. It may include health information and wellness information, such as an individual's exercise and diet. The consumer decides who has access to the information and controls the content of the record. The adoption and use of patient portals and PHRs are

discussed further on in this chapter. For now, we begin with a brief historical overview of how these various clinical and administrative systems evolved in health care. History and Evolution Since the 1960s, the development and use of health care information systems has changed dramatically with advances in technology and the impact of environmental influences and payment reform (see Figure 3.1). In the 1960s to 1970s, health care executives invested primarily in administrative and financial information systems that could automate the patient billing process and facilitate accurate Medicare cost reporting. The administrative applications that were used were generally found in large hospitals, such as those affiliated with academic medical centers. These larger health care organizations were often the only ones with the resources and staff available to develop, implement, and support such systems. It was common for these facilities to develop their own administrative and financial applications in-house in what were then known as “data processing” departments. The systems themselves ran on large mainframe computers, which had to be housed in large, environmentally controlled settings. Recognizing that small, community-based hospitals could not bear the cost of an in-house, mainframe system, leading vendors began to offer shared systems, so called because they enabled hospitals to share the use of a mainframe with other hospitals. Vendors typically charged participating hospitals for computer time and storage, for the number of terminal connects, and for reports. Figure 3.1 History and evolution of health care information systems (1960s to today)

By the 1970s, departmental systems such as clinical laboratory or pharmacy systems began to be developed, coinciding with the advent of minicomputers. Minicomputers were smaller and more powerful than some of the mainframe computers and available at a cost that could be justified by revenue-generating departments. Clinical applications including departmental systems such as laboratory, pharmacy, and radiology systems became more commonplace. Most systems were stand-alone and did not interface well with other clinical and administrative systems in the organization.

The 1980s brought a significant turning point in the use of health care information systems primarily because of the development of the microcomputer, also known as the personal computer (PC). Sweeping changes in reimbursement practices designed to rein in high costs of health care also had a significant impact. In 1982, Medicare shifted from a cost-based reimbursement system to a prospective payment system based on diagnosis related groups (DRGs). This new payment system had a profound effect on hospital billing practices. Reimbursement amounts were now dependent on the accuracy of the patient's diagnosis and procedures(s) and other information contained in the patient's record. With hospital reimbursement changes occurring, the advent of the microcomputer could not have been more timely. The microcomputer was smaller, often as or more powerful, and far more affordable than a mainframe computer. Additionally, the microcomputer was not confined to large hospitals. It brought computing capabilities to a host of smaller organizations including small community hospitals, physician practices, and other care delivery settings. Sharing information among microcomputers also became possible with the development of local area networks. The notion of best of breed systems was also common; individual clinical departments would select the

best application or system for meeting their unique unit's needs and attempt to get the “systems to talk to each other” using interface engines.

Rapid technological advances continued into the 1990s, with the most profound being the evolution and widespread use of the Internet and electronic mail (e-mail). The Internet provided health care consumers, patients, providers, and industries with access to the World Wide Web and new and innovative opportunities to access care, promote services, and share information. Concurrently, the Institute of Medicine (IOM, 1991) published its first landmark report The Computer-Based Patient Record: An Essential Technology for Health Care, which called for the widespread adoption of computerized patient records (CPRs) as the standard by the year 2001. CPRs were the precursor to what we refer to today as EHR systems. Numerous studies had revealed the problems with paper-based medical records (Burnum, 1989; Hershey, McAloon, & Bertram, 1989; IOM, 1991). Records are often illegible, incomplete, or unavailable when and where they are needed. They lack any type of active decision-support capability and make data collection and analysis very cumbersome. This passive role for the medical record was no longer sufficient. Health care providers needed access to active tools that afforded them clinical decision-support capabilities and access to the latest relevant research findings, reminders, alerts, and other knowledge aids. Along with patients, they needed access to systems that would support the integration of care across the continuum. By the start of the new millennium, health care quality and patient safety emerged as top priorities. In 2000, the IOM published the report To Err Is Human: Building a Safer Health Care System, which brought national attention to research estimating that 44,000 to 98,000 patients die each year to medical errors. Since then, additional reports have indicated that these figures are grossly underestimated and the incidents of medical errors are much higher (Classen et al., 2011; James, 2013; Makary & Daniel, 2016;). A subsequent report, Patient Safety: Achieving a New Standard of Care (2004), called for health care providers to adopt information technology to help prevent and reduce errors because of illegible prescriptions, drug-to-drug interactions, and lost medical records, for example.

By 2009, the US government launched an “unprecedented effort to reengineer” the way we capture, store, and use health information (Blumenthal, 2011, p. 2323). This effort was realized in the Health Information Technology for Economic and Clinical Health (HITECH) Act. Nearly $30 billion was set aside over a ten-year period to support the adoption and Meaningful Use of EHRs and other types of health information technology with the goal of improving health and health care. Rarely, if ever, have we seen public investments in the advancement of health information technology of this magnitude (Blumenthal, 2011). Interest also grew in engaging patients more fully in providing access to their EHR through patient portals or the concept of a PHR. We have also seen significant advances in telemedicine and telehealth, cloud computing, and mobile applications that monitor and track a wide range of health data. Electronic Health Records Features and Functions Let's first examine the features and functions of an EHR because it is core to patient care. An EHR can electronically collect and store patient data, supply that information to providers on request, permit clinicians to enter orders directly into a computerized provider order entry

(CPOE) system, and advise health care practitioners by providing decision-support tools such as reminders, alerts, and access to the latest research findings or appropriate evidence-based guidelines. CPOE at its most basic level is a computer application that accepts provider orders electronically, replacing handwritten or verbal orders and prescriptions. Most CPOE systems provide physicians and other providers with decision-support capabilities at the point of ordering. For example, an order for a laboratory test might trigger an alert to the provider that the test has already been ordered and the results are pending. An order for a drug to which the patient is allergic might trigger an alert warning to the provider of an alternative drug. These decision-support capabilities make the EHR far more robust than a digital version of the paper medical record.

Figure 3.2 illustrates an EHR alert reminding the clinician that the patient is allergic to certain medication or that two medications should not be taken in combination with each other. Reminders might also show that the patient is due for a health maintenance test such as a mammography or a cholesterol test or for an influenza vaccine (Figure 3.2).

Figure 3.2 Sample drug alert screen

Source: Epic. Used with permission.

Up until the passage of the HITECH Act of 2009, EHR adoption and use was fairly low. HITECH made available incentive money through the Medicare and Medicaid EHR Incentive Programs for eligible professionals and hospitals to adopt and become “meaningful users” of EHR. As mentioned in Chapter One, the Meaningful Use criteria were established and rolled out in three phases. Each phase built on the previous phase in an effort to further the advancement and use of EHR technology as a strategy to improve the nation's health outcome policy priorities:

Improve health care quality, safety, and efficiency and reduce health disparities. Engage patients and families in their health care. Improve care coordination. Improve population and public health. Ensure adequate privacy and security of personal health information. To accomplish these goals and facilitate patient engagement in managing their health and care, health care organizations provide patients with access to their records typically through a patient portal. A patient portal is a secure website through which patients can electronically access their medical records. Portals often also enable users to complete forms online, schedule appointments, communicate with providers, request refills on prescriptions, review test results, or pay bills (Emont, 2011) (see Figure 3.3). Some providers offer patients the opportunity to schedule e-visits for a limited number of nonurgent medical conditions such as allergic skin reactions, colds, and nosebleeds.

Figure 3.3 Sample patient portal

Source: Epic.

EHR Adoption Rates in US Hospitals As of 2015, nearly 84 percent of US nonfederal acute care hospitals had adopted basic EHR systems representing a nine-fold increase from 2008 (Henry, Pylypchuck, Searcy, & Patel, 2016) (see Figure 3.4). Table 3.2 lists the difference functionality between a basic system and a fully functional system (DesRoches et al., 2008). A key distinguishing characteristic is fully functional EHRs provide order entry capabilities (beyond ordering medications) and decision-support capabilities.

The Veterans Administration (VA) has used an EHR system for years, enabling any veteran treated at any VA hospital to have electronic access to his or her EHR. Likewise, the US Department of Defense is under contract with Cerner to replace its EHR system. EHR adoption among specialty hospitals such as children's (55 percent) and psychiatric hospitals (15 percent) is significantly lower than general medicine hospitals because these types of hospitals were not eligible for HITECH incentive payments. Small, rural, and critical access hospitals that have historically lagged behind in EHR adoption are now closing the gap with general acute care hospitals (Henry et al., 2016). Figure 3.4 Percent of non-federal acute care hospitals with adoption of at least a basic EHR with notes system and position of a certified EHR: 2008–2015

Note: Basic EHR adoption requires the EHR system to have a set of EHR functions defined in Table 3.2. A certified EHR is EHR technology that meets the technological capability, functionality, and security requirements adopted by the Department of Health and Human Services. Possession means that the hospital has a legal agreement with the EHR vendor but is not equivalent to adoption. *Significantly different from previous year (p<0.05).

Source: ONC (2015a).

EHR Adoption in Office-Based Physician Practices In addition to EHR use in hospitals, we have also seen significant increases in the adoption and use of EHR systems among office-based physician practices. By 2014, 79 percent of primary care physicians had adopted a certified EHR system and 70 percent of medical and surgical specialties had as well (Heisey-Grove & Patel, 2015) (see Figure 3.5).

Ninety-eight percent of physicians in community health centers had adopted an EHR, three-quarters of them using a certified EHR. Not surprisingly, physicians in solo and small group practices were less likely to have adopted EHR systems (Heisey-Grove & Patel, 2015).

EHR Adoption in Other Settings Less is known nationally about EHR adoption rates in settings other than hospitals and physician practices. Among home health and hospice agencies, the latest national estimates based on data from the 2007 National Home and Hospice Care survey indicate that 44 percent of home health and hospice agencies have adopted EHR systems (16 percent EHRs only and

28 percent EHRs and mobile technologies such as tablets or hand-held devices used to gather information at the point of care) (Bercovitz, Park-Lee, & Jamoom, 2013).

Table 3.2 Functions defining the use of EHRs

Basic System Fully Functional System Health Information Data Patient demographics X X Patient problem lists X X Electronic lists of medications taken by patients X X Clinical notes X X Notes including medical history and follow-up X Order Entry Management Orders for prescriptions X X Orders for laboratory tests X Orders for radiology tests X Prescriptions sent electronically X Orders sent electronically X Results Management Viewing laboratory results X X Viewing imaging results X X Electronic images returned X Clinical Decision Support Warnings of drug interactions or contraindications provided X Out-of-range test levels highlighted X Reminders regarding guidelines-based interventions or screening X

Figure 3.5. Office-based physician practice EHR adoption since 2004

Source: ONC (2015a).

Some states, such as New York, have attempted to assess EHR adoption in long-term care facilities such as nursing homes. One study found that among 473 nursing homes in New York, 56.3 percent had implemented an EHR system (Abramson, Edwards, Silver, & Kaushal, 2014). Among the nursing homes that did not have EHRs, the majority had plans to implement one within two years. One-fifth had plans to implement one in more than two years, and 11.7 percent had no EHR implementation plans (Abramson et al., 2014). The majority of nursing homes indicated the biggest barriers to health IT investment were the initial cost, a lack of IT staff members, and the lack of fiscal incentives. National estimates on EHR adoption in long-term care are nearly nonexistent. Most are qualitative studies examining the experiences of early adopters (Cherry, Ford, & Peterson, 2011).

Impact of EHR Systems

Numerous studies over the years have demonstrated the value of using EHR systems and other types of clinical applications within health care organizations. The majority of benefits fall into three broad categories: (1) quality, outcomes, and safety; (2) efficiency, improved revenues, and cost reduction; and (3) provider and patient satisfaction. Following is a brief discussion of these major categories, along with several recent examples and reports illustrating the value of EHRs to the health care process. It is important to note, however, that despite the benefits, some studies have found mixed results or negative consequences. Quality, outcomes, and safety. EHR systems can have a significant impact on patient quality, outcomes, and safety. Three major effects on quality are increased adherence to evidence-based care, enhanced surveillance and monitoring, and decreased medication errors. Banger and Graber (2015) recently conducted a review of the literature on the impact of health IT (including EHR systems) on patient quality and safety and found four major systematic reviews had been conducted from 2006 through 2014 each using a consistent methodology (Buntin, Burke, Hoaglin, & Blumenthal, 2011; Chaudhry et al., 2006; Goldzweig, Towfigh, Maglione, & Shekelle, 2009; Jones, Rudin, Perry, & Shekelle, 2014). Two of the reviews were published before the HITECH Act and two afterward. Collectively, 59 percent of the studies examined demonstrated positive effects on quality and safety, 25 percent had mixed-positive outcomes, 9 percent were neutral, and 8 percent were negative (Banger & Graber, 2015). Limitations of most of the earlier studies were based on the fact that they did not include many commercially available EHR systems. Since then, more than half of EHR evaluation studies involved commercially available EHR systems (Jones et al., 2014). Findings from the most recent systematic review conclude that CPOE effectively decreases medication errors. Hydari, Telang, and Marella (2014) studied the incidence of adverse patient safety events reported from 231 Pennsylvania hospitals from 2005 to 2012 in relation to their level of health IT use. After controlling for several possibly confounding factors, the authors found that hospitals adopting advanced EHRs (as defined by HIMSS) experienced a 27 percent overall reduction in reported patient safety events. Using advanced EHRs was associated with a 30 percent decline in medication errors and a 25 percent decline in procedure-related errors (Hydari et al., 2014). Efficiency, improved revenue, and cost reduction. In addition to improving quality and safety, some studies have shown that the EHR can improve efficiency, increase revenues, and lead to cost reductions (Barlow, Johnson, & Steck, 2004; Grieger, Cohen, & Krusch, 2007). A fairly recent study by Howley, Chou, Hansen, and Dalrymple (2014) examined the financial impact of EHRs on ambulatory practices by tracking the productivity (e.g., the number of patient visits) and reimbursement of thirty practices for two years after EHR implementation. They found that practice revenues increased during EHR implementation despite seeing fewer patients. Another study looked at seventeen primary care clinics that used EHR systems and found that the clinics recovered their EHR investments within an average period of ten months (95 percent CI 6.2–17.4 months), seeing more patients with an average increase of 27 percent in the active-patients-to-clinicians full-time equivalent ratio, and an increase in the clinic net revenue (p<.001) (Jang, Lortie, & Sanche, 2014). Provider and patient satisfaction. Provider and patient satisfaction are common factors to assess when implementing EHR systems. Results from satisfaction surveys are often mixed. In a 2008 national survey of physicians, 90 percent of providers using EHRs reported they were satisfied or very satisfied with them and a large majority could point to specific quality benefits

(DesRoches et al., 2008). Those who had systems in place for two or more years were more likely to be satisfied (Menachemi, Powers, Au, & Brooks, 2010). A study that examined EHR satisfaction among obstetrics/gynecology (OB/GYN) physicians found that 63 percent reported being satisfied with their EHR system, and nearly 31 percent were not satisfied (Raglan, Margolis, Paulus, & Schulkin, 2014). Among study participants, younger OB/GYN physicians were more satisfied with their EHR than older physicians. A study by Rand (in collaboration with the AMA) found that although many physicians approved of EHRs in concept (for example, they appreciated the fact that they could remotely access patient information and provide improved patient care), they expressed frustrations with usability and work flow (Friedberg et al., 2013). The time-consuming nature of data entry, interference with face-to-face patient care, inefficiency, and the inability to exchange health information between EHR products led to dissatisfaction. Physicians across the full range of specialties and practice models also described other concerns regarding the degradation of clinical documentation. Among US hospitals, a 2011 national study found that those with EHRs had significantly higher patient satisfaction scores on items such as “staff always giving patients information about what to do for the recovery at home,” “patients rating the hospital as a 9 or 10 overall,” and “patients would definitely recommend the hospital to others” than hospitals that did not (Kazley, Diana, Ford, & Menachemi, 2011, p. 26). Yet the same study found that the EHR use was not statistically associated with other patient satisfaction measures (such as having clean rooms) that one would not expect to be affected by EHR use. A more recent study by Jarvis and colleagues (2013) assessed the impact of using advanced EHRs (as defined as Stages 6 or 7 on the HIMSS Analytics EMR Adoption Model [EMRAM] level of health IT adoption) on hospital quality patient satisfaction using a composite score for measuring patient experience. (See the following Perspective.) They found that hospitals with the most advanced EHRs had the greatest gains in improving clinical process of care scores, without negatively affecting the patient experience (Jarvis et al., 2013). Another study found that physicians using EHRS that met Meaningful Use criteria and had two or more years EHR experience were more likely to report clinical benefits (King, Patel, Jamoon, & Furukawa, 2014). Limitations and Need for Further Research Not all studies have demonstrated positive outcomes from using EHR systems. For example, the same EHR or clinical information system can be implemented in different organizations and have different results. As example of variability, two children's hospitals implemented the same EHR (including CPOE) in their pediatric intensive care units. One hospital experienced a significant increase in mortality (Han et al., 2005), and the other did not (Del Beccaro, Jeffries, Eisenberg, & Harry, 2006). The hospital that experienced an increase in mortality noted that several implementation factors contributed to the deterioration in quality; specific order sets for critical care were not created, changes in workflow were not well executed, and orders for patients arriving via critical care transportation could not be written before the patient arrived at the hospital, delaying life-saving treatments. Many factors can influence the successful use and adoption of EHR systems. These are discussed more fully in Chapter Six.

Personal Health Records In addition to EHRs and patient portals, the broader concept of a personal health record has emerged in recent years. Initially, the PHR was envisioned as a tool to enable individuals to

keep their own health records, and they could share information electronically with their physicians or other health care professionals and receive advice, reminders, test results, and alerts from them. Unlike the EHR and patient portal, which is managed by health care provider organizations, the PHR is managed by the consumer. It may include health and wellness information, such as an individual's exercise and diet. The consumer decides who has access to the information and controls the content of the record. Personal data the consumer gathers through use of health apps such as My Fitness Pal or Fitbits may be included. What is the value of the PHR, and how does it relate to the EHR? Tang and Lansky (2005) believe the PHR enables individuals to serve as copilots in their own care. Patients can receive customized content based on their needs, values, and preferences. PHRs should be lifelong and comprehensive and should support information exchange and portability. Patients are often seen by multiple health care providers in different settings and locations over the course of a lifetime. In our fragmented health care system, this means patients are often left to consolidate information from the various participants in their care. A PHR that brings together important health information across an individual's lifetime and that is safe, secure, portable, and easily accessible can reduce costs by avoiding unnecessary duplicate tests and improving health care communications. The concept of patient portals and PHRs are also inherent in the CMS Meaningful Use program. Stage 3 Meaningful Use recommendations (originally scheduled for implementation in 2017 but now under policy reconsideration) state that patients should be able to (1) communicate electronically using secure messaging, (2) access patient education materials on the Internet, (3) generate health data into their providers' EHRs, and (4) view, download, and transmit their provider-managed EHRs. Taken together, Ford, Hesse, and Huerta (2016) argue that these requirements outline the basic functionalities of a consumer-managed PHR. Perspective HIMSS Analytics EHR Adoption Levels among US Hospitals Stage Cumulative Capabilities 2016—Q1 Stage 7 Complete EHR is used; data warehousing and data analytics is used to improve care; clinical information can be shared via standardized electronic transactions across continuum of care. 4.3% Stage 6 Physician documentation with structured templates and discrete data is implemented for at least one inpatient area. Full CCSS. The closed loop medication administration with bar coding is used. The five rights of medication administration are verified. 29.1% Stage 5 A full complement of radiology PACS system provides medical images to physicians via an intranet. 34.4% Stage 4 Computerized provider order entry (CPOE) used to create orders; CDSS is used with clinical protocols. 10.0% Stage 3 Nursing/clinical documentation has been implemented including electronic medication administration record (MAR); clinical decision support (CDS) capabilities allow for error checking with order entry. Medical image access from picture archive and communication systems (PACS) is available within organization. 15.3% Stage 2 Major clinical systems feed into clinical data repository (CDR) that enables viewing of orders and results. CDR contains a controlled medical vocabulary, and clinical

decision support system (CDSS) capabilities. Hospital may have health information exchange (HIE) capabilities and can share CDR information with patient care stakeholders. 2.5% Stage 1 All three major ancillary clinical systems (laboratory, pharmacy, radiology) are installed. 1.8% Stage 0 All three key ancillary department systems (laboratory, pharmacy, radiology) are not installed. 2.6% N=5,456 Source: Adapted from HIMSS Analytics EMR Adoption Model (EMRAM). © HIMSS Analytics 2016. Retrieved from http://www.himssanalytics.org/provider-solutions. Used with permission. Ford and his colleagues (2016) examined US consumers PHR use over time, the factors that influence use, and projected the diffusion of PHR under three scenarios. Not surprisingly, they found that consumers were increasingly using electronic means for storing health data and communicating with their clinical providers. An estimated 5 percent of consumers used PHRs in 2008, and by 2013, this number had reached 17 percent (Ford et al., 2016), still relatively low. Using various prediction models, they estimate that PHR use will increase significantly within the next decade.

PHRs and personal health applications have the potential to positively affect medication adherence and quality of life for patients with chronic diseases. For example, a recent controlled study examined the impact of a text-based message reminder system on medication adherence among adolescents with asthma (Johnson et al., 2016). Compared to adolescents in the control group, they found improvements in self-reported medication adherence (p = .011), quality of life (p = .037), and self-efficacy (p = .016). System use varied considerably, however, with lower use among African American adolescents (Johnson et al., 2016).

Consumers are also increasingly capturing health, wellness, and clinical data about themselves using a wide range of mobile technologies and applications—everything from wrist-worn devices that track steps and sleep patterns to web-based food diaries, networked weight scales, and blood pressure machines (Rosenbloom, 2016). They also use social media networks to connect with others who share a similar health condition. Such approaches are referred to as person-generated health data (PGHD) technologies given that consumers may use these technologies independent of situations in which they are patients per se. According to Rosenbloom (2016) the field of PGHD and related technologies is in its infancy, particularly in studying the real value these technologies add to health care delivery. Shaw and his colleagues (2016) found, for example, that individuals with chronic illnesses (who may have the most to benefit from using mobile health devices) may be less likely to adopt and use these devices compared to healthy individuals. As health care organizations and providers move to managing population health and cohorts of patients under value-based payment models, the use of such technologies with certain populations of patients may be incredibly useful. Chapter Four discusses further the health IT tools needed to support population health management. Key Issues and Challenges Despite the proliferation in the adoption and use of EHR systems, health care providers and organizations still face critical issues and challenges related to interoperability, usability, and health IT safety. Following is a brief discussion of each.

Interoperability In simple terms, interoperability is “the ability of a system to exchange electronic health information with and use electronic health information from other systems without special effort on the part of the [user]” (Institute for Electrical and Electronics Engineering [IEEE], n.d.). The ONC's report Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap (ONC, 2015a) describes the importance of interoperability in a creating a “learning health system” in which “health information flows seamlessly and is available to the right people, at the right place, at the right time.” The overarching vision of a learning health system is to put patients at the center of their care—“where providers can easily access and use secure health information from different sources; where an individual's health information is not limited to what is stored in EHRs, but includes information from other sources (including technologies that individuals use) and portrays a longitudinal picture of their health, not just episodes of care; where diagnostic tests are only repeated when necessary, because the information is readily available; and where public health agencies and researchers can rapidly learn, develop and deliver cutting edge treatments” (ONC, 2015a, p. vi) (see Figure 3.6).

Today, providers are challenged to knit together multiple EHRs, financial systems, and analytic solutions in an effort to effectively manage population health and facilitate care coordination. As health care providers and organizations coalesce to manage performance and utilization risk in their communities, they need high degrees of interoperability among these systems (Glaser, 2015). The systems must also fit well into the clinical workflow and patient care process while ensuring patient safety and quality. Additionally, interoperability will enable data generated by personal fitness and wearable devices to be included in the patient's EHR (Glaser, 2015).

Figure 3.6 The ONC's roadmap to interoperability

Source: ONC (2015a).

True interoperability has yet to be realized. Several factors make interoperability among health care information systems complicated. EHR systems are often developed using different platforms with inconsistent use of standards, no universal patient identifier exists, and pulling together from a wide range of sources is complicated (Glaser, 2015). Moreover, historically there has not been a great deal of incentive for providers to share information, nor for health IT vendors to bridge together a number of different systems, giving rise to the concept of information blocking. According to the ONC, information blocking occurs “when persons or entities knowingly and unreasonably interfere with exchange or use of electronic health information” (ONC, 2015b). The concept of information blocking implies that the entity intentionally and knowingly interferes with sharing the data and is objectively unreasonable in light of public policy. The ONC has developed comprehensive strategies for identifying, deterring, and remedying information blocking and coordinating with other federal agencies that can investigate and take action against certain types of information blocking.

The ONC Roadmap to Interoperability postulates that work is needed in three critical areas: (1) requiring standards, (2) motivating the use of those standards through appropriate incentives, and (3) creating a trusted environment for collecting, sharing, and using electronic health information. Broad stakeholder involvement is critical to achieving interoperability. Stakeholders include those who receive or support care, those who deliver care, those who pay for care, and people and organizations that support health IT capabilities, oversight of health care organizations, and those who develop and maintain standards (ONC, 2015b). (See the following Perspective.) In addition to the ONC, which resides in the Department of Health and Human Services, CMS and state governments also play key roles in advancing interoperability. Statewide health information exchanges can be found in Massachusetts, New York, and Delaware (Glaser, 2015). Interoperability efforts and standards development are discussed more fully in Chapter Ten. Partnerships are also occurring within the private sector to advance interoperability among systems by creating standards and promoting the sharing of data. CommonWell Health Alliance has created and implemented patient identification and record-locating service capabilities, Carequality is developing an interoperability and governance framework, and the Argonaut Project is testing the next generation of interoperability standards. Glaser (2015) argues that we must focus on several important goals in making interoperability in health care a reality by doing the following:

Advancing standards development and pursuing new technical approaches to effecting standards-based interoperability Strengthening sanctions, perhaps through the certification process, to minimize business practices that thwart interoperability Increasing transparency of vendor and provider progress in achieving interoperability Developing a trust framework that balances the need for efficient exchange with the privacy rights of patients Promoting collaborative multi-stakeholder efforts, such as CommonWell Health Alliance, Carequality, and eHealth Initiative Encouraging provider-led activities within communities to broaden the range of interconnections and include stakeholders such as safety net providers Creating a governance mechanism that ensures an effective interchange across a wide range of health information exchanges Making reimbursement changes that emphasize care coordination and population health management, all of which must continue to evolve and be implemented Unfortunately, there is no silver bullet or easy road to achieving true interoperability. However, with collaboration among stakeholders, appropriate incentives, and keeping the patient at the center of our work and efforts, secure and efficient interoperability is certainly within reach. Perspective The ONC Roadmap to Interoperability Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap (ONC, 2015b) was released by the Office of the National Coordinator for Health Information Technology in 2015. This document was published as a companion to the Connecting Health and Care for the Nation: A 10-Year Vision to Achieve an Interoperable Health IT Infrastructure.

The following facts are taken from the Roadmap and its companion infographic, Shared Nationwide Interoperability Roadmap: The Journey to Better Health and Care. This outline lists progress toward interoperability since 2009, the current state of health care supporting the need for interoperability, and the future goals and selected payer and outcome milestones for achieving the ultimate in interoperability, “learning health systems in which health information flows seamlessly and is available to the right people, at the right place, at the right time” (ONC, 2015a).

Selected Historical Interoperability Achievements 2009 16% of hospitals and 21% of providers adopted basic EHRs. 2011 27% of hospitals and 34% of providers adopted EHRs. 2013 94% of nonfederal acute care hospitals use a certified EHR. 78% of office-based physicians use an EHR. 62% of hospitals electronically exchanged health information with providers outside their system. 2014 80% of hospitals can electronically query other organizations for health information. 14% of office-based providers electronically share patient information with other providers. Current State of Health Care

One in three consumers must provide his or her own health information when seeking care for a medical problem. A typical Medicare beneficiary sees seven providers annually. A typical primary care physician has to coordinate care with 229 other physicians working in 117 practices. Eighty to ninety percent of health determinants are not related to health care. One in eight Americans tracks a health metric using technology. It takes seventeen years for evidence to go from research to practice. Barriers to Interoperability

States have different laws and regulations making it difficult to share health information across state lines. Health information is not sufficiently standardized. Payment incentives are not aligned to support interoperability. Privacy laws differ and are misinterpreted. There is a lack of trust among health care providers and consumers. 2015–2017 Goal and Milestones

Goal: Send, receive, find, and use priority data domains to improve health care quality and outcomes

Roadmap Milestones for a Supportive Payment and Regulatory Environment and Outcomes

CMS will aim to administer 30 percent of all Medicare payments to providers through alternative payment models that reward quality and value and encourage interoperability by the end of 2016.

A majority of individuals are able to securely access their electronic health information and direct it to the destination of their choice.

Providers evolve care processes and information reconciliation to ensure essential health information is sent, found, or received to support safe transitions in care.

ONC, federal partners, and stakeholders develop a set of measures assessing interoperable exchanges and the impact of interoperability on key processes that enable improved health and health care.

2018–2020 Goal and Milestones

Goal: Expand interoperable health IT and users to improve health and lower cost

Roadmap Milestones for a Supportive Payment and Regulatory Environment and Outcomes

CMS will administer 50 percent of all Medicare payments to providers through alternative payment models that reward quality and value by the end of 2018.

Individuals regularly access and contribute to their longitudinal electronic health information via health IT, send and receive that information through a variety of emerging technologies, and use that information to manage their health and participate in shared decision making with their care, support, and service teams.

Providers routinely and proactively seek outside information about individuals and can use it to coordinate care.

Public and private stakeholders report on progress toward interoperable exchange, including identifying barriers to interoperability, lessons learned, and impacts of interoperability on health outcomes and costs.

2020–2024 Goal and Milestones

Goal: Achieve nationwide interoperability to enable a learning health system

Roadmap Milestones for a Supportive Payment and Regulatory Environment and Outcomes

The federal government will use value-based payment models as the dominant mode of payment for providers.

Individuals are able to seamlessly integrate and compile longitudinal electronic health information across online tools, mobile platforms, and devices to participate in shared decision making with their care, support, and service teams.

Providers routinely use relevant info from a variety of sources, including environmental, occupational, genetic, human service, and cutting-edge research evidence, to tailor care to the individual.

Public and private stakeholders report on progress on key metrics identified to achieve a learning health system.

Source: ONC (2015a). Usability In addition to interoperability concerns, clinicians often express frustration with the usability of EHR systems and other clinical information systems. In fact, 55 percent of physicians reported that it was difficult or very difficult to use. Common frustrations include confusing displays, iconography that lacks consistency and intuitive meaning, and the feeling that systems do not support clinicians' cognitive workflow or inhibit them from easily drawing insights or conclusions from the data. Similarly, physicians who participated in a Rand study (Friedberg et al., 2013) felt that EHR data entry was time-consuming, interfered with face-to-face patient care, and was overall inefficient. They also reported that inability to exchange health information and the degradation of clinical documentation were of concern. Others argue that poor usability of EHR systems not only contributes to clinician frustration but also can lead to errors and patient safety concerns (Meeks, Smith, Taylor, Sittig, Scott, & Singh, 2014; Sittig & Singh, 2011). In essence, usability refers to “the effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of produce use” (Bevan, 2001). Smartphones are typically viewed as having high usability, because they require little training and are intuitive to use. In fact, we often see young children navigating them before they can even talk!

Given the importance of system usability, a task force was formed by the American Medical Informatics Association (Middleton et al., 2013) to study the issue. They identified key recommendations on critical usability issues, particularly those that may adversely affect patient safety and the quality of care. The recommendations fall into four categories: (1) usability and human factors research, (2) policy recommendations, (3) industry recommendations, and (4) clinical end user recommendations. (See the Perspective.)

As one can discern from AMIA's task force recommendations, usability is a multifaceted issue and one that requires thoughtful research, standardization and interoperability, a common user interface style guide, and systems for identifying best practices and monitoring use as well as adverse events that may affect patient safety.

Perspective AMIA EHR Usability Recommendations Usability and human factors research agenda in health IT

a. Prioritize standardized use cases. b. Develop a core set of measures for adverse events related to health IT use. c. Research and promote best practices for safe implementation of EHR. Policy recommendations d. Standardization and interoperability across EHR systems should take account of usability concerns. e. Establish an adverse event reporting system for health IT and voluntary health IT event reporting. f. Develop and disseminate an educational campaign on the safe and effective use of EHR. Industry recommendations g. Develop a common user interface style guide for select EHR functionalities. h. Perform formal usability assessments on patient-safety sensitive EHR functionalities. Clinical end user recommendations i. Adopt best practices for EHR implementation and ongoing management. j. Monitor how IT systems are used and report IT-related adverse events. Source: Middleton et al. (2013). Reproduced with permission of Oxford University Press. Health IT Safety In 2011, the Institute of Medicine published a report titled Health IT and Patient Safety: Building Safer Systems for Better Care in which they outlined a number of recommendations to ensure health IT systems are safe. In brief, they suggest that safety is a shared responsibility between vendors and health care organizations and requires the following:

Building systems using user-centered design principles with adequate testing and simulation Embedding safety considerations throughout the implementation process Developing and publishing best practices Having accreditation agencies (such as the Joint Commission) assume a significant role in testing as part of their accreditation criteria Focusing on shared learning and transparency Creating a nonpunitive environment for reporting (IOM, 2011) Since then, the topic of health IT safety has grown in importance as more EHR systems have been deployed. Health IT patient safety concerns include adverse events that reached the patient, near misses that did not reach the patient, or unsafe conditions that increased the likelihood of a safety event (Meeks et al., 2014). Such events are often difficult to define and detect. Consequently, Singh and Sittig (2016) have developed a health IT safety measurement framework that takes into account eight technological and nontechnological dimensions or sociotechnical dimensions (see Table 3.3).

Table 3.3 Sociotechnical dimensions

Source: Reproduced from Measuring and Improving Patient Safety through Health Information Technology: The Health IT Safety Framework, Singh and Sittig, 25: p.228, 2016. With permission from BMJ Publishing Group Ltd.

Dimension Description

Hardware and software Computing infrastructure used to support and operate clinical applications and devices Clinical content The text, numeric data, and images that constitute the “language” of clinical applications, including clinical decision support Human-computer interface All aspects of technology that users can see, touch, or hear as they interact with it People Everyone who is involved with patient care and/or interacts in some way with health care delivery (including technology). This would include patients, clinicians and other health care personnel, IT developers and other IT personnel, informaticians Workflow and communication Processes to ensure that patient care is carried out effectively, efficiently, and safely Internal organizational features Policies, procedures, the physical work environment, and the organizational culture that govern how the system is configured, who uses it, and where and how it is used External rules and regulations Federal or state rules (e.g., CMS's Physician Quality Reporting Initiative, HIPAA, and Meaningful Use program) and billing requirements that facilitate or constrain the other dimensions Measurement and monitoring Evaluating both intended and unintended consequences through a variety of prospective and retrospective, quantitative, and qualitative methods The Health IT Safety Framework provides a conceptual framework for defining and measuring health IT–related patient safety issues. The framework is also built on continuous quality improvement methods that require stakeholders to ask themselves, How are we doing? Can we do better? How can we do better (Singh & Sittig, 2016)? In fact, Singh and Sittig (2016) argue that it is essential that clinicians and leaders make health IT patient safety an organizational priority by ensuring that the governance structure facilitates measuring and monitoring and creating an environment that is conducive to detecting, fixing, and learning from system vulnerabilities. Meeks and colleagues (2014) used a variation of the Health IT Safety Framework in analyzing one hundred different EHR-related safety concerns reported to and investigated by the VA's Informatics Patient Safety Office, which is a voluntary reporting system. The major categories of errors were because of (1) unmet display needs (mismatch between information needs and content display; (2) software modifications (concerns about upgrades, modifications, or configurations); (3) system-to-system interfacing (concerns about failure of interfacing between systems); and (4) hidden dependencies on distributed systems (one component of the EHR is unexpectedly or unknowingly affected by the state or condition of another component) (Meeks et al., 2014). They concluded that because EHR-related safety concerns have sociotechnical origins and are multifaceted, health care organizations should build a robust infrastructure to monitor and learn from them.

Numerous factors can affect the safety and effective use of health care information systems—everything from poor usability to software glitches to unexpected downtime or cyber attacks. Health care executives should be aware of these issues and vulnerabilities and ensure their organizations have in place mechanisms to prevent, detect, monitor, and address adverse events that may affect patient safety and quality of care. Summary

This chapter provided an overview of health care information systems including administrative and clinical information systems. We gave a brief history of the evolution of the use of information systems in health care. Special attention was given to the adoption, use, and features of EHR systems, patient portals, and PHR systems. We also summarized recent literature on the value of EHR systems, which may be categorized into three main areas: (1) quality, outcomes, and safety; (2) efficiency, improved revenues, and cost reduction; and (3) provider and patient satisfaction. Limitations to research findings were noted along with the need for future research. Key issues related to the use of health care information systems were discussed including interoperability, usability, and health IT safety. The chapter concludes with a discussion of a health IT safety framework that may be useful to health care leaders in preventing, detecting, and monitoring health IT–related patient safety issues.