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  246. Chapter 1: Overview of Health Informatics </h1>
  247. <section class="entry">
  248. <p>ROBERT E. HOYT</p>
  249. <p>ELMER V. BERNSTAM</p>
  250. <p>&nbsp;</p>
  251. <p><a title="Chapter 1: Overview of Health Informatics Additional Resources" href="http://informaticseducation.org/overview/ch1-resources/" target="_parent"><strong>Link to Resource Page</strong></a></p>
  252. <p><a title="Chapter 1 Instructor’s Manual" href="http://informaticseducation.org/chapter-1-instructors-manual/"><strong>Instructor&#8217;s Manual</strong></a></p>
  253. <p><strong>Learning Objectives</strong></p>
  254. <p>After reading this chapter the reader should be able to:</p>
  255. <ul>
  256. <li>State the definition and origin of health informatics</li>
  257. <li>Identify the forces behind health informatics</li>
  258. <li>Describe the key players involved in health informatics</li>
  259. <li>State the potential impact of the ARRA and HITECH Act on health informatics in the United States</li>
  260. <li>List the barriers to health information technology (HIT) adoption</li>
  261. <li>Describe educational and career opportunities in health informatics</li>
  262. </ul>
  263. <p style="text-align: center;"><span style="font-size: large;"><strong>Introduction</strong></span></p>
  264. <p>“During the past few decades the volume of medical knowledge has increased so rapidly that we are witnessing an unprecedented growth in the number of medical specialties and subspecialties. Bringing this new knowledge to the aid of our patients in an economical and equitable fashion has stressed our system of medical care to the point where it is now declared to be in a crisis. All these difficulties arise from the present, nearly unmanageable volume of medical knowledge and the limitations under which humans can process information.”</p>
  265. <p>- Marsden S. Blois, <em>Information and Medicine: The Nature of Medical Descriptions, </em>1984</p>
  266. <p><span style="font-size: large;"><strong>H</strong></span>ealth informatics began as a new field of study in the 1950s-1960s time frame but only recently gained recognition as an important component of many aspects of healthcare. Its emergence is partly due to the multiple challenges facing the practice of medicine today. As the 1984 quote above indicates, the growth in the volume of medical knowledge and patient information that has occurred due to better understanding of human health has resulted in more treatments and interventions that produce more information. Likewise, the increase in specialization has also created the need to share and coordinate patient information. Furthermore, clinicians need to be able to access medical information expeditiously, regardless of location or time of day. Technology has the potential to help with each of those areas. With the advent of the internet, high speed computers, voice recognition, wireless and mobile technology, healthcare professionals today have many more tools available at their disposal. However, in general, technology is advancing faster than healthcare professionals can assimilate it into their practice of medicine. One could also argue that there is a critical limitation of current information technology that manages data and not information. Thus, there is a mismatch between what we need (i.e. something to help us manage meaningful data = information) and what we have (ineffective ways to manage information). Additionally, given the volume of data and rapidly changing technologies, there is a great need for ongoing Informatics education of all healthcare workers.</p>
  267. <p>In this chapter we will present an overview of health informatics with emphasis on the factors that helped create and sustain this new field and the key players involved.</p>
  268. <div class="youtube" style="width: 350; height: 300;"><object width="350" height="300" classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=6,0,40,0"><param name="wmode" value="transparent" /><param name="src" value="http://www.youtube.com/v/9PuxfRxflLE " /><embed width="350" height="300" type="application/x-shockwave-flash" src="http://www.youtube.com/v/9PuxfRxflLE " wmode="transparent" /></object></div>
  269. <p><strong>Data, Information, Knowledge, Wisdom Hierarchy</strong></p>
  270. <p>Informatics is the science of information and the blending of people, biomedicine and technology. Individuals who practice informatics are known as informaticians or informaticists, such as, a nurse informaticist. There is an information hierarchy that is important in the information sciences, as depicted in the pyramid in Figure 1.1. Notice that there is much more data than information, knowledge or wisdom. As data are consumed and analyzed the amount of knowledge and wisdom produced is much smaller. The following are definitions to better understand the hierarchy:</p>
  271. <ul>
  272. <li>Data are symbols or observations reflecting differences in the world. Data are the plural of datum (singular). Thus, a datum is the lowest level of abstraction, such as a number in a database (e.g. 5), or packets sent across a network (e.g. 10010100). Note that there is no meaning associated with data; the <em>5</em> could represent five fingers, five minutes or have no real meaning at all. Modern computers process data accurately and rapidly.</li>
  273. <li>Information is meaningful data or facts from which conclusions can be drawn by humans or computers. For example, <em>five fingers</em> has meaning in that it is the number of fingers on a normal human hand. Modern computers do not process information, they process data. This is a fundamental problem and challenge in informatics.</li>
  274. <li>Knowledge is information that is justifiably considered to be true. For example, a rising prostate specific antigen (PSA) level suggests an increased likelihood of prostate cancer.</li>
  275. <li>Wisdom is the critical use of knowledge to make intelligent decisions and to work through situations of signal versus noise. For example, a rising PSA could mean prostate infection and not cancer.</li>
  276. </ul>
  277. <p><strong>Figure 1.1: Information hierarchy</strong></p>
  278. <p><a href="http://informaticseducation.org/wp-content/uploads/2012/08/1.1.png"><img class="aligncenter size-medium wp-image-577" title="1.1" src="http://informaticseducation.org/wp-content/uploads/2012/08/1.1-300x202.png" alt="" width="300" height="202" /></a></p>
  279. <p>&nbsp;</p>
  280. <p>Health information technology provides the tools to generate information from data that humans (clinicians and researchers) can turn into knowledge and wisdom.<sup>1-2</sup> Thus, enabling and improving human decision making with usable information is a central concern of informaticians. This concept is discussed in much more detail in Chapter 2 on healthcare data, information and knowledge.</p>
  281. <p>Another important concept to understand about data is that there are different levels of data (Figure 1.2). Paper forms would be considered level 1 with serious limitations, in regards to sharing, storing and analyzing. Level 2 data could be scanned-in documents. Level 3 data are entered into a computer and are data that are structured and retrievable, but not computable between different computers. Level 4 data are computable data. That means the data are electronic, capable of being stored in data fields and computable because it is in a format that disparate computers can share (interoperable) and interpret (analyzable).</p>
  282. <p><strong>Figure 1.2 Levels of data (Courtesy Government Accounting Office)</strong></p>
  283. <p><a href="http://informaticseducation.org/wp-content/uploads/2012/08/1.2-Overview.jpg"><img class="aligncenter size-medium wp-image-398" title="1.2 Overview" src="http://informaticseducation.org/wp-content/uploads/2012/08/1.2-Overview-300x218.jpg" alt="" width="300" height="218" /></a></p>
  284. <p>&nbsp;</p>
  285. <p>Therefore, the information sciences tend to promote data in formats that can be rapidly transmitted, shared and analyzed. Paper records and reports do not allow this, without a great deal of manual labor. The advent of electronic health records, health information exchanges (HIEs) and multiple hospital electronic information systems provided the ability and the need to collate and analyze large amounts of data to improve health and financial decisions. Enterprise systems have been developed that: integrate disparate information (clinical, financial and administrative); archive data; provide the ability to data mine using business intelligence and analytic tools. Figure 1.3 demonstrates a typical enterprise data system.</p>
  286. <p><strong>Figure 1.3 Enterprise data warehouse and data mining</strong></p>
  287. <p><a href="http://informaticseducation.org/wp-content/uploads/2012/08/1.3-Overview.jpg"><img class="aligncenter size-medium wp-image-399" title="1.3 Overview" src="http://informaticseducation.org/wp-content/uploads/2012/08/1.3-Overview-300x152.jpg" alt="" width="300" height="152" /></a></p>
  288. <p>&nbsp;</p>
  289. <p align="left"><strong>Informatics Definitions</strong></p>
  290. <p align="left"><strong>Health informatics</strong> is the field of information science concerned with management of healthcare data and information through the application of computers and other technologies. In reality, it is more about applying information in the healthcare field than it is about technology per se. That is one of the many reasons it is different than a pure information technology (IT) position in a healthcare organization. Technology merely facilitates the collection, storage, transmission and analysis of data. This field also includes data standards (such as HL7) and controlled medical vocabularies (such as SNOMED) we will cover in the chapter on data standards.</p>
  291. <p align="left">The definition of health informatics is dynamic because the field is relatively new and rapidly changing. The following are four definitions frequently cited:</p>
  292. <ul>
  293. <li>“science of information, where information is defined as data with meaning. Biomedical informatics is the science of information applied to, or studied in the context of biomedicine. Some, but not all of this information is also knowledge”<sup>3</sup><em></em></li>
  294. <li>“scientific field that deals with resources, devices and formalized methods for optimizing the storage, retrieval and management of biomedical information for problem solving and decision making”<sup>4</sup></li>
  295. <li>“application of computers, communications and information technology and systems to all fields of medicine &#8211; medical care, medical education and medical research”<sup>5</sup></li>
  296. <li>“understanding, skills and tools that enable the sharing and use of information to deliver healthcare and promote health”<sup>6</sup></li>
  297. </ul>
  298. <p><em>Health informatics</em> is also known as <em>clinical informatics or medical informatics</em> and<em> biomedical informatics </em>in some circles. If the information science deals primarily with actual applications and programs and not theory, it can be referred to as applied informatics. <em>Bioinformatics</em>, on the other hand involves the integration of biology and technology and can be defined as the:</p>
  299. <p style="text-align: center;">“analysis of biological information using computers and statistical techniques; the science of developing and utilizing computer databases and algorithms to accelerate and enhance biological research.”<sup>7</sup></p>
  300. <p>Some prefer the broader term <em>biomedical informatics</em> because it encompasses bioinformatics as well as medical, dental, nursing, public health, pharmacy, medical imaging and veterinary informatics.<sup>8</sup> As we move closer to integrating human genetics into the day-to-day practice of medicine this more global definition may gain traction. We have chosen to use health informatics throughout the book for consistency. The Americian Medical Informatics Association no longer uses the term medical informatics and they include clinical informatics and public health informatics under health informatics, which in turn falls under biomedical informatics.</p>
  301. <div class="youtube" style="width: 350; height: 300;"><object width="350" height="300" classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=6,0,40,0"><param name="wmode" value="transparent" /><param name="src" value="http://www.youtube.com/v/vfx0a8VUcxQ" /><embed width="350" height="300" type="application/x-shockwave-flash" src="http://www.youtube.com/v/vfx0a8VUcxQ" wmode="transparent" /></object></div>
  302. <p><strong>Health information technology (HIT or healthIT)</strong> is defined as the application of computers and technology in healthcare settings.</p>
  303. <p><strong>Health information management (HIM)</strong> traditionally focused on the paper medical record and coding. With the advent of the electronic health record HIM specialists now have to deal with a new set of issues, such as privacy and multiple new concepts such as voice recognition.</p>
  304. <p>For a discussion of the definition, concepts and implications (e.g. distinguishing from other related fields) of this field, we refer you to a 2010 article by Bernstam, Smith and Johnson and a 2009 article by Hersh.<sup>3,9</sup></p>
  305. <p>&nbsp;</p>
  306. <p style="text-align: center;"> <span style="font-size: large;"><strong>Background</strong></span></p>
  307. <p>Given the fact that most businesses incorporate technology into their enterprise fabric, one could argue that it was just a matter of time before the tectonic forces of medicine and technology collided. As more medical information was published and more healthcare data became available as a result of computerization, the need to automate, collect and analyze data escalated. Also, as new technologies such as electronic health records appeared, ancillary technologies such as disease registries, voice recognition and picture archiving and communication systems arose to augment functionality. In turn, these new technologies prompted the need for expertise in health information technology that spawned new specialties and careers.</p>
  308. <p>Health informatics emphasizes <em>information brokerage</em>; the sharing of a variety of information back and forth between people and healthcare entities. Examples of medical information that needs to be shared include: lab results, x-ray results, vaccination status, medication allergy status, consultant’s notes and hospital discharge summaries. Medical informaticians harness the power of information technology to expedite the transfer and analysis of data, leading to improved efficiencies and knowledge. The field also interfaces with other fields such as the health sciences, computer sciences, biomedical engineering, biology, library sciences and public health, to mention a few. Informatics training, therefore, must be expansive and in addition to the topics covered in the chapters of this book must include IT knowledge about networks and systems, usability, process re-engineering, workflow analysis and redesign quality improvement, project management, leadership, teamwork, implementation and training.</p>
  309. <p>Health information technology (HIT) facilitates the processing, tranmsmission and analysis of information and HIT interacts with many important functions in healthcare organizations and serves as a common thread. (Figure 1.4). This is one of the reasons the Joint Commission created the management of information management standard for hospital certification.<sup>10</sup><em></em></p>
  310. <p><strong>Figure 1.4 Information, information technology and healthcare functions</strong><br clear="all" /><br />
  311. <a href="http://informaticseducation.org/wp-content/uploads/2012/08/1.4-Overview.jpg"><img class="aligncenter size-medium wp-image-400" title="1.4 Overview" src="http://informaticseducation.org/wp-content/uploads/2012/08/1.4-Overview-300x204.jpg" alt="" width="300" height="204" /></a></p>
  312. <p>&nbsp;</p>
  313. <p>Many aspects of health informatics noted in Figure 1.4 are interconnected. To accomplish data collection and analysis there are hospital information systems (HISs) that collect financial, administrative and clinical information and subsystems such as the laboratory (LISs) and radiology information systems (RISs). As an example, a healthcare organization is concerned that too many of its diabetics are not well controlled and believes it would benefit by offering a diabetic web portal. With a portal, diabetics can upload blood sugars and blood pressures to a central web site so that diabetic educators and/or clinicians can analyze the results and make recommendations. They also have the option to upload physiologic parameters via their smart phone. The following technologies and issues are involved with just this one initiative and we will cover each in other chapters:</p>
  314. <ul>
  315. <li>The web-based portal involves consumer (patient) informatics and telemedicine</li>
  316. <li>Use of a smart phone is an important type of mobile technology</li>
  317. <li>Management of diabetes requires online medical resources, evidence based medicine, clinical practice guidelines, disease managment and an electronic health record with a disease registry</li>
  318. <li>If the use of the diabetic web portal improves diabetic control, clinicians may be eligible for improved reimbursement, known as pay-for-performance, a quality improvement strategy</li>
  319. </ul>
  320. <p>There are multiple forces driving the adoption of health information technology, but the major ones are the need to: increase the efficiency of healthcare (i.e. decrease medical costs and improve physician productivity), improve the quality (patient outcomes) of healthcare, resulting in improved patient safety. Over the past 40 years, there has been increasing recognition that wide variation in practice cannot be justified. For example, patients in some areas of the United States are undergoing more invasive procedures than similar patients in other areas. Thus, there has been a movement to standardize the care of common and expensive conditions, such as coronary artery disease, congestive heart failure and diabetes. Computerized clinical practice guidelines are one way to provide advice at the point of care and we will discuss this in more detail in the chapter on evidence based medicine.</p>
  321. <p>In this book we will discuss the driving forces motivating informatics and their inter-relationships. In addition to the motivation to deliver more efficient, safer and less costly healthcare, there is the natural diffusion of technology which also exerts an influence. In other words, as technologies such as wireless and voice recognition become more common place, easier to use and less expensive, they will have an inevitable impact on the practice of medicine. Technological innovations appear at a startling pace as stated by Moore’s Law.</p>
  322. <p align="center">“The number of transistors on a computer chip doubles every 1.5 years”<sup>11</sup></p>
  323. <p align="center">- Gordon Moore, co-founder Intel Corporation 1965</p>
  324. <p>Moore’s Law describes the exponential growth of transistors in computers. Technology will continue to evolve at a rapid rate but it is important to realize that it often advances in an asynchronous manner. For example, laptop computers have advanced greatly with excellent processor speed and memory but their utility is limited by a battery life of roughly 4-6 hours. This is a significant limitation given the fact that most nurses now work eight to 12 hour shifts, so short battery life is one factor that currently limits the utility of laptop computers in healthcare. This may be overcome with tablet computers or a new battery design.</p>
  325. <p>It is also important to realize that one of the outcomes of EHRs will be voluminous healthcare data. As pointed out by Steve Balmer, the CEO of Microsoft, there will be an “explosion of data” as a result of automating and digitizing multiple medical processes.<sup>13</sup> Adding new technologies such as electronic prescribing and health information exchanges will produce data that heretofore has not been available. This explains, in part, why technology giants such as Microsoft, Intel and IBM have entered the healthcare arena. As we begin mining medical data from entire regions or organizations we will be able to make much better evidence based decisions. As we will point out in other chapters, large organizations such as Kaiser Permanente have the necessary information technology tools and large patient population to be able to make evidence based decisions in almost all facets of medicine. Pooling data is essential because most practices in the United States are small and do not provide enough information on their own to show the kind of statistical significance we need to alter the practice of medicine.<sup>14 </sup>The electronic health record (EHR), covered in Chapter 3, could be considered the centerpiece of health informatics with its potential to improve patient safety, medical quality, productivity and data retrieval. EHRs will likely become the focal point of all patient encounters in the future. Multiple resources that are currently standalone programs are being incorporated into the EHR, e.g. electronic prescribing, physician/patient education, genetic profiles and artificial intelligence. It is anticipated that EHR use will eventually be shown to improve patient outcomes like morbidity and mortality as a result of decision support tools that decrease medication errors and standardize care with embedded clinical guidelines. However, at present, because EHRs do not adequately support clinicians’ information needs and workflow, they do little to improve patient care and in some cases have been shown to reduce the quality of care.<sup>12</sup> Informaticians will play a major role in helping to reverse this trend. It will not be enough to simply store electronic data; it must be shared among disparate partners. We will address health information exchange (information sharing) in a separate chapter. <strong></strong></p>
  326. <p>The federal government understands the importance of data and information to make evidence based medical decisions. For that reason, they developed <a href="http://www.data.gov/communities/health">http://www.data.gov/communities/health</a> to make datasets from the federal agencies available to a multitude of interested parties, such as healthcare organizations, developers, researchers, etc. Datasets are available through several categories: raw data, special tools and a geodata catalog. As a result of this initiative, a variety of applications, mashups and visualizations have been developed.</p>
  327. <p>Similarly, the Department of Health and Human Services created a Health Indicators Warehouse (HIW) in 2010 that included hundreds of health indicators that will help measure progress towards the Healthy People 2020 program (see info box below). New indicators continue to be added and updated. Importantly, this initiative will be working with technology companies, researchers and others to develop applications and initiatives to improve healthcare.<sup>15-17</sup></p>
  328. <table style="background-color: #789bf6; border: #000000 0px solid;" border="0" align="center">
  329. <tbody>
  330. <tr lang="" align="middle" valign="center">
  331. <td>
  332. <p style="text-align: center;"><strong>Health Indicators Warehouse</strong></p>
  333. <p>Users can search by:</p>
  334. <p style="text-align: left;"><strong>Topics: </strong>Chronic disease and conditions, demographics, disabilities, geography, health behaviors, health care, health care resources, health outcomes, health risk factors, hospital referral region, infectious disease initiative, injury and violence, maternal and infant health, mental health and substance abuse, occupational health and safety, oral health, physical environment, population, prevention through healthcare, public health infrastructure, social determinants of health and women&#8217;s health</p>
  335. <p style="text-align: left;"><strong>Geography: </strong>State or county</p>
  336. <p style="text-align: left;"><strong>Initiative: </strong>Mobilizing Action towards Community Health, 2008 Community Health Status Indicators,Healthy People 2020, CMS Community IndicatorsData is available to developers via an open application programming interface (API).<a href="http://www.healthindicators.gov/">www.healthindicators.gov</a></p>
  337. </td>
  338. </tr>
  339. </tbody>
  340. </table>
  341. <p>&nbsp;</p>
  342. <p>The most recent and significant event to affect the information sciences in the United States was the multiple programs associated with the HITECH Act of 2009, discussed later in the chapter. The programs include substantial financial support for electronic health records, health information exchange and a skilled HIT workforce. In other chapters we will refer to accountable care organizations and their technology requirements that are part of the Affordable Care Act of 2010.</p>
  343. <p>The introduction of information technology into the practice of medicine has been tumultuous for many reasons. Not only are new technologies expensive, they affect workflow and require advanced training. Unfortunately, this type of training rarely occurs during medical or nursing school or after graduation. More healthcare professionals who are <em>b</em><em>ilingual</em> in technology and medicine will be needed to realize the potential of new technologies. Vendors, insurance companies and governmental organizations will also be looking for the same expertise.</p>
  344. <p style="text-align: center;"><span style="font-size: large;"><strong>Historical Highlights</strong></span></p>
  345. <p>Information technology has been pervasive in the field of Medicine for only about three decades but its roots began in the 1950s.<sup>18</sup> Since the earlier days we have experienced astronomical advances in technology, to include, personal computers, high resolution imaging, the internet, mobile technology and wireless, to mention only a few. In the beginning there was no strategy or vision as to how to advance healthcare using information technology. Now, we have the involvement of multiple federal and private agencies that are plotting future healthcare reform, supported by health information technology. The following are some of the more noteworthy developments in health information technology:</p>
  346. <ul>
  347. <li>Computers. The first general purpose computer (ENIAC) was released in 1946 and required 1,000 sq. ft. of floor space. Primitive computers such as the Commodore and Atari appeared in the early 1980s along with IBM’s first personal computer, with a total of 16K of memory.<sup>19</sup> Computers were first theorized to be useful for medical diagnosis and treatment by Ledley and Lusted in the 1950’s.<sup>20</sup> They reasoned that computers could archive and process information more rapidly than humans. The programming language known as MUMPS was developed in Octo Barnett’s lab at Massachusetts General Hospital in the 1970s. MUMPS exists today in the popular electronic health record know as VistA, used by the Veterans Affairs medical system<sup>21</sup> and Epic Systems Corporation.</li>
  348. <li>Origin of health informatics. It is thought that the origin of the term medical informatics dates back to the 1960’s in France (“Informatique Medicale”).<sup>22</sup></li>
  349. <li>MEDLINE. In the mid-1960s MEDLINE and MEDLARS were created to organize the world’s medical literature. For older clinicians who can recall trying to research a topic using the multi-volume text Index Medicus, this represented a quantum leap forward.</li>
  350. <li>Artificial Intelligence. Artificial intelligence (AI) medical projects such as MYCIN (Stanford University) and INTERNIST-1 (University of Pittsburg) appeared in the 1970s and 1980s.<sup>23</sup> Since 1966 AI has had many periods where research flourished and where it floundered, known as AI winters.<sup>12</sup> Natural language processing (NLP) is gaining traction in medicine as it has the potential to intelligently interpret free text.</li>
  351. <li>Internet. The development of the internet began in 1969 with the creation of the government project ARPANET.<sup>24</sup> The World Wide Web (WWW or web) was conceived by Tim Berners-Lee in 1990 and the first web browser Mosaic appeared in 1993.<sup>25-26</sup> The internet is the backbone for digital medical libraries, health information exchanges and web-based medical applications, to include electronic health records. Although the terms <em>web</em> and <em>internet</em> are often used interchangeably, the internet is the <em>network-of-networks</em> consisting of hardware and software that connects computers to each other. The web is a set of protocols (particularly related to HyperText Transfer Protocol or HTTP) that are supported by the internet. Thus, there are many internet applications (e.g. email) that are not part of the web. This is discussed further in the chapter on architectures of information systems.</li>
  352. <li>Electronic Health Record (EHR). The electronic health record has been discussed since the 1970’s and recommended by the Institute of Medicine in 1991.<sup>27</sup> EHRs will be discussed in much more detail in Chapter 3.</li>
  353. <li>Mobile technology. The PalmPilot PDA appeared in 1996 as the first truly popular handheld computing device.<sup>28</sup> Personal Digital Assistants (PDAs) loaded with medical software became standard equipment for residents in training. They have been quickly supplanted by smartphones like the iPhone. Smartphones and tablets will be discussed in more detail in the chapter on mobile technology.</li>
  354. <li>Human Genome Project. In 2003 the Human Genome Project (HGP) was completed after thirteen years of international collaborative research. Mapping all human genes was one of the greatest accomplishments in scientific history. Finalizing a draft of the genome is the first step. What remains is making sense of the data. In other words, we need to understand the difference between data (the code), information (what the code means) and knowledge (what we do with the information).<sup>29</sup> Data from mega-databases will likely change the way we practice medicine in the future. The HGP will be discussed in the chapter on bioinformatics.</li>
  355. <li>Nationwide Health Information Network (NwHIN). The concept was developed in 2004 as the National Health Information Infrastructure and renamed the Nationwide Health Information Network (NwHIN). The goal of the NwHIN is to connect all electronic health records, health information organizations and government agencies in one decade.<sup>30</sup> Achieving interoperability among all healthcare systems and workers in the United States will be a monumental challenge. This will be discussed in more detail in several other chapters.</li>
  356. </ul>
  357. <p style="text-align: center;"><span style="font-size: large;"><strong>Key Players in Health Information Technology</strong></span></p>
  358. <p>Health information technology (HIT) is important to multiple players in the field of medicine. The common goals of these different groups are outlined in Table 1.1.</p>
  359. <p><strong>Table 1.1: Goals of HIT</strong><br />
  360. <table id="t1">
  361. <thead>
  362. <tr><th scope="col" class="t1" id="n1">Goal</th><th scope="col" class="t1" id="n2">Process</th></tr></thead>
  363. <tbody><tr class="table-alternate row1"> <td class="start">Improve</td><td>Communication and continuity of care
  364. Quality of care
  365. Patient outcomes
  366. Clinician productivity
  367. Return on investment</td></tr><tr class= "table-noalt row2"><td class="start">Reduce</td><td>Medical errors and litigation
  368. Duplication of tests</td></tr><tr class="table-alternate row3"> <td class="start">Standardize</td><td>Medical care by individuals and organizations</td></tr><tr class= "table-noalt row4"><td class="start">Accelerate</td><td>Access to care and administrative transactions</td></tr><tr class="table-alternate row5"> <td class="start">Protect</td><td>Privacy and ensure security</td></tr></tbody></table></p>
  369. <div align="center"> </div>
  370. <p>&nbsp;</p>
  371. <p>In the next section we list the key players in HIT and how they utilize health information technology (adapted from <em>Crossing the Quality Chasm</em>).<sup>31</sup></p>
  372. <p><strong>Patients</strong></p>
  373. <ul>
  374. <li>Online searches for health information</li>
  375. <li>Web portals for storing personal medical information, making appointments, checking lab results, e-visits, etc.</li>
  376. <li>Research choice of physician, hospital or insurance plan</li>
  377. <li>Online patient surveys</li>
  378. <li>Online chat, blogs, podcasts, vodcasts and support groups and Web 2.0 social networking</li>
  379. <li>Personal health records</li>
  380. <li>Limited access to electronic health records and health information exchanges (HIEs)</li>
  381. <li>Telemedicine and home telemonitoring</li>
  382. </ul>
  383. <p><strong>Clinicians and Nurses</strong></p>
  384. <ul>
  385. <li>Online searches with PubMed, Google and other search engines</li>
  386. <li>Online resources and digital libraries</li>
  387. <li>Patient web portals, secure e-mail and e-visits</li>
  388. <li>Physician web portals</li>
  389. <li>Clinical decision support, e.g. reminders and alerts</li>
  390. <li>Electronic health records (EHRs)</li>
  391. <li>Smartphones loaded with medical software</li>
  392. <li>Telemedicine and telehomecare</li>
  393. <li>Voice recognition software</li>
  394. <li>Online continuing medical education (CME)</li>
  395. <li>Electronic prescribing</li>
  396. <li>Disease management registries</li>
  397. <li>Picture archiving and communication systems (PACS)</li>
  398. <li>Pay-for-performance (P4P)</li>
  399. <li>Health information organizations (HIOs)</li>
  400. <li>E-research</li>
  401. <li>Electronic billing and coding</li>
  402. </ul>
  403. <p><strong>Support Staff</strong></p>
  404. <ul>
  405. <li>Patient enrollment</li>
  406. <li>Electronic appointments</li>
  407. <li>Electronic coding and billing</li>
  408. <li>EHRs</li>
  409. <li>Web-based credentialing</li>
  410. <li>Web-based claims clearinghouses</li>
  411. <li>Telehomecare monitoring</li>
  412. <li>Practice management software</li>
  413. <li>Secure patient-office e-mail communication</li>
  414. <li>Electronic medication administration record (e-Mar)</li>
  415. <li>Online educational resources and CME</li>
  416. <li>Disease registries</li>
  417. </ul>
  418. <p><strong>Public Health</strong></p>
  419. <ul>
  420. <li>Incident reports</li>
  421. <li>Syndromic surveillance as part of bio-terrorism program and Meaningful Use program criteria</li>
  422. <li>Establish link to all public health departments</li>
  423. <li>Geographic information systems to link disease outbreaks with geography</li>
  424. <li>Telemedicine</li>
  425. <li>Disease registries as part of EHRs or health information exchanges</li>
  426. <li>Remote reporting using mobile technology</li>
  427. </ul>
  428. <p><strong>Federal and State Governments</strong></p>
  429. <ul>
  430. <li>Nationwide Health Information Network</li>
  431. <li>Financial support for EHR adoption and health information exchange</li>
  432. <li>Development of standards, services and policies for HIT</li>
  433. <li>Information technology pilot projects and grants</li>
  434. <li>Disease management</li>
  435. <li>Pay-for-performance</li>
  436. <li>Electronic health records and personal health records</li>
  437. <li>Electronic prescribing</li>
  438. <li>Telemedicine</li>
  439. <li>Broadband adoption</li>
  440. <li>Health information organizations</li>
  441. <li>Regional extension centers</li>
  442. <li>Health IT workforce development</li>
  443. </ul>
  444. <p><strong>Medical Educators</strong></p>
  445. <ul>
  446. <li>Online medical resources for clinicians, patients and staff</li>
  447. <li>Online CME</li>
  448. <li>PubMed searches</li>
  449. <li>Telehealth via video teleconferencing, podcasts, etc.</li>
  450. </ul>
  451. <p><strong>Insurance Companies (Payers)</strong></p>
  452. <ul>
  453. <li>Electronic claims transmission</li>
  454. <li>Trend analysis</li>
  455. <li>Physician profiling</li>
  456. <li>Information systems for quality improvement initiatives</li>
  457. <li>Monitor adherence to clinical guidelines</li>
  458. <li>Monitor adherence to preferred formularies</li>
  459. <li>Promote claims-based personal health records and information exchanges</li>
  460. <li>Reduce litigation by improved patient safety through fewer medication errors</li>
  461. <li>Alerts to reduce test duplication</li>
  462. <li>Member of HIOs</li>
  463. </ul>
  464. <p><strong>Hospitals</strong></p>
  465. <ul>
  466. <li>Electronic health records</li>
  467. <li>Electronic coding and billing</li>
  468. <li>Information systems to monitor outcomes, length of stay, disease management, etc.</li>
  469. <li>Bar coding and radio frequency identification (RFID) to track patients, medications, assets, etc.</li>
  470. <li>Wireless technology</li>
  471. <li>E-intensive care units (eICUs)</li>
  472. <li>Patient and physician portals</li>
  473. <li>E-prescribing</li>
  474. <li>Member of health information organizations (HIOs)</li>
  475. <li>Telemedicine</li>
  476. <li>Picture archiving and communication systems (PACS)</li>
  477. </ul>
  478. <p><strong>Medical Researchers</strong></p>
  479. <ul>
  480. <li>Database creation to study populations, genetics and disease states</li>
  481. <li>Online collaborative web sites e.g. CaBIG</li>
  482. <li>Electronic case report forms (eCRFs)</li>
  483. <li>Software for statistical analysis of data e.g. SPSS</li>
  484. <li>Literature searches with multiple search engines</li>
  485. <li>Randomization using software programs</li>
  486. <li>Improved subject recruitment using EHRs and e-mail</li>
  487. <li>Smartphones to monitor research</li>
  488. <li>Online submission of grants</li>
  489. </ul>
  490. <p><strong> Technology Vendors</strong></p>
  491. <ul>
  492. <li>Applying new technology innovations in the field of medicine: hardware, software, genomics, etc.</li>
  493. <li>Data mining</li>
  494. <li>Interoperability</li>
  495. <li>Certification</li>
  496. </ul>
  497. <p style="text-align: center;"><span style="font-size: large;"><strong>Organizations Involved with HIT</strong></span></p>
  498. <p><strong>Academic Organizations</strong></p>
  499. <p><strong>Institute of Medicine (IOM). </strong>One of the leading organizations in the United States to promote health information technology is the Institute of Medicine. It was established in 1970 by the National Academy of Sciences with the task of evaluating policy relevant to healthcare and providing feedback to the Federal Government and the public. In their two pioneering books <em>To Err is Human </em>(1999) and <em>Crossing the Quality Chasm</em> (2001), they reported approximately 98,000 deaths occur yearly due to medical errors. It is their contention that an information technology infrastructure will help the six aims set forth by the IOM: safe, effective, patient centered, timely, efficient and equitable medical care. The infrastructure would support “efforts to re-engineer care processes, manage the burgeoning clinical knowledge base, coordinate patient care across clinicians and settings over time, support multidisciplinary team functioning, and facilitate performance and outcome measurements for improvement and accountability.” They also stress “the importance of building such an infrastructure to support evidence based practice, including the provision of more organized and reliable information sources on the internet for both consumers and clinicians and the development and application of decision support tools.”<em></em></p>
  500. <p>Two of the IOM’s twelve executive recommendations regarding improved healthcare directly relate to information technology:</p>
  501. <ul>
  502. <li>“improve access to clinical information and support clinical decision making”</li>
  503. <li>“Congress, the executive branch, leaders of health care organizations, public and private purchasers and health informatics associations and vendors should make a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade.”</li>
  504. </ul>
  505. <p>The IOM cited twelve information technology applications that might narrow the quality chasm. Many of these will be discussed in other chapters:</p>
  506. <ul>
  507. <li>Web-based personal health records</li>
  508. <li>Patient’s access to hospital information systems to access their lab and x-ray reports</li>
  509. <li>Access to general health information via the internet</li>
  510. <li>Electronic medical records with clinical decision support</li>
  511. <li>Pre-visit online histories</li>
  512. <li>Inter-hospital data sharing (health information exchange), e.g. lab results</li>
  513. <li>Information to manage populations using patient registries and reminders</li>
  514. <li>Patient &#8211; physician electronic messaging</li>
  515. <li>Online data entry by patients for monitoring, e.g. glucose results</li>
  516. <li>Online scheduling</li>
  517. <li>Computer assisted telephone triage and assistance (nurse call centers)</li>
  518. <li>Online access to clinician or hospital performance data.<sup>32-33</sup></li>
  519. </ul>
  520. <p><strong>The Association of American Medical Colleges (AAMC). </strong>For more than twenty years the AAMC has been an advocate of incorporating informatics into medical school curricula and promoting health informatics in general. In their <em>Better Health 2010 Report</em> they made the following recommendations:</p>
  521. <ul>
  522. <li>Optimize the health and healthcare of individuals and populations through best practice information management</li>
  523. <li>Enable continuous and life-long performance-based learning</li>
  524. <li>Create tools and resources to support discovery, innovation and dissemination of research results</li>
  525. <li>Build and operate a robust information environment that simultaneously enables healthcare, fosters learning and advances science.<sup>34</sup></li>
  526. </ul>
  527. <p><strong>Public-Private Organizations</strong></p>
  528. <p><strong>Bridges to Excellence.</strong> This organization consists of employers, physicians, health plans and patients. They currently have multiple care recognition programs incentivized by bonuses: diabetes, cardiac care, congestive heart failure, coronary artery disease, spine care, COPD, asthma, depression, hypertension, physician’s office and medical home.<sup>35</sup></p>
  529. <p><strong>eHealth Initiative.</strong> This is a non-profit organization promoting the use of information technology to improve quality and patient safety. Its membership includes virtually all stakeholders involved in the delivery of healthcare. This organization deals with multiple topics related to HIT and has a reports section that provides multiple articles on a variety of HIT topics. They also provide an annual survey of HIOs, starting in 2005. The 2011 survey results are available for a fee, but free for members.<sup>36</sup></p>
  530. <p><strong>Leapfrog. </strong>Leapfrog is a consortium of over one hundred and seventy major employers seeking to purchase the highest quality and safest healthcare. Voluntary reporting by hospitals has made hospital comparisons possible and the results are reported on their website. They also have a hospital rewards program to provide incentives to hospitals that show they deliver quality care. One of their patient safety measures is the use of inpatient computerized physician order entry (CPOE) that will be covered in several other chapters.<sup>37</sup></p>
  531. <p><strong>Markle Connecting For Health. </strong>This organization is a public-private collaboration operated by the Markle Foundation and funded partially by the Robert Wood Johnson Foundation. With over 100 stakeholders, its primary mission is to promote interoperable HIT. They published <em>Common Framework: Resources for Implementing Private and Secure Health Information Exchange</em> that helps organizations exchange information in a secure and private manner, with shared policies and technical standards. The Common Framework with nine policy guides and seven technical guides is available free for download on their web site.<sup>38</sup></p>
  532. <p><strong>National eHealth Collaborative (NeHC).</strong> This government-civilian-consumer collaborative took over in early 2009 when the American Health Information Community (AHIC) was dissolved. They are charged with prioritization of HIT standards to promote interoperability. They create <em>value cases</em> and refer those for harmonization of standards and once accepted they will be adopted by the certification organizations such as the Certification Commission for Health Information Technology (CCHIT). NeHC is a cooperative agreement partner of the Office of the National Coordinator for Health IT (ONC) and the US Dept. of Health and Human Services (HHS). NeHC University is a new (2011) online education program to inform stakeholders about multiple HIT issues.<sup>39</sup></p>
  533. <p><strong>Healthcare Information Technology Standards Panel (HITSP). </strong>This panel was a public-private partnership established in 2005 by the Department of Health and Human Services (DHHS). HITSP was charged by the ONC to harmonize standards-based on <em>use cases</em> derived from AHIC requirements. Each interoperability specification is a suite of documents that provides a roadmap of how standards and specifications will answer the requirements of the use case. For instance, specifics of the standard for using the Continuity of Care Document (CCD) were released as C32 in March 2008 with a detailed explanation of the technical aspects. The CCD is discussed further in the chapter on data standards. Their contract with the government was terminated in April 2010 and their function was largely replaced by the HIT Standards Sub-Committee discussed in a following section.<sup>40</sup></p>
  534. <p><strong>The Certification Commission for Healthcare Information Technology (CCHIT)</strong> was created by HIMSS and multiple other healthcare professional organizations. Its goals are to: reduce the risk of health information technology (HIT) investment by physicians; ensure interoperability of HIT; enhance the availability of HIT incentives and accelerate the adoption of interoperable HIT. Their initial step was to certify ambulatory electronic health records. By mid-2011 they certified the following categories of HIT: ambulatory EHRs, inpatient EHRs, Health Information Exchanges, Emergency EHRs, Cardiovascular Medicine EHRs, Child Health EHRs, Behavioral Health EHRs, Dermatology, Long Term/Post-Acute Care EHRs, Home Health EHRs and E-prescribing. EHRs that have received certification are listed on the web site. The Commission consists of 20 commissioners from a variety of backgrounds and numerous volunteers in their work groups. CCHIT decided they would offer different levels of EHR certification so more EHRs would qualify for Medicare or Medicaid reimbursement under ARRA: (1) CCHIT certified® 2011, a comprehensive certification that would actually exceed federal standards and includes a usability score, (2) ONC-ATCB Certification 2011-2012 will test EHRs against Meaningful Use regulations, hosted by the National Instititue of Standards and Technology (NIST), (3) EHR vendors can elect to be certified by both CCHIT and ONC-ATCB criteria, and (4) EHR Alternative Certification for Healthcare Providers (EACH) that certifies homegrown technology created by healthcare organizations and not vendors.</p>
  535. <p>As of mid-2011 eighty two ambulatory EHRs had been CCHIT certified with details posted on their site, to include usability ratings. Multiple EHR-related resources are also available. Certification is quite expensive as noted by one reference.<sup>41-42</sup></p>
  536. <p><strong>National Committee on Vital and Health Statistics (NCVHS) </strong>is a public advisory body to the Secretary of Health and Human Services. It is composed of 18 members from the private sector who are subject matter experts in the fields of health statistics, electronic health information exchange, privacy/security, data standards and epidemiology. They have been very involved in advising the Secretary in matters related to the Nationwide Health Information Network (NwHIN).<sup>43</sup></p>
  537. <p><strong>US Federal Government</strong></p>
  538. <p>The federal government has maintained that information technology is essential to improving the quality of medical care and containing costs; two important aspects of healthcare reform. It is a major financer of health care with the following programs: Medicare/Medicaid, Veterans Health Administration, Military Health System, Indian Health Service and the Federal Employees Health Benefits Program. It is therefore no surprise that they are heavily involved in health information technology and stand to benefit greatly from an interoperable Nationwide Health Information Network. Agencies such as Medicare/Medicaid and the Agency for Healthcare Research and Quality conduct HIT pilot projects that potentially could improve the quality of medical care and/or decrease medical costs. The federal government has recognized the importance of technology in multiple areas and as a result has a new federal chief technology officer and chief technology officer for HHS.</p>
  539. <p>Before specific government agencies are discussed we will outline the new programs included in the American Recovery and Reinvestment Act of 2009 that impact the information sciences.</p>
  540. <p><strong>American Recovery and Reinvestment Act (ARRA).</strong> <strong> </strong>Without a doubt, the most significant recent governmental initiative that affected the field of Informatics was the ARRA. This legislation will impact HIT adoption, particularly EHRs, as well as training and research. ARRA had five broad goals: (a) improve medical quality, patient safety, healthcare efficiency and reduce health disparities; (b) engage patients and families; (c) improve care coordination; (d) ensure adequate privacy and security of personal health information (e) improve population and public health. Title IV and XIII of ARRA, known as the Health Information Technology for Economic and Clinical Health (HITECH) Act was devoted to funding of HIT programs. Table 1.2 summarizes the major pertinent programs that have monies dedicated for these initiatives. The HealthIT website under the DHHS outlines the details of many of the programs listed in the table. In addition to the programs listed in Table 1.2 the following are also important initiatives that were part of the ARRA:</p>
  541. <ul>
  542. <li>Privacy and HIPAA changes; to be discussed in chapter on privacy</li>
  543. <li>The National Telecommunications and Information Administration’s Broadband Technology Opportunities Program. This will fund the National Broadband plan discussed in the chapter on telemedicine</li>
  544. <li>USDA’s Distance Learning, Telemedicine and Broadband Program</li>
  545. <li>Indian Health Services HIT programs</li>
  546. <li>Social Security Administration HIT programs</li>
  547. <li>Veterans Affairs (VA) HIT programs <sup>44</sup></li>
  548. </ul>
  549. <div class="youtube" style="width: 350; height: 300;"><object width="350" height="300" classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=6,0,40,0"><param name="wmode" value="transparent" /><param name="src" value="http://www.youtube.com/v/GzeUKKWvC0o " /><embed width="350" height="300" type="application/x-shockwave-flash" src="http://www.youtube.com/v/GzeUKKWvC0o " wmode="transparent" /></object></div>
  550. <p><strong>US Department of Health &amp; Human Services (HHS) </strong>is the department that serves as an umbrella for most of the important government agencies that impact HIT. The Office of the National Coordinator for Health Information Technology reports directly to the Secretary of HHS and is not an agency. The following are some of the operating divisions under HHS:</p>
  551. <ul>
  552. <li>Agency for Healthcare Research &amp; Quality</li>
  553. <li>Centers for Medicare &amp; Medicaid Services</li>
  554. <li>Centers for Disease Control &amp; Prevention</li>
  555. <li>Health Resources &amp; Services Administration</li>
  556. <li>Indian Health Service</li>
  557. <li>Food and Drug Administration</li>
  558. <li>Administration on Aging</li>
  559. <li>National Institutes of Health <sup>45</sup></li>
  560. </ul>
  561. <p><strong>Office of the National Coordinator for Health Information Technology (ONC)</strong>. The most significant goal of (ONC) is the creation of a universal interoperable electronic health record by the year 2014. To accomplish this goal they are working to harmonize data standards to ensure interoperability and to facilitate health information exchange. ONC reorganized in December 2009, resulting in the following offices: Office of Economic Modeling and Analysis, Office of the Chief Scientist, Office of the Deputy Coordinator for Programs and Policy, Office of the Deputy National Coordinator for Operations and Office of the Chief Privacy Officer. In early 2011 ONC proposed the Goals of the Federal Health IT Strategic Plan and asked for public comment. The following are the broad goals without specific objectives:</p>
  562. <p><strong>Table 1.2: ARRA and HITECH programs that impact the information sciences and HIT</strong></p>
  563. <table id="t4">
  564. <thead>
  565. <tr><th scope="col" class="t4" id="n1">Program</th><th scope="col" class="t4" id="n2">Programmatic Details</th></tr></thead>
  566. <tbody><tr class="table-alternate row1"> <td class="start">ONC</td><td>Discretionary money to develop the support for multiple programs. Establish Privacy Officer, HIT Standards and HIT Policy Committees</td></tr><tr class= "table-noalt row2"><td class="start">STATES</td><td>Support for statewide health information exchanges. As of mid-2011, fifty six states, territories and other entities have been funded. Details discussed in the chapter on health information exchange</td></tr><tr class="table-alternate row3"> <td class="start">NIST</td><td>Develop HIT standards</td></tr><tr class= "table-noalt row4"><td class="start">HRSA</td><td>Upgrade community health centers to include HIT initiatives, such as EHRs</td></tr><tr class="table-alternate row5"> <td class="start">AHRQ, NIH</td><td>Develop comparative effective research (CER) programs</td></tr><tr class= "table-noalt row6"><td class="start">Medicare/Medicaid</td><td>Medicare and state administered Medicaid will reimburse physicians for Meaningful Use of certified electronic health records (EHRs). Details outlined in the chapter on EHRs</td></tr><tr class="table-alternate row7"> <td class="start">REGIONAL EXTENSION CENTERS</td><td>Create 60 Regional Extension Centers to promote HIT, particularly EHRs for primary care physicians in rural areas. Goal is to support 100,000 clinicians in two years. 100,000 primary care physicians have signed on as of November 2011 </td></tr><tr class= "table-noalt row8"><td class="start">HIT RESEARCH CENTERS</td><td>Collect feedback from the regional extension centers, in order to generate lessons learned</td></tr><tr class="table-alternate row9"> <td class="start">BEACON COMMUNITY PROGRAM</td><td>Beacon Program will support 15-20 communities that serve as role models for the early adoption of HIT</td></tr><tr class= "table-noalt row10"><td class="start">COMMUNITY COLLEGE CONSORTIA TO EDUCATE HIT PROFESSIONALS</td><td>82 participating community colleges throughout all 50 states receive funding to rapidly create or expand H IT training programs that can be completed in six months or less; emphasis is on training the following roles: practice workflow and information management redesign specialists, clinician/practitioner consultants, implementation support specialists, implementation managers, technical/software support, and trainers</td></tr><tr class="table-alternate row11"> <td class="start">HEALTH IT CURRICULUM PROJECT</td><td>ONC Health IT Curriculum Project designated 12 healthcare workforce roles, six of to be educated through 6-month community college programs and six to be educated through one to two year programs at the university level. Five universities were funded as Curriculum Development Centers. The community college curriculum built by the Curriculum Development Centers covers 20 components with 8-12 units within each component and is available to faculty and the public at http://www.onc-ntdc.org/</td></tr><tr class= "table-noalt row12"><td class="start">COMPETENCY EXAM PROGRAM</td><td>Support one center to create a competency exam. There will be no charge for the first 10,000 students to take the exam</td></tr><tr class="table-alternate row13"> <td class="start">PROGRAM OF ASSISTANCE FOR UNIVERSITY BASED TRAINING</td><td>Support for eight institutions to develop programs for HIT professionals requiring university level training. The professional roles targeted by this program are: Clinician/Public Health Leader, Health Information Management and Exchange Specialist, Health Information Privacy and Security Specialist, Research and Development Scientist, Programmers and Software Engineer, and Health IT Sub-specialist</td></tr><tr class= "table-noalt row14"><td class="start">STRATEGIC HIT ADVANCED RESEARCH PROJECT (SHARP)</td><td>Awarded to four centers in 2010. Four focus areas are: HIT security to reduce risk and cultivate technologies of trust, support clinicians to align patient centered care with their practice, improve architectures and applications to exchange information accurately and securely and secondary use of EHR data to improve quality, population health and clinical research</td></tr></tbody></table>
  567. <div align="center"> </div>
  568. <p>&nbsp;</p>
  569. <p>Goal 1: Achieve Adoption and Information Exchange through Meaningful Use of Health IT</p>
  570. <ul>
  571. <li>Accelerate adoption of EHRs</li>
  572. <li>Facilitate information exchange to support Meaningful Use of EHRs</li>
  573. <li>Support health IT adoption and information exchange for public health and populations with unique needs</li>
  574. </ul>
  575. <p>Goal 2: Improve Care, Improve Population Health and reduce Health Care Costs through the use of Health IT</p>
  576. <ul>
  577. <li>Support more sophisticated uses of EHRs and other health IT to improve health system performance</li>
  578. <li>Better manage care, efficiency, and population health through EHR-generated reporting measures</li>
  579. <li>Demonstrate health IT-enabled reform of payment structures, clinical practices, and population health management</li>
  580. <li>Support new approaches to the use of health IT in research, public and population health and national health security</li>
  581. </ul>
  582. <p>Goal 3: Inspire Confidence and Trust in Health IT</p>
  583. <ul>
  584. <li>Protect confidentiality, integrity and availability of health information</li>
  585. <li>Inform individuals of their rights and increase transparency regarding the uses of protected health information</li>
  586. <li>Improve safety and effectiveness of health IT</li>
  587. </ul>
  588. <p>Goal 4: Empower Individuals with Health IT to Improve their Health and the Health Care System</p>
  589. <ul>
  590. <li>Engage individuals with health IT</li>
  591. <li>Accelerate individual and caregiver access to their electronic health information in a format they can use and reuse</li>
  592. <li>Integrate patient-generated health information and consumer health IT with clinical applications to support patient centered care</li>
  593. </ul>
  594. <p>Goal 5: Achieve Rapid Learning and Technological Advancement</p>
  595. <ul>
  596. <li>Lead the creation of a learning health system to support quality, research and public and population health</li>
  597. <li>Broaden the capacity of health IT through innovation and research</li>
  598. </ul>
  599. <p>In summary, ONC is responsible for coordinating all aspects of health information technology in the United States. They are involved with the adoption, standards harmonization, interoperability, privacy/security and certification of electronic health records. In addition they are coordinating the efforts to create the Nationwide Health Information Exchange (NwHIN). They participate with and support multiple private and public health information technology initiatives.</p>
  600. <p>In 2011 Dr. David Blumenthal resigned and Dr. Farzad Mostashari was selected as the National Coordinator by President Obama. The next two federal advisory committees discussed are part of ONC and were created as part of the ARRA. An organizational chart follows below in Figure 1.5.<sup>46</sup></p>
  601. <ul>
  602. <li>Health IT Policy Committee (HITPC). The main goal of this committee is to set priorities regarding what standards are needed for information exchange and establish the policy framework for the development and adoption of national health information exchange. The committee has 20 multi-disciplinary members. In 2011 the working groups were as follows: Meaningful Use, Certification, HIE, NwHIN, Strategic Plan, Privacy and Security, Enrollment, Governance and Quality Measures. The National Coordinator is the chair of the HITPC and their recommendations are posted on their web site. <sup>46</sup><em></em></li>
  603. <li>Health IT Standards Committee (HITSC). This committee has 27 multi-disciplinary members and chaired by Jonathan Perlin. They are tasked to look at standards, implementation specifications and certification criteria for the exchange of health information. They will likely focus on issues that are prioritized by HITPC. They will use the National Institute of Standards and Technology (NIST) to test standards. Both committees will make recommendations to the National Coordinator. They have established four working groups: clinical quality, clinical operations, implementation and privacy/security.<sup>46</sup></li>
  604. </ul>
  605. <p><strong>Figure 1.5: ONC organization chart (Courtesy ONC)</strong></p>
  606. <p><a href="http://informaticseducation.org/wp-content/uploads/2012/08/1.5-Overview.jpg"><img class="aligncenter size-medium wp-image-579" title="1.5 Overview" src="http://informaticseducation.org/wp-content/uploads/2012/08/1.5-Overview-300x221.jpg" alt="" width="300" height="221" /></a></p>
  607. <p><br clear="all" /><strong></strong></p>
  608. <p><strong>Agency for Healthcare Research and Quality (AHRQ). </strong>The AHRQ is “the lead Federal agency charged with improving the quality, safety, efficiency, and effectiveness of health care for all Americans. As one of 12 agencies within the Department of Health and Human Services, AHRQ supports health services research that will improve the quality of health care and promote evidence based decision making.”<sup>47</sup> This agency sets aside significant grant money to support healthcare information technology (HIT) each year. Since 2004 AHRQ has invested about $280 million in grants to research HIT. The AHRQ also maintains the National Resource Center for HIT and an extensive patient safety and quality section. They also maintain an extensive HIT Knowledge Library with over 6,000 resources.<sup>47</sup></p>
  609. <p><strong>Centers for Medicare and Medicaid Services (CMS).</strong> CMS is responsible for providing care to 44 million Medicare and 48 million Medicaid patients (2007 data). In an effort to improve quality and decrease costs, CMS has information technology pilot projects in multiple areas, to include pay-for-performance demonstration projects that link payments to improved patient outcomes. They will reimburse for Meaningful Use of certified EHRs. Several projects will be discussed in later chapters.<sup>48-49</sup><em></em></p>
  610. <p><strong>Centers for Disease Control and Prevention (CDC).</strong> Although not a primary information technology agency, the CDC has used HIT to promote population health-related issues. Among their programs of interest:</p>
  611. <ul>
  612. <li>Public Health Information Network (PHIN), covered in the chapter on public health informatics</li>
  613. <li>Human Genome Epidemiology Network (HuGENET™) correlates genetic information with public health</li>
  614. <li>Family History Public Health Initiative is a web site that records family history information and encourages saving it in a digital format so it can be shared. Discussed more in chapter on bioinformatics</li>
  615. <li>Public Health Image Library contains photos, images and videos on medical topics</li>
  616. <li>Geographic information systems (GIS) are also covered in chapter on public health informatics</li>
  617. <li>Podcasts, RSS feeds and web widgets on medical topics</li>
  618. <li>Online Health Library</li>
  619. <li>Mobile Pilot Project to text message patients about public health issues <sup>50</sup></li>
  620. </ul>
  621. <p><strong>Health Resources and Services Administration (HRSA) </strong>is part of HHS with the primary mission of assisting medical care for the underserved and uninsured in the United States, particularly in rural areas. They support federally qualified health centers (FQHCs) and rural health centers (RHCs). As noted in the section on the ARRA, HRSA will support grants for community health centers to include the installation and upgrades of health information technology. They have been a long term grant supporter of telemedicine. On their site they post a variety of health-related data in their HRSA data warehouse. A variety of searchable topics are presented with the ability to present as a table, chart, map or report. <sup>51</sup><em></em></p>
  622. <p><strong>State Governments and HIT</strong></p>
  623. <p>There are a variety of state-based HIT initiatives, evaluating the adoption of technologies such as electronic health records and e-prescribing. State Medicaid offices are anxious to conduct pilot projects aimed at reducing costs and/or improving quality of care. The State Alliance for e-Health was created in 2006 in an attempt to navigate the issues of best practices, policies and adoption obstacles. Support for the Alliance is from ONC as well as a private-public advisory committee. They have three task forces: health information protection, health care practice-health information communication and data exchange taskforces. Their highest priorities are e-prescribing and the privacy and security of health information.<sup>52</sup></p>
  624. <p style="text-align: center;"><span style="font-size: large;"><strong>Barriers to Health Information Technology Adoption</strong></span></p>
  625. <p>According to Anderson, the United States was at least 12 years behind many industrialized nations, in terms of HIT adoption. Total investment in 2005 per capita was 43 cents, compared to $21 for Canada, $4.93 for Australia, $21 for Germany and $192 for the United Kingdom.<sup>53</sup> This situation changed after HITECH implementation. Healthcare organizations tend to spend only 3-4% of their budget on information technology, which is far less than other information dependent industries.<sup>54</sup> Healthcare information technology adoption has multiple barriers listed below and discussed in later chapters:</p>
  626. <ul>
  627. <li>Inadequate time. This complaint is a common thread that runs throughout most discussions of technology barriers. Busy clinicians complain that they don&#8217;t have enough time to read, learn new technologies or research vendors. They are also not reimbursed to become technology experts. They usually have to turn to physician champions, local IT support or others for technology advice.</li>
  628. <li>Inadequate information. As already pointed out earlier in the chapter, clinicians need information, not data. Current HIT systems are data rich but information poor. This is discussed in detail in the Healthcare Data, Information and Knowledge chapter.</li>
  629. <li>Inadequate expertise and workforce. In order for the United States to experience widespread HIT adoption and implementation, it will require education of all healthcare workers. According to Dr. Blumenthal (previous National Coordinator for Health Information Technology) the United States will need approximately 51,000 skilled health informaticians over the next five years to create, install and maintain HIT.<sup>46</sup> Dr. William Hersh of the Oregon Health and Science University, echoes the need for a work force capable of leading implementation of the electronic health record and other technologies.<sup>55</sup> Educational offerings will need to be expanded at universities, community colleges and medical, nursing and pharmacy schools. There is a substantial difference between healthcare organizations, in terms of HIT sophistication. The first Work Force for Health Information Transformation Strategy Summit, hosted by the American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHIMA) made several strategic recommendations regarding how to improve the work force.<sup>56</sup> The American Medical Informatics Association has been the leader in attempting to increase the health information technology workforce with its AMIA 10&#215;10 Program.<sup>57</sup> Their goal is to train 10,000 skilled workers in the next 10 years. The Community College Consortium graduated about 3300 students in mid-July 2011 and it is too early to know how successful job placement will be, given the economic downturn. HIT vendors are looking for applicants with both IT and clinical experience.<sup>58</sup> In addition to skilled informaticians; we will need to educate residents in training and faculty at medical schools, given the rapidly changing nature of HIT. The APA Summit on Medical Student Education Task Force on Informatics and Technology recommended that instead of CME, we need “longitudinal, skills-based tutoring by informaticians.”<sup>59</sup> Family Medicine residency programs are generally ahead of other specialty training programs in regards to IT training. They also recommend a longitudinal approach to IT competencies.<sup>60</sup></li>
  630. <li>Cost. It is estimated that a Nationwide Health Information Network (NwHIN) will cost $156 billion dollars over five years and $48 billion annually in operating expenses.<sup>61</sup> Technologies such as picture archiving and communications systems (PACS) and electronic health records are also very expensive. The ARRA will help underwrite the initial purchase of some technologies but long term support will be a different challenge.</li>
  631. <li>Lack of interoperability. Electronic health records and the NwHIN cannot function until data standards are adopted and implemented nationwide. Interoperability and data standards are covered in more detail in other chapters.</li>
  632. <li>Change in workflow. Significant changes in workflow will be required to integrate technology into the inpatient and outpatient setting. As an example, clinicians may be accustomed to ordering lab or x-rays by giving a handwritten request to a nurse who actually places the order. Now they have to learn to use computerized physician order entry (CPOE). As with most new technologies, older users have more difficulty changing their habits, even if it will eventually save time or money. Poor usability is also an important impediment to good workflow and we will address this in the chapter on electronic health records. According to Dr. Carolyn Clancy, the director of AHRQ:</li>
  633. </ul>
  634. <p style="padding-left: 30px;">“The main challenges are not technical; it’s more about integrating HIT with workflow, making it work for patients and clinicians who don’t necessarily think like the computer guys do”<sup><em>62</em></sup></p>
  635. <ul>
  636. <li>Privacy. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was created initially for the portability, privacy and security of personal health information (PHI) that was largely paper-based. HIPAA regulations were updated in 2009 to better cover the electronic transmission of PHI or (ePHI). This Act has caused healthcare organizations to re-think healthcare information privacy and security. This will be covered in more detail in the chapters on privacy and security. In the past few years there have been a series of privacy breeches and stolen identities in healthcare organizations, thus adding to the angst.</li>
  637. <li>Legal. The Stark and Anti-kickback laws prevent hospital systems from providing or sharing technology such as computers and software with referring physicians. Exceptions were made to these laws in 2006, as will be pointed out in other chapters. This is particularly important for hospitals in order to share electronic health records and e-prescribing programs with clinician’s offices. Many new legal issues are likely to appear. As an example, there has been discussion of empowering the US Food and Drug Administration to regulate electronic health records and medical devices.</li>
  638. <li>Behavioral change. Perhaps the most challenging barrier is behavior. In The <em>Prince</em> by Machiavelli, it was stated “there is nothing more difficult to be taken in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things.”<sup>63</sup> Dr. Frederick Knoll of Stanford University described the five stages of medical technology acceptance: (1) abject horror, (2) swift denunciation, (3) profound skepticism, (4) clinical evaluation, then, finally (5) acceptance as the standard of care.<sup>64</sup>It is unrealistic to expect all medical personnel to embrace technology. In 1962 Everett Rogers wrote Diffusion of Innovations in which he delineated different categories of acceptance of innovation:
  639. <ul>
  640. <li>the innovators (2.5%) are so motivated they may need to be slowed down</li>
  641. <li>early adopters (13.5%) accept the new change and teach others</li>
  642. <li>early majority adopters (34%) require some motivation and information from others in order to adopt</li>
  643. <li>the late majority (34%) require encouragement to get them to eventually accept the innovation</li>
  644. <li>laggards (16%) require removal of all barriers and often require a direct order<sup>65</sup></li>
  645. </ul>
  646. </li>
  647. </ul>
  648. <p style="padding-left: 60px;">It is important to realize, therefore, that at least 50% of medical personnel will be slow to accept any information technology innovations and they will be perceived as dragging their feet or being <em>Luddites</em>.<sup>66 </sup>With declining reimbursement and emphasis on increased productivity, clinicians have a natural and sometimes healthy dose of skepticism. They dread widespread implementation of anything new unless they feel certain it will make their lives or the lives of their patients better. In this situation, selecting clinical champions and conducting intensive training are critical to implementation success.</p>
  649. <ul>
  650. <li>Health Information Technology Hype versus Fact. The Gartner IT Research Group describes five phases of the hype-cycle that detail the progression of technology from the technology trigger to the peak of inflated expectations to the trough of disillusionment to the slope of enlightenment to the plateau of productivity.<sup>67</sup> Figure 1.6 shows the hype curve for a variety of IT technologies for 2009. As already noted, clinicians tend to be leery about new technologies that promise a lot, but deliver little. As a rule, if technology doesn’t save time or money physicians are not interested. Importantly, current studies that evaluate HIT are often lacking for multiple reasons, discussed in these articles.<sup>68-69 </sup>Both the RAND Corporation and the Center for Information Technology Leadership reported in 2005 that HIT would save the US about $80 billion annually.<sup>70</sup> The Congressional Budget Office (CBO), on the other hand, refuted this optimistic viewpoint in May 2008. They published a monograph entitled <em>Evidence on the Costs and Benefits of Health Information Technology</em> that reviews the evidence on the adoption and benefits of HIT, the costs of implementing, possible factors to explain the low adoption rate and the role of the federal government in implementing HIT. The bottom line for the CBO is that “By itself, the adoption of more health IT is generally not sufficient to produce significant cost savings.”<sup>71 </sup>There has been several recent articles that called into question the presumption that HIT adoption will generate significant cost saving and one positive review.<sup>72-75</sup> Karsh et al. discusses twelve HIT fallacies that adds a sobering note to the discourse.76 Finally, Carol Diamond of the Markle Foundation points out that HIT success can’t be measured by the number of hospitals that have adopted EHRs or other HIT, but instead whether patient outcomes improve.<sup>77</sup><em></em></li>
  651. </ul>
  652. <p><strong>Figure 1.6: Gartner Hype Cycle of Emerging Technology 2009 (Courtesy <a href="file:///C:/Users/NBailey/AppData/Local/SugarSync/TEMP_MON_AREA/7837108_50472/www.Gartner.com">www.Gartner.com</a>)</strong></p>
  653. <p><a href="http://informaticseducation.org/wp-content/uploads/2012/08/1.6.gif"><img class="aligncenter size-medium wp-image-580" title="1.6" src="http://informaticseducation.org/wp-content/uploads/2012/08/1.6-300x187.gif" alt="" width="300" height="187" /></a></p>
  654. <p style="text-align: center;"><span style="font-size: large;"><strong>Health Informatics Programs, Organizations and Careers</strong></span></p>
  655. <p><strong>Health Informatics Programs</strong></p>
  656. <p>One of the best sites to review the various health informatics programs in the United States and overseas can be found on the American Medical Informatics Association’s web site. Another excellent site for listing available health informatics programs in the United States and the United Kingdom is the Biohealthmatics web site. Health informatics programs can be degree, certificate, fellowship and short courses. Most programs are part of a university, community college, medical or nursing school and others may be part of a health related organization such as the National Library of Medicine. Courses can be online, taught in a classroom setting or both. Health informatics degree programs are available as follows: associate degree, undergraduate degree, Master’s degree, PhD degree or part of another degree program. Master’s degrees may be focused on applied training or readying students for a research career. The AMIA program listings will give the reader an idea of how many programs are available in North America and in which category; see table 1.3 (note that 2011 data is not included because the search methodology changed). In addition, it will provide an idea as to the rapid growth of health informatics programs in a relatively short period of time. <sup>57, 78</sup></p>
  657. <p>As of October 2011, community colleges participating in ONC’s Community College Consortia to Educate Health IT Professionals have graduated 5,717 HIT professionals, with 10,065 more students currently in the training pipeline. As of November 2011, universities have produced more than 500 post-graduate and masters-level health information technology professionals, with more than 1,700 expected to graduate by July 2013. The majority of health informatics students in the past have come from healthcare fields. With the current economy and the new monies from the ARRA, IT professionals from other industries are enrolling in health informatics training programs. Often these professionals bring expertise in technology implementation, evaluation and/or user training and programming skills but they often lack clinical experience in healthcare.</p>
  658. <p><strong> </strong><strong>Table 1.3: Health informatics programs listed on the AMIA web site</strong></p>
  659. <table id="t3">
  660. <thead>
  661. <tr><th scope="col" class="t3" id="n1">Program Type</th><th scope="col" class="t3" id="n2">2008</th><th scope="col" class="t3" id="n3">2010</th></tr></thead>
  662. <tbody><tr class="table-alternate row1"> <td class="start">Associate degree</td><td>1</td><td>1</td></tr><tr class= "table-noalt row2"><td class="start">Undergraduate degree</td><td>5</td><td>9</td></tr><tr class="table-alternate row3"> <td class="start">Master's degree</td><td>65</td><td>70</td></tr><tr class= "table-noalt row4"><td class="start">PhD degree</td><td>26</td><td>30</td></tr><tr class="table-alternate row5"> <td class="start">Certificate</td><td>36</td><td>43</td></tr><tr class= "table-noalt row6"><td class="start">Short courses</td><td>13</td><td>14</td></tr><tr class="table-alternate row7"> <td class="start">Online courses</td><td>28</td><td>33</td></tr><tr class= "table-noalt row8"><td class="start">10 x 10 programs</td><td>3</td><td>10</td></tr></tbody></table>
  663. <div align="center"> </div>
  664. <p style="text-align: center;"><span style="font-size: large;"><strong>Health Informatics Organizations</strong></span></p>
  665. <p>The following organizations are considered among the most important and influential in health information technology.</p>
  666. <p><strong>American Medical Informatics Association (AMIA) </strong></p>
  667. <ul>
  668. <li>Founded in 1990 by the merger of the American Association for Medical Systems and Informatics, the American College of Medical Informatics and the Symposium on Computer Applications in Medical Care</li>
  669. <li>In 2006 it became a member of the Council of Medical Specialty Societies</li>
  670. <li>As of 2009 AMIA has greater than 4000 members from clinical, technical and research sectors</li>
  671. <li>They support five main domains: translational bioinformatics, clinical research informatics, health informatics, consumer health informatics and public health informatics</li>
  672. <li>Members are from 65 countries</li>
  673. <li>In 2009 Dr. Ted Shortliffe became the President and CEO of AMIA</li>
  674. <li>Web site includes job exchange, academic programs, fellowships, grants, and an e-newsletter</li>
  675. <li>Membership includes subscription to the Journal of the American Medical Informatics Association (JAMIA)</li>
  676. <li>Opportunity to join a working group (20) to discuss issues and formulate white papers</li>
  677. <li>Annual national symposium in the fall as well as a spring Congress <sup>57</sup></li>
  678. </ul>
  679. <p><strong>International Medical Informatics Association (IMIA)</strong></p>
  680. <ul>
  681. <li>Began in 1967 but became officially an independent endorsed organization in 1989</li>
  682. <li>Membership consists of national, institutional, affiliate members and honorary fellows</li>
  683. <li>AMIA is the US representative to the IMIA</li>
  684. <li>IMIA supports the triennial World Congress on Medical and Health Informatics, known as Medinfo</li>
  685. <li>IMIA supports multiple working groups and special interest groups</li>
  686. <li>Official journals: International Journal of Medical Informatics, Methods of Information in Science and Applied Clinical Informatics <sup>79</sup></li>
  687. </ul>
  688. <p><strong>Healthcare Information and Management Systems Society (HIMSS) </strong></p>
  689. <ul>
  690. <li>Founded in 1961</li>
  691. <li>As of 2011 has over 35,000 individual members and 520 corporate members</li>
  692. <li>Annual symposium with more than 20,000 attendees</li>
  693. <li>Professional certification</li>
  694. <li>Educational publications, books and CD-ROMs</li>
  695. <li>Web conferences on health informatics topics</li>
  696. <li>HIMSS Health IT Body of Knowledge resource site</li>
  697. <li>HIMSS Analytics is a subsidiary that provides data and analytic expertise</li>
  698. <li>Surveys on multiple topics <sup>80</sup><em></em></li>
  699. </ul>
  700. <p><strong>American Health Information Management Association (AHIMA)</strong></p>
  701. <ul>
  702. <li>Founded in 1928 for medical records librarians</li>
  703. <li>As of 2011 has more than 61,000 members</li>
  704. <li>It began as a medical records association but now includes any healthcare worker involved in information management. It offers seven credentials related to four areas: Coding, HIM, privacy and analysis</li>
  705. <li>“AHIMA supports the common goal of applying modern technology to and advancing best practices in health information management”<sup>56</sup></li>
  706. <li>AHIMA web site has an excellent HIT resource section</li>
  707. <li>AHIMA Journal and Perspectives in Health Information Management are available on their web site at no cost <sup>56</sup></li>
  708. </ul>
  709. <p><strong>Alliance for Nursing Informatics (ANI) </strong></p>
  710. <ul>
  711. <li>Combines 25 separate nursing informatics organizations</li>
  712. <li>As of 2007 has more than 3,000 members</li>
  713. <li>Sponsored by both the AMIA and HIMSS</li>
  714. <li>Provides a collaborative group for consensus about nursing informatics<sup> 81</sup><em></em></li>
  715. </ul>
  716. <p><strong>American Telemedicine Association</strong><strong><em></em></strong></p>
  717. <ul>
  718. <li>Established in 1993 to promote telecommunications technology</li>
  719. <li>Has transitioned to telemedicine, telehealth or eHealth</li>
  720. <li>Mission is to promote remote access to medical care through telemedicine technology</li>
  721. <li>Web site has a variety of educational resources and telemedicine forms</li>
  722. <li>Official journal is Telemedicine and e-Health<sup>82</sup></li>
  723. </ul>
  724. <p>&nbsp;</p>
  725. <p><strong>Health Informatics Careers</strong></p>
  726. <p>The timing is excellent for a career in health informatics. With the emphasis on increasing adoption of electronic health records and health information exchange, coupled with support from the HITECH Act there has been tremendous interest in health informatics. Healthcare organizations and HIT vendors will be looking for workers who are knowledgeable in both technology and medicine. The Department of Labor estimates that there will be 4% growth in the demand for trained health informatics specialists in multiple areas in the private, federal and military sectors. Informaticians will be needed to design, implement and govern many new technologies arriving on the medical scene, as well as train users. It is anticipated that government reimbursement for EHRs and support for health information exchange will only increase the need for skilled HIT workers. The Biohealthmatics, HIMSS, American Nurse Informatics, Health IT News, AHIMA and the AMIA web sites list multiple interesting health IT jobs. Examples include nurse and physician informaticists, systems analysts, information directors, chief information officers (CIOs) and chief medical information officers (CMIOs).<sup>56-57,</sup> <sup>78, 80-81, 83</sup> Recruiting organizations also maintain multiple listings for health IT jobs.</p>
  727. <p>There are a wide variety of jobs available in the informatics realm. The following are just a few of the known positions in a healthcare organization:</p>
  728. <ul>
  729. <li>Chief Medical Informatics Officer (CMIO) is usually a physician but could be a nurse who generally reports to the Chief Information Officer (CIO), Chief Executive Officer (CEO) or Chief Medical Officer (CMO). This individual usually works with the CIO to develop a strategic IT plan and to help with the implementation of technologies by clinical staff. They are less IT oriented and more oriented towards overcoming the barriers to adoption and they provide feedback and education to their staff. They evaluate new technologies that may transform healthcare and along with the CIO they help develop policies that affect privacy and security. They commonly have a Master’s degree in one of the information sciences.</li>
  730. <li>Nurse Informaticist (NI) is a nurse who can be the CMIO or can be an individual who works in the nursing department, IT department or is dual hatted. There are three million nurses in the United States, compared to about 800,000 physicians so they are a large pool of knowledge workers. Most nurses are trained to think in terms of systems and process improvement. They are therefore extremely valuable for project management, IT systems managers, data analysts, technology adoption, implementation and training. Nurse Informaticians have had a certification exam since 1995 and have published Scope and Standards of their field in 2008.</li>
  731. <li>Clinician Informatician (CI) is a clinician who may have formal training with a variety of degrees or simply may have extensive on the job experience and an aptitude for technology. As a result, they are usually early adopters and clinician champions who help the clinical staff in a healthcare organization understand and accept transformational technologies.<sup>84</sup></li>
  732. </ul>
  733. <p>The American Medical Informatics Association has been in the process of establishing the medical subspecialty of <em>clinical informatics</em>. In September 2011 it was announced that <em>clinical informatics</em> was an approved subspecialty, sponsored by the American Board of Preventive Medicine and the American Board of Pathology. The certification will be available to physicians who have a primary specialty designated through the American Board of Medical Specialties (ABMS). In the 2009 March/April issue of the JAMIA, the core content for this new specialty is spelled out.<sup>85-86</sup> The plan is to make board certification available starting in the Fall of 2012. For the first five years practicing informaticians can apply for board eligibility-based on their work experience and criteria to be established by the ABMS which will include board specialty certification in a primary specialty. After five years candidates must complete training in health informatics that is certified by the Accreditation Council on Graduate Medical Education. Similar certification is being discussed for nurses, pharmacists, PhDs and others.<em></em></p>
  734. <p>Although physicians can become chief medical information officers in very large organizations, the reality is that nurses have the greatest potential to be involved with IT implementation and training at the average hospital or large clinic. Larger, more urban clinics may have the luxury of in-house IT staff, unlike smaller and more rural practices. Notably, nursing already has an informatics specialty certification.</p>
  735. <div class="youtube" style="width: 350; height: 300;"><object width="350" height="300" classid="clsid:d27cdb6e-ae6d-11cf-96b8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/flash/swflash.cab#version=6,0,40,0"><param name="wmode" value="transparent" /><param name="src" value="http://www.youtube.com/v/Zc9i3m8Auqk" /><embed width="350" height="300" type="application/x-shockwave-flash" src="http://www.youtube.com/v/Zc9i3m8Auqk" wmode="transparent" /></object></div>
  736. <p style="text-align: center;"> </p>
  737. <p style="text-align: center;"><span style="font-size: large;"><strong>Health Informatics Resources</strong></span></p>
  738. <p>Because of the rapidly changing nature of technology it is difficult to find resources that are current. It is also difficult to find resources that are not overly technical that would be appropriate for the health informatics neophyte. There are numerous excellent journals, e-journals and e-newsletters that contain articles that discuss important aspects of health information technology. Because health informatics is gaining popularity in the field of medicine many excellent articles can also be found in major medical journals that do not normally focus on technology. As an example, <em>Health Affairs</em>, a bimonthly journal features web exclusives, blogs and e-newsletters of interest to informaticians.87 Furthermore, several informatics-related web sites link to the major national and international health informatics print and online journals.<sup>88</sup>-<sup>90</sup><em></em></p>
  739. <p><strong>Books</strong><strong></strong></p>
  740. <ul>
  741. <li>Handbook of Biomedical Informatics. Wikipedia Books. 2009<sup>91</sup></li>
  742. <li>Guide to Health Informatics. Enrico Coiera. 2003<sup>92</sup></li>
  743. <li>Biomedical informatics: Computer Applications in Health Care and Biomedicine. EH Shortliffe and J Cimino 2006<sup>93</sup></li>
  744. <li>Sabbatini RME Medical Informatics: Concepts, Methodologies, Tools and Applications. J Tan. Four Volumes. 2009<sup>94</sup></li>
  745. </ul>
  746. <p><strong>Journals</strong></p>
  747. <ul>
  748. <li><em>Journal of the American Medical Informatics Association </em>is the bimonthly journal of the AMIA. It features peer reviewed articles that run the gamut from theoretical models to practical solutions. The journal is included in the AMIA membership and is most appropriate for medical and IT professionals.<sup>95</sup><em></em></li>
  749. <li><em>International Journal of Medical Informatics </em>is an international monthly journal that covers information systems, decision support, computerized educational programs and articles aimed at healthcare organizations. In addition to standard articles, they publish short technical articles and reviews.<sup>96</sup><em></em></li>
  750. <li><em>Journal of Biomedical Informatics </em>was formally known as <em>Computers and Biomedical Research.</em> Its editor is Dr. Ted Shortliffe and the emphasis of this bimonthly journal is bioinformatics.<sup>97</sup></li>
  751. <li><em>Journal of AHIMA</em> is published 11 months of the year for its members to stay current in health information management-related issues.<sup>98</sup></li>
  752. <li><em>Computers, Informatics, Nursing (CIN) </em>is a bimonthly print journal targeting the nursing professional. Also offers PDA downloads, RSS feeds and a newsletter.<sup>99</sup></li>
  753. </ul>
  754. <p><strong>E-journals</strong></p>
  755. <ul>
  756. <li><em>BMC Medical Informatics and Decision Making </em>is an open-access free online journal publishing peer-reviewed research articles. This journal is part of BioMed Central, an online publisher of 188 online free full text journals. Because it is an open-access model it allows for much more rapid review and publication, a plus for informatics journals. <sup>100</sup></li>
  757. <li><em>The Open Medical Informatics Journal </em>is another open-access free online journal that publishes health informatics research articles and reviews. Bentham Science publishes 89 online and print journals as well as 200 online open-access journals. An abstract is available online and the full text pdf copy is downloadable. <sup>101</sup></li>
  758. <li><em>Journal of Medical Internet Research </em>(JMIR) is an independent open-access online journal that publishes articles related to medicine and the internet. The articles are free to read in an html format but there is a cost to download articles in a pdf format or to become a member. <sup>102</sup><em></em></li>
  759. <li><em>Electronic Journal of Health Informatics </em>(eJHI) is an Australian-based international open access electronic journal that offers open access (no fee) to both authors and readers. <sup>103</sup></li>
  760. <li><em>Applied Medical Informatics </em>is the fee-based e-journal for the International Medical Informatics Association (IMIA) and the Association of Medical Directors of Information Systems (AMDIS).Its first issue appeared in early 2010. <sup>104</sup></li>
  761. <li><em>Perspectives in Health Information Management </em>is the open-access research peer-reviewed e-journal for AHIMA, published four times a year.<sup>105</sup></li>
  762. </ul>
  763. <p><strong>Informatics-Related E-newsletters</strong></p>
  764. <ul>
  765. <li><em>iHealthBeat </em>is a free daily e-mail newsletter on health information technology published as a courtesy by the California Healthcare Foundation. It is also available through RSS feeds, Twitter and they offer frequent podcasts.<sup>106</sup></li>
  766. <li><em>HealthCareITNews </em>is available as a daily online, RSS feed or print journal. It is published in partnership with HIMSS and reviews broad topics in HIT. They also publish the online e-journals <em>NHINWatch</em>, <em>MobileHealthWatch </em>and<em> Health IT Blog.</em><sup>83</sup></li>
  767. <li><em>eHealth SmartBrief </em>is a free newsletter e-mailed three times weekly. In addition to broad coverage of HIT, they offer RSS feeds, blogs, reader polls and job postings.<sup>107</sup></li>
  768. <li><em>Health Data Management </em>offers a free daily e-newsletter, in addition to their comprehensive web site. The web site offers 20 channels or categories of IT information, webinars, whitepapers, podcasts and RSS feeds.<sup>108</sup></li>
  769. </ul>
  770. <p><strong>Online Resource Sites</strong></p>
  771. <ul>
  772. <li>University of West Florida Health Informatics Program Resource Site augments this book with valuable web links organized in a similar manner as the book chapters. It also includes links to excellent informatics newsletters and journals.1<sup>09</sup><em></em></li>
  773. <li>Agency for Healthcare Research and Quality Knowledge Library is another excellent resource with over 6,000 articles and other resources that discuss health information technology related issues.<sup>110</sup><em></em></li>
  774. <li>HIMSS Health IT Body of Knowledge is a new site to introduce readers to more than 25 topic categories. Articles, tools and guidelines are offered by HIMSS and other resources. <sup>111</sup></li>
  775. <li>Family Medicine Digital Resources Library was created by Dr. Tom Agresta and supported by the Society of Teachers of Family Medicine to promote Informatics education of Family Medicine physicians. In early 2010 they posted 14 presentations that are available to the public.<sup>112</sup></li>
  776. </ul>
  777. <p><strong>Informatics Blogs</strong><strong><em></em></strong></p>
  778. <ul>
  779. <li>HealthIT Buzz is a new Blog offered on the HHS HealthIT web site.1<sup>13</sup></li>
  780. <li>Life as a Health CIO by Dr. John Halamka offers insights from his perspective as CIO of Harvard Medical School and Beth Israel Deaconess Medical Center.<sup>114</sup><em></em></li>
  781. <li>The Health Care Blog is hosted by Matthew Holt and considered to be<em> </em>“a free-wheeling discussion of the latest healthcare developments&#8221; to include health information technology.<sup>115</sup><em></em></li>
  782. <li>E-CareManagement focuses on chronic disease management, technology, strategy, issues and trends. Content is posted by Vince Kuraitis, a HIT consultant for Better Health Technologies.<sup>116</sup><em></em></li>
  783. <li>Health Informatics Forum is an international forum dedicated to health informatics professionals and students. Has extensive web links.<sup>117</sup><em></em></li>
  784. <li>Biological Informatics was created by Marcus Zillman to compile multiple biomedical informatics sites (100+) into one, as well as a blog.<sup>118 </sup> <em></em></li>
  785. <li>HealthTechtopia compiles the top 50 health informatics blogs. It is subdivided into General Health Informatics, Anatomy &amp; Physiology, Information Science and Information Technology, Computer Science, Statistics and Radiology and Medical Imaging.<sup>119</sup><em></em></li>
  786. <li>Biomedexperts is a free social network for biomedical researchers. They have created groups based on what articles have been published by the scientists involved. The claim to have profiles on 1.8 million biomedical researchers from 190 countries. Profiles were generated from the last 10 years of PubMed. In this manner research networks can be created.<sup>120</sup><em></em></li>
  787. <li>EMR &amp; HIPAA Blog hosted by John Lynn covers EHRs, HIPAA and HIT issues.121<em></em></li>
  788. </ul>
  789. <p style="text-align: center;"><span style="font-size: large;"><strong>Future Trends</strong></span></p>
  790. <p align="left">Given the relative newness of health informatics it is not easy to predict the future but some trends seem worth stressing. Many of these points are discussed in more detail in other chapters:</p>
  791. <ul>
  792. <li>Regardless of the speed of HIT adoption in medicine, the technology itself will continue to evolve rapidly. Many disruptive technologies such as tablets will present outstanding opportunities. This will require uniquely well trained individuals who understand the technology and have the clinical experience to know how it can be applied successfully in the field of medicine.</li>
  793. <li>Meaningful Use requirements will continue to evolve (stages 2 and 3) and the bar will be slowly raised. More research is needed to determine what additions are evidence based, worthwhile and will actually impact clinical outcomes.</li>
  794. <li>New healthcare delivery models such as accountable care organizations will be an experiment well worth watching. If they demonstrate cost savings that are strongly supported by HIT we can expect increased adoption.</li>
  795. <li>We anticipate more patient centric medical care and associated technologies. For example, more medical apps for smartphones and personalized genetic profiles.</li>
  796. <li>Mobile technologies will continue to be an important medical platform for patients and clinicians.</li>
  797. <li>Expect more artificial intelligence in medicine (AIM) to retrospectively and prospectively interpret medical data. WellPoint plans to use IBM’s Watson Computer to analyze medical data.<sup>122</sup></li>
  798. </ul>
  799. <p>&nbsp;</p>
  800. <div align="center">
  801. <table style="background-color: #789bf6; width: 624px; border: #000000 1px solid;" border="1" cellspacing="0" cellpadding="0">
  802. <tbody>
  803. <tr>
  804. <td valign="top" width="624">
  805. <p style="text-align: center;"><span style="font-size: 12px;"><strong>Key Points</strong></span></p>
  806. </td>
  807. </tr>
  808. <tr>
  809. <td valign="top" width="624">
  810. <ul>
  811. <li><span style="font-size: 12px;"><strong>Health informatics focuses on the science of information, as applied to healthcare and biomedicine</strong></span></li>
  812. <li><span style="font-size: 12px;"><strong>Health information technology (HIT) holds promise for improving healthcare quality, reducing costs and expediting the exchange of information</strong></span></li>
  813. <li><span style="font-size: 12px;"><strong>The HITECH Act programs have been a major driver of HIT in the United States</strong></span></li>
  814. <li><span style="font-size: 12px;"><strong>Barriers to widespread adoption of HIT include: time, cost, privacy, change in workflow, legal, behavioral barriers and lack of high quality studies </strong></span></li>
  815. <li><span style="font-size: 12px;"><strong>Many new degree and certificate programs are available in health informatics</strong></span></li>
  816. <li><span style="font-size: 12px;"><strong>A variety of health informatics resources are available for a wide audience </strong></span></li>
  817. <li><span style="font-size: 12px;"><strong>Interoperability and health information exchange is a major priority of the federal government but is challenged by sustainable issues</strong></span></li>
  818. </ul>
  819. </td>
  820. </tr>
  821. </tbody>
  822. </table>
  823. </div>
  824. <p style="text-align: center;"><span style="font-size: large;"><strong>Conclusion</strong></span></p>
  825. <p>Health informatics is a new, exciting and evolving field. New specialties and careers are now possible. In spite of its importance and popularity, significant obstacles remain. Health information technology has the potential to improve medical quality, patient safety, educational resources and patient &#8211; physician communication, while decreasing cost. Although technology holds great promise, it is not the solution for every problem facing medicine today. As noted by Dr. Safran of the American Medical Informatics Association “technology is not the destination, it is the transportation.”79 We must continue to focus on improved patient care as the single most important goal of this new field.<em></em></p>
  826. <p>Research in health informatics is being published at an increasing rate so hopefully new approaches and tools will be evaluated more often and more objectively. Better studies are needed to demonstrate the effects of health information technology on actual patient outcomes and return on investment, rather than studies based solely on surveys and expert opinion.</p>
  827. <p>The effects of the multiple programs supported by the HITECH and Affordable Care Acts will likely be both transformational and challenging for the average practitioner.</p>
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  838. <div class="quizResults">
  839. <div class="quizResultsCopy">
  840. <h3 class="quizScore">Your Score: <span>&nbsp;</span></h3>
  841. <h3 class="quizLevel">Your Ranking: <span>&nbsp;</span></h3>
  842. </div>
  843. </div>
  844. </div>
  845. <p><strong>References</strong></p>
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