Clinical Computing Infrastructure
Construction Of Health IT
Health IT consists of a multiple set of technologies, policies, standards, and user sets. The text and diagram is intended to help put some of the buzzwords into perspective.
A general framework for understanding the levels of health IT from a technical perspective is as follows:
? Application Level:
1. Computerized Provider Order Entry (CPOE), Clinical Decision Support (CDS), Electronic Prescribing (e-prescribing), Electronic Medication Administration Records (eMAR), Results Reporting, Electronic Documentation, Interface Engines, and so on.
? Communication Level:
1. Messaging Standards:
Health Level Seven, ADT,,National Council For Prescription Drug Programs, X12, Digital Imaging and Communications in Medicine, ASTM,etc.
2. Coding Standards:
LOINC, ICD-9, CPT, NDC, RxNorm, SNOMED CT,etc.
? Process Level:
1. Health Information Exchange (HIE), Master Patient Index (MPI), HIPAA Security/Privacy,etc.
? Device Level:
1. Tablet PCs, Application Service Provider (ASP) models, Personal Digital Assistants (PDAs), Bar Coding,etc.
The various facts of health IT can fall into the various other categories. Applications include the following:
• Computerized Provider Order Entry (CPOE)
• Clinical Decision Support (CDS)
• Electronic Prescribing (e-prescribing)
• Electronic Medication Administration Record (eMAR)
• Results Reporting
• Clinical Documentation
• Interface Engines
HEALTH INFORMATION EXCHANGE
Health information Exchange (HIE) implementers confront a number of issues as they convene partners, establish a governance structure, and begin constructing a technical architecture to share data within a diverse consortium.
Best practices for the implementation and use of inpatient CPOE systems.
Presented in this article is the Indiana Network for Patient Care, an integrated citywide medical record system that promotes health quality by enabling efficient access to clinical information throughout the broader population of Indianapolis and the rest of the caregivers within the state of Indiana. Usually begins with a description of the system’s infrastructure, which includes an explanation of how the system accomplishes data integration. This is followed by a series of descriptions and rationales behind the many clinical applications that interface with these data. The keys to success for this project include leveraging the value of the integrated data and identifying workflow inefficiencies, having a commitment to standards such as LOINC and SNOMED so all participants use the same standard language, and managing sociopolitical challenges specific to our community. In doing so, some of the factors that we feel contribute to the success of the system are illustrated.
The United Hospital Fund Meeting on Evaluating Health Information Exchange
Health information exchange (HIE) projects are sweeping the nation, with hopes that they will lead to high quality, efficient care, but the literature on their measured benefits remains sparse. To the degree that the field adopts a common set of evaluation strategies, duplicate work can be reduced and meta-analysis will be easier. The United Hospital Fund sponsored a meeting to address HIE evaluation. HIE projects are diverse with many kinds of effects. Assessment of the operation of the HIE infrastructure and of usage should be done for all projects. The immediate business case must be demonstrated for the stakeholders. Rigorous evaluation of the effect on quality may only need to be done for a handful of projects, with simpler process studies elsewhere. Unintended consequences should be monitored. A comprehensive study of return on investment requires an assessment of all effects. Program evaluation across several projects may help set future policy.
A Randomized, Customized Trial of Clinical Information Shared from another Institution
Emergency physicians often must deliver medical care with minimal access to historical clinical information. A pilot randomized, controlled trial of providing information from a large, longitudinal, computer-based patient record system of clinical data from an urban hospital to emergency physicians at either of two urban EDs was conducted. The emergency physician received information both as a printed abstract and by means of online access to the computer-based patient record. We assessed charges, hospital admissions, repeat visits to EDs, and the emergency physicians satisfaction with the information.
This pilot study is the first to demonstrate the feasibility of sharing clinical information between different health care systems. We observed a trend toward cost savings at one of two hospitals and no differences in the quality measures we studied. Our experience underscores the difficulties inherent in studying the effects of community-wide health care interventions on cost and quality of ED care.
State and Community-based efforts to Foster Interoparability
The MidSouth eHealth Alliance is developing a comprehensive health information infrastructure supporting providers in three Tennessee counties. The greatest contribution of a formal RHIO might be to articulate and support a single, common legal and technical framework for realizing an interoperable regional health information infrastructure. The state will have to assume a greater role in setting and adopting guidelines for RHIOs; regions should continue their oversight of the technical infrastructure and enforcing regional policies. Success in the alliance’s first year is the result of sustained leadership (and capital), a systematic assessment of regional needs and capabilities, a flexible technical architecture, and a critical review of best practices from four different data exchange models already operating in other states. Long-term evolution to a truly interoperable health information infrastructure will depend on the extent to which the alliance demonstrates value to consumers and practitioners.
Building an Interoparable Regional Health Information
One of the key challenges of architecting electronic record sharing solutions that are scalable and can provide acceptable performance is how to create a longitudinal record for a patient when the desired data will be stored in several distributed point-of-service systems. This paper will review the design and standards selection process made byIntegrating the Healthcare Enterprise, a multinational collaborative of care providers and developers that analyzed a variety of approaches. Guidance will be offered to architects of regional health information organizations to take advantage of this experience and leverage the IHE Technical Framework, its testing processes, and tools to accelerate their projects and facilitate the interfacing of EHR systems serving different care settings from different vendors or developers. The implementation experience in 2005-2006 of the IHE Integration Profile specifications supporting an interoperable RHIO solution among various EHR systems from more than 30 vendors will be analyzed, with key lessons summarized.
The Santa Barbara County Care Data Exchange
The Santa Barbara County Care Data Exchange was once one of the most ambitious and publicized U.S. health information exchange (HIE) efforts. Eight years after its inception, and several months after providing some data, the Santa Barbara Project shut down operations. Despite its developed HIE infrastructure, participants found no compelling value proposition in initial HIE services. Although there are several proximate causes for the project’s slow progress – California HealthCare Foundation (CHCF) grant money, lack of community leadership, vendor limitations, and the duration of the process – the main underlying cause was lack of a compelling value proposition for Santa Barbara organizations. Even with fewer technology delays and more community leadership, other regional health information organizations (RHIOs) may also stumble over HIE service-value propositions without some combination of grants, incentives, and mandates that develop initial RHIO infrastructure and services and ensure provision of unprofitable yet socially valuable services.
AREAS OF CURRENT INVESTIGATION
More recent developments include the Nationwide Health Information Network (NHIN) initiative and the advent of Personal Health Records (PHRs). The NHIN is a secure backbone concept that links existing regional HIEs through a standard set of “core services” that allows one HIE to share data with another HIE. This effectively creates a “network of networks” that spans the Nation and provides stakeholders (payers, consumers, providers, policymakers, and administrators) with the ability to access data from across institutions, States, and repositories.
PHRs allow consumers to track their clinical data, medication histories and clinical notes and share them with other providers in an effort to reduce the fragmentation that exists in health care today. EMRs and HIEs can directly connect to these PHRs.
Applications that run stand-alone on the client or server devices.
One flow of data within health care organizations begins with multiple specialized systems that efficiently collect and store specific data within hospital information systems. For instance, a patient may have blood drawn and analyzed by the hospital laboratory. Specialized laboratory information systems have been developed to collect all the data about processed specimens. Similar systems have been developed for radiology, billing, pharmacy, and other services. These hospital information systems are designed to serve narrow functions with great efficiency, but this situation results in multiple silos of information.
HL7 (Health Level 7) is the most ubiquitous and overarching messaging standard. It can encapsulate many kinds of clinical information. ADT (Admission/Discharge/Transfer) messages signal patient registration events within different clinical service delivery settings (radiology, laboratory, pharmacy, outpatient clinic, ER, and so on). NCPDP codes are for transmitting medication data. DICOM is used to transmit radiology images and reports.
Coding Standards includes many types as well:
1. LOINC is a laboratory and clinical observation coding standard.
2. CPT codes for procedures.
3. ICD codes for diagnoses.
4. NDC and RxNorm code for medications.
5. SNOMED CT codes for clinical concepts.
Bar-coded Medication Administration
Each year, an estimated 7,000 deaths are linked to medication errors. These errors occur at all stages of the medication-use process, including ordering, transcribing, dispensing, and administration. One widely discussed method of reducing errors during the administration phase is “Bar-Coded Medication Administration. BCMA pairs implementation of an information technology solution called “Electronic Medication Administration Record” (eMAR) with item-specific identification (bar-coding). BCMA helps users to be in compliance with the “Five Rights” of medication administration: right patient, right dose, right route, right time, and right medication.
Health IT for Improved Disease Management
Chronic diseases such as heart disease, cancer, and diabetes–are placing a growing burden on the U.S. health care system. In response, some health care organizations are instituting chronic disease management programs to reduce the incidence of preventable hospitalizations and adverse events by more effectively and comprehensively managing the health of patients with chronic conditions. Many of these organizations are implementing health information technology to facilitate their chronic disease management programs.
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