Chapter 3

Health Information
Technology
Computer Based Electronic Health
Records (EHR)
• 1990s: Advent of commercially produced,
“off the shelf” systems for large volume
sales to hospitals; lack of standardization
continues to prevent interface across
software platforms.
• 2004: President Bush established Office
of the National Coordinator for Health
Information Technology (“the ONC”) as
first step in creation of the Nationwide
Health Network.
 Electronic Health Records EHR
• 2009: The American Recovery and
Reinvestment Act (ARRA) through the
HITECH ACT, designated $20.8 billion
through Medicare and Medicaid to
incentivize physicians and health care
organizations to adopt and achieve
“Meaningful Use” of EHRs.
 Shortcomings...

• HITECH programs and funding drive toward

EHR adoption, but:
• HITECH did not incentivize interoperability
between systems across institutional
boundaries.
– Large numbers of disparate “siloed” systems
unable to exchange patient records in an
effective, efficient, or secure manner
– They are developed by multiple software firms
that are designed to work only with their firm
Historical Challenges in
Implementing HIT
 Technology
• Often mistaken belief that the “right
technology” or “right EHR” is most
important
– “Right technology” requires a relational
database, a computer network and computer
workstation; these are easy compared with
needs for policies, procedures, and cultural
changes required for successful
implementation.
 Policies and Procedures
• Policies and procedures describe in
exquisite detail the ways an organization
carries out its work
– HIT implementers must understand all
details, but:
o Many details are not documented or actual
processes differ from those documented.
o Implementing an HIT system often brings
undocumented procedures to light for the first
time—a root cause of many system failures.
 Culture
• Institutional and organizational culture is the
most critical, least studied, and least
understood of all HIT implementation
components
– Individuals must change the ways they work
– Requires steadfast administrative and clinical
leadership with both moral and financial support
– Requires training, patience, and staff who
understand both clinical and technical issues
– Individuals must be willing to change
 Other Challenges in Implementing
HIT
• Costs versus benefits:
– Purchase and operation of EHR system are
major investments for large organizations;
even more so for small physician practice
groups; all bear costs of purchase, staff
training, ongoing maintenance fees
– Economies of scale are lower for large
organizations, but both small and large
organizations may experience losses due to
service duplications, e.g., redundant testing
The Federal Government’s Response
to HIT Implementation Challenges
(1 of 3)

• Federal financial incentives for EHR

“Meaningful use” attempt to bridge chasm
between costs and benefits for large health
care organizations and private practices.
– ONC Mission: Promote development of nationwide HIT
infrastructure; lead standards development; certify HIT
products; coordinate HIT policy; plan for HIT adoption and
HIE; establish governance for Nationwide Health
Information Network.*
*Your professor, having worked in hospital systems, and working closely
with IT on projects for many years is dubious that this will happen in the
next decade, or two.
The Federal Government’s Response to
HIT Implementation Challenges
(2 of 3)

– ONC organization (Fig. 3.2): $60 million budget

– HIT Policy and Standards Committees with multiple
expert workgroups composed of payers, academics,
and health care industry representatives
– Adoption facilitation funding: Health care training for
IT professionals; standards development across
EHR platforms, annual surveys to track adoptions*

* Your professor continues her skepticism of implementation and concern over

gaming systems.
The Federal Government’s Response to
HIT Implementation Challenges
(3 of 3)

– Meaningful Use incentives: Eligible Professionals

(EP) and Eligible Hospitals (EH) for incentive
payments based on CMS standards and meeting
objectives in three stages. See Table 3.1.
– Stage 1: Capturing patient data in a standard format
and sharing it with patients and health professionals
– “Modified Stage 2” revised and simplified based on
many complaints and challenges reported by EPs
and EHs
o By Nov 2014, 25.2% of EPs and 43.1% of EHs had
met Stage 2 requirements.
 HIT Opportunities (1 of 3)
• Driving force for HIT: Overcome human
limitations associated with information
volume, complexity and fatigue
– Combine humans’ intuitive strengths with
computers’ data retention strengths to create a
hybrid with intuition and tireless data processing
capacity that outperforms either EHR element
alone (Computerized Decision Support System-
CDSS)*
* Okay, in fairness, the VA system had an early DSS by 2001. I was working
there. But, it could only run numbers, like how many patients with psychosis
are we treating? (The top VA diagnosis, following chemical dependency.)
 HIT Opportunities (2 of 3)
– CDSS: Electronic information-based system
matching individual patient data with a
computerized knowledge base; e.g.,
evidence-based clinical practice guidelines to
assist providers with diagnoses,
recommendations, and treatment plans
– CPOE (Computerized Physician Order
Entry): A component of a CDSS enabling
physicians and other providers to enter
orders for patient treatment such as
prescriptions or consultations.
 HIT Opportunities (3 of 3)
– Error prevention and appropriateness
assurance: “soft stops” and “hard stops”
• AHRQ CDSS Systematic Review, evidence:
– Strong: Ordering, completing preventive care
and recommended treatments
– Moderate: Appropriate clinical studies; reduces
morbidity and cost; increases provider
satisfaction
– Low: Efficiency of user, hospital length of stay,
mortality, health quality of life, medical errors
 Health Information Exchanges (1 of 2)
• Barriers to inter-institutional/provider
information sharing
– No common platform for multiple vendor
systems
– Highly voluminous, complex data
– HIPAA security and privacy regulations
– Continuous advancements in knowledge and
technology
• Regional Health Information Organizations
(RHIOs) create systems, agreements,
processes, technology for information exchange
 Health Information Exchanges (2 of 2)
• Health Information Exchanges (HIEs):
Organized and governed by RHIOs,
networks enabling basic interoperability
among records maintained by individual
providers and organizations. Participating
organizations configure “interface
engines” to convert data format to that
used by an HIE.
 Health Information Exchanges
(Data Standardization) (1 of 2)
• Logical Observations Indexes Names and
Codes (LOINC): Uniquely defines codes
for clinical data transmission between
computer systems (70,000 codes for lab
tests and clinical observations; 419
different codes for blood pressure)
– Unique codes allow receiving computers to
provide exact interpretations (semantic
interoperability)
 Health Information Exchanges
(Data Standardization) (2 of 2)
• Systematic Nomenclature of Medicine
(SNOMED, SNOMED Clinical Terms: Tissue
pathology and clinical observations
• Unified Medical Language System (UMLS):
National Library of Medicine tools for
mapping between and discovery of 200+
biomedically-related terminology standards.
 Health Information Exchange
Architectures (1 of 3)
• Monolithic Model (Fig. 3-4): Member
institutions transmit copies of clinical data to
one central repository; patients’
comprehensive data in one place, one
format
Disadvantages:
– Variable timeliness of transmissions
– “Mixed data” makes all institutions responsible
for HIPAA security
– Difficult individual institution control of data
 Health Information Exchange
Architectures (2 of 3)
• Federated Model (Fig. 3-5): Data resides
within each institution’s system; HIE
database contains only a Master Patient
Index of unique institution patient record
numbers and sufficient demographic data
to distinguish patients of same name;
information is mapped to all institution-
specific patient identifiers in the HIE; HIE
stores no clinical data.
 Health Information Exchange
Architectures (3 of 3)
• (Federated Model, cont’d): Real-time
information is available per episode of
care by authorized user.
Advantages
– Each institution maintains complete control
– Trans-institutional data are accurate up-to-
the-minute
 HIE Support and Sustainability
• Most HIEs heavily subsidized by federal
research grant funding; RHIOs have not
developed business models applicable to
all communities to sustain their HIEs.
– HIE revenue generating tactics: Charging
payers for access to HIE records to aid
claims processing and for comprehensive
quality reports to track physician/health plan
outcomes or to assist in meeting “meaningful
use” criteria.
 Information Blocking
• Some EHR vendors suspected of actively
making it difficult for their systems to
interface to other vendors’ systems, i.e.,
“Information Blocking”
– Sparked congressional investigation in 2015
– Report confirmed occurrences, but difficult to
prove conclusively
– ONC taking series of actions to address
 ICD-9 to ICD-10 Switchover
• International Classification of Disease Version 9
billing codes (ICD-9) used for years
• ICD-10 now required by CMS and others to
more specifically define exacting diagnoses
• No 1-to-1 mapping due to many more ICD-10
codes (over 65,000) as compared to ICD-9
(about 13,000)
• ICD-10 requires much more information to code
correctly
 Veterans Administration Health
Information System Model
• Unlike U.S. healthcare delivery system, the
VA is a single-payer model with a universal
EHR system with CDSS and CPOE.
– Closed system with single set of data
standards
– Centralized administration to which all are
accountable
– One pharmaceutical formulary; one provider
group (VA employees); one laboratory system,
etc.
 EHR Adoption Progress
• The National Center for Health Statistics
(NCHS) tracks EHR use in outpatient
setting since 2006.
• Uses exacting definition of “Any” and
“Basic” EHRs
Physicians
– 2013: 78% of office-based physicians used
“Any” EHR system and 48% “Basic” system
(Figure 3-6).
 EHR Adoption Progress (1 of 2)

Reproduced from CDC/NCHS, National Ambulatory

Medical Care Survey and National Ambulatory Medical
Care Survey, Electronic Health Records Survey NCHS
Data Brief No 143 28
http://www.cdc.gov/nchs/data/databriefs/db143.htm
 EHR Adoption Progress (2 of 2)

Reproduced from ONC/American Hospital

Association (AHA), AHA Annual Survey
Information Technology Supplement
 E-prescribing Adoption

• Much more successful than overall EHR

adoption (Fig. 3-8)
– Over 70% of physicians now e-prescribing
– Pharmacies at almost universal adoption at
93%
Reproduced from ONC analysis of physician
prescriber data from Surescripts. Denominator from
SK&A 2011 Office Based Providers
Database.https://www.healthit.gov/sites/default/files/on
cdatabriefe-prescribingincreases2014.pdf
 Future Challenges (1 of 2)
• Increasing research evidence supports value
of EHRs in several areas: e.g., improving
preventive care delivery, but also
inconclusive and negative findings.
• Profit-making (proprietary) companies
offered alternative approaches with Personal
Health Records (PHRs) to the Nationwide
Health Information Network with little
success: e.g., Microsoft, Google, other
EHRs.
 Future Challenges (2 of 2)
• PHR problems: Semantic interoperability, vetting
PHR user identities, privacy concerns, absence of
business models to support long-term PHR
operation
• Creation of standardized formats for data portability,
work culture barriers, expense, training
requirements
• 50+ years of effort finally yield recognition of the
variety and complexity of issues*

• *Truthfully, a continuation of the same problems forwarded into a

new generation of software tools and regulatory environment.