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7 Using Information Technology Throughout this report, the committee has emphasized that health care should be supported by systems that are carefully and consciously designed to produce care that is safe, effective, patient-centered, timely, efficient, and equitable. This chapter examines the critical role of information technology (IT) in the design of those systems. IT has enormous potential to improve the quality of health care with regard to all six of the aims set forth in Chapter 2. In the area of safety, there is growing evidence that automated order entry systems can reduce errors in drug prescrib- ing and dosing (Bates et al., 1997, 1998a, 1999). In the area of effectiveness, there is considerable evidence that automated reminder systems improve compli- ance with clinical practice guidelines (Balas et al., 2000; Shea et al., 1996), and some promising studies, although few in number, indicate that computer-assisted diagnosis and management can improve quality (Durieux et al., 2000; Evans et al., 1998). There are many opportunities to use IT to make care more patient- centered, for example, by facilitating access to clinical knowledge through un- derstandable and reliable Web sites and online support groups (Cain et al., 2000); customized health education and disease management messages (Goldsmith, 2000); and the use of clinical decision support systems to tailor information according to an individual patientâs characteristics, genetic makeup, and specific conditions (Garibaldi, 1998) (see Chapter 6 for additional discussion). Both patients and clinicians can benefit from improvements in timeliness through the use of Internet-based communication (i.e., e-visits, telemedicine) and immediate access to automated clinical information, diagnostic tests, and treatment results. Clinical decision support systems have been shown to improve efficiency by 164
USING INFORMATION TECHNOLOGY 165 reducing redundant laboratory tests (Bates et al., 1998b). Finally, Internet-based health communication can enhance equity by providing a broader array of options for interacting with clinicians, although this can only happen if all people, regard- less of race, ethnicity, socioeconomic status, geographic location, and other fac- tors, have access to the technology infrastructure (Science Panel on Interactive Communication and Health, 1999). The committee believes IT must play a central role in the redesign of the health care system if a substantial improvement in health care quality is to be achieved during the coming decade. This is a theme underlying many of the topics addressed in this report. Chapter 5 emphasizes the importance of a strong information infrastructure in supporting efforts to reengineer care processes, manage the burgeoning clinical knowledge base, coordinate patient care across clinicians and settings and over time, support multidisciplinary team functioning, and facilitate performance and outcome measurements for improvement and ac- countability. Chapter 6 stresses the importance of building such an infrastructure to support evidence-based practice, including the provision of more organized and reliable information sources on the Internet for both consumers and clini- cians, and the development and application of clinical decision support tools. And Chapter 9 considers the need to build information-rich environments for undergraduate and graduate health education, as well as the potential to enhance continuing education through Internet-based programs. Central to many IT applications is the automation of patient-specific clinical information. Efforts to automate clinical data date back several decades, and have tended to focus on creation of an automated medical record. For example, in 1991 the IOM set forth a vision and issued a strong call for nationwide imple- mentation of computer-based patient records (Institute of Medicine, 1991). But progress has been slow. It is important to recognize that a fully electronic medi- cal record, including all types of patient information, is not necessary to achieve many if not most of the benefits of automated clinical data. For example, use of medication order entry systems using data on patient diagnoses, current medica- tions, and history of drug interactions or allergies can result in sizable reductions in prescribing errors (Bates et al., 1998a; Leapfrog Group, 2000). The automa- tion and linking of data on services provided to patients in ambulatory and insti- tutional settings (e.g., encounters, procedures, ancillary tests) would provide a rich source of information for quality measurement and improvement purposes. The challenges of applying IT to health care should not be underestimated. Consumers and policy makers share concerns about the privacy and confidential- ity of these data (Cain et al., 2000). The United States still lacks national stan- dards for the protection of health data and the capture, storage, communication, processing, and presentation of health information (Work Group on Computer- ization of Patient Records, 2000). Sizable capital investments will also be re- quired. Moreover, widespread adoption of many IT applications will require
166 CROSSING THE QUALITY CHASM behavioral adaptations on the part of large numbers of patients, clinicians, and organizations. The committee believes solutions to these barriers can and must be found given the critical importance of the judicious application of IT to addressing the nationâs health care quality concerns. The time has come to establish a national health information infrastructure that will encourage public- and private-sector investments in IT while providing adequate safeguards for consumers. As dis- cussed in Chapter 4, a sizable portion of the resources of the recommended Health Care Quality Innovation Fund (see Recommendation 6) should be in- vested in projects that implement and evaluate IT applications and are likely to contribute to quality improvements. Recommendation 9: Congress, the executive branch, leaders of health care organizations, public and private purchasers, and health informatics associations and vendors should make a renewed na- tional commitment to building an information infrastructure to sup- port health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade. POTENTIAL BENEFITS OF INFORMATION TECHNOLOGY In less than 5 years, the IT landscape has changed dramatically. The share of households with Internet access grew from 26.2 percent in December 1998 to 41.5 percent in August 2000, an increase of 58 percent in 20 months (U.S. Department of Commerce, 2000). The explosive growth of the Internet has opened up many new promising applications that have implications for the roles of consumers, clinicians, and organizations in the delivery of health care services. A recent report by the National Research Council of The National Academies identified six major health-related application domains: consumer health, clini- cal care, administrative and financial transactions, public health, professional education, and research (see Table 7-1) (National Research Council, 2000). Many of the applications in these domains, such as online searching for health informa- tion by patients and providers, are commonplace. Others, such as remote and virtual surgery and simulations of surgical procedures, are in the early stages of development. â¢ Consumer Health. A September 1999 poll conducted by Harris Interac- tive found that 70 million of the 97 million American adults who were online had searched for health information in the last year (Cain et al., 2000). Consumers are using the Internet to search for health information, to obtain information
USING INFORMATION TECHNOLOGY 167 useful in selecting a health plan or provider, and to participate in formal and informal support groups. Comparative performance data are available on the Internet for many health plans (National Committee for Quality Assurance, 2000), and depending on the geographic area of interest, there may be relevant informa- tion on hospitals and providers. The Internet can also be used to post customized health education messages according to a personâs profile and needs (Kendall and Levine, 1997). â¢ Clinical Care. The Internet has the potential to make health care delivery more timely and responsive to consumer preferences. As discussed in Chapter 6, the Internet is playing an increasingly critical role in making scientific publica- tions, syntheses of the evidence, practice guidelines, and other tools required to support evidence-based practice available to both patients and clinicians. Ex- amples of information technologies that are of growing importance in the health care arena are reminder systems (Alemi et al., 1996); telemedicine applications, such as teleradiology and e-mail; and online prescribing (National Health Policy Forum, 2000; Schiff and Rucker, 1998). â¢ Administrative and Financial Transactions. To date, the area in which information systems have been used most extensively in health care has been to improve the service and efficiency of various administrative and financial trans- actions (Starr, 1997; Turban et al., 1996). In 1999, almost 65 percent of the 4.6 billion medical claims processed by private and public health insurance plans were transmitted electronically (Goldsmith, 2000). â¢ Public Health. IT can be used to improve the quality of health care at the population level. Applications include incident reporting, videoconferencing among public health officials during emergency situations, disease surveillance, transfer of epidemiology maps and other image files for monitoring of the spread of disease, delivery of alerts and other information to clinicians and health work- ers, and maintenance of registries. â¢ Professional Education. The Internet can be a powerful tool for under- graduate, graduate, and continuing medical education for all types of health pro- fessionals. A variety of Internet-based educational programs have made their curricula and training materials available on the Web. There are also educational videos, lectures, virtual classrooms, and simulation programs to teach surgical skills. â¢ Research. The Internet opens up many options for improving research- ersâ access to databases and literature, enhancing collegial interaction, and short- ening the time required to conduct certain types of research and disseminate results to the field. These applications are already gaining widespread accep- tance. Of course, not all computer health applications are Internet-based. There are computerized order entry systems, reminder systems, and other applications that run on legacy systems (older IT systems, often built around mainframes, owned
168 TABLE 7-1 Health-Related Applications for the Internet Application Domain Types of Applications Consumer health â¢ Online searching for health information â¢ Searches of medical literature â¢ Downloading of educational videos â¢ Search for a clinician or health plan â¢ Participation in chat and support groups â¢ Online access to personal health records â¢ Completion of patient surveys Clinical care â¢ Searches of medical literature â¢ Routine care delivery (e.g., e-visits) and chronic disease management (e.g., periodic reports on health conditions to clinicians) â¢ Reminders and alerts; decision support systems â¢ Consultations among clinicians (perhaps involving manipulation of digital images) â¢ Remote monitoring of patients in home and long-term care settings â¢ Transfer of medical records and images â¢ Remote and virtual surgery Administrative and â¢ Videoconferencing with real-time sharing of documents financial transactions â¢ Enrollment of patients â¢ Scheduling of appointments â¢ Billing for services, payment of providers â¢ Certain aspects of clinician credentialing â¢ Consumer access to information about health plans, participating providers, eligibility for procedures, covered drugs in formulary, etc.
Public health â¢ Videoconferencing among public health officials during emergency situations â¢ Incident reporting â¢ Collection of information from local public health departments â¢ Surveillance for emerging diseases or epidemics â¢ Transfer of epidemiology maps or other image files for monitoring the spread of a disease â¢ Delivery of alerts and other information to providers and health workers Professional education â¢ Accessing reference material â¢ Distance education with real-time transmission of lectures or prerecorded videos â¢ Real-time consultations with experts about difficult cases â¢ Virtual classrooms, distributed collaborative projects and discussions â¢ Simulation of surgical procedures â¢ Virtual exploration of three-dimensional environments Health services, â¢ Health services research using administrative and clinical data biomedical, and â¢ Searching of remote databases and professional literature clinical outcomes â¢ Collaboration among researchers, peer review, interactive virtual conferences research â¢ Control of experimental equipment, such as electron microscopes, visual feedback from remote instrumentation â¢ Real-time monitoring of compliance with protocols â¢ Transfer of large datasets between computers for high-speed computation and comparisons â¢ Enrolling of populations in clinical trials SOURCE: Adapted from National Research Council, 2000. 169
170 CROSSING THE QUALITY CHASM by some hospitals, medical centers, and group practices) (Turban et al., 1996). In the future, however, the Internet will likely be the platform of choice for many if not most health applications because of the ready access it provides to both consumers and clinicians, as well as other financial and technical considerations. It must be acknowledged that although the potential benefits of IT are com- pelling, the evidence in support of these benefits varies greatly by type of appli- cation. As discussed in Chapter 6, there is strong evidence to support the effec- tiveness of computerized reminder systems in improving compliance with practice guidelines. For computerized medication order entry systems, recent studies substantiate reductions in errors and unnecessary services, but such studies are few in number (Bates et al., 1998a). A recent review of 80 controlled trials carried out between 1966 and 1996 concluded that telephone-based distance medicine or telemedicine technologies are beneficial in the areas of preventive care and the management of osteoarthritis, cardiac rehabilitation, and diabetes care (Balas et al., 1997). In a review of 15 controlled trials in which diabetic patients received computer-generated information, it was found that 12 of the 15 trials documented positive clinical outcomes, such as improved hemoglobin and blood glucose levels (Balas et al., 1998). In summary, the strength of the evidence on the effects of various IT applica- tions is highly varied. Many applications, such as simulation of surgical proce- dures for educational purposes and remote and virtual surgery, are in the early developmental stages. Others may be highly promising, but their adoption and testing are hampered by the lack of computerized patient information (e.g., com- puter-aided diagnosis), regulatory or legal impediments (e.g., e-mail communica- tions across state lines), and payment issues (e.g., for e-visits). Still other appli- cations, such as telemedicine, have not been rigorously evaluated (Grigsby and Sanders, 1998; Institute of Medicine, 1996). AUTOMATED CLINICAL INFORMATION Much of the potential of IT to improve quality is predicated on the automa- tion of at least some types of clinical data. Automated clinical data are required by many of the most promising IT applications, including computer-aided deci- sion support systems that couple medical evidence with patient-specific clinical data to assist clinicians and patients in making diagnoses and evaluating treat- ment options (see Chapter 6) (Burger, 1997; Weed and Weed, 1999). Automated clinical data also open up the potential to glean medical knowledge from patient care (Institute of Medicine, 2000). An example is the extraordinary gains in cancer survival for children as compared with adults, attributable in part to the participation of virtually all pediatric cancer patients in clinical trials that system- atically collect, pool, and analyze data and disseminate results to all participants (Simone and Lyons, 2000). Automated clinical and administrative data also enable many types of health service research applications, such as assessment of
USING INFORMATION TECHNOLOGY 171 clinical outcomes associated with alternative treatment options and care pro- cesses; identification of best practices; and evaluation of the effects of different methods of financing, organizing, and delivering services. Both private- and public-sector groups have identified the need to move forward expeditiously with the automation of clinical information. In 1991, the IOM issued a report concluding that computer-based patient records are an âes- sential technologyâ for health care and that electronic records should be the standard for medical and all other records related to health care. In that same year, the U.S. General Accounting Office issued a report stating that automated medical records offer great potential to improve patient care, increase efficiency, and reduce costs, and calling for the development of standards to ensure uniform electronic recording and transmission of medical information. A 1993 report of the U.S. General Accounting Office called for leadership and the acceleration of efforts to develop standards. In 1997, a revised edition of the 1991 IOM report noted the strides that had been made in the power and capacity of personal computers and other computer-based technologies, the remarkable growth of the Internet for research and some health applications, the increasing level of com- puter literacy among health professionals and the public, and the linkage of organizations and individuals in local and regional networks that were beginning to tackle the development of population databases. Some health care organizations have made important advances, but overall progress has been slow. In a few large systemsâmost notably the health systems of the Department of Veterans Health Affairsâintegrated electronic records sys- tems have been implemented. There are also examples of robust, well-integrated hospital-based information systems (National Research Council, 2000), such as Intermountain Health Care (in Salt Lake City, Utah), but they are few and notable for their rarity. Many other organizations have automated major portions of clinical information systemsâlaboratory data, order entry, and the likeâand others are on their way to becoming paperless in the next few years (McDonald et al., 1997; Warden and Lawrence, 2000). There are numerous barriers to the automation of clinical information. The remainder of this section addresses four of these barriers: privacy concerns, the need for standards, financial requirements, and human factors issues. Privacy Concerns and the Need for Standards Two of the greatest impediments to the widespread automation of clinical information are the absence of national policies pertaining to privacy, security, and confidentiality and the lack of standards for the coding and exchange of clinical information (e.g., definitions and nomenclature, patient identifiers, and electronic transfer) (Dwyer, 1999; Kleinke, 1998; McDonald, 1998; U.S. Depart- ment of Commerce, 1994). Indeed, the issues of protecting privacy and data standardization are closely interrelated. In 1998, for example, plans of the De-
172 CROSSING THE QUALITY CHASM partment of Health and Human Services to issue recommendations for establish- ing unique patient identifiers were put on hold in response to public outcry over potential violations of medical privacy (Goldman, 1998). There is general agreement that privacy protections are needed for consum- ers, but there is also recognition that unless carefully balanced, such protections may limit the future prospects of IT (Detmer, 2000a). Public opinion polls conducted during the last decade document high and increasing levels of concern about privacy, raising questions about whether peopleâs fear of violations of their privacy may lead some to forego seeking necessary health services or to withhold personal information from clinicians (Goldman, 1998). Others point out that, if too stringent, privacy protections will impede the adoption of many IT applica- tions critical to addressing health care quality concerns (Detmer, 2000a). The demands of health care with regard to security and availability are both more stringent and more varied than those of other industries (Institute of Medi- cine, 1994). Automated records can make it much easier for hackers to assemble lists or to find (or alter) information about individuals. At the same time, there are many different sources and types of health data, and clinical information must be available to all clinicians and others involved in care delivery whenever needed. Well-crafted policies can be implemented to ensure timely access for those with a valid need to access the data, including treating clinicians and pa- tients, while denying access to unauthorized users. Information security tech- nologies, such as encryption, authentication of both the sender and receiver of data, and audit trails to detect unauthorized users, are available to support such policies (Detmer, 2000a; National Research Council, 1998; U.S. General Ac- counting Office, 1999). Legal enforcement of privacy and confidentiality rights with strong remedies can serve as both a deterrent to unauthorized users and a method of redress for individuals whose privacy rights have been violated. The lack of commonly accepted definitions and nomenclature for the collec- tion and coding of data and standards for the exchange of information has also been recognized as an obstacle to broad adoption of clinical information tech- nologies (Dwyer, 1999; Kleinke, 1998; McDonald, 1998; U.S. Department of Commerce, 1994). Data standards are needed to facilitate sharing and communi- cation of the data across different health care information systems, and to ensure that the data are complete, accurate, and comparable (National Committee on Vital and Health Statistics, 2000). Numerous groups, including the American National Standards Instituteâs Healthcare Informatics Standards Board, High Level 7, the American Sociey for Testing and Material, the American Standards Committee, the Institute of Electrical and Electronics Engineers, international organizations, and numerous governmental groups, have developed standards for claims forms, datasets, diagnostic and procedure classifications, vocabularies, and messaging formats (Agency for Healthcare Research and Quality, 1999; Cushman and Detmer, 1998). The Library of Medicine has made extensive efforts to standardize vocabulary (including the construction and maintenance of
USING INFORMATION TECHNOLOGY 173 a metathesaurus as part of the unified medical language system). But these efforts, as important as they are, amount to a patchwork of standards that address some areas and not others, and are not adhered to by all users. To begin addressing the need for comprehensive national standards, Con- gress passed the Health Insurance Portability and Accountability Act in 1996, creating a federal mandate to develop standards for all electronic health transmis- sions (Health Care Financing Administration, 2000). The law directed the Secre- tary of Health and Human Services to make recommendations to Congress re- garding the privacy of individually identifiable health information by August 1997, and if Congress failed to pass privacy legislation by August 1999, the Secretary of DHHS was directed to issue health privacy regulations by January 2000. The law also provided that the National Committee on Vital and Health Statistics was to report to the Secretary of DHHS by August 21, 2000, on recom- mendations and legislative proposals pertaining to data standards for patient medi- cal record information (National Committee on Vital and Health Statistics, 2000). Congress failed to enact legislation implementing a comprehensive package of privacy protections by the August 1999 deadline. Therefore, DHHS worked to develop these regulations, based on the Secretaryâs recommendations to Con- gress in 1997 (U.S. Department of Health and Human Services, 1997). These regulations were extremely controversial and generated over 50,000 comments when published in proposed rulemaking form. However, DHHS was able to finalize and announce them in December 2000 (U.S. Department of Health and Human Services, 2000). DHHS also has efforts under way to develop national standards for the definition, collection, coding, and exchange of patient medical record informa- tion, but progress has been slow. In July 2000, the National Committee on Vital Health Statistics forwarded a report to the Secretary of Health and Human Ser- vices addressing a variety of process, technical, organizational, financing, and other issues related to the development of national standards (National Commit- tee on Vital and Health Statistics, 2000). Some progress has been made toward developing coding standards for data elements; however, none has emerged as a comprehensive standard (Institute of Medicine, 1997), and, as noted above, the adoption of a standardized health identifier has been suspended. Chief informa- tion officers and other health care executives have reported they do not believe that health records can be restructured to comply with electronic formats in the time frame required by the law (Shinkman and Jonathan, 2000). In the absence of strong national leadership in establishing standards and defining appropriate legal and regulatory structures for an IT-driven health care delivery system, states and various branches of the federal government have responded to issues and concerns primarily on an ad hoc basis. For example, more than two-thirds of states have made legislative efforts to affect various types of health information practices, resulting in an increasingly complex array of laws (Cushman and Detmer, 1998). In other instances, existing legal and
174 CROSSING THE QUALITY CHASM regulatory structures are being applied to IT issues, creating confusion and prob- ably ineffective oversight. For example, online pharmacies, whereby the physi- cian enters orders into pharmacy computers often using a handheld wireless electronic prescription pad, have given rise to a set of jurisdictional issues. These issues relate both to federal and state responsibilities and, at the federal level, to questions about the responsibilities of different agencies (i.e., Federal Trade Com- mission, Food and Drug Administration, Drug Enforcement Administration, De- partment of Justice, U.S. Customs Service, and U.S. Postal Service) for consumer protection, rooting out of fraud and misinformation, drug quality, advertising of prescription drugs, and importation and domestic mailing of pharmaceutical prod- ucts (National Health Policy Forum, 2000). Financial Requirements The 21st-century health care system will require a significant financial in- vestment in information technologyâfar greater than current investments by most health care organizations. Capital will be needed to purchase and install new technology, while installation of the new systems is likely to produce tempo- rary disruptions in the delivery of patient care and result in sizable short-term costs to manage the transition. Some specialized training and education will also be needed to help the workforce adapt to the new environment. In addition, some health care organizations have invested heavily in legacy systemsâolder computer systems built around mainframes (Turban et al., 1996). There is no easy way to shift from such systems to state-of-the-art information systems based on an open clientâserver architecture, personal computer net- works, and more flexible, nonproprietary protocols. These are important consid- erations for all health care organizations when making decisions about investing in IT. Recent reductions in Medicare payments under the 1997 Balanced Budget Act have likely contributed to an even more cautious approach to long-term investment in technology on the part of many health care institutions. Access to capital may be particularly limited for certain types of health care organizations. Not-for-profit hospitals and health plans must obtain capital from bond rather than equity markets. Many small physician group practices have a limited ability to obtain capital. Large for-profit health plans may have ready capital to invest in IT, but absent strong, long-term partnerships with provider groups, lack the leverage and incentive to implement such systems. These capital decisions are also being made in an environment in which benefits are difficult to quantify. Unlike billing or pharmaceutical transactions, clinical transactions have only an indirect effect on profitability, and demonstrat- ing the value of clinical information systems in improving the quality of care has been difficult although, as discussed above, evidence has begun to accumulate about their usefulness in specific settings and applications. Moreover, as dis-
USING INFORMATION TECHNOLOGY 175 cussed in Chapter 8, current payment policies do not adequately reward improve- ments in quality. There are some indications that the use of IT is slowly becoming more widespread. In 1997, the health information technology industry sold $15 billion worth of products to health care organizations (Kleinke, 1998). The development of Web-based applications for use on the Internet may also open the door to new forms of financing the expenses of IT. For example, if IT shifts from an equip- ment purchase to a service expense, it can be bought on a monthly basis and upgraded easily in response to both technological advances and changes in medi- cal practice. Maintaining up-to-date applications that reflect the evolution of technology and the knowledge base and making them available by subscription at a Web site rather than requiring users in individual organizations to purchase and maintain them is likely to provide great impetus for the development and use of these systems. Human Factors Issues One of the most challenging, and least understood, barriers to the application of useful information technologies in health care relates to human factors. These barriers include both workforce and patient issues. The health care sector is labor-intensive, with about 700,000 physicians, over 2 million nurses, and many other health care workers being involved in the delivery of patient care to varying degrees (Health Resources and Services Ad- ministration, 2000). The workforce is highly variable in terms of IT-related knowledge and experience, and probably also in terms of receptivity to learning or acquiring these skills. Some clinicians may also be wary of embracing new IT applications because of frustrating experience with earlier IT applications that failed to prove useful in solving diagnostic and therapeutic problems (Kassirer, 2000). Moreover, the development of new data infrastructures and the incorpora- tion of new IT applications into clinical practice generally entails disruptions in patient care, resulting in lost revenues for many clinicians. Many IT applications require the forging of new relationships between clini- cians and institutional providers, which may be slow to develop. For example, some have observed that the deeply ingrained economic distrust and cultural conflict between physicians and hospitals has impeded the adoption of IT appli- cations that require Web-based integration (Kleinke, 2000). IT will undoubtedly alter the clinician and patient relationship, and in some cases, these changes may be threatening to clinicians. The standardization and automation of various types of clinical data opens up many new opportunities to make comparative quality data available to consumers who must chose among clinicians, sites of care, and treatment options, and to bolster oversight and ac- countability programs (Kleinke, 2000). The availability of clinical knowledge on
176 CROSSING THE QUALITY CHASM the Internet will lead to more informed patients who will be increasingly likely to question clinician recommendations. Not all patients will embrace these new roles of IT. Although consumers are migrating to the Internet at a rapid pace, there will likely be some proportion of individuals who do not have access either by personal choice or because of economic or other constraints (Conte, 1999). Consequently, there will be a need for the health system to operate in the old and the new, automated ways in parallel for the foreseeable future (Ferguson, 1999). NEED FOR A NATIONAL HEALTH INFORMATION INFRASTRUCTURE Many developments now under way augur well for the future adoption of IT by the health care sector. A growing body of evidence supports the conclusion that various types of IT applications lead to improvements in safety, effective- ness, patient-centeredness, timeliness, efficiency, and equity. Some progress is being made on the specification of standards for protecting privacy, and various private- and public-sector standardization efforts are being undertaken to provide the foundation for a more expansive effort focused on achieving national consen- sus. The extraordinary growth of the Internet has opened up a plethora of new applications; provided a highly accessible platform for tapping the clinical knowl- edge base, running applications, and sharing data; and lowered capital require- ments. Nonetheless, IT has barely touched patient care. The vast majority of clini- cal information is still stored in paper form. Only a fraction of clinicians offer e- mail as a communication option to patients (Hoffman, 1997). Few patients benefit even from very simple decision aids, such as reminder systems, which have been shown repeatedly to improve compliance with practice guidelines. Many medical errors, ubiquitous throughout the health care system, could be prevented if only clinical data were accessible and readable, and prescriptions were entered into automated order entry systems with built-in logic to check for errors and oversights in drug selection and dosing. The pace of change is unac- ceptably slow. Much more can and should be done. To achieve a substantial improvement in quality, the United States, like other industrialized countries, will need to begin developing a comprehensive national health information infrastructure (Detmer, 2000b). As defined by the National Committee on Vital and Health Statistics, such a structure is âa set of technolo- gies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health (Work Group on Computeriza- tion of Patient Records, 2000). A national health information infrastructure is not a centralized government database, but rather ârules for the roadâ that offer a way to connect distributed health data in the framework of a secure network.
USING INFORMATION TECHNOLOGY 177 As discussed above, some elements of such a structure are in various stages of development, but at the current pace, many more years will be required for its completion. To further the development process, the country must move forward expeditiously with the promulgation of national standards to protect data privacy. Moreover, these standards should be reevaluated and fine-tuned periodically to strike the right balance between protecting consumer privacy and providing ac- cess to clinical data for legitimate purposes, such as care delivery, quality evalu- ation, research, and public health (Detmer, 2000a). A high priority for the com- ing 2 years should be to achieve national consensus on comprehensive standards for the definition, collection, coding, and exchange of clinical data. As technological barriers are overcome, much greater attention should be focused on legal, societal, organizational, and cultural issues (Work Group on Computerization of Patient Records, 2000). Legal and regulatory structures that have the unintended consequence of impeding the adoption of useful IT applica- tions must be identified and modified (Moran, 1998). Health care organizations and the health professions will need strong leadership and a clear direction as they move forward with what will be a dramatic transformation of care delivery (Shortliffe, 2000). Finally, efforts should also be made to better inform the American public about IT issues, and to ensure that all individuals have the opportunity to benefit from the extraordinary innovations now under way. The American public should be fully informed of both the benefits and risks of automated clinical data and electronic communication, as well as the various options available for protecting privacy. Steps must also be taken to ensure that all Americans have ready access to the Internet, should they so desire, and that the benefits of IT reach practice settings that serve a disproportionate share of the most vulnerable populations. REFERENCES Agency for Healthcare Research and Quality. 1999. âHealth Care Informatics Standards: Activities of Selected Federal Agencies.â Online. Available at http://www.ahcpr.gov/data/infostd1.htm [accessed Dec. 15, 2000]. Alemi, Farrokh, Sonia A. Allemango, Jeffrey Goldhagen, et al. Comptuer Reminders Improve On- time Immunization Rates. Medical Care 34(10[Supplement]):OS45â51, 1996. Balas, E. Andrew, Suzanne A. Boren, and G. Griffing. Computerized Management of Diabetes: A Synthesis of Controlled Trials. A Paradigm Shift in Health Care Information Systems: Clini- cal Infrastuctures for the 21st Century: Proceedings of the 1998 AMIA Annual Symposium. Christopher G. Chute, ed., 295â9, 1998. Balas, E. Andrew, Farah Jaffrey, Gilad J. Kuperman, et al. Electronic Communication With Patients: Evaluation of Distance Medicine Technology. JAMA 278(2):152â9, 1997. Balas, E. Andrew, Scott Weingarten, Candace T. Garb, et al. Improving Preventive Care by Prompt- ing Physicians. Arch Int Med 160(3):301â8, 2000. Bates, David W., Lucian L. Leape, David J. Cullen, et al. Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors. JAMA 280(15): 1311â6, 1998a.
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