Health Informatics Careers

Chief Medical Information Officer: an executive who is responsible for

overseeing all of an organization’s initiatives related to health informatics and
patient records. While they can be involved in specific projects, such as software
launches and new process development, they also draft and implement strategic
plans related to the long-term IT infrastructure of the organization.

Clinical Informatics Analysts: compile and analyze health data and then use
that analysis to adjust their organization’s practices, processes, and workflows to
improve patient outcomes. For example, a hospital that has seen an increase in
post-op readmission rates might turn to a clinical informatics analyst to identify
methods for reducing that rate, which might be as simple as educating patients on
proper wound care to reduce infections.

Health Information Technology Project Managers: are project

managers who focus specifically on projects related to health informatics. They
are responsible for performing all of the primary duties of a project manager,
including initiating, planning, executing, monitoring, and closing the project. The
work can be incredibly varied, and the projects often focus on implementing new
technology or optimizing workflows.

Health Informatics Consultants: are professionals employed by healthcare

organizations, often on a contract or project basis. Their job is to advise the
organization on all informatics- related questions, challenges, and initiatives. They
typically assist in a wide variety of projects, including selecting and installing new
software, updating and securing networks, monitoring and troubleshooting
systems and training teams.
Electronic Medical Record Keepers:
- Ensure patient records are filled out properly, accurately, and
completely
- Assign codes to patient data within electronic medical record
systems
- Consult with physicians to ensure the accuracy of patient
record(s)
- Collect information for medical researchers and studies
Disperses information to those allowed to receive medical
information such as insurance companies, family members,
guardians etc.

Informatics Nurses: are responsible for bridging the gap between clinical and
IT — for example, the role might involve evaluating a health care facility to
determine what clinical IT applications will help increase efficiency, then training
staff and on any new systems and technology. Informatics nurses also facilitate
communication between IT, vendors and the staff.

Healthcare Data

Information Hierarchy
Data is a raw and unorganized fact that required to be processed to make it
meaningful. Data can be aggregated into a variety of formats such as
image files (JPG, GIG, PNG), text files, sound files (WAV, MP3)
or video files (WMV, MP4).
There is no meaning associated with data; the 5 could represent five fingers, five
minutes or have no real meaning at all

Information is a set of data which is processed in a meaningful

way according to the given requirement. Information is processed, structured, or
presented in a given context to make it meaningful and useful.
From information, conclusions can be drawn by humans or computers. For
example, five fingers have meaning in that it is the number of fingers on a normal
human hand.

Knowledge is information that is justifiably considered to be true. For example,

an elevated fasting blood sugar level suggests an increased likelihood of diabetes
mellitus.
Knowledge is really about facts and ideas that we acquire through study, research,
investigation, observation, or experience.

Wisdom is the critical use of knowledge to make intelligent decisions. For

example, a rising blood sugar can indicate diabetes and other secondary causes of
hyperglycemia.
Wisdom is the ability to distinguish and judge which aspects of that knowledge
are true, right, lasting, and applicable to your life.

Terms
Interpreting free text requires natural language
processing (NLP)

A clinical data warehouse (CDW) is a database system that collects, integrates

and stores clinical data from a variety of sources including electronic health
records, radiology and other information systems.
The important of CDW
- CDWs do a better job of analyzing and reporting aggregate healthcare data
than the average EHR, which tends to focus on the individual
- CDWs can be used to evaluate a critical clinical process, cost estimates and
they can analyze potential solutions
- CDWs are highly valuable for informatics and evidence based medical
research
- CDWs can help track infections and report trends to public
health.

Example of CDW schema (i2b2 platform)

- Informatics for Integrating Biology and the Bedside (i2b2) is a
Harvard project used by many other academic institutions in the US
The program is open source and modular and incorporates genomic
and clinical information for research purposes
- Data base consists of facts (diagnoses, lab results, etc.) queried by
users and dimensions that describe the facts
- With this model data can be aggregated from multiple
hospitals

What Makes Informatics Difficult?

- With other industries such as banking, data and information are much
closer (smaller semantic gap). For example, banking data such as $100.50 is
close to an account balance of $100.50. It leaves little leeway for a different
interpretation
- In healthcare, there are subjective factors (“I feel sick”) that are difficult to
measure and vary from patient to patient and physician to physician. Lab
results are more objective and easier to interpret
- It is difficult to model all of healthcare. View the HL7 RIM
model on next slide Biomedical information is difficult due to incomplete,
imprecise, vague, inconsistent and uncertain information
 - Humans can adapt to this dynamic and vague information but computers
cannot. Clinical decision support in EHRs is precise, when in reality it might
need to be flexible over time

Why Health IT Fails Sometimes

-

- Health IT is an attractive solution to our troubled healthcare system, but is it

realistic?
- Other IT fields have experienced serious “ups and downs” such as artificial
intelligence
- There is a large gap between healthcare data generated and information
(semantic gap)
- Is it too early to expect EHRs and computerization to
change healthcare?

Sources of Healthcare Data

The advent of electronic health records (EHRs) and multiple other healthcare
information systems provided the ability and the need to collate and analyze large
amounts of data to improve health and financial decisions. As genetic information
collection grows, datasets are huge (big data) and part of EHRs

EHR=electronic health records,

PHR=personal health record,
HIE=health information exchange
Healthcare Big Data
Five Vs: the definition started with three Vs but has increased to five:
Volume: massive amounts of data are being generated each minute
Velocity: data is being generated so rapidly that it needs to be analyzed without
placing it in a database
Variety: roughly 80% of data in existence is unstructured so it won’t fit into a
database or spreadsheet. There is tremendous variety, in terms of the data that
could potentially be analyzed.
Veracity: current data can be “messy” with missing data and other challenges.
Because of the very significant volume of data, missing data may be less
important than in the past
Value: data scientists now have the capability to turn large volumes of
unstructured data into something meaningful. Without value, data scientists will
drown in data and not information or knowledge.

HealthData.gov makes federal datasets available to healthcare organizations,

developers and researchers

Health information technology (HIT) is defined as the application of computers

and technology in healthcare settings
HIT is not solely a technical discipline but focuses on the relationship between the
technology and its use in real-world settings i.e. solutions are designed in context,
taking into account the social, cultural and organizational settings in which
computing and information technology will be used in healthcare sectors.

Driving Forces Behind Health Information Technology

- Increase healthcare efficiency and productivity Improve healthcare quality
(patient outcomes) resulting in
- improved patient safety Reduce healthcare costs
 - Improve healthcare access with technologies such as telemedicine and
online scheduling
- Improve coordination and continuity of care
- Improve medical education of clinicians and patients Standardize medical
care
- Reducing Errors
o Order entry systems
 Reduce medication errors
 Detect potential drug interactions
o Clinical decision support systems
 Improve drug dosing
 Improve preventive care Not diagnosis

Barriers to HIT Adoption

Inadequate time: Busy clinicians complain that they don’t have enough time to
read or learn about new technologies or research vendors. They are also not
reimbursed to become technology experts.
Inadequate information: clinicians need information, not data. Current HIT
systems are data rich, but information poor.
Inadequate expertise and workforce: to experience the widespread of HIT
adoption and implementation, it will require education of all healthcare workers.
Inadequate cost and return on investment data: There is a mismatch between
costs and benefits of HIT. The clinicians/providers bear the costs (and/or do the
extra work), whereas hospitals/insurers/government reap the
benefits.
High cost to adopt: There is still limited evidence that most technologies will save
money.
Change in workflow: Significant changes in workflow will be required to integrate
technology into the inpatient and outpatient setting.
Privacy concerns: different organizations have different privacy rules. In the past
decade, there have been many serious healthcare security breaches and stolen
identities.
Legal issues: Some laws prevent hospital systems from providing or sharing
technology such as computers and software with referring physicians.
Behavioral change: large number of medical personnel will be slow to accept any
information technology innovations and they will be perceived as dragging their
feet.

Health (Medical) Informatics

Medical informatics is the application of computers, communications and
information technology and systems to all fields of medicine - medical care,
medical education and medical research.

Informatics Use in Healthcare

- Communication
o Telemedicine
o Tele-radiology
o Patient e-mail
o Presentations
- Knowledge management
o Journals
o Consumer Health
o Information
o Evidence-based medical
o Information
- Decision Support
o Reminder systems
o Diagnostic Expert Systems
o Drug Interaction
- Information Management
o Electronic Medical Records
o Billing transactions
o Ordering Systems
Healthcare Information Systems
An information system (IS) is an arrangement of data (information), processes,
people, and information technology that interact to collect, process, store, and
provide as output the information needed to support the organization.

Healthcare information system (and hospital information system)—a group of

systems used to support and enhance healthcare.

Key Users of Health Information Systems

Patient – the individual who receives healthcare, often called a consumer or
citizen when they are well
Provider – those who “provide” healthcare, e.g., physicians, nurses, allied health
providers
Purchaser – those who buy healthcare, usually employers or the government
Payor – those who “pay” the healthcare system, i.e., the insurance companies and
government
Public health – protectors of the public’s health

Categories of healthcare Information Systems

Administrative Information System (or an administrative application) contains

primarily administrative or financial data and is generally used to support the
management functions and general operations of the healthcare organization.

Clinical Information System (or clinical application) contains clinical or health-

related information used by providers in diagnosing and treating a patient and
monitoring that patient’s care.
Admission, discharge, transfer (ADT) tracks the patient’ movement of care in an
inpatient setting Registration may be coupled with ADT system; includes patient
demographic and insurance information as well as date of visit(s), provider
information
Scheduling aids in the scheduling of patient visits; includes information on
patients, providers, date and time of visit, rooms, equipment, other resources
Patient billing or accounts receivable includes all information needed to submit
claims and monitor submission and reimbursement status Utilization management
tracks use and appropriateness of care
Accounts payable monitors money owed to other organizations for purchased
products and services
General ledger monitors general financial management and reporting
Personnel management manages human resource information for staff, including
salaries, benefit, education, and training
Materials management monitors ordering and inventory of supplies, equipment
needs, and maintenance
Payroll manages information about staff salaries, payroll deductions, tax
withholding, and pay status Staff scheduling assists in scheduling and monitoring
staffing needs
Staff time and attendance tracks employee work schedules and attendance
Revenue cycle management monitors the entire flow of revenue generation from
charge capture to patient collection; generally relies on integration of a host of
administrative and financial applications

Laboratory information supports collection, verification, and reporting of

laboratory tests
Radiology information supports digital image generation (picture archiving and
communication systems [PACS]), image analysis, image management
Pharmacy information supports medication ordering, dispensing, and inventory
control; drug compatibility checks; allergy screening; medication administration
Nursing documentation facilitates nursing documentation from assessment to
evaluation, patient care decision support (care planning, assessment, flowsheet
charting, patient acuity, patient education)
Electronic health record (EHR) facilitates electronic capture and reporting of
patient’ s health history, problem lists, treatment and outcomes; allows clinicians
to document clinical findings, progress notes, and other patient information;
provides decision-support tools and reminders and alerts Computerized provider
order entry (CPOE) enables clinicians to directly enter orders electronically and
access decision- support tools and clinical care guidelines and protocols
Telemedicine and telehealth supports remote delivery of care; common features
include image capture and transmission, voice and video conferencing, text
messaging
Rehabilitation service documentation supports the capturing and reporting of
occupational therapy, physical therapy, and speech pathology services Medication
administration is typically used by nurses to document medication given, dose,
and time
Monitoring: Comprised of devices that monitor temperature, pulse, respirations,
blood pressures, oxygen saturation, or other measures automatically feeding the
input into a clinical information system. Alarms notify caregivers of readings that
are outside the range of “normal”

EMR in healthcare, which stands for ‘Electronic Medical Records', is a digitized

version of hand-written paper records maintained at the office of medical
specialists.
Such documents include medical diagnosis, treatment, and prescribed
medications aimed at tracking patient data over time.

The main advantage of EMR healthcare data

is that it helps
- practitioners to receive quick access to the patient’s basic vitals, including
age, weight, blood pressure, and so on.
- Based on EMR, medical specialists can provide a more personalized medical
treatment for patients.
- While EMR software solutions could be used within a particular office,
doctors cannot share this data with other departments.
EHR, which means ‘Electronic Health Records software.
The main difference between EHR and EMR is that HER systems offer much more.
EHR systems collect information about patients from multiple sources, such as
hospitals, physicians, labs, and patients. Such an approach improves the way
patients receive treatment.

The advanced features of EHR systems significantly

Patient portals: a secure website through which patients can electronically access
their medical records. Portals often also enable users to complete forms online,
schedule.
Electronic prescriptions, transmitted directly to pharmacies, save patients’ time
since all the medicine will be processed while the patient travels to the pharmacy
from the doctor’s office.
Voice-to-text translation and speech recognition saves doctors’ time rather than
having to manually write patient healthcare information.
Reporting makes it easy to track revenue projections and provide details on how
many patients have paid or failed to pay their bills.

PHR or ‘Personal Healthcare Records' may seem similar to

EHRs or EMRs. However, the patient is responsible for
updating and keeping all data up to date.

Which one will work for you?

If your healthcare facility has specific expertise in particular healthcare services,
such as dentistry, choose Electronic Medical Records.
In the case of your medical facility including numerous departments, such as labs,
X Rays, emergency, and surgery, and you need to provide seamless transactions of
patient- related data across these departments, consider developing
the Electronic Health Records system.
If your healthcare organization puts patients first and need to track their recovery
progress, Patient Healthcare Records is your system of choice.
Computer and Network Architectures
Computers and Data

Computers recognize the binary digit (bit): 0 and 1 Bits represent everything in a
ll

computer: text, images, etc.

8 bits is a byte which can have 256 combinations Text is represented by 7 bit
alphanumeric combinations (ASCII). For more text characters Unicode is used. For
example, 16 bit UTF means 16 bit Images are represented by pixels. Each
black/white pixel is 1 bit. Images are “memory hogs”, compared to text
Central processing unit (CPU): where the computer chip resides and is related to
data processing speed
Memory: random access memory (RAM) is the working memory that is lost when
the computer is turned off.
Auxiliary storage: active storage is where data is stored that is needed
continuously. Archival storage can refer to tape, hard disks, optical drives or cloud
Input and Output devices: keyboards, mouse, monitors, etc.

Software programs instructs the hardware what to do

Application Programming Interfaces (APIs) are a common way now for
computers to react with other programs or apps
Operating systems provide a standardized way for software programs to perform
tasks

C, C++, C# – used in many modern applications

MUMPS – used in many early medical applications, now renamed to M and with
many modern enhancements
BASIC – common in early days of PCs
Python – originated as “scripting” languages for Unix and Web, but achieving
larger-scale use, e.g., in machine learning applications
Java – attempt to create standard language for Web applications
JavaScript – scripting language for Web browsers R – emerging important
language for statistics and data analytics

Database Systems
Spreadsheets are considered flat files or one dimensional; unlike relational
databases which link tables together for more robust storage and queries
A database management system (DBMS) is a program that manages the database
Most common language to query the database is structured query language (SQL)
There is a trend towards non-relational database systems, like NoSQL for large
“big data”
The Internet and World Wide Web
The Internet is the largest and arguably most important large scale international
network
The Internet is a global “network-of-networks” using the Telecommunications
Protocol/Internet Protocol stack (TCP/IP) as the communications standard. The
TCP/IP stack allows for layering of different standards and technologies based on
the participants in an exchange and the payload being exchanged
The Internet began in the late 1960 as a network known as Advanced Research
Projects Agency Network (ARPANET) capable of tying together universities and
research organizations securely
The World Wide Web (WWW) operates on top of the Internet and was created by
Tim Berners-Lee in 1989
The WWW introduced the web browser, a software program that allows for
connection to web servers over the Internet using Hypertext Transfer Protocol
(HTTP)
Web pages are written using Hypertext Markup Language (HTML), an
implementation of a markup language, or method for defining formatting of text
in a document, which has become synonymous with the Web
Achieving interoperability on the Internet depends on global use of standards
Standards exist for the exchange of data, such as HTTP; the format of data, such
as HTML, and the transport of data, such as TCP/IP
In a TCP/IP network, each device (host) must have an Internet Protocol (IP)
address. IP addresses can be distributed amongst different tiers of lower layer
networks, or “sub- networks”
- It is useful to think of the Internet as comprised of two main components,
protocols and hardware
- Each machine addressable on a network is known as a node Computers
connect to the internet through an Internet Service Provider (ISP) such as
Bell South or AT&T
The Internet and World Wide Web
An electronic request for an IP address is sent via the network link provided by the
one’s ISP to a DNS server
The DNS server then matches the requested domain name and responds with an
IP address
The browser is now capable of sending an HTTP GET request (again routed
through one’s ISP provided link) to the IP address returned from the DNS request
The browser can now render and display the document defined by the HTML
response on the user’s screen
A message must be sent using small packets of information that can arrive via
different routes, useful when there is web congestion, and are reassembled back
at one’s computer
All traffic sent using TCP/IP (such as phone calls over the internet (VoIP) and
email) are sent using packets
A router is a node which directs the packets on the Internet.
The role of ordering these packets and making sure that they make it to their
intended recipient in the proper structure is one of the jobs of TCP/IP

RESTful Services
Representational State Transfer (or RESTful) services are lightweight services
which use existing Internet infrastructure and World Wide Web (WWW) concepts
as their backbone
REST is an architecture, not a standard with endless possibilities as to how REST
can be applied to act as a service bus Communication with a RESTful service is a
relatively quick process and can utilize any existing content standard for packaging
its messaging. Most commonly, a RESTful service will use XML or JavaScript Object
Notation (JSON) for this content delivery
Service Oriented Architecture (SOA) Web Services
SOA is based on SOAP, a protocol standard for interacting with web services
These services require a set of standards for content and a service-oriented
architecture (SOA) stack, a collection of services
The most common standards used in web services transactions are HTTP, as the
internet protocol, with XML as the delivery language
SOAP (Simple Object Access Protocol): a communication protocol between
applications. It is a XML-based platform neutral format for the invocation and
response of web services functions over a network
WSDL (Web Services Description Language): a XML document used to describe
and locate web services. A WSDL can inform a calling application as to the
functionality available from a given service, as well as the structure and types of
function arguments and responses
UDDI (Universal Description, Discovery and Integration): a directory for storing
information about web services, described by WSDL.
UDDI utilizes the SOAP protocol for providing access to WSDL documents
necessary for interacting with services indexed

The OSI Model Layers

Transport. This layer deals with error recognition and recovery and handles
message size issues and can send receipt acknowledgments. The Internet protocol
related to this is TCP
Network. This layer is involved with message control, switching and routing. It
translates logical addresses into physical addresses
Data link. This layer packages data from the physical layer into frames (special
packets) and is responsible for error free from transfer from one computer (node)
to another.
Physical. This layer deals with the unstructured raw data stream from the other
layers. Specifically, it encodes data and decides whether the bits will be sent via a
digital or analog mode and decides if the bits will be transmitted as electrical or
optical signals.
This layer is involved with communication with devices. Examples: USB, Bluetooth
and RS-232

Networks
A network is a group of computers that are linked together in order to share
information
A network can share patient information as well as provide internet access for
multiple users
Networks can be small, connecting just several computers in a clinician’s office or
very large, connecting computers in an entire organization in multiple locations
There are several ways to access the internet: dial-up modem, wireless fidelity
(WiFi), a Digital Subscription Line (DSL), 3G/4G telecommunication, cable modem
or T1 lines.
Data Transfer Affected By
Bandwidth is the size of the pipe to transmit packets (a formatted data unit
carried by a packet mode computer network) Packet loss is an issue because
packets may rarely fail to reach their destination. The IP Transmission Control
Protocol (TCP) makes sure a packet reaches its destination or re-sends it. The User
Datagram
Protocol (UDP) does not guarantee delivery and is used with, for example, live
streaming video
End-to-end delay is the latency or delay in receiving a packet. With fiber optics the
latency is minimal
Jitter is the random variation in packet delay and reflects Internet spikes in activity

Network Types
Networks are named based on connection method, as well as configuration or
size. As an example, a network can be connected by fiber optic cable,
Ethernet or wireless. Networks can also be described by different configurations
or topologies. They can be connected to a common backbone or bus, in a star
configuration using a central hub or a ring configuration.

Personal Area Networks (PANs)

A PAN is a close proximity network designed to link phones, computers, PDAs, etc.
The most common technology to create a wireless personal area network or
WPAN is Bluetooth (BT)
BT is designed to wirelessly connect an assortment of devices at a maximum
distance of about 300 feet with the most recent
Bluetooth devices (version 5.0). It does have the advantages of not requiring
much power and connecting automatically. It operates in the 2.4 MHz frequency
range
The most common application of Bluetooth today is as a wireless headset to
connect to a mobile phone but wearable technology (e.g. fitness devices) is a
close second.
Bluetooth can be used to wirelessly connect computers to keyboards, mice,
printers, PDAs and smartphones
Security must be enabled due to the fact that even though the transmission range
is short, hackers have taken advantage of this common frequency
Bluetooth Smart or Low Energy 5.0 requires less power, has better battery life and
is less expensive. The frequency is the same but the range is less (about 50
meters)
PANs can also use other standards: Infrared to connect devices using the IrDA
standard, ZigBee networks, Wireless
USB and a body area networks (BANs) A wireless body area network (WBAN) is
also known as a body sensor network which is gaining importance in healthcare
Another wireless sensor network protocol known as ANT™ is available for ultra-
low power applications. The proprietary network operates on the 2.4 GHz ISM
band
LANs generally refer to linked computers in an office, hospital, home or close
proximity situation
A typical network consists of nodes (computers, printers, etc.), a connecting
technology (wired or wireless) and specialized equipment such as hubs, routers
and switches
LANs can be wired or wireless

Wired LANs
To connect several computers in a home or office scenario, a hub or a network
\

switch is needed
Routers direct messages between networks and the Internet; whereas, switches
connect computers to one another and prevent delay
Unlike Hubs that share bandwidth, switches operate at full bandwidth. Switches
are like traffic cops that direct simultaneous messages in the right direction
To handle larger enterprise demands Gigabit Ethernet LANs are available that are
based on copper or fiber optics. Cat5e or Cat6 cables are necessary
Greater bandwidth is necessary for many hospital systems that now have multiple
IT systems, an electronic medical record and picture archiving and communication
systems (PACS)
Phone lines can connect a computer to the internet by using a dial-up modem.
The downside is that the connection is relatively slow
Digital subscription lines (DSL) also use standard phone lines that have additional
capacity (bandwidth) and are much faster network connection than dial up
DSL also has the advantage over modems of being able to access the internet and
use the telephone at the same time.

Electronic Health Records

Electronic Health Record: “An electronic record of health-related information on
an individual that conforms to nationally recognized interoperability standards
and that can be created, managed and consulted by authorized clinicians and staff
across more than one healthcare organization”

Why do we need EHRs?

Paper records are severely limited: less legible, more difficult to retrieve, store
and share and unstructured data. Also, electronic records less likely to be missing
and available 24/7 from multiple locations. Paper records do not permit clinical
decision support
Need for improved efficiency and productivity: clinicians are more productive if
charts are available and retrieval of results is faster. EHR access from home while
on call helps productivity
Quality of care and patient safety: the factors already described in last two
bullets plus clinical decision support, quality reports and secure messaging as part
of an HER
Public expectations: EHRs may increase patient satisfaction through faster results,
messaging, patient portals, electronic patient education, e-prescribing and online
scheduling
Governmental expectations: federal government considers EHR to be
transformational and hence why they support reimbursement for use
Financial savings: EHRs may save money by eliminating transcription and
improving coding. Decreased file room storage and faster chart pulls and info
retrieval may result in cost savings
Technological advances: computers are much faster, the Internet is more
prevalent, wireless and mobile technologies are ubiquitous; all supporting EHRs
Need for aggregated data: healthcare data must be electronic to be shared,
stored and analyzed. Research depends on large study populations and data sets
which EHRs can provide
Need for integrated data: electronic data permits integration with health
information organizations, data analytics, public health reporting, artificial
intelligence and genomic information
EHR as a transformational tool: select organizations such as the VA and Kaiser
Permanente made huge investments in EHRs to standardize care and transform
delivery and analysis of healthcare
Need for coordinated care: with an aging population with multiple physicians and
medications, care coordination is important. Sharing electronically has great
potential, but barriers exist as we point out in the chapter on health information
exchange

Electronic Health Record Key Components

- Clinical decision support
- Secure messaging
- Computerized physician order entry
- Practice management
- Manage care module
- Referral management
- Results retrieval
- Prior encounter retrieval
- Patient reminders
- Ability to scan in data
- Evaluation and management help
- Ability to graph and track results
- Ability to create patient lists
- Ability to create registries
Computerized Physician Order Entry (CPOE)
CPOE is an EHR feature that processes orders for medications, lab tests, imaging,
consults and other diagnostic tests. It is not the same as electronic prescribing
CPOE has the potential to reduce medical errors but the literature is mixed. Most
early studies came from a select number of academic institutions with home
grown EHRs and large IT departments

Potential Benefits of CPOE

- Overcomes the issue of illegibility
- Fewer errors associated with
- ordering drugs with similar names,
- More easily integrated with decision
- support systems than paper, Easily linked to drug-drug interaction warning
- More likely to identify the prescribing physician,
- Able to link to adverse drug event (ADE) reporting systems
- Able to avoid medication errors like trailing zeroes
- Creates data that is available for analysis
- Can point out treatment and drugs of choice
- Can reduce under and over- prescribing
- Prescriptions reach the pharmacy quicker

CPOE
One study suggested cost savings from reduced length of stay, compared to paper
based orders
Some studies have shown improved standardized care with EHRs, but this is not
universal
CPOE is difficult to implement in hospitals because it disrupts workflow and slows
physicians down. They often don’t realize, however, that CPOE benefits others on
the team, such as nurses and pharmacists

Clinical Decision Support Systems (CDSSs)

Knowledge support: programs embedded into the HER that educate clinicians or
patients
Calculators: part of the EHR
Flow charts and graphs: to look at lab or vital sign trends over time
Order sets: inpatient clinical practice guidelines for specific scenarios (e.g.
pneumonia), standardizing care
Reminders: remind clinician or patient about pending tests, etc.
Differential diagnosis: software exists that helps clinicians analyze symptoms and
signs, to arrive at a diagnosis
Lab and Imaging decision support: what tests are indicated and at what costs?
Public health alerts: primarily infectious disease alerts for new outbreaks, e.g.
MERS virus

Electronic Prescribing (eRx)

Currently, the vast majoring of eRx occurs as part of an EHR and not a standalone
program
69% of office-based prescriptions are now electronic
93% of community pharmacies are connected to the Surescripts network

eRx Potential Benefits

- Ability to check formulary status and copays
- Can interface with practice and drug management software
- The process is secure and HIPAA compliant
- Associated with CDDSs
- Digital records improve data analysis of prescribing habits
- Batch refills can save time
- Better use of generic or preferred drugs

eRx Clinical Decision Support

- Details about drug allergies
- Drug-drug interaction alerts
 - Formulary alerts to tell you drug is either not recommended or not
reimbursed
- Alerts can exist to ask about pregnancy, kidney or liver function and safety
in the elderly
- Dosing alerts can arise based on age or size of patient

eRx Challenges
Alert fatigue: too many alerts result in deletions, some justified, others not. Hot
topic and area of much future research
Prescribing errors still occur with eRx but they are different; wrong drug or wrong
dose
There are still issues at the pharmacist’s end but these should improve over time
Still not clear how many adverse drug events are prevented with eRx; perhaps too
soon to know

Practice Management Systems (PMSs)

Prior to EHR adoption, most medical practices used an electronic PMS. Now most
are part of their EHR
PMSs are essential to run any practice: for billing, dealing with insurance
companies, evaluating physician performance and practice trends.

EHR Challenges
Financial: in spite of government reimbursement, some practices will gain and
some will lose money. What will the long term annual costs be after
reimbursement ends? Will some stop using EHRs?
Physician resistance: complying with meaningful use has been onerous and may
not result in any immediate and direct benefit to clinicians and patients
Loss of productivity: there is almost always initial loss of productivity and if the
practice doesn’t change workflow habits there will be a long-term loss as well
Workflow changes: everyone must adapt to doing business differently but some
seek strange workarounds
Reduced physician-patient interaction: without careful forethought and planning,
there will be less eye contact and interaction with patients
Usability issues: some EHRs are not user friendly and require too many mouse
clicks or illogical steps, impeding workflow
Integration with other systems: practices may need to build expensive interfaces
to communicate with HIOs, practice management systems, etc.
Lack of interoperability: EHRs are not capable of communicating with each other
without additional technology, thus an impediment to data sharing
Privacy concerns: hacking into EHRs could result in loss of privacy for thousands,
rather than a single paper chart
Legal: It is not known if EHRs will increase or decrease malpractice over the long
haul
Inadequate proof of benefit: in spite on many published studies, there is not
adequate proof that EHRs improve quality of care
Patient safety and unintended consequences: not only are studies suggesting
improved patient safety mixed, there is evidence that new medical errors may
occur (at least in the short term) with EHR use. “E-iatrogenesis” means medical
errors due to technology

HITECH ACT and EHR Reimbursement

(1) be eligible
(2) register for reimbursement
(3) use a certified HER
(4) demonstrate and prove Meaningful Use
(5) receive reimbursement.

Eligible Professionals (EPs)

Medicare defines EPs as doctors of medicine or osteopathy, doctors of dental
surgery or dental medicine, doctors of podiatric medicine, doctors of optometry
and chiropractors.
Medicaid defines EPs as physicians, nurse practitioners, certified nurse midwives,
dentists and physician assistants (physician assistants must provide services in a
federally qualified health center or rural health clinic that is led by a physician
assistant). Medicaid physicians must have at least 30% Medicaid volume (20% for
pediatricians)

Implementing an EHR Steps

Develop an office strategy: why are you considering EHRs? Is your entire staff
onboard? Don’t do it just for reimbursement. Plan, plan, plan
Do Research: take advantage of courses, books, articles, HER survey results,
regional extension centers, HIT consultants, etc.
List features: be sure to include inputting methods, backup, warrantees, mobile
presence, etc.
Analyze and re-engineer workflow: consider all processes likely to change when
you transition from paper to electronic
Use project management tools: these will improve your organization for tasks
Choose client versus ASP model: the web-based model will be easier with less of
the need for in house IT support
Practice management system needs: should you purchase a combination or build
an interface?
Survey your hardware and network needs: will you need more bandwidth?
Wireless? How many computer stations and will they require upgrades?
Develop a vendor strategy: create request for proposals (RFPs) for vendors to
outline all of your needs, to include price, maintenance, etc. Obtain commitments
in writing.
Select a vendor: develop a contract and have it reviewed by legal
Develop a paper to EHR conversion strategy: it is likely you will initially run a dual
paper and electronic practice. Textbook discusses this in more detail
Training: you can’t train too much and be sure to discuss the details with your
vendor early on
Implementation: decide whether you will phase in implementation or have a “go
live” date. Be prepared to decreased productivity for several months and a new
glitch along the way

Data Standards and Exchange

Data standards promote consistent naming of individuals, events, diagnoses,
treatments, and everything else that takes place in healthcare
Standards enhance the ability to transfer data among applications, thus leading to
better system integration
Standards also facilitate interoperability among information systems and users
a standard document established by consensus and approved by a recognized
body that provides for common and repeated use, rules, guidelines or
characteristics for activities or their results, aimed at the optimum degree of order
in a given context.

Interoperability
Standards facilitate an important process known as interoperability
The Institute for Electronic and Electrical Engineers (IEEE)
updates its definition of interoperability regularly and its 2016 definition is “the
ability of a system or product to work with other systems or products without
special effort on the part of the customer. Interoperability is made possible by the
implementation of standards.”
 Level 1 – no interoperability, e.g., mail, fax, phone, etc.
 Level 2 – machine-transportable (structural); information cannot be
manipulated, e.g., scanned document, image, PDF
 Level 3 – machine-organizable (syntactic); sender and receiver must
understand vocabulary, e.g., email, files in proprietary forma
 Level 4 – machine-interpretable (semantic); structured messages
with standardized and coded data, e.g., coded results from
 structured notes, lab, problem list, etc.

Types of Standards
- Identifier standards
- Transaction standards
- Messaging standards
- Imaging standards
- Terminology standards

Identifier Standards
Patient Identifiers
Benefits are easy linkage of records but can also compromise privacy and
confidentiality for the patient
Reduce the problems of both duplicate and overlaid records
A duplicate record occurs when more than one record exists for a patient,
whereas an overlaid record takes place when more than one patient is mapped
to the same record

Patient identifier key attributes (Connecting for Health 200%)

• Unique – only one person has an identifier
• Non-disclosing – discloses no personal information
• Permanent – will never be re-used
• Ubiquitous – everyone has one
• Canonical – each person has only one
• Invariable – will not change over time
Other Identifiers
The National Provider Identifier (NPI), which is assigned to all physicians in the US.
The payor for Medicare in the US, the Centers for Medicare and Medicaid Services
(CMS), will not process claims without use of the NPI
Employers must have a standard Employer Identifier Number (EIN). In addition,
the Affordable Care Act requires health plans to have either a Health Plan
Identifier (HPI) or an Other Entity Identifier (OEID) that is an identifier for use in
transactions

Transaction Standards
There is a set of transaction standards for healthcare called ASC X12N
• developed to encourage electronic commerce for health claims, simplifying
what was previously a situation of over 400 different formats between insurance
companies and others for healthcare transactions
HIPAA legislation mandated the use of the ASC X12N standards for healthcare
business electronic data exchange under the guise of “administrative
simplification”
The original version of ASC X12 was called 4010. This was superseded by a new
version that was released in 2012 called 5010. The major transactions in 5010 and
their identifier numbers include:
• Health claims and equivalent encounter information (837)
• Enrollment and disenrollment in a health plan (834)
• Eligibility for a health plan (request 270/response 271)
• Health care payment and remittance advice (835)
• Health plan premium payments (820)
• Health claim status (request 276/response 277)

Messaging Standards
Message exchange standards focus on different types of messages and different
types of data
HL7 is the organization that develops and supports standards and is properly
called HL7 International
The name HL7 comes from the OSI 7-layer model of network communications.
Version 2 of HL7 is widely used throughout health
care
HL7 Version 2 is mostly a syntax. This means that the sender and the receiver
must understand the meaning of the messages Within HL7 Version 2, each
message has segments, and each of the segments has a three-character identifier
and then values that follow it
HL7 Version 2 message
segments and identifiers:
• MSH – message
header
• EVN – event type
• PID – patient
identifier
• OBR – results header
• OBX – result details
HL7 Version 3 is an attempt to introduce semantics into messaging
HL7 Version 3 is based on Reference Information Model (RIM)
The elements of the message defined in the context of these abstract classes:
• Entity – things in world, e.g., people, organizations, other living
subjects, drugs, devices
• Role – capability or capacity, e.g., patient, practitioner
• Participation – role in context of an act, e.g., performer, target
• Act – clinical or administrative definitions, e.g., observation,
diagnosis, procedure
• Act relationship – links between acts, e.g., diagnosis act

All clinical, administrative, financial, etc. activities of healthcare can be expressed

in “constraints” to the RIM.
Fast Health Interoperability Resources (FHIR) With the widespread adoption of
electronic health records and other clinical data systems, a new robust
interoperability standard was needed.
When FHIR emerged as the leading candidate for interoperability, HL7
International took over its development.
A key component of FHIR is its Resources, which comprise the content of its
messages:
 Clinical: The content of a clinical record
 Identification: Supporting entities involved in the care process
 Workflow: Manage the healthcare process
 Financial: Resources that support the billing and payment parts of FHIR
 Conformance: Resources use to manage specification, development and
testing of FHIR solutions
 Infrastructure: General functionality, and resources for internal FHIR
requirements
Other HL7 Standards
Clinical Document Architecture (CDA)
Another important activity of HL7 is the Clinical Document
Architecture (CDA). CDA is important because most health care information is in
the form of documents, and these are used to allow humans to read them.
The current version of CDA, Version 2, has three levels of interoperability
• Level 1 – general document specification
• Level 2 – adds document types with allowable structures
• Level 3 – adds mark-up expressible in structured form, such as RIM

Imaging Standards
We want to move image data from the devices that capture the data into records
so that they can be viewed, and then we may want to archive them in various
ways.
The Digital Imaging and Communications (DICOM) standard is intended for the
transport of images.
DICOM was developed by the American College of Radiology and the National
Electrical Manufacturers Association.
Patient Summary Standards
Over a decade ago, the need to exchange patient summaries led to the
development of the Continuity of Care Record (CCR)
The goal for the CCR was to be, “a set of basic patient information consisting of
the most relevant and timely facts about a patient's condition” (ASTM
International 2003)
The original CCR standard, however, was not compatible with any existing
standards, and this led HL7 and several vendors to create the Continuity of Care
Document (CCD), which would be based on HL7 Version 3, and the Clinical
Document Architecture (CDA).

Messaging Standard Platforms

Today’s EHRs are large, monolithic systems and not platforms on top of which
other applications and innovations can be built
Mandl et al. have developed the Substitutable Medical Apps Reusable
Technologies (SMART) platform, based on the idea that there should be an
underlying platform upon which “apps” can built that access a common store of
data and functions (Mandl 2012)
SMART has also adapted FHIR as its API for accessing data, hence the phrase
SMART on FHIR. It has been implemented for EHRs and extended to areas like
genomics and precision medicine applications

Terminology Standards
The benefits of computerization of clinical data depend upon its “normalization”
to a consistent and reliable form so we can carry out tasks such as aggregation of
patient data, clinical decision support, and clinical research
But clinical language is also inherently vague, sometimes by design, and that can
be at odds with the precision of computers
Terminology standards are important for establishing reliable terms for transfer
and use of data through the computer.
ICD-10
There have been several informatics concerns about ICD-10- CM
• One of these is the excess granularity as noted in the comparison with ICD-9
• Many advocated that ICD-10 never be adopted, that it just be skipped, and the
US move from ICD-9-CM directly to ICD-11
• However, ICD-11 is not yet completed, and it would probably be another two,
maybe three, years before the development of ICD-11-CM

Health Information Exchange

Health Information Exchange (HIE) is the “electronic movement of health-related
information among organizations according to nationally recognized standards”
Health Information Organization (HIO) is “an organization that oversees and
governs the exchange of health-related information among organizations
according to nationally recognized standards”
Regional Health Information Organization (RHIO) is “a health information
organization that brings together health care stakeholders within a defined
geographic area and governs health information exchange among them for the
purpose of improving health and care in that community.”
Interoperability is defined as “the ability of two or more systems or components
to exchange information and to use the information that has been exchanged”.
This implies that the data is computable and that standards exist that permit
interoperability.
Interoperability Levels
- Foundational: refers to the technology or platform used to exchange
information
- Syntactic: means messages have a structure and syntax that is
understandable. Uses XML and HL7 standards
- Semantic: terminology and coding must be the same for the sending and
receiving organizations
Healthcare Data Potentially Shared
Clinical results: Lab, pathology, medication , allergies, immunizations and
microbiology data
Images: Actual images and radiology reports
Documents: Office notes, discharge notes and emergency room notes
Clinical summaries: Continuity of Care Documents (CCDs); XML-based documents
that standardize and summarize care
Financial information: Claims data and eligibility checks
Medication data: Electronic prescriptions, formulary status, and prescription
history
Performance data: Quality measures like blood pressure or diabetes control,
cholesterol levels, etc.
Case management: Management of the underserved and emergency room
utilization
Public health data: Infectious diseases outbreak data, immunization records
Referral management: Management of referrals to
specialists

NwHIN
The reality is that HIE is expensive to create and maintain and the interest in
national sharing is limited
For that reason the federal government funded a state level HIE program we will
discuss later and they also created a simple secure messaging (email) service to
help with Meaningful Use because many hospital and healthcare systems refused
to share (more in other slides)
In 2012 NwHIN was renamed to the eHealth Exchange and became managed by
HealtheWay, a government and private consortium. Later the same year, the
initiative was renamed the Sequoia Project.

Direct Project
With the slow adoption of HIE nationwide an alternative plan had to be developed
for Meaningful Use
The Direct Project involves secure messaging (email) between clinicians, patients,
hospitals, etc. Consults and discharge summaries could be attached
The Project requires all parties to apply and register for a unique email. The
project is administered by multiple health information service providers (HISPs)
that can be almost any organization.
Here is an example of a secure message address [email protected]
The goal will be for EHR vendors to include this mechanism within the EHR email
system and not an external email
Continuity of Care Documents (covered in the data standards chapter) will be a
standard way to summarize care and attach to a secure email
Patients will email their clinicians this way It is difficult to gauge the success of this
program.

Blue Button Project

Another avenue to allow healthcare data sharing is to allow patients to download
their records and results using a recognized “blue button” (see above icon)
This approach was taken by the VA and other healthcare organizations
Blue Button Plus Project will use data standards such as the CCD so downloads can
be printed or shared and assist with
Meaningful Use requirements
Meaningful Use mandates data sharing so HIOs can assist
Health Information Organizations (HIOs)
HIOs have the potential to link together disparate healthcare systems, offices, labs
, etc. into one entity
This permits “pull” technology, where for example, a physician in Cincinnati can
search for a patient and pull discharge summaries and other results from a variety
of organizations
The technology is the easy part. HIOs must be trusted and deal with fiercely
competitive organizations and they must have a long-term financial sustainability
plan. This is much harder than originally anticipated.
Many HIOs were started with early federal funds that are no longer available
HIOs can charge subscription or transaction fees but healthcare organizations
have to see value to be willing to pay for this HIOs can support Meaningful Use
and be HISPs
There are some well-known well run HIOs in the country, but there have been
many failures and stagnation

HIO Potential Functions

 Results delivery
 Quality reporting

 Connectivity with EHRs

 Results distribution

 Clinical documentation
 Electronic health record (EHR) hosting
 Alerts to clinicians
 Assist data loads into EHRs

 Electronic prescribing
 EHR interfaces

 Health summaries
 Drug-drug alerts

 Electronic referral processing

 Drug-allergy alerts
  Consultation/referrals
 Drug-food allergy alerts

 Credentialing Billing

HIO Facts
Can be centralized or decentralized (federated)
Can be for profit or not-for-profit
Can be government, private or community based
HIE Barriers
 Lack of successful business models

 Environment is highly competitive

 Federal support monies are gone

 HIOs seem to work better in high population areas

 Return on investment (ROI) is unclear

 Proof of benefit is weak

 Privacy/Security issues

Newer HIE Models

FHIR: covered in multiple other chapters. Will use the FHIR data standard and
RestFul APIs to request information from remote and disparate systems. Not
standard of care, however
Blockchain: same technology as used for Bitcoins. It is a “distributed transaction
ledger” that is difficult to hack. Decentralized approach that is being tested in
healthcare
OpenHIE: open-source initiative aimed at low to middle income countries. Uses a
service-oriented architecture (SOA)
EHR Vendor-based HIE: vendors, such as Epic, have options to share to physicians
not in the network and with those who are not using their EHR. Product is known
as Care Everywhere.