HCA360 Assignment 2 Lecture Digital Equity, Online Health Information Seeking, Legacy Systems, and Common Hardware/Software/Interfaces Introduction Module 2 explores the advantages and limitations of online health information research to the consumer, the medical practitioner, and the health services organization. Central to the ability to access online health information is, of course, having the tools and/or connectivity necessary to access the Internet or other communications modalities. In this module, we consider the concept of "digital equity" as well as the current options that exist to span the "digital divide." Module 2 also considers the history of the development and continuing existence of legacy systems in the health services organization. In addition, it examines the hardware, software, and interfaces that are common to health services organizations. Online Health Information Seeking The numbers of Internet users are expected to grow dramatically over the coming years. Much of this growth will be seen in developing countries and specifically from economic powerhouses with large populations, e.g., China and India. Tan and Payton (2010) maintain that the Internet facilitates organization and diffusion of health information, reduces social isolation, builds relationships between health care organizations and consumers, and increases consumer empowerment. There is also evidence to suggest that consumer empowerment improves the patient/physician relationship. However, what might the downsides of this consumer empowerment be? A significant point is that health information found on the Internet may be erroneous or misunderstood. Another is that Internet use to source health information can also promote a condition in hypochondriacs called cyberchondriasis, in which users obsessively seek medical information. In fact, some medical practitioners believe that cyberchondria can be responsible for patient symptoms that can actually impede a physician's ability to make a correct diagnosis. Given that physical symptoms are very often shared by a number of conditions and diseases, do you think that online health information seeking might have the unintentional consequence of unduly alarming consumers? Think about it, and then check out some unintentional consequence examples listed after the Conclusion to this Reading. To access online health information, one must have Internet access, which is not universal even in the United States. An interesting study of home computer and Internet use among novice, low-income urban users was conducted in 2007. The study's findings were published in "Barriers and Facilitators to Home Computer and Internet Use Among Urban Novice Computer Users of Low Socioeconomic Position." This Harvard School of Public Health study found that living conditions, including space constraints, lack of suitable furniture for computer equipment, and the number of people in the household impacted use of the computer and Internet navigation. Financial limitations also needed to be considered because these low-income users were at times unable to pay for monthly Internet access. Job demands and family conflicts over who would use the computer also limited participants' abilities to HCA360 Assignment 2 Lecture both use the computer and access the Internet frequently enough to gain confidence and skills. Participants also identified lack of troubleshooting support as an additional barrier. What does this study indicate about the prospects for online health information research across society? Digital Equity Not surprisingly, in the United States, educators have been responsible for spearheading the promotion of digital equity. The International Society for Technology in Education, in its 2007 publication, "A National Consideration of Digital Equity," defines digital equity as: ...equal access and opportunity to digital tools, resources, and services to increase digital knowledge, awareness, and skills. When considering the role of technology in development of the 21st century learner, digital equity is more than a comparable delivery of goods and services, but fair distribution based on needs. Digital equity, then, is based on social justice theory, in which the equitable distribution of goods and services is based on fairness, as opposed to the market justice theory, which distributes goods and services based on a person's willingness and ability to pay. Consider the Internet and the broader implications of digital equity. Given a world population approaching 8 billion, and wide national disparities in economic resources, what relevance would the principles of social and market justice have to the feasibility of digital equity? Which do you think would be the fastest or most cost-effective routes to achieving online digital equity? Short-Term Solutions On a worldwide basis, Internet use is clearly tied to education, income, and infrastructure. Without question, another factor is age. According to a 2005 survey conducted by the Kaiser Family Foundation of U.S. respondents, "less than a third (31%) of seniors (age 65 and older) have ever gone online" (Kaiser Family Foundation, 2005). While the age group of 50-64 year-olds (U.S. baby boomers) indicated that they do go online, it is almost a certainty that seniors in less developed countries will not have had similar opportunities. Referring again to the findings of the Harvard School of Public Health study presented earlier in the lecture, conditions that could be barriers to achieving global digital equity in terms of the Internet include education, income, infrastructure, and age. To counter these limiting factors the textbook presents an expanded list of communication modalities to include "mobile phones, television, print, and radio" as well as the Internet (Tan & Payton, 2010, p. 58). The authors take the position that any and all methods of communication should be utilized to disseminate health information to reach as many populations as possible. Do you agree? Legacy Systems HCA360 Assignment 2 Lecture As defined in the Module 1 lecture, a legacy system is an old computer system or application program that continues to be used because it still functions to meet users' needs. Most legacy systems were developed or purchased to support discrete administrative functions, such as accounting and finance, human resources, inventory, etc. However, to this day, many of these aging and in many cases no longer efficient legacy systems remain in service. Why would a healthcare organization continue to rely on what is often outdated technology? (A key point to remember is that legacy systems may or may not be compatible with other systems within the organization, meaning that they may not use common codes and data definition that are necessary to affect data exchange with other systems.) There are a number of reasons why a legacy system might not be replaced, including: cost (a major concern to all businesses in today's economic climate), time necessary to retrain staff, the system's critical function (which may not permit downtime), and, perhaps, the system's complexity. Interfaces The textbook discusses a variety of computer user interfaces, including graphical, iconic, direct manipulation, and group interfaces, but taking a moment to discuss interfacing is important because it is particularly germane to legacy systems. Let's say you have a great, tried and true claims management system that you want to link to the medical management system, but there is a problem: the two systems have incompatible data formats. You already know that there is no budget to purchase a new integrated system, and you are not sure you would recommend that in any case. What course might you recommend? A good idea would be to investigate the feasibility of a systems sharing interface, which essentially bridges the gap between the two systems by translating the data format from the first system to the second. This could be a good, cost-effective approach, which would enable your organization to retain its current claims management system while gaining the efficiencies of data manipulation and sharing across systems. Another benefit of a systems sharing interface is that the manager is not limited to an integrated, modular information system that is purchased from a single vendor (Austin & Boxerman, 2003). The manager can select the best systems(s) for any given application or applications. Austin and Boxerman also state that this strategy "can sometimes result in lower costs by leveraging one vendor against another, and obviate the need to replace all existing modules" (p. 76). Common Hardware and Software The textbook provides a short discussion about typical organizational hardware needs. The following list applies to the needs of health care organizations. Workstations, which are comprised of radiology imaging units, are commonly seen in the healthcare workplace, as are simulators (for simulating surgical procedures) and minicomputers. A minicomputer, which is not to be confused with a microcomputer (also known as a personal computer, or PC), has computing power which is somewhere between a mainframe and a microcomputer. Minicomputers can be dedicated on a stand-alone basis to certain systems or to processing certain tasks. Additionally, they can be networked to a mainframe(s). They also can be used to assume some of the mainframe processing load. Software HCA360 Assignment 2 Lecture Systems management software refers to the group of programs that manage the overall computer system, including the operating system (OS − the deep down programming "guts" of the system), language translation programs (LTP, as in computer languages and codes), and utility programs. Utility programs are those that perform data processing and computational functions of a general nature, such as keeping track of jobs being run, managing printers and disk drives, etc.; these systems programs support applications like patient billing, but are not application-specific. Tan and Payton (2010) define application software as "programs written to solve specific domain problems and cannot be used without the system software" (p. 90). The following list will give you an idea of the spheres of activity for which application-system software is designed: claims management; clinical laboratory; coding and classification; EMR; decision support; document imaging; financial information; home health; long-term care; managed care; physician practice management; radiology; and storage/data recovery (Austin & Boxerman, 2003). This software can be developed in-house, purchased, or leased. At the enterprise level, supply chain management (SCM), customer relationship management (CRM), and enterprise resource planning (ERP) systems increasingly are being implemented in larger organizations and hospital networks. In general, an enterprise refers to any profit-oriented business. SCM systems assist the healthcare organization in managing supplies and materials, and are used in purchasing, inventory control, barcoding, tracking purchase orders, and matching with payment, etc. A CRM enhances the healthcare organization's ability to create and improve relationships with customers, and it is emerging as the organization's most powerful healthcare marketing tool. A CRM creates relationships by conferring informational and service resources to consumers. Consumers can create their own personal profiles, customize their coverage plans, query coverage and care options, and view their accounts. A CRM allows the healthcare organization to both broaden its marketing reach to new customers and deepen its relationship with existing customers through increased interaction and targeted communication. Finally, an ERP system provides the means by which clinical and financial information can be shared by all areas of the enterprise. In the case of health care, this means physicians, hospitals, ambulatory care centers, home health agencies, and the other profit centers that are found within a large healthcare delivery system. Rather than posting data in separate systems, ERP is based on integrating data from all sources into a single HMIS, which is examined in depth as the course unfolds. Conclusion Module 2 acquaints us with the vast potential of online health information surfing. The Internet, even with its limitations, is the fastest, most efficient means of accessing information. As noted in Module 1's axiom "... that health care organizations drown in data, but starve for information," another axiom applies to information/knowledge: "A little knowledge can be dangerous." Digital equity, at least in the short-term, may not become a worldwide reality through computers, but there are other electronic vehicles, such as the cellular phone, by which consumers can be made aware of needed information and be provided access to health services. HCA360 Assignment 2 Lecture From the exciting future that the Internet allows us to envision, Module 2 provided an overview of data management legacy systems, which still function as important components of healthcare management technology and are being coupled with emerging technologies to improve overall capabilities. This module also reviewed some of the hardware, software, and interfaces that are utilized in the healthcare organization's services delivery, and in its day-to-day operations. Some unintentional consequence examples are: Consider, for instance, the case of a seemingly healthy person who starts having chest pains. He becomes stressed and worried and turns to the Internet to research possible causes. What he finds is a plethora of possible causes. Several sites note that caffeine can cause chest pains, especially if large amounts are suddenly introduced into a person's diet. It turns out that at his new job, coffee is provided for free and he is now drinking 8 − 10 cups a day ... and he was not a coffee drinker before. Before seeing a doctor, a friend suggested cutting out the coffee (and its caffeine). He did, and the chest pains went away. Conversely, consider the same case wherein caffeine is only a factor that possibly exacerbates an underlying serious condition that otherwise only rarely exhibits chest pain. By turning to self-diagnosis and treatment, this person can easily be putting his health and/or life in serious jeopardy. References Kaiser Family Foundation. (2005). Online Health Information Poised to Become Important Resource For Seniors, But Not There Yet: Digital Divide Puts Many Seniors At Disadvantage. Retrieved November 17, 2009, fromhttp://www.kff.org/entmedia/entmedia011205nr.cfm Kontos, E. Z., Bennett, G. G., & Viswanath, K. (2007). Barriers and facilitators to home computer and internet use among urban novice computer users of low socioeconomic position [Electronic version]. Journal of Medical Internet Research 9(4):e31). Retrieved November 17, 2009, fromhttp://www.jmir.org/2007/4/e31 Austin, C. J. & Boxerman, S. B. (2003). Information systems for healthcare management (6th ed.). Chicago, IL: AUPHA/Health Administration Press. Tan, J. & Payton F. C. (2010). Adaptive Health Management Information Systems: Concepts, Cases, and Practical Applications (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers, LLC. HCA360 Assignment 3 Lecture EHR and Health Information Networks Introduction This lecture describes the community health information network and explains its relationship to the regional health information organization and the National Health Information Network. It also reviews one of the principal organizations that seeks to integrate community organizations into healthcare services delivery by standardizing health data and achieving interoperability among systems and organizations. It also discusses the electronic medical record (EMR), which has gained prominence over the past several years and which is a critical component of a patient-centered management system. It also considers the merits of smart cards, discussing possible uses of smart card technology in distributing patient services and in patient privacy protection. What is a Community Health Information Network? A community health information network (CHIN) links patients, providers, insurers, and suppliers throughout a specific community. At this time, participation in a CHIN is voluntary. Participant organizations transfer information to a shared server via the Internet. In 2004, President G.W. Bush signed an executive order authorizing the development and implementation of a national, interoperable health information system to include electronic health records for all citizens with a 2014 implementation target date. The CHIN, which predated the 2004 executive order, constitutes the basic level of a multi-tier hierarchy, above which is the regional health information organization (RHINO) and the projected National Health Information Network (NHIN). Regional Health Information Organization (RHINO, also known as RHIO) The RHINO is a more sophisticated and geographically dispersed network than is a CHIN. Also known as a health information exchange, or HIE, the RHINO can be formed at different levels: regional, state, and local (local RHINOs are seen predominately in urban areas since those areas are more likely to contain a number of, often overlapping, organizations). Experts foresee that the RHINO will increasingly replace the CHIN (except in rural locations) as states and the nation aggressively work to accelerate the process of standardizing data definitions and language with the goal of improving interoperability among systems. As can be expected, the RHINO level, the types and numbers of stakeholders dramatically increase (vs. a CHIN) to include state departments of health, research institutions, claims repository services, major regional hospital systems, and many more constituent organizations. The upside is that the resources necessary to establish a health information network are generally more available to a RHINO than to a CHIN. The downside, of course, is that whenever the numbers of stakeholders increase, so does the risk that conflicts of interests will ensue. As is the case with a CHIN, participation in a RHINO is also voluntary. This has had a negative impact on establishment of RHINOs because they have experienced sporadic or withdrawn financial support. Given the difficulties experienced in establishing RHINOs to HCA360 Assignment 3 Lecture date, it is doubtful that we could realistically expect to see RHINOs operating across the nation without the impetus of government intervention. Fundamental to both the CHIN and the RHINO is the electronic health record (EHR), which will be central to standardizing patient information and efficiently exchanging it. The good news is that the financial support and incentives provided through the HITECH Act (discussed in the second lecture of this module) are anticipated to jumpstart the development of RHINOs around the country. National Health Information Network (NHIN) The NHIN is defined as being comprised of 'information-rich' technologies guiding healthcare professionals, 'consumer-centric' applications giving patients control and choice, and RHINOs to diffuse knowledge and construct regional technologies as well as interoperability among technologies and providers (The Healthcare Information and Management Systems Society, n.d.). Planning for and oversight of NHIN is assigned to the Office of the National Coordinator for Health Information Technology (ONCHIT), as is the adoption of EHR by health providers. According to HIMSS (n.d.), RHINOs, described as the "building blocks" of NHIN, will give rise to an NHIN that will ...distribute a unified patient record based on data from different information systems, formats, organizations, and locations without affecting systems in which information is shared across decentralized, heterogeneous technology environments including hospitals, clinics, and physician practices - in a complete, accurate, real-time data exchange environment. (The Healthcare Information and Management Systems Society, n.d.). For all practical purposes, CHINs can be considered the building blocks of RHINOs, and, in turn, RHINOs are the building blocks of the NHIN. HL7 Standard Health Data Exchange Health Level Seven (HL7), a not-for-profit organization, was the brainchild of a group of users, vendors, and consultants who convened to discuss the range of problems they were confronted with in interfacing departmental systems. This 1987 meeting produced the HL7 Standard Health Data Exchange, which is now in use throughout healthcare systems in more than 55 countries. Health Level Seven's expertise is clinical and administrative data; the organization is one of several American National Standards Institute (ANSI) Accredited Standards Developing Organizations (SDOs) that operate in the healthcare industry. It is important to note that Health Level Seven provides healthcare organizations with specifications for making their systems interoperable within technical, semantic and process domains. The organization does not produce software. The HL7 Web site offers an informative Powerpoint presentation that presents the philosophy underlying health information standards and other interesting information relating to HL7 standards. HCA360 Assignment 3 Lecture You can access this Powerpoint presentation at: http://www.hl7.org/documentcenter/public/training/IntroToHL7/player.html. Patient-centered Management Systems The concept of a patient-centered management system rests on objectives that target improved outcomes, reduced costs, and increased accountability to the patient. The concept includes development of flexible, interoperable technology; customization of patient care; production of healthcare information for public health agencies; rationalization of pricing through the identification of evidence-based care and the elimination of redundant and/or unnecessary services; and dissemination of health services information. A number of patient care applications contribute to a patient-centered management system: EMR, computerized physician order entry, ambulatory care, clinical services, computer-assisted medical instrumentation, clinical support systems, decision support systems, security, medical research, etc., as well as administrative applications. EHR The first concept to understand is that a personal health record (PHR) is not the same thing as an electronic health record (EHR) or an electronic medical record (EMR). A PHR is a health record that is compiled and maintained by the patient. It can be electronic or it can simply be a paper file. It includes only the information that a patient chooses to include, and the patient is responsible for its security. An EHR (as opposed to an EMR) is a medical record that is designed for authorized medical professional use. It is generated and maintained within the healthcare organization to facilitate patient care. This means that until uniform data standards are universally adopted, an EHR is really only of value if patient care and services are accessed within an organization, such as a hospital, practice, or integrated delivery system. "An EHR is not a longitudinal record of all care provided to the patient in all venues over time" (National Institutes of Health, 2006).A key point to be aware of is that an EHR is a legal record; it must be authenticated by the custodian (the specific healthcare organization) and cannot be altered by anyone other than an authorized representative of the custodian. One final, important note: while the custodian owns and maintains the record, HIPAA regulation has established that the patient owns the information found in the EHR. The terms EHR and EMR are often used interchangeably, however there is a further distinction that we should mention. Increasingly, an EMR is considered to be a complete software system that fulfills the following basic requirements: computerized order entry of prescriptions and tests, reporting of test results, and access to and storage of physician notes. While many healthcare organizations (practices and hospitals) utilize electronic health records, fewer enjoy the full facility of an EMR system. The HITECH Act, discussed below, will do much to encourage healthcare providers to adopt EHR and EMR by way of payment incentives and through regulation. HCA360 Assignment 3 Lecture HITECH Act The EHR has been the focus of attention on the part of government, academic medical centers, and healthcare administrators since the 1960s. In 2006, the Bush administration formalized efforts to implement EHR throughout the United States. This has been followed by the latest governmental initiative, the HITECH Act, which was included in the February 2009 American Recovery and Reinvestment Act of 2009 (Stimulus Bill). The Health Information Technology for Economic and Clinical Health Act (HITECH Act) allocates $19.2B to increase the use of electronic health records (EHR) by physicians and hospitals. Of this amount, $18B is to be paid beginning in 2011 through the Medicare and Medicaid reimbursement systems as incentives for hospitals and physicians who are "meaningful users" of EHR systems. Note that the final definition of "meaningful use" is currently being written. A Congressional Budget Office analysis estimates that 70% of all hospitals and 90% of all physicians in the country will have adopted health IT systems meeting certification standards by 2019. Smart Cards A significant reason that healthcare has lagged behind other industries in adopting IS innovation is the fragmented nature of the healthcare organization's operations and the manner in which healthcare is delivered and utilized in this country. This fragmentation is the result of standalone computer systems, patient relocation over a lifetime, employment and health insurance changes, the involvement of specialist physicians, etc. Current smart card technology offers healthcare organizations, patients, and payers a number of benefits, not limited to storage of electronic prescription and physician contact information, streamlined claims services and payment, and storage capacity that is equivalent to approximately 60 typewritten pages. At this time, there are limitations to smart card technology. For instance, a smart card would not currently accommodate radiologic and other files that use a large amount of space. From the earlier section of the lecture, we know that at present EHR can only be used within a healthcare organization. Therefore, smart card technology, with its virtues of flexibility and portability, has the potential to bridge some systemic gaps by enabling patients to carry a limited amount of secure medical information from provider to provider. Conclusion The EHR is at the core of creating a national health information network. With the passage of the HITECH Act, the government has committed to underwrite a substantial portion of the nation's EHR infrastructure, which, in turn, will constitute the underpinnings of the patient-centered management system as well as the health information networks that will ultimately link health care providers for the betterment of patient care. References Austin, C. J., & Boxerman, S. B. (2003). Information systems for healthcare management (6th ed.). Chicago, IL: AUPHA/Health Administration Press. HCA360 Assignment 3 Lecture Ball, M. J., Smith, C., & Bakalar, R. S. (2007). Personal health records: empowering consumers. Journal of Healthcare Information Management, 21 (1). Retrieved October 31, 2009, from http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=37 Halamka, J. (2007). The perfect storm for electronic health records. Journal of Healthcare Information Management, 20,(3). Retrieved November 2, 2009, from: http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=37 The Healthcare Information and Management Systems Society. (n.d.). Health Information Exchange. Retrieved November 25, 2009, from http://www.himss.org/asp/topics_rhio.asp National Institutes of Health. (2006). Electronic Health Records Overview. Washington, DC: The Mitre Corporation. Retrieved November 22, 2009, from www.ncrr.nih.gov/publications/informatics/ehr.pdf Smart Card Alliance. (2007, February). Smart cards in U.S. healthcare: Benefits for patients, providers and payers. White paper [Electronic version]. Retrieved November 3, 2009, from http://www.smartcardalliance.org/pages/download Van de Velde, R., & Degoulet, P. (2003). Clinical information systems: A component-based approach. New York: Springer-Verlag.
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