What are the challenges of implementing HIT based on the three essential components necessary, Unit 3 Assignment 1 help

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This assignment reinforces information in your textbook and concepts presented in this unit. It is recommended that you work through this assignment as you complete your reading assignment. Complete the questions and items below.


  1. What are the challenges of implementing HIT based on the three essential components necessary for successful implementation: technology, culture, and policies and procedures? (One paragraph is an appropriate length).
  2. What are the benefits of Health Information Exchanges (HIEs) and Regional Health Information Organizations (RHIOs) in creating systems, processes, and technologies that enable a basic level of interoperability between EHRs ?(One paragraph is an appropriate length.)
  3. Discuss the relationship between publication bias in biomedical literature against publishing HIT implementation failures. Why is this a problem (with regard to HIT implementation)? (One paragraph per heading is an appropriate length.)
  4. What is the impact of HIT on healthcare quality, effectiveness, and efficiency? Provide one example of each. (One paragraph per innovation in an appropriate length).

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4/19/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery CHAPTER 3 Health Information Technology Philip J. Kroth, MD, MS This chapter outlines major historical developments in the evolution of health information technology and discusses government initiatives to support its implementation. It highlights both benefits and challenges of using this new technology and progress in implementation to date. Historical Overview Applying modern information technology (IT) to the health care system to improve its quality and reduce its costs is not new. On April 27, 2004, President Bush created the Office of the National Coordinator for Health Information Technology (ONCHIT or “the ONC”) by Executive Order as the first step to create the Nationwide Health Network.1 On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act (ARRA) that designated $20.8 billion through the Medicare and Medicaid reimbursement systems to incentivize physicians and health care organizations to adopt and achieve “Meaningful Use” of electronic health records (EHRs).2 These programs are the latest in a long history of government health information technology (HIT) initiatives. One of the earliest government inquiries into the potential benefits of HIT occurred in the Kennedy Administration in the early 1960s. A report from the President’s Science Advisory Committee, “Some New Technologies and their Promise for the Life Sciences,” was optimistic about the benefits HIT would bring to biomedical research and the health care system. Ironically, the report written a half century ago is still relevant to current HIT issues: The application of computer technology to the recording, storage, and analysis of data collected in the course of observing and treating large numbers of ill people promises to advance our understanding of the cause, course, and control of disease. The need for a general-purpose health information technology stems in large part from increasingly rapid changes in the pattern of illness in the United States and from equally significant changes in the way medicine is practiced. The acute infectious diseases from which the patient either recovered or died have largely given place to chronic disorders which run an extremely variable course dependent on many factors both in the environment and within the patient himself. … Within any sizable community there are numerous administrative organizations charged with providing health services. It is not uncommon for a single patient to be cared for by a large number of agencies in a single city, and workers in any one agency usually cannot find out about the activities of others; sometimes they even fail to learn that other agencies are active at all. … Modern data-processing techniques make it possible to assemble all the necessary information about all the patients in a given geographical or administrative area in one place with rapid access for all authorized health and welfare agencies. Such a system would produce an immediate and highly significant improvement in medical care with a simultaneous reduction in direct dollar costs of manual record processing and an even greater economy in professional time now wasted in duplicating tests and procedures.3 To date, despite a half century of government programs and technological advancement, the best and most current scientific evidence indicates that the benefits of HIT on the quality and cost of health care are at best, mixed.4 This chapter will explore the history of how HIT has evolved, the imprint HIT has made on the current health care system, and speculate about how HIT will likely influence the future of health care and the health care system as a whole. Using computers to improve health care in many ways parallels the development of modern IT. The late 1960s and early 1970s saw several pioneering efforts at a small number of universities to apply IT to various aspects of the health care delivery process. Early systems were not the web-based, interactive systems of today but were usually a hybrid of computer and paper integrated into a clinical work process. One early example was a system at Indiana University where a small army of data entry clerks manually entered data into a computer on key parts of all patients’ medical records. The night before a patient’s clinic appointment, a one-page, paper encounter form was printed for the appointment listing the patients’ name, record number, medical problem list (i.e., the known diagnoses and medical problems), medication list, medication allergies, and suggestions based on the data in the computer system. A suggestion was printed on the list when the https://ecpi.vitalsource.com/#/books/9781284055139/cfi/6/28!/4/26/4/2@0:0 1/14 4/19/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery computer software detected any of 290 agreed-upon patient care protocols or conditions defined by rules applied to the computer’s database. When a physician saw the patient in the clinic, they would handwrite encounter notes on the appropriate section of the paper encounter form and manually annotate the computer-printed problem list, medication list, and other items. The next day, a team of data entry clerks would review all encounter forms and update the computer data to reflect the physician’s orders and updates to the patient’s condition. The paper form would then be filed to the patient’s chart. The Indiana group conducted a study demonstrating a 29% improvement in adherence to agreed-upon treatment protocols in the group of physicians who received the computer “suggestions” for recommended treatment protocols on the encounter forms versus those who did not.5 With the introduction of the IBM PC in the late 1970s and early 1980s, paper forms were mostly eliminated and physicians began interacting with the patient’s EHR in real time on the video screen. Similar experimental systems were designed and built during the same time period at a number of other U.S. universities, including The University of Pittsburgh,6 The University of Utah,7,8 Vanderbilt University,9,10 Duke,11 and Harvard University/Massachusetts General Hospital.12 These early systems were custom designed, built, and maintained by in-house dedicated teams of computer programmers and systems engineers. Because of the custom designs, the unique work process that existed at each institution, and the advanced nature of these early systems, they were not portable and could not be transplanted to other institutions without extensive software design rework. More importantly, because each of these early systems had a unique design, they were incapable of electronically transferring any of the patients’ records to any other system. Despite these limitations, the pioneering works done with these early systems laid the foundation for modern EHR design. It was not until the 1990s that commercially produced comprehensive EHR systems were marketed and sold to health care institutions in high volume. These commercially produced systems allowed hospitals to implement EHRs without the prohibitive expenses of building custom systems. Instead, hospitals could buy an “off the shelf” system that although not completely customized to institutional work flows, could be configured to meet most of their perceived HIT institutional needs. However, as with the pioneering EHR systems at academic institutions, the “off the shelf,” commercially produced EHRs of today still require extensive configuration to accommodate the unique and varying work processes at each institution. The configuration differences between institutions are often so significant that even institutions with the same commercial EHR systems cannot electronically exchange patients’ records without customized software. The ONC Website reports that there are a total of 2,648 certified ambulatory EHR products and a total of 878 inpatient products currently on the Certified HIT Product List.13 While many of these are merely different versions of the same software, there are at least 200 unique systems. None of these systems is designed to interface with each other for patient data sharing across different software platforms. Due to this lack of standardization, regional health information organizations (RHIOs) have been created to facilitate the exchange of patient data among different health care institutions to support improved patient care. RHIOs and health information exchanges (HIEs) are discussed in more detail later in this chapter. The 2009 HITECH Act created several programs to incentivize individual physicians and health care organizations to buy, install, and adopt EHR systems in the hope that this will yield significant benefits by reducing the cost and improving the quality of care.2 “The provisions of the HITECH Act are specifically designed to work together to provide the necessary assistance and technical support to providers, enable coordination and alignment within and among states, establish connectivity to the public health community in case of emergencies, and assure the workforce is properly trained and equipped to be meaningful users of EHRs.”14 The scope of this text does not allow detailed delineations of HITECH Act programs; however, the following brief descriptions of programs created and supported by the HITECH Act provide an overview of its comprehensive approach to HIT implementation14: Beacon Community Program to assist communities in building their HIT infrastructures and exchange capabilities Consumer eHealth Program to help empower Americans’ access to their personal health information and use this as a tool to gain more control over their health State Health Information Exchange Cooperative Agreement Program to support states in establishing HIE capability among health care providers and hospitals in their jurisdictions HIT Exchange Program to establish regional extension centers for education and training of health providers in use of EHRs Strategic Health IT Advanced Research Projects to fund research advances to overcome major barriers to EHR adoption While the HITECH Act and its funding provide a new thrust toward EHR adoption, the state of EHR technology does not allow most systems to interface with each other. Despite this large government investment and over half a century of technological development, U.S. health care system HIT still consists of a large number of disparate “siloed” systems that cannot electronically exchange patient records in an efficient and secure manner. Historical Challenges in Implementing HIT Figure 3-1 illustrates the three essential components required for successful HIT implementation. The first essential component is the technology. Organizations often focus on this first component with the mistaken belief that merely selecting the “right” technology or the “right EHR” is the most important aspect of HIT implementation. The essential technologies needed to implement an EHR system are a relational database, a computer network, and computer workstation. All three technologies have existed for more than 40 years, begging the question of why adoption of HIT in the clinical environment https://ecpi.vitalsource.com/#/books/9781284055139/cfi/6/28!/4/26/4/2@0:0 2/14 4/19/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery has been so slow compared to the adoption of IT in other industries such as the airline industry’s reservation system. The second component of successful implementation, work policies and procedures, makes implementing HIT systems in the clinical environment extremely challenging due to wide variations in work policies and procedures among different organizations and institutions. FIGURE 3-1 The Three Essential Components of a Successful HIT Implementation. An organization’s policies and procedures describe and define the processes through which work is carried out. The process component is complex, because it requires HIT system implementers to fully understand all existing work processes. Many such processes are not written or formalized, having evolved over the years to accommodate the unique characteristics of a particular organization. Often existing work processes are significantly different from those officially documented or assumed to be in place, while many critical work processes are not documented at all. When a HIT system is implemented, it is common for many of the undocumented processes to become apparent for the first time.15 Undocumented or unknown work processes have been the root cause for many HIT implementation failures.16 In addition, it is well known that the most significant component of HIT implementation is the institutional and organizational culture—what people are willing to do.17 This is the most critical, least studied, and least understood of the HIT implementation components.18 Ash and Bates summarized the importance of organizational culture with regard to EHR adoption19: The organizational culture must be ready to support adoption by the individuals within it. There has been a period when clinicians have not experienced a sense of collaboration and trust between them and hospital administration. Consequently, if clinicians believe the administration wants to force them to use Computerized Physician Order Entry (CPOE), for example, they may dig in their heels. They may be more resistant to arguments based on safety and patient care benefit if the level of trust is not there. On the other hand, if the impetus comes from the clinical staff, other clinicians may be more apt to adopt sooner, and readiness will be at a higher level. One gauge of readiness is the extent to which certain categories of people hold positions within the organization. In particular, administrators at the highest level must offer both moral and financial support and demonstrate that they really believe in the patient care benefits of the systems. There must be clinical leaders, including a chief medical information officer if at all possible, who understand the fine points of implementation strategies, and opinion leaders among the clinical staff members. In addition, there need to be sufficiently skilled implementation, training, and support coordinators who understand both clinical and technical issues.* There is a significant publication bias in the biomedical literature against publishing on HIT implementation failures. Because of the human tendency to avoid publicizing individual’s mistakes, the body of literature is strongly skewed toward successful implementations and studies. Unfortunately, this has made it difficult to study and understand causes of HIT implementation failures. A significant advance for the HIT industry as a whole would be a shift in its culture toward not only reporting HIT failures, but viewing them as valuable learning opportunities rather than events to be downplayed and forgotten. One major example of a HIT implementation failure occurred at the prestigious Cedars-Sinai Hospital in Los Angeles, California, in 2002. After implementing a new $34 million HIT system, several hundred physicians refused to use the new system 3 months after it was turned on. Cedars-Sinai attempted to implement a new electronic medical record that changed the way physicians ordered patient treatments and tests in the hospital. Prior to implementing the new system, physicians wrote their orders on paper forms in the patients’ paper charts. After new patient orders were written, physicians gave the chart to nurses or ward clerks to read and implement the orders. The new system required physicians to type orders directly into a computer workstation, where the software provided the physician with immediate feedback if they attempted to enter an order that the computer either did not understand or interpreted as a mistake. An article in the Washington Post reported20: A veteran physician at the prestigious Cedars-Sinai Medical Center here had been mixing up a certain drug dosage for decades. Every time he wrote the prescription for 10 times the proper amount, a nurse simply corrected it, recalled Paul Hackmeyer. The computers arrived—and when the doctor typed in his medication order, the machine barked at him and he barked back. … “What we discovered was that for 20 years he was writing the wrong dose.” This failure illustrates the three principal HIT implementation components described above. Technology: With physicians required to enter orders directly to the computer system, time required to enter orders became dependent on the computer’s ordering input format and system response time. Process: Many undocumented processes in the old system were not carried to the https://ecpi.vitalsource.com/#/books/9781284055139/cfi/6/28!/4/26/4/2@0:0 3/14 4/19/2017 ECPI: Health Care USA: Understanding Its Organization and Delivery new system. In this example, the nurse’s automatic correction of an obvious dosage error was a critical, undocumented, process step—a check on the orders’ accuracy. Although the new system caught the error, the physician user in this case could no longer rely on the nurse’s checking and correcting his orders. Culture: The new system required physicians to interact with a computer, which took more time than writing orders on paper forms. The new system required physicians to change the way they practiced medicine in the hospital and as is common, people dislike change. This was a significant change in physicians’ work culture in which nurses had routinely checked and corrected physician orders without communicating the corrections. Physicians also had to deal with a barrage of system alerts when they were imprecise or inaccurate in entering their orders. While possibly enhancing patient safety, responding to the system alerts increased the time required for physicians to place orders. Another historical barrier to broad implementation of HIT is the chasm between those who bear the costs of the technology and those who receive its benefits. The purchase and operation of an EHR system represent a major investment for large health care organizations and especially for small private physician groups. Not only must physician groups bear the costs of the hardware and software, but they must also support ongoing IT maintenance, staff training, and software upgrade costs. Because small practice groups often have no experience or expertise with IT issues, they also experience anxiety about making decisions necessary to convert from paper to electronic charting. While economies of scale make the marginal costs of adopting EHR technology somewhat lower for large health care organizations, these organizations often do not realize costs savings from their investment. For example, a health care system participating in a HIE may reduce the number of duplicate laboratory and imaging tests saving the patient and the payer significant expense, but the health care system may actually lose money by not receiving revenue for the duplicate tests. As with large health care systems, small practices that invest in EHR technology may not directly benefit from the technology. Patients may receive better age appropriate screening21,22 and preventative care23 as well as reduced duplicate testing because of physician access to HIEs and patient records from outside of the practice group or health system.24 However, from a practice financial perspective, these factors actually may produce a significant disincentive for adopting EHRs. The Federal Government’s Response to HIT Implementation Challenges The federal government’s financial incentive programs for large health care organizations and private practices that adopt and demonstrate “meaningful use” of EHRs are an effort t ...
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Tutor Answer

School: UC Berkeley









Health Information Technology


Technological implementation challenges in HIT are due to the fact that healthcare data

consumption is growing very fast. The current existing data infrastructure is overwhelmed by the
resource taxing applications, the digital imaging technologies and the modern electronic medical
records. There is an existence of inadequate data storage capacity.

For the proper

implementation of the HIT, the organizational culture must be ready to give maximum support
between the hospital administrators and the clinicians. Failure of their collaboration has always
been a major challenge to the adoption of the HIT system. The org...

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