Health information technology has proliferated across the US in the last two decades, encouraged by the Institute of Medicine and the economic incentives of the American Recovery and Reinvestment Act. From the most basic programs of computerized physician order entry (CPOE) through clinical decision support (CDS) to a true electronic health record (EHR), software applications are now readily available to even small operations. In fact, there are so many options that it can be hard to choose among them.
What is Health Information Technology?
In the broadest sense, health information technology (HIT) is simply the application of information technology to health care. HIT is another way to describe the comprehensive management of information among consumers, clinicians, government, quality entities and insurers. Ideally, the use of HIT should improve the quality and effectiveness of health care, promote individual and public health, increase accuracy and prevent medical errors, reduce costs and paperwork, and improve the efficiency of both administrative and clinical processes. In practice, the ability to achieve these goals has been mixed.
From Paper to Computer
Computerized physician order entry allows physicians to enter medical orders into a computer system. Rather than writing paper prescriptions or hand-written orders for laboratory and diagnostic tests, referrals or patient care into a patient’s chart, the physician types the orders into the computer. The impact on patient safety is immediate in that orders are legible and can be sent electronically to outside entities like pharmacies.
Clinical decision support increases the value of computerized order entry systems by providing immediate, real-time feedback on diagnostic and treatment-related information. The decision support program can check for potential errors, such as a doctor prescribing an antibiotic to which the patient is allergic. The checking is performed in the background and the system alerts the user of potential problems. When used together, computerized physician order entry and clinical decision support can improve medication safety and quality of care, and reduce costs, according to the Agency for Healthcare Research and Quality (AHRQ).
Healthcare Information Management
The terms electronic medical record and electronic health record are often used interchangeably, but they are not exactly the same. An electronic medical record is simply a digital version of a patient’s chart. Confined to a single practice, it can provide valuable information for patient management, such as when someone is due for an immunization and what patients’ blood pressure readings look like over time.
An electronic health record, however, contains that information but is also designed to allow information about the patient to travel outside of the practice, so data is available to all those involved in a patient’s care. For example, an electronic health record would contain the patient’s allergies and current medications, which would be available to the laboratory pathologist, the radiologist, the home care nurse or the insurance company. Aggregated de-identified patient data could also be used for medical research, public health measures such as managing an epidemic, and policy developments at the state and federal level.
Although HIT offers many potential benefits, many individuals and institutions have been slow to adopt the technology or to use it to best effect. In some cases the issues are financial, as even with monetary incentives from the federal government, implementing HIT is very expensive. In others, the problems are technical, such as interfacing different proprietary systems that contain laboratory or medication data into a particular HIT patient care system.
Interoperability between systems can be a major challenge; systems designed for a hospital don’t necessarily work well in outpatient care and vice versa. A laboratory pathologist has different information needs than the cardiologist caring for a hospitalized patient. Another problem is the need to train all users, assure that people use the system correctly and to retrain as new software becomes available.
To choose software and hardware systems and to use HIT effectively, an organization must be diligent in researching both current and proposed requirements. Vendor choice and support are two of the most critical factors in implementing HIT. Another is the need to bring physicians on board. Resources are available to help in this process, such as our free templates for medical software requirements.