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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5537_Библиотеки_им_академика_М_И_Перельмана.pdf
desires for high quality care in the hospital. When designed or implemented
improperly, HIT can frustrate providers and potentially harm patients.
Nevertheless, the true potential of HIT has yet to be realized. Hospitalists
are ideally positioned to lead efforts to implement and improve systems
with a vision of delivering safe, efficient, reliable and quality healthcare.
Health informatics involves understanding and promoting the effective
organization, analysis, management and use of information in healthcare.
1
Health informatics tools include not only hardware, software, networks
and devices, but also clinical guidelines, medical terminologies, information and communication systems as well as methods required to optimize
information acquisition, storage, retrieval and use. Hospitalists should possess a fundamental understanding of health informatics that goes beyond
simply using the technology. This chapter provides an introduction to the
field of health informatics as it pertains to hospital medicine.
Drivers for Health Information Technology
HIT is increasingly viewed as the most promising tool for improving the
quality, safety and efficiency of our health care delivery system.
2
Broad
and consistent utilization of effective HIT can:
• Prevent medical errors
• Reduce healthcare costs
• Improve healthcare quality
• Improve administrative efficiency
• Improve utilization of evidenced-based practices
• Expand access to affordable care
However, HIT is not a panacea and users must be aware of unintended
consequences.
3
Beyond well publicized cost and privacy issues, HIT adoption has been
slow primarily because HIT products and applications are difficult to implement and use effectively. Moreover, because healthcare delivery is highly
complex, developing ideal informatics solutions has proven to be challenging
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A.K. Dalal and K. Rogers
and costly as a consequence of individual variations among providers and
hospitals, incomplete evidence of benefit, and many undefined processes.
Nevertheless, to meet clinical needs, HIT must surpass the sophistication of
information technology in other industries.
The ARRA and the HITECH Act of 2010 established HIT adoption as
a major national initiative in the United States. Currently, hospitals are
working towards “meaningful use of a certified EHR” and will likely
engage hospitalists to achieve this goal. The federal government established objectives for “meaningful use” of certified EHRs and will provide
payment incentives to physicians, clinics, and hospitals who realize significant improvements in care through effective use of the EHR. Core
objectives include utilization of essential features (e.g. entry of basic
demographic and medical data) and functions that improve the safety,
quality, and efficiency of care (e.g. computerized physician order entry
(CPOE), clinical decision support, and quality measure reporting).
4
On an
individual provider level, the ABIM now requires an understanding of
“meaningful use” in its Maintenance of Certification (MOC) evaluations.
The Electronic Health Record
The Electronic Health Record (EHR) is defined as “a longitudinal electronic record of patient health information generated by one or more
encounters in any care delivery setting.”
5
The EHR is the primary HIT
tool used by hospitalists. Its functionality extends beyond point-of-care
applications by integrating clinical, administrative, financial, and increasingly, quality and population health functions.
Most EHR systems were initially developed to facilitate administrative functions such as registration, billing, coding and scheduling. Clinical
functions, such as storing and retrieving clinical data, were added over
time. These functions now include other aspects of data management such
as picture archiving and communication software (PACS), documentation, and analysis of trends in care. Although sharing of patient information is currently limited across different EHR platforms, interoperability
will facilitate point-of-care access for clinicians caring for patients across
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Health Informatics for Hospitalists
hospitals and healthcare networks, thereby reducing redundancy and
costs.
Sophisticated EHR systems can integrate almost every aspect of patient
care and are becoming an essential part of the healthcare delivery process.
EHRs provide clinicians with tools for robust results and data viewing,
medication management, communication, CPOE and CDS. Adoption of
these advanced tools has been markedly low: Less than 10% of hospitals
utilize CPOE and less than 1% of hospitals have achieved high levels of
adoption per Health Level 7.
6
The EHR’s potential for aggregating and sharing data will provide
nationwide access to de-identified patient data for population health
analysis. Although enhancing patient care and monitoring quality are the
primary drivers for promoting interoperability of EHRs, an interconnected
health information network will also facilitate real-time disease detection,
epidemiological surveillance, drug resistance monitoring, and sophisticated outcomes and comparative effectiveness research.
Clinical Decision Support (CDS)
Evidenced-based CDS is one of the most valuable features of the EHR.
CDS encompasses a wide variety of tools and interventions that aid in therapeutic and diagnostic decision making. Well-designed CDS is integrated
within daily workflow and facilitates evidence-based care. Examples of
CDS extend far beyond unsolicited alerts (e.g. drug–drug interaction) and
include order sets promoting best practices, documentation templates helping with diagnosis, data displays showing real-time patient parameters, and
dashboards showing quality outcomes. (See Table 1.)
To be successful, CDS tools should follow the “CDS 5 Rights”: Provide
the right information (pertinent evidenced-based guidelines) to the right
person, in the right format (i.e. an alert, order set, reference info-button),
through the right channel (i.e. the clinical information system, Internet,
mobile-device), at the right time (i.e. the time in the workflow when action
is needed).
7
Speed, delivery, and integration within clinical work-flow can
have a tremendous impact on user acceptance. Understanding the patterns
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A.K. Dalal and K. Rogers
of physician resistance, providing simple interventions, monitoring impact,
requesting feedback, and maintaining the knowledge-based system are key
strategies for managing clinical decision support systems.
8
The Risks and Benefits of HIT
To effectively advocate for EHRs that enhance patient safety and quality of
care, hospitalists should understand the risks and benefits of EHR systems.
When implemented and used effectively, HIT can facilitate safe and efficient
delivery of care. This has been convincingly shown for CPOE with CDS and
medication management. When developed, implemented and locally adapted
at institutions with adequate infrastructure support, CPOE with CDS can
reduce the rate of serious medication errors by 55% and all medication errors
by 88%.
9,10
However, a report showed that 33% of fatal medication errors were
still missed by CPOE systems,
11
demonstrating an ongoing need to optimize
the configuration of existing systems. It has been estimated that CPOE could
prevent 3 million adverse drug events each year in non-rural hospitals.
12
Much
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Health Informatics for Hospitalists
Table 1. Examples of CDS Interventions
A. CDS during data-entry tasks
1. Smart documentation forms
2. Order sets, care plans and protocols
3. Parameter guidance
4. Critiques and warning — “immediate alerts”
B. CDS during data-review tasks
5. Relevant data summaries (single-patient)
6. Multi-patient monitors
7. Predictive and retrospective analytics
C. CDS during assessment and understanding tasks
8. Filtered reference information and knowledge resources
9. Expert workup and management advisors
D. CDS not triggered by a user task
10. Event-driven alerts (data-triggered) and reminders (time-triggered)
Reprinted with permission from Osheroff J, et al. (2012) Improving Outcomes with
Clinical Decision Support: An Implementers Guide, 2nd ed. HIMSS: Chicago.
of medication error reduction has been attributed to CDS systems that provide
alerts for drug interactions and drug allergies at the time of order entry.
In recent years, electronic medication reconciliation applications and
bar-coding electronic medication administration systems have demonstrated a reduction of medication errors and potential adverse drug
events.
13–15
HIT has the potential to impact other areas as well. For example, automated test result alerting systems have been shown to reduce the
time until appropriate treatments are ordered for patients with critical
laboratory results.
16
Computerized test result management applications
may improve the coordinated hand-off of the results of tests pending at
discharge. Although few studies have rigorously evaluated the impact of
HIT on sign-outs, discharge modules, and diagnosis errors to date, HIT
holds much promise in these areas.
Implementing or adopting HIT may have many untoward and unanticipated effects (Table 2). Some studies of CPOE implementations have
demonstrated problems with organizational adaptation and change,
17
speed of order entry, alert fatigue, increased medication error risk,18and
an increase in mortality.
19
It is important to recognize that errors may
occur with either the design or local implementation of a system; both
aspects must be considered to ensure safe and effective adoption.
Roles for Hospitalists in Health Informatics
Hospitalists are ideal candidates for certain hospital-based informatics
roles and are naturally poised for advancement in these areas. Examples
of typical roles include:
• A physician champion that works with the informatics department to
develop order sets,
• A participating member on IT-oriented committees (e.g. pharmacy
and therapeutics, EHR, CPOE committees, etc.),
• A physician liaison to the Chief Medical Information Officer (CMIO).
Training in quality improvement and acquisition of management
skills are important in such roles. Increasingly, a number of professional
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A.K. Dalal and K. Rogers
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Health Informatics for Hospitalists
Table 2. Unintended Consequences of HIT
20
Unintended Consequence (UC) Description
More/New work issues Physicians find that CPOE adds to their workload
by forcing them to enter required information,
respond to alerts, deal with multiple
passwords, and expend extra time.
Workflow issues Many UCs result from mismatches between the
clinical information systems (CIS) and
workflow, including issues related to process,
policy/procedure, human-computer interaction,
clinical personnel, and situation awareness.
Never-ending demands Because CPOE requires hardware technically
advanced enough to support the clinical
software, there is a continuous need for new
hardware, more space in which to put this
hardware, and more space on the screen to
display information. In addition, maintenance
of the knowledge base for decision support and
training demands are ongoing requirements.
Paper persistence It has long been hoped that CIS will reduce the
amount of paper used to communicate and store
information, but that is not necessarily the case
since it is useful as a temporary display interface.
Communication issues The CIS changes communication patterns among
care providers and departments, creating an
“illusion of communication.” A user may feel
that the right person will see and act on
information appropriately because the
information was sent electronically.
(Continued)
societies are providing this training, including the Health Information
Management Systems Society, the American Medical Informatics
Association, the Association of Medical Director of Information Systems,
and the American College of Physician Executives.
Even without formal informatics training, hospitalists should learn to
navigate their local EHR system and know their institution’s organizational
structure. Because they are well-positioned to recognize potential errors
and identify needed enhancements in their institution’s existing EHR, they
should possess a basic understanding of how such systems operate and
how to provide feedback and suggestions for improvement. As per
Berwick’s “Soldiers of Quality,” hospitalists are one of the last lines of
defense for patients. As such, hospitalists should be vocal advocates for
improved HIT tools to provide efficient, high quality care.
Conclusion
The field of health informatics is in its infancy and in the future we will
look back at current conditions as untenable. Advancement will require not
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A.K. Dalal and K. Rogers
Table 2. (Continued )
Unintended Consequence (UC) Description
Emotions CIS causes intense emotions in users, many
which are negative and often result in reduced
efficacy of system use initially.
New kinds of errors CPOE generates new kinds of errors. For example,
juxtaposition errors occur when clinicians click
on the adjacent patient name or medication from
a list and inadvertently enter the wrong order.
Changes in the power The presence of a system that enforces specific
structure clinical practices through mandatory data
entry fields may change the power structure
of organizations. Often the power or autonomy
of physicians is reduced in an effort to
standardize, while the power of the nursing staff,
information technology specialists, and
administration is increased.
Over-dependence on As hospitals become more dependent on CIS,
technology system failures can spread havoc when paper
backup systems are not readily available.
Adapted with permission from Ash, Sitting et al. (2009) The unintended consequences of computerized
provider order entry: Findings from a moved methods exploration. Int J Meth Inform 78(Suppl1): S69–S76.
only significant improvement in HIT design and implementation strategies,
but also active involvement by the users of these technologies. Hospitalists
will play a vital role at the local and national levels to ensure that HIT
achieves its potential to revolutionize the quality and safety of healthcare.
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