Understanding the role information systems play in health care is essential to the success of health care professionals. Data and information share a common thread; they w

Chapter 3 Health Care Information Systems Learning Objectives To be able to identify the major types of administrative and clinical information systems used in health care. To be able to give a brief explanation of the history and evolution of health care information systems. To be able to discuss the key functions and capabilities of electronic health record systems and current adoption rates in hospitals, physician practices, and other settings. To be able to describe the use and adoption of personal health records and patient portals. To be able to discuss current issues pertaining to the use of HCIS systems including interoperability, usability, and health IT safety.

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

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

Major Health Care Information Systems There are two primary categories of health care information systems: administrative and clinical. A simple way to distinguish them is by purpose and the type of data they contain. An administrative information system (or an administrative application) contains primarily administrative or financial data and is generally used to support the management functions and general operations of the health care organization. For example, an administrative information system might contain information used to manage personnel, finances, materials, supplies, or equipment. It might be a system for human resource management, materials management,

patient accounting or billing, or staff scheduling. Revenue cycle management is increasingly important to health care organizations and generally includes the following:

Charge capture Coding and documentation review Managed care contracting Denial management of claims Payment posting Accounts receivable follow-up Patient collections Reporting and benchmarking By contrast, a clinical information system (or clinical application) contains clinical or health-related information used by providers in diagnosing and treating a patient and monitoring that patient's care. Clinical information systems may be departmental systems—such as radiology, pharmacy, or laboratory systems—or clinical decision support, medication administration, computerized provider order entry, or EHR systems, to name a few. They may be limited in their scope to a single area of clinical information (for example, radiology, pharmacy, or laboratory), or they may be comprehensive and cover virtually all aspects of patient care (as an EHR system does, for example). Table 3.1 lists common types of clinical and administrative health care information systems. Table 3.1. Common types of administrative and clinical information systems

Administrative Applications Clinical Applications Patient administration systems Admission, discharge, transfer (ADT) tracks the patient's movement of care in an inpatient setting Ancillary information systems Laboratory information supports collection, verification, and reporting of laboratory tests Registration may be coupled with ADT system; includes patient demographic and insurance information as well as date of visit(s), provider information Scheduling aids in the scheduling of patient visits; includes information on patients, providers, date and time of visit, rooms, equipment, other resources Patient billing or accounts receivable includes all information needed to submit claims and monitor submission and reimbursement status Utilization management tracks use and appropriateness of care Other administrative and financial systems Accounts payable monitors money owed to other organizations for purchased products and services General ledger monitors general financial management and reporting Radiology information supports digital image generation (picture archiving and communication systems [PACS]), image analysis, image management Pharmacy information supports medication ordering, dispensing, and inventory control; drug compatibility checks; allergy screening; medication administration Other clinical information systems

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

History and Evolution Since the 1960s, the development and use of health care information systems has changed dramatically with advances in technology and the impact of environmental influences and payment reform (see Figure 3.1). In the 1960s to 1970s, health care executives invested primarily in administrative and financial information systems that could automate the patient billing process and facilitate accurate Medicare cost reporting. The administrative applications

that were used were generally found in large hospitals, such as those affiliated with academic medical centers. These larger health care organizations were often the only ones with the resources and staff available to develop, implement, and support such systems. It was common for these facilities to develop their own administrative and financial applications in-house in what were then known as “data processing” departments. The systems themselves ran on large mainframe computers, which had to be housed in large, environmentally controlled settings. Recognizing that small, community-based hospitals could not bear the cost of an in-house, mainframe system, leading vendors began to offer shared systems, so called because they enabled hospitals to share the use of a mainframe with other hospitals. Vendors typically charged participating hospitals for computer time and storage, for the number of terminal connects, and for reports.

Figure 3.1 History and evolution of health care information systems (1960s to today)

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

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

Rapid technological advances continued into the 1990s, with the most profound being the evolution and widespread use of the Internet and electronic mail (e-mail). The Internet provided health care consumers, patients, providers, and industries with access to the World Wide Web and new and innovative opportunities to access care, promote services, and share information.

Concurrently, the Institute of Medicine (IOM, 1991) published its first landmark report The Computer-Based Patient Record: An Essential Technology for Health Care, which called for the widespread adoption of computerized patient records (CPRs) as the standard by the year 2001. CPRs were the precursor to what we refer to today as EHR systems. Numerous studies had revealed the problems with paper-based medical records (Burnum, 1989; Hershey, McAloon, & Bertram, 1989; IOM, 1991). Records are often illegible, incomplete, or unavailable when and where they are needed. They lack any type of active decision-support capability and make data collection and analysis very cumbersome. This passive role for the medical record was no longer sufficient. Health care providers needed access to active tools that afforded them clinical decision-support capabilities and access to the latest relevant research findings, reminders, alerts, and other knowledge aids. Along with patients, they needed access to systems that would support the integration of care across the continuum.

By the start of the new millennium, health care quality and patient safety emerged as top priorities. In 2000, the IOM published the report To Err Is Human: Building a Safer Health Care System, which brought national attention to research estimating that 44,000 to 98,000 patients die each year to medical errors. Since then, additional reports have indicated that these figures are grossly underestimated and the incidents of medical errors are much higher (Classen et al., 2011; James, 2013; Makary & Daniel, 2016;). A subsequent report, Patient Safety: Achieving a New Standard of Care (2004), called for health care providers to adopt information technology to help prevent and reduce errors because of illegible prescriptions, drug-to-drug interactions, and lost medical records, for example.

By 2009, the US government launched an “unprecedented effort to reengineer” the way we capture, store, and use health information (Blumenthal, 2011, p. 2323). This effort was realized in the Health Information Technology for Economic and Clinical Health (HITECH) Act. Nearly $30 billion was set aside over a ten-year period to support the adoption and Meaningful Use of EHRs and other types of health information technology with the goal of improving health and health care. Rarely, if ever, have we seen public investments in the advancement of health information technology of this magnitude (Blumenthal, 2011). Interest also grew in engaging patients more fully in providing access to their EHR through patient portals or the concept of a PHR. We have also seen significant advances in telemedicine and telehealth, cloud computing, and mobile applications that monitor and track a wide range of health data.

Electronic Health Records Features and Functions Let's first examine the features and functions of an EHR because it is core to patient care. An EHR can electronically collect and store patient data, supply that information to providers on request, permit clinicians to enter orders directly into a computerized provider order entry (CPOE) system, and advise health care practitioners by providing decision-support tools such as reminders, alerts, and access to the latest research findings or appropriate evidence-based guidelines. CPOE at its most basic level is a computer application that accepts provider orders electronically, replacing handwritten or verbal orders and prescriptions. Most CPOE systems provide physicians and other providers with decision-support capabilities at the point of ordering.

For example, an order for a laboratory test might trigger an alert to the provider that the test has already been ordered and the results are pending. An order for a drug to which the patient is allergic might trigger an alert warning to the provider of an alternative drug. These decision-support capabilities make the EHR far more robust than a digital version of the paper medical record.

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

Figure 3.2 Sample drug alert screen

Source: Epic. Used with permission.

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

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

Source: Epic.

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

functional EHRs provide order entry capabilities (beyond ordering medications) and decision-support capabilities.

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

Figure 3.4 Percent of non-federal acute care hospitals with adoption of at least a basic EHR with notes system and position of a certified EHR: 2008–2015

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

Source: ONC (2015a).

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

Ninety-eight percent of physicians in community health centers had adopted an EHR, three-quarters of them using a certified EHR. Not surprisingly, physicians in solo and small group practice

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