Table of Contents:

Information Management

The TIGER competencies define information management as "a process consisting of (a) collecting data, (b) processing the data, and (c) presenting and communicating the processed data as information or knowledge" (TIGER, n.d., p. 11). EHRs are the primary source of stored information that is discussed in this chapter; however, it is important to note that other sources of data also contribute to information management in health care. Among other sources of stored data not discussed in this chapter include the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and National Public Health databases.

Electronic Health Record (EHR)

The EHR is a specific application within the broader category of HIT. It is a data repository that allows health care providers to access a complete collection of patient information using a single resource (see Exhibit 14.1). The EHR often provides the structure for other HIT functions designed to improve patient safety and outcomes such as computerized practitioner order entry (CPOE), clinical decision support (CDS), interoperability, health information exchanges (HIE), and quality improvement (QI).

The 2004 mandate for widespread adoption of EHRs was based on the premise that using the technology would "improve health outcomes by improving quality and efficiency of care, enhancing patients' engagement in their care, and building an infrastructure to digitally exchange health information" (Marcotte et al., 2012, p. 731). Although some evidence exists to support this premise of improved health outcomes (Buntin et al., 2011; King, Patel, Jamoom, & Furukawa, 2014), other studies suggest the adoption of EHRs and HIT alone is not sufficient to improve patient outcomes (Bowman, 2013; Romano & Stafford, 2011; Zhou et al, 2009).

To enhance patient safety and health care efficiency, the HITECH Act not only requires the adoption of EHRs but also mandates that providers show evidence of meaningful use (MU) of the technology by meeting specific objectives during three stages (Marcotte et al, 2012). Each stage of MU includes and expands upon the preceding stage and requires progressively higher levels of technology. Stage 1 objectives emphasize functionality and building an EHR structure capable of capturing required data. Stage 2 builds upon the first stage by underscoring development and application of clinical processes such as integration of laboratory results into the EHR, clinical decision support (CDS), and providing increased patient accessibility to the EHR. Stage 3 objectives are expected to require measurement and documentation of improvement in patient and population health outcomes as well as evidence of increasing interoperability (Marcotte et al, 2012). Stage 1 criteria were finalized in 2010 with hospitals and providers beginning to receive incentive payments in 2011. Stage 2 criteria were finalized in 2012 with full implementation extended from 2014 to 2016 due to difficulties encountered by eligible providers and hospitals in achieving the mandated elements (HiMSS, 2014). Stage 3 requirements are anticipated to be released during the first half of 2015 with implementation beginning in 2017 for those who have participated in stage 2 for a minimum of 2 years (HiMSS, 2014). Detailed overviews of stages 1 and 2 criteria are available on the CMS website at Legislation/EHRIncentivePrograms/Meaningful_Use.html.

Personal Health Record (PHR)

PHRs are EHRs owned and maintained by consumers. Although the exact definition of PHRs continues to evolve (Jordan-Marsh, 2011), they are generally described as repositories for health data contributed by the consumer and providers. PHRs include tools that allow consumers to become more engaged in their own health care decisions (Koeniger-Donohue, Kumar, Hawkins, & Stowell, 2014). The American Medical Informatics Association (AMIA) and the American Health Information Management Association (AHiMA) differentiate the PHR from the EHR based upon who controls the record, with the consumer mamtaining control of the PHR (Jordan-Marsh, 2011).

PHRs can be divided into comprehensive and focused health records. The comprehensive PHR includes information similar to that found in the EHR maintained by health care providers and ideally includes interoperable features capable of importing data from the EHR. Focused PHRs are customized to maintain information related to specific health problems. Microsoft HealthVault and Google Health are examples of comprehensive, proprietary PHRs that are currently available.

Clinical Decision Support Systems (CDSSs)

CDSSs integrate information about a particular patient with a knowledge base from a variety of sources to generate patient-specific alerts and recommendations designed to aid the provider or patient in making health-related decisions (HiMSS, 2010; Hunt, Haynes, Hanna, & Smith, 1998). Bright et al. (2012) classified CDSSs into three categories: classic, information retrieval tools, and knowledge sources.

Classic CDSSs are those systems that automatically provide patient-specific alerts and treatment recommendations based upon preprogrammed criteria (Bright et al., 2012). The classic CDSSs are often an element of EHRs and are commonly related to drug dosages, treatment interactions, and alerts related to patient diagnoses, age, allergies, and potential drug duplications. The second type of CDSSs described by Bright et al. (2012) are "information retrieval tools," the prototype of which is the info button. Infobuttons are often embedded within EHRs or clinical information systems to assist providers in retrieving online information based upon the context of specific patient and/or provider attributes (Del Fiol et al., 2012). "Knowledge resources," the third type of CDSSs, are point-of-care products that allow the health care provider to obtain pertinent information related to the care of the patient at hand. Knowledge resources differ from the other CDSS categories in that the health care provider, not the CDSS, must apply the information accessed from the CDSS to the specific attributes of the patient. Examples of knowledge resources include proprietary products such as UpToDate, Epocrates, and Lexicomp, as well as numerous low-cost and free apps developed by government agencies and professional health care organizations. These resources are designed to be accessed quickly and used at the point of care. They are often available online or by using wireless mobile devices (mHealth CDSS).

The IOM report Crossing the Quality Chasm (IOM, 2001) identified CDSSs as a key approach to enhancing the quality of patient safety and improving patient outcomes by providing access to evidence-based recommendations at the point of care. There is some evidence that the projection made in the IOM reports was correct and CDSSs can be effective in improving the quality of either provider processes and/or patient outcomes (Bright et al, 2012; Jaspers, Smuelers, Vermeulen, & Peute, 2011; Robbins et al., 2012; Roshanov et al, 2011). However, recent systematic reviews of CDSSs indicate the results of randomized controlled trials investigating CDSSs are mixed, demonstrating some improvement in provider processes but limited evidence of improved patient outcomes (Bright et al., 2012; Jaspers et al., 2011; Roshanov et al, 2011).


The terms telemedicine and telehealth are often differentiated into whether health care providers use the technology as a means of interaction with patients (telemedicine) or consumers use the technology to access health information (telehealth) (Kvedar, Coye, & Everett, 2014; Sprague, 2014). However, because this differentiation between telemedicine and telehealth is not universally defined, for the purposes of this chapter, the more encompassing term of teleheath will be used in reference to the use of telecommunications in health care (see Exhibit 14.1).

Telehealth can be divided into three categories: interactive videoconferencing, store and forward (asynchronous) technology, and remote patient monitoring. Interactive videoconferencing uses live video between providers and patients, most often for specialty consultations. The technology brings the expert to the patient and primary care provider, eliminating distance as a barrier to accessing specialty medical care. Psychiatry, dermatology, and cardiology are examples of specialty consultations routinely conducted via teleheath. Project ECHO (Extension for Community Healthcare Outcomes) is a highly acclaimed telehealth project that was adopted in New Mexico to provide specialty care to patients with chronic hepatitis C in remote areas of the state. It has now spread to other regions of the United States and encompasses other chronic illnesses. This program uses videoconferencing to provide a venue for specialists and primary care providers to meet virtually to discuss specific patient cases. The interaction provides two advantages by simultaneously providing remote specialty consultations and primary care provider education on specialty care of patients with chronic illness. Other examples of telehealth videoconferencing include its use in emergency departments (EDs) and intensive care units (ICUs) for direct access to specialist care. The Veterans Administration (VA) and Department of Defense have extensive telehealth videoconferencing programs throughout the United States and abroad.

Store and forward telehealth is used for consultations in which simultaneous participation of two or more health care providers is not required. Radiology is currently the most common store and forward telemedicine specialty practice. Radiographs are digitized, transmitted, and read at a distance. The practice is often used when a radiologist is not on site in health care facilities that use outside specialty radiologists (Thrall, 2007). Other store and forward telemedicine specialties include ophthalmology and dermatology.

The third common type of telehealth is remote monitoring, which allows remote observation of patient status using technology. Telemonitoring equipment available for use in the home includes scales, blood pressure monitors, pulse oximeters, glucose monitoring equipment, electrocardiograph monitoring equipment, and peak flow meters, all used to monitor patients from a distance.

The VA and home health agencies have been using remote monitoring successfully for many years and have demonstrated the value of tele-monitoring in the home. Patients are instructed in the use of a variety of devices that connect to a central system to monitor their health conditions. For example, measurements taken using the remote monitoring equipment automatically transmit through a phone line to a central server, which is then accessed by a nurse monitoring a patient caseload. The advantage of the system is that the nurse monitors the patient daily, allowing recognition of subtle changes in the patient's condition from the uploaded data. The nurse can then contact the patient and other health care providers as needed. Studies have found the monitoring process to be very effective in decreasing hospital days and clinic visits (Dang, Dimmick, & Kelkar, 2009).

Mobile Health (mHealth)

mHealth, a subset of telehealth, is the use of mobile or wireless devices by health care providers and/or health care consumers (see Exhibit 14.1). Mobile technology provides a system to continuously monitor patient health status, provides communication between two or more health care providers, provides communication between patients and HPCs, promotes healthy lifestyles, and enhances management of chronic disease (Klonoff, 2013; Kumar et al., 2013). Examples of mHealth devices include smartphones, tablets, personal digital assistants (PDAs), patient monitoring devices, wearable health devices, and laptop computers. Stand-alone patient monitoring devices, such as wearable appliances that continuously track specific health parameters (e.g., pulse, blood pressure and blood glucose) and transmit this information to health care providers, are becoming widely available (Klonoff, 2013). Similar commercial technology for download to smartphones, tablets, and PDAs is being developed and marketed at exponential rates with the reported number of health and medical apps increasing from 1,000 to 20,000 between 2011 and 2013 (HiMSS, 2013).

Health Professional mHealth CDSSs

Health care providers are increasingly using mobile devices to access CDSSs. Popular proprietary CDSS programs such as UpToDate, Epocrates, and Lexicomp were discussed previously. These programs provide a thorough review of the most recent information on disease processes, diagnostics, and treatment choices. Other mobile CDSS apps provide easy access to patient-specific recommendations simply by entering a few quick keystrokes, eliminating the need to search through pages of algorithms and clinical practice guidelines. One such program is the AHRQ electronic preventive services selector (ePSS) software that is available for download to Android, iOS, BlackBerry and Windows devices at no cost. The software provides instant access to U.S. Preventive Services Task Force (USPSTF) recommendations for specific patients based upon provider input into drop-down boxes of patient age, sex, pregnancy status, tobacco use, and sexual activity status. Similar free apps are available from the CDC for selection of contraceptive methods based upon patient health conditions. Other apps are available for a small price from reputable health care associations such as one from the Society for Lower Genital Tract Disorders that provides immediate access to the Updated Consensus Guidelines for Managing Abnormal Cervical Cancer Screening Tests and Cancer Precursors. A full discussion of available mHealth CDSS apps is beyond the scope of this chapter. The reader is encouraged to search government and professional health care websites if interested in mHealth apps that provide quick access to treatment guidelines.

Consumer mHealth CDSSs

Continuous patient monitoring devices with embedded decision support that automatically analyzes patient data and provides immediate treatment advice to the patient are rapidly being implemented in the care of patients with diabetes and other chronic illnesses. Using mHealth technology, the health care provider can preprogram these devices with decision support advice individualized to the patient.

Like all HIT applications, rigorous research is needed to determine the safety and efficacy of mHealth CDSSs (Klonoff, 2013; Kumar et al., 2013; Silberman & Clark, 2012; van Heerden, Tomlinson, & Swartz, 2012). This is especially important in the use of consumer mHealth CDSSs, where it is essential that the reliability of the monitoring devices is established before widespread use to ensure patient safety. Rigorous investigation of mHealth has been met with unique challenges, however, because the devices and apps quickly become obsolete as newer technology is developed and marketed (Kumar et al., 2013).

Consumer Engagement

Consumer engagement is increasingly becoming a national priority for changing the health care landscape. It is asserted that improved patient engagement will result in improved patient outcomes and enhancement of the health of the nation (Ammenwerth et al., 2012; Goldzweig et al., 2013). Two examples of patient engagement, PHRs and mHealth, have previously been discussed. A third mechanism for patient engagement is the increasing use of patient portals. Often provided through EHRs and maintained by health care organizations, these web-based applications enable the consumer to carry out simple tasks, including ordering prescription refills, requesting an appointment, and sending questions to a health care provider. Patient portals allow consumers to view parts of their records under certain circumstances. For example, some laboratory values may be shown to the consumer immediately, primarily those that require little interpretation and are familiar to consumers, such as cholesterol level. Other laboratory results might be revealed to the patient after review and interpretation by the provider. Still others might never be available through the web-based application due to privacy concerns, such as the results of an HIV test or genetic screening result. Overall, consumer response to patient portals has been positive although there is little evidence at this time to support the assertion that patient portals affect patient outcomes (Ammenwerth et al, 2013).

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