Key Advances in Clinical Informatics: Transforming Health Care through Health Information Technology

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Part I

An Introduction to Clinical Informatics

Outline

Chapter 1 An Overview of Clinical Informatics

Chapter 2 Inpatient Clinical Information Systems

Chapter 3 Outpatient Clinical Information Systems

Chapter 4 Electronic Clinical Documentation

Chapter 5 Interoperability

Chapter 6 Privacy and Security

Chapter 1

An Overview of Clinical Informatics

Kathrin M. Cresswell¹, David W. Bates², Adam Wright³ and Aziz Sheikh¹,⁴,    ¹The University of Edinburgh, Edinburgh, United Kingdom,    ²Harvard Medical School; Harvard School of Public Health, Boston, MA, United States,    ³Harvard Medical School; Partners HealthCare, Boston, MA, United States,    ⁴Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, United States

Abstract

This chapter sets the scene for the book, beginning with a brief history of clinical informatics, followed by an outline of key concepts and definitions, discussion of the overall existing empirical evidence base, and consideration of contextual and evaluation factors that are important to consider when approaching the field. It concludes with a section on key future developments. Throughout, reference is made to more detailed discussions of key issues discussed in subsequent chapters.

Keywords

Clinical informatics; eHealth; medical informatics; health information technology

Introduction: The Evolving and Expanding Role of Information Technology

Information technology (IT) is increasingly pervading everything we do. For instance, worldwide statistics show that more people have access to a mobile phone than to working toilets (Times Magazine, 2013), and while the existence of genome editing may have seemed unimaginable just a few years ago, tools have now equipped scientists with the ability to genetically modify human embryos (Liang et al., 2015). Such developments are occurring exponentially with an increasing array of technological features, designs, and data generated from applications impacting on all aspects of human life including food, health, energy, and the environment. The first personal computer was released in 1974, and within a mere seven decades, by 2045 computing power is expected to exceed that of all human brains combined. This technological singularity is a widely debated hypothetical moment in time where artificial intelligence (AI) will surpass our cognitive limitations (Kurzweil, 2005).

Not surprisingly, most industries have drawn heavily on technological developments to transform their services, and although somewhat lagging behind, healthcare is following suit, driven by increasing pressures on health systems to improve quality, reduce errors, and increase efficiency (Travis et al., 2004). This chapter will provide an overview of past, present, and future developments in the area of clinical informatics. It will introduce the most important concepts and definitions, provide a high-level perspective of the existing empirical evidence base in relation to the effectiveness of health IT (HIT), and provide a contextual overview of the chapters in this book.

The following three sections serve as an overall structure: Section 1 introduces clinical informatics as a discipline, outlining key terms and tensions; Section 2 tackles issues surrounding the impact of clinical informatics applications on quality, safety, and efficiency of care; and Section 3 delves deeper into future developments that are likely to dominate the sector in the foreseeable future, though undoubtedly many other developments will occur that cannot yet be predicted.

A Brief History of the Field of Clinical Informatics

The first use of HIT in a clinical setting can be traced back to 1952, when Dr. Arthur Rappoport reported his experiences with using the McBee Manual Punch Card in a pathology laboratory setting (Porth and Lübke, 1996). This was followed by the emergence of hospital information systems in the 1960s, with the Latter Day Saints Hospital in Utah (USA, now Intermountain) being the first to implement this in 1967. Others, including The COmputer STored Ambulatory Record and the Regenstrief Medical Record System, followed. The Health Evaluation through Logical Programming system had the ability to collect demographic and clinical data with decision support features. It is used to the present day, but may be replaced by Cerner in the near future (Gardner et al., 1999; Healthcare IT News, 2015). The development of clinical specialty systems for laboratory, radiology, pathology, radiotherapy, pharmacy, and primary care followed. Integration of these was not possible until the 1980s, when larger integrated medical information systems emerged, facilitated by the development of high-speed communication networks. In 1985, the first patient scheduling software called Cadence was launched by Epic Systems, followed by EpicCare in 1992. Subsequent developments in the 21st century have been characterized by growing clinical uses of technologies drawing on an ever increasing array of data sources (including patients and various care settings), mobile applications that allow patients and providers to gather and view data on the go, and the exploitation of digital data generated for reuse (Cresswell and Sheikh, 2016). An overview of key historical developments is provided in Box 1.1.

Box 1.1

Key Historical Developments in Clinical Informatics

¹,²,³

1949: establishment of the German Society for Medical Documentation, Computer Science and Statistics (first professional informatics organization)

1950s: first time IT applied to the field of medicine in biomedical context

1952: Arthur Rappoport reported on using the McBee Manual Punch Card in a laboratory setting

1960s: first peer-reviewed informatics journals launched

1960s: emergence of hospital information systems that included digital patient information

1967: Latter Day Saints Hospital in Utah first hospital to use an Electronic Health Record (EHR)

1970s: first mention of English term medical informatics

1960s/70s: clinical specialty systems were developed for laboratory, radiology, pathology, radiotherapy, pharmacy, and primary care

1970: first Computerized Physician Order Entry system used in El Caminio Hospital, California

1980s: development of local, national, and worldwide high-speed communication networks

1980s: emergence of larger integrated medical information systems

1985: first patient scheduling software launched (Cadence)

1988: creation of the American Medical Informatics Association

1990s: emergence of the internet facilitating exchange of clinical data

1992: EpicCare launched

2000s: clinical users could use IT to view/order tests/medications from various databases

2010s: emergence of cloud networks and integration of data across multiple locations

¹Collen, M.F., 2015. A History of Medical Informatics in the United States. Ball, M.J. (Ed.), Springer, New York.

²Hayes, G.M., Barnett, D.E. (Eds.), 2008. UK Health Computing: Recollections and Reflections. British Computer Society.

³http://www.healthworkscollective.com/frankie-xavier/162251/long-road-digitization-history-healthcare-informatics

What Is Clinical Informatics?

Clinical informatics represents a highly interdisciplinary field that involves "analyzing, designing, implementing, and evaluating information and communication systems that enhance individual and population health outcomes, improve patient care, and strengthen the clinician-patient relationship (Gardner et al., 2009)." As such, the field can be positioned at the intersection of clinical care, the health system, and information and communication technology. Its interdisciplinary nature is a core feature, and it includes clinical providers such as physicians, nurses, and pharmacists, but also medical librarians, information scientists, and communication specialists, to name just a few of the types of professionals involved.

Related terms that are sometimes used interchangeably include health informatics, medical informatics, and eHealth. There are a range of published definitions with varying understandings of the field in the published literature—the exponential development of applications and increasing convergence of functionalities complicates navigating the area further (Boogerd et al., 2015; Oh et al., 2005). Various chapters of this book will delve deeper into specific applications and associated concepts. These begin with overviews of inpatient systems, outpatient systems, and clinical documentation in Chapters 2, 3, and 4, respectively.

Overall, existing applications can broadly be divided into three categories (Black et al., 2011): (1) systems informing and supporting decisions (see Chapter 10 on medication, laboratory, and radiology testing; and Chapter 12 on knowledge management and computerized guidelines); (2) storage and management of data (Chapter 11 on bioinformatics and precision medicine); and (3) delivery of expertise and care at a distance (see Chapter 13 on mobile health).

There has been an increasing emergence of clinical informatics as a discipline (Greenes and Shortliffe, 1990). Associated activity includes the growing demand for organizational capacity in this area, but also the need for academic expertise to develop new educational trajectories and evaluate ongoing implementation, adoption, and optimization activities associated with the increasing range of technologies. Formal accreditation and certification of clinical informatics expertise are closely associated activities that are presently receiving attention (Fridsma, 2015; Gadd et al., 2016; Shortliffe et al., 2016), particularly in the United States (Middleton, 2014), but also many other countries.

Empirical Evidence Surrounding Effectiveness of Clinical Informatics Applications

Clinical informatics applications have been shown to result in a number of benefits including, among others, the prevention of life-threatening allergic reactions to medication through systems facilitating clinical decision making (Bates et al., 1999; Kaushal et al., 2003), reductions in prescribing errors (Avery et al., 2012), and the ability to manage diabetes and high blood pressure remotely (Wild et al., 2016). However, it is often difficult to demonstrate the clinical effectiveness and cost-effectiveness of HIT (Black et al., 2011; Chaudhry et al., 2006; Jones et al., 2014), this at least in part reflecting the need for workflow reconfiguration and systems optimization (Cresswell et al., 2017).

Chapter 8 will explore HIT and value in more detail, while Chapter 14 will examine the impact of technology on safety.

There is increasing understanding of the potential risks associated with the introduction of new technologies in healthcare settings (Black et al., 2011; Buntin et al., 2011). The most commonly examined areas in this respect include privacy, confidentiality, and security (see Chapter 6: Privacy and Security); effects on work practices and interdisciplinary working; and difficulties surrounding accessibility of data (Ash et al., 2004; Barrows and Clayton, 1996; Harrison et al., 2007).

The underlying reasons for this overall lack of evidence may partly be due to difficulties evaluating technologies, as these are often embedded in wider organizational change initiatives resulting in difficulties attributing effects (Campbell et al., 2000; Lilford et al., 2009). There is also a growing literature reexamining traditional evaluation paradigms advocating randomized controlled trials (RCTs) as the gold standard, toward a more flexible use of various evaluation methods including qualitative, mixed methods, human factors, and engineering-based approaches (Cresswell et al., 2017; Klasnja et al., 2011; Yusof et al., 2008). This is because RCTs tend to be costly and time-consuming (resulting in issues surrounding the applicability of results and major challenges associated with changing software/technology) and may not be appropriate for effectively evaluating the range of different rapidly changing existing applications. Conversely, it can be easy and less costly to conduct clinical trials using EHRs, and in industry for example it is now routine to employ AB testing, where when it is not clear which of two options is superior, both are tried for half a user base. Whichever is more effective at achieving the desired outcome (e.g., a digital purchase) is then used as the default.

Clinical Informatics in Context

Having touched upon the challenges inherent in evaluating clinical informatics applications above, it is important to briefly discuss the importance of appreciating the range of contextual dimensions and various stakeholders that are involved in deploying and adopting technologies in healthcare (Fig. 1.1) (Cresswell and Sheikh, 2009).

Figure 1.1 Overview of contextual factors. Factors important for the successful implementation of EHRs identified in the literature. Adopted from Cresswell, K., Sheikh, A., 2009. The NHS Care Record Service (NHS CRS): recommendations from the literature on successful implementation and adoption. J. Innov. Health Inform. 17 (3), 153–160.

Contextual aspects may include technical features (e.g., usability), social contexts (e.g., changes in work practices), organizational strategies (relating to implementation and optimization), and wider sociopolitical dimensions (such as state and federal approaches to implementation and regulatory environments). Stakeholders within these various contexts include patients, academics, providers, vendors, developers, third-sector organizations, and policy makers. All of these have different interests that need to be aligned for initiatives to be successful. Chapter 9 will discuss organizational issues in more detail, while Chapter 7 will examine policy considerations and associated international strategies to promote clinical informatics implementations.

Empirical evaluations that take this range of stakeholders and contextual factors into account are now widely advocated (Catwell and Sheikh, 2009). These should involve a longitudinal component to facilitate tracing developments over time, playing an active role in aligning interests through providing formative feedback to stakeholders in participating healthcare settings, and summative feedback to policy makers (Ammenwerth et al., 2003).

Visions Surrounding Future Developments in Clinical Informatics

A central theme of this book will be examining state-of-the-art developments in clinical informatics, exploring progress toward realizing the vision of more effective, better quality, and safer care through the application of IT in healthcare settings. Key current developments in this respect are likely to include the creation of integrated health informatics infrastructures where data can be seamlessly shared between settings and applications (see Chapter 5 on interoperability, Chapter 16 on application programming interfaces, and Chapter 17 on cloud-based computing), and the creation of learning health systems that effectively draw on digital data collected in a variety of settings and by a variety of stakeholders to improve performance and services (see Chapter 15 on predictive analytics and population health, Chapter 18 on social/consumer informatics, and Chapter 19 on machine learning and AI).

It is important to place this work in the context of a continuously evolving field, where innovations are created at a rapid pace. HIT has, if appropriately conceptualized, developed and implemented, the potential to continue to have major transformative effects on healthcare and can through so doing help deal with one of the most pressing healthcare challenges facing healthcare worldwide, namely to achieve more in terms of health gain for less and to support patient involvement/enablement/empowerment.

Conclusions

Significant international policy efforts and investments in clinical informatics are taking place to improve adoption and use of healthcare IT, with the underlying aim of improving healthcare safety, quality, and efficiency. We have outlined some of the past, present, and potential future developments in this domain and provided an overview of definitions and core issues in the field. Subsequent chapters in this book aim to share state-of-the-art developments with nonexpert clinical and academic audiences across the globe.

References

1. Ammenwerth E, Gräber S, Herrmann G, Bürkle T, König J. Evaluation of health information systems—problems and challenges. Int J Med Inform. 2003;71(2):125–135.

2. Ash JS, Berg M, Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J Am Med Inform Assoc. 2004;11(2):104–112.

3. Barrows RC, Clayton PD. Privacy, confidentiality, and electronic medical records. J Am Med Inform Assoc. 1996;3(2):139–148.

4. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc. 1999;6(4):313–321.

5. Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med. 2011;8(1):e1000387.

6. Boogerd EA, Arts T, Engelen LJ, van De Belt TH. What is eHealth: time for an update? JMIR Res Protoc. 2015;4(1):e29.

7. Buntin MB, Burke MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff. 2011;30(3):464–471.

8. Campbell M, Fitzpatrick R, Haines A, Kinmonth AL. Framework for design and evaluation of complex interventions to improve health. Br Med J. 2000;321(7262):694.

9. Catwell L, Sheikh A. Evaluating eHealth interventions: the need for continuous systemic evaluation. PLoS Med. 2009;6(8):e1000126.

10. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144(10):742–752.

11. Cresswell K, Sheikh A. The NHS Care Record Service (NHS CRS): recommendations from the literature on successful implementation and adoption. J Innov Health Inform. 2009;17(3):153–160.

12. Cresswell KM, Sheikh A. Key global developments in health information technology. J R Soc Med. 2016;109(8):299–302.

13. Cresswell KM, Bates DW, Sheikh A. Ten key considerations for the successful optimization of large-scale health information technology. J Am Med Inform Assoc. 2017;24(1):182–187.

14. Fridsma DB. Update on informatics-focused certification and accreditation activities. J Am Med Inform Assoc. 2015;22(2):489–490.

15. Gadd CS, Williamson JJ, Steen EB, Fridsma DB. Creating advanced health informatics certification. J Am Med Inform Assoc. 2016;23(4):848–850.

16. Gardner RM, Pryor TA, Warner HR. The HELP hospital information system: update 1998. Int J Med Inform. 1999;54(3):169–182.

17. Gardner RM, Overhage JM, Steen EB, et al. Core content for the subspecialty of clinical informatics. J Am Med Inform Assoc. 2009;16(2):153–157.

18. Greenes RA, Shortliffe EH. Medical informatics: an emerging academic discipline and institutional priority. JAMA. 1990;263(8):1114–1120.

19. Harrison MI, Koppel R, Bar-Lev S. Unintended consequences of information technologies in health care—an interactive sociotechnical analysis. J Am Med Inform Assoc. 2007;14(5):542–549.

20. Healthcare IT News, 2015. Intermountain live with Cerner EHR. Available from: http://www.healthcareitnews.com/news/intermountain-live-cerner-ehr (last accessed 01.01.17).

21. Jones SS, Rudin RS, Perry T, Shekelle PG. Health information technology: an updated systematic review with a focus on meaningful use. Ann Intern Med. 2014;160(1):48–54.

22. Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003;163(12):1409–1416.

23. Klasnja, P., Consolvo, S., Pratt, W., 2011. How to evaluate technologies for health behavior change in HCI research. In: Proceedings of the SIGCHI Conference on Human Factors in Computing Systems. ACM, pp. 3063–3072.

24. Kurzweil R. The Singularity Is Near: When Humans Transcend Biology Penguin 2005.

25. Liang P, Xu Y, Zhang X, et al. CRISPR/Cas9-mediated gene editing in human tripronuclear zygotes. Protein Cell. 2015;6:363–372.

26. Lilford RJ, Foster J, Pringle M. Evaluating eHealth: how to make evaluation more methodologically robust. PLoS Med. 2009;6(11):e1000186.

27. Middleton B. First diplomates board certified in the subspecialty of clinical informatics. J Am Med Inform Assoc. 2014;21(2):384.

28. Oh H, Rizo C, Enkin M, Jadad A. What is eHealth (3): a systematic review of published definitions. J Med Internet Res. 2005;7(1):e1.

29. Porth AJ, Lübke B. History of computer-assisted data processing in the medical laboratory. Eur J Clin Chem Clin Biochem. 1996;34(3):215–229.

30. Shortliffe EH, Detmer DE, Munger BS. Clinical informatics: emergence of a new profession. In Clinical Informatics Study Guide Springer International Publishing 2016;3–21.

31. Time Magazine, 2013. More people have cell phones than toilets, U.N. Study shows. <http://newsfeed.time.com/2013/03/25/more-people-have-cell-phones-than-toilets-u-n-study-shows/> (accessed 12.07.16).

32. Travis P, Bennett S, Haines A, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004;364(9437):900–906.

33. Wild SH, Hanley J, Lewis SC, et al. Supported telemonitoring and glycemic control in people with type 2 diabetes: the telescot diabetes pragmatic multicenter randomized controlled trial. PLoS Med. 2016;13(7):e1002098.

34. Yusof MM, Papazafeiropoulou A, Paul RJ, Stergioulas LK. Investigating evaluation frameworks for health information systems. Int J Med Inform. 2008;77(6):377–385.

Recommended Further Reading

1. Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet. 2012;379(9823):1310–1319.

2. Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med. 2011;8(1):e1000387.

3. Coiera E. Guide to Health Informatics CRC Press 2015.

4. Collen MF. A History of Medical Informatics in the United States New York: Springer; 2015.

5. Cresswell, K., Blandford, A., Sheikh, A., Reconsidering paradigms for the evaluation of health information technology. Submitted to JAMIA.

6. Hovenga EJ. Health Informatics: An Overview IOS Press 2010.

Chapter 2

Inpatient Clinical Information Systems

Kathrin M. Cresswell¹ and Aziz Sheikh¹,²,    ¹The University of Edinburgh, Edinburgh, United Kingdom,    ²Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, United States

Abstract

Electronic health records (EHRs) are increasingly being deployed as digital inpatient information systems of clinical and administrative data. The interplay of social and technical factors is important when considering effective implementation and adoption strategies in busy, complex hospital environments. These systems offer considerable potential to enhance the safety, quality, and efficiency of hospital healthcare provision, but realizing these benefits is heavily dependent on system optimization. The optimization of inpatient information systems is best conceptualized as an ongoing journey. Developments such as the move to cloud-based EHRs, the opening up of application program interfaces, the opportunity to connect with other digitized hospital infrastructure such as smart infusion pumps and beds, patient access to EHRs, and developments in approaches to and capacity for interrogating standalone and linked EHR-based datasets in real time present major new opportunities to improve outcomes. These developments will however also bring important new ethical, organizational, and privacy related challenges that society will need to address.

Keywords

Hospital; healthcare; information technology; inpatient; sociotechnical factors

Introduction

Hospitals are typically large complex organizational environments, where many different specialties and groups of healthcare professionals work together to provide patient care (Czarniawska, 1997). The introduction of health information technology (HIT) presents significant opportunities to reduce variations in the quality of care, improve safety, and also reduce the currently high and ultimately unsustainable costs of healthcare provision. Opportunities, for instance, include central management of large volumes of electronic data for quality improvement (e.g., helping to identify and target high-risk clinical areas) (Murdoch and Detsky, 2013), sophisticated decision support for different specialties (e.g., to support prescribing decisions in those with impaired kidney function) (Kaushal et al., 2003), and improved streamlining of work practices of healthcare workers (e.g., facilitating ordering of diagnostic tests) (Brandao de Souza, 2009). There are however also important challenges. These may be technical, such as the creation of large-scale infrastructures required to integrate different specialty systems, or social, including workarounds being introduced by intended users (e.g., if the system hinders users fulfilling their tasks such as nurses’ inability to any longer request X-rays in the new online image requesting system) (Lapointe and Rivard, 2005).

This chapter will begin by discussing the range of different technical inpatient information system functionality currently used in healthcare settings internationally. This will be followed by considering the complex high-pressure social and organizational environments into which these technologies are implemented and the impact of these contextual factors on adoption and implementation. A discussion of potential risks emerging from these sociotechnical challenges and some suggestions on how to mitigate these then follows. In order to plan for obstacles and minimize risks, we argue that implementation of digital inpatient systems is best conceptualized as a journey, with continuing optimization activities required to ensure ongoing development to suit changing needs of different stakeholder groups. The chapter will conclude with some international examples of sophisticated system implementation and optimization, and a brief discussion on potential future technological