Patient Safety Achieving a New Standard for Care (2004) / Chapter Skim
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2 Components of a National Health Information Infrastructure
2 Components of a National Health Information Infrastructure
Pages 52-95
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From page 52... ...
This chapter is divided into three sections: the first provides a general overview of the national health information infrastructure and a con ceptual model of standards-based integrated data systems to support patient safety in institutional and office practice settings for all audi ences; the second presents a technical review of the informatics com ponents that support an information infrastructure for the technical reader; and the third provides a discussion of how standards-based clinical systems can be and have been implemented to support this endeavor for both audiences.
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From page 53... ...
, a capability that is especially important for the chronically ill. The capabilities provided by these clinical information systems cannot be achieved, however, without standards-based interoperability founded on the national health information infrastructure (NHII)
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From page 54... ...
Several promising Health Care Provider · Patient ID Personal Health Dimension · Health history Dimension · Health insurance · Provider notes · Consent forms · Nonshared personal · Clinical orders · Medication alerts information · Practice guidelines · Self-care trackers · Decision support programs · Audit logs · Personal library · De-identified data · Mandatory reporting · Community directories · Public health services · Vital statistics · Survey data · Population health risks · Inspection reports · Communicable diseases · Public education materials · Socioeconomic conditions · Neighborhood · Registries environmental hazards Population Health Dimension · Infrastructure data · Planning and policy documents · Surveillance systems · Health disparities data FIGURE 2-1 Examples of content for the three NHII dimensions and their overlap. SOURCE: National Committee on Vital and Health Statistics, 2001.
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From page 55... ...
. INPC not only allows for the secure storage and exchange of clinical information but also provides clinical decision support and public health surveillance and reporting.
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From page 56... ...
At the organizational level, moving forward with a health information infrastructure requires the development of comprehensive, standards-based systems necessary for delivering clinical information at the point of care, facilitating communication for care coordination, and supporting patient safety systems for detection and prevention of adverse events and for detection and recovery from near misses. The first section of this chapter presents a conceptual model of a standards-based data system that draws on the above core informatics components of a national health information infrastructure; the second section provides a brief overview of each of those components.
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From page 57... ...
Pharmacy Reporting Capture Clinicians Patients FIGURE 2-2 Conceptual model of standards-based, integrated data systems to support patient safety. NOTE: aEHR = electronic health record; bCPOE = computerized physician order entry.
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From page 58... ...
Evidence-based care is enhanced over time with a constant infusion of new medical knowledge from the biomedical literature into decision support systems so that significant aspects of care are supported for such purposes as delivering preventive care reminders to clinicians. Patient care data, along with other useful data sources, are aggregated for analysis in registries, analytic databases, and data warehouses.
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From page 59... ...
While large institutions and office practices require somewhat different information technology architectures, the informatics requirements to support systems integration and clinical decision support tools are the same. Instead of linking with internal departmental systems within larger organizations that account for the majority of patient data (e.g., pharmacy, laboratory, radiology)
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From page 60... ...
Under this model, office practices will utilize the wide range of clinical information systems that make up the totality of the EHR. Information technology systems may include computers, personal digital assistants (PDAs)
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TECHNICAL CONSIDERATIONS: INFORMATICS COMPONENTS OF THE INFORMATION INFRASTRUCTURE The informatics components of the NHII provide a foundation for a comprehensive standards-based system and a migration strategy for its implementation. This section briefly describes the key components of a health information infrastructure that supports patient safety.
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From page 62... ...
According to these principles, such technologies should provide for unique identification of the patient, accuracy of information capture through the use of standards-based terminologies, completeness of information and minimization of duplication, timeliness such that data can be captured at the point of care, interoperability with any clinical information system, retrievability so that information can be found efficiently, authentication and accountability so that all data can be attributed to its source, auditability for ongoing assessments of quality, and confidentiality and security features to protect the data. An intuitive and efficient user interface, that part of the computer system that communicates with the user, is utilized for interactive data entry, and controls the execution and flow of data (van Bemmel and Musen, 1997)
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From page 63... ...
The status of various types of health care data standards and the gaps that need to be addressed are described in detail in Chapter 4. TABLE 2-1 Data Standards of Relevance to the Structure of Patient Safety Systems Stand-alone Integrated Standard Database Information System Data element definitions, including standardized • • measures Datasets representing clinical practice measures • • Standardized terminology • • Knowledge representation (concepts, guidelines)
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From page 64... ...
Data Repositories and Clinical Event Monitors A clinical data repository is a database that collects and stores patient care information from diverse data sources. It is typically optimized for storage and retrieval of information on individual patients and used to support health care delivery, surveillance, and clinical decision support (e.g., drug– drug interactions at the time of order entry, reminders about preventive care)
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From page 65... ...
using a variety of communication technologies and are also stored in the repository. A recent comprehensive review of studies in which information technology was used to detect adverse events documented the utility of clinical event monitors for preventing adverse drug events, nosocomial infections, and injurious falls (Bates et al., 2003)
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From page 66... ...
However, natural language extraction is currently a difficult and knowledge-intensive task. To date, only a few NLP systems have been integrated with clinical information systems and used for improved quality of care and patient safety, including error detection and prevention, but the results of such efforts are encouraging (Fiszman and Haug, 2000; Friedman et al., 1995; Haug et al., 1990)
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From page 67... ...
are another key component of a health information infrastructure and are essential for evidence-based practice. Sources of evidence, including bibliographic references, evidence-based clinical guidelines, and comparative databases, must be integrated with clinical expertise as practitioners make decisions (Bakken, 2001)
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From page 68... ...
. For example, within the context of a system to support patient safety and quality of care that is integrated with clinical care processes, digital sources of evidence would include, among others, guidelines related to the 20 priority health areas identified by the IOM, access to context-specific bibliographic retrieval, diagnostic decision support systems to assist with difficult diagnoses, and alerts and reminders of relevance to errors of omission and commission.
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From page 69... ...
. Leveraging the vast quantities of health care data and enterprise-wide knowledge requires the development of health information resource networks at the regional or national level.
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The credibility of online health information must also be addressed (Rice and Katz, 2001)
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However, use of such technologies will depend on data standards and other components of the NHII so that compatibility and interoperability within the health information system can be established.
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From page 72... ...
Ideally, the NHII will rely on the EHR as the central integrating component for data acquisition, analysis, and storage. Key capabilities of an EHR system include core health information, results management, order management, decision support, communication, patient support, and reporting (Institute of Medicine, 2003)
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From page 73... ...
The events in this scenario were characterized by the need to coordinate care across multiple providers in different settings; thus the demonstration was focused in particular on exploring the potential for using interoperability standards to improve care coordination. From the committee's perspective, the goals of participating in this demonstration were to: • Highlight how interoperability standards can improve communication and coordination of clinical data among care settings (inpatient, outpatient, pharmacy)
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From page 74... ...
Box 2-2 presents the results of the demonstration in terms of a report card summarizing progress to date on interoperability standards in health information management systems. From the data standards perspective, the assessment of systems functionality was based on whether a standard exists and was/was not used in the demonstration, whether there are nonstandard methods for executing the task, or whether no technology exists to solve this interoperability issue.
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From page 75... ...
The scenario demonstrated that even with the current state of relatively disparate data standards and interaction of multiple vendors, use of available data standards1 allowed for a level of interoperability to support cross-organizational data flows and care coordination. The committee found participation in the demonstration to be a useful experience.
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Physician orders complete blood count and blood Hospital chemistries. Lab results indicate low sodium (hyponatremia)
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Discharge summary is human readable but not coded for automated decision support (it does not encode symptom data or diagnosis)
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From page 78... ...
Building comprehensive systems to support both EHRs and patient safety systems must begin with a solid infrastructure based on the essential informatics components discussed in this chapter. Early adopters of EHRs are already using many of the data standards recommended in this report.
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From page 79... ...
Some of these institutions have BOX 2-3 Nicholas E Davies Award Winners 1995 Intermountain Health Care, Salt Lake City, Utah Columbia Presbyterian Medical Center, New York, New York Department of Veterans Affairs 1996 Brigham and Women's Hospital, Boston, Massachusetts 1997 Kaiser Permanente of Ohio, Cleveland, Ohio North Mississippi Health Services, Inc., Tupelo, Missouri Regenstrief Institute for Health Care, Indianapolis, Indiana 1998 Northwestern Memorial Hospital, Chicago, Illinois Kaiser Permanente Northwest, Portland, Oregon 1999 Kaiser Permanente of Colorado Queens Medical Center, Honolulu, Hawaii 2000 Harvard Vanguard Medical Associates, Boston, Massachusetts Veterans Administration Puget Sound Health Care System, Washington St.
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From page 80... ...
. Other applications, such as those for reporting adverse events, are spearheading the use of health information systems to
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From page 81... ...
: allergies/side effects, vital signs, smoking status (coded) Clinical • Targeted additional information based on clinical service, visit Billing Billing Data type, and patient characteristics HRA • Verify optical mark sense data extraction • Medical record coder work queue FIGURE 2-3 Information management in the medical automated record system of Kaiser Permanente of Ohio.
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From page 82... ...
The reminders have made a significant contribution to Kaiser's quality improvement initiatives and could do the same for patient safety. Patient safety reminders, such as those related to drug–drug interactions and comormidities, could easily be added to Kaiser's information system and generated for the patient's clinical information packet.
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From page 83... ...
Of particular note, the NMHS EHR incorporates real-time decision support tools to screen patients at risk for adverse events and provide caregivers with individualized clinical information. NMHS's long-standing programs encompass drug–drug and drug–food interactions and drug allergy checks.
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From page 84... ...
before being forwarded electronically for the targeted medical action. This is a critical step in the care process, a point at which intervention through the use of clinical information systems can have a high impact on preventing adverse events and improving adherence to care guidelines (Metzger et al., 2003)
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From page 85... ...
De-identification policies and practices are reviewed, documented, and modi fied as necessary to ensure that the vendor meets or exceeds all such requirements. pendent on data from departmental systems, they necessitate upgrading of legacy systems for interoperability and the use of common data standards to allow sharing of data.
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From page 86... ...
. OVERCOMING CHALLENGES TO IMPLEMENTATION OF INFORMATION TECHNOLOGY FOR THE NATIONAL HEALTH INFORMATION INFRASTRUCTURE Organizational Leadership Traditionally, a lack of organizational commitment to information technology and organizational culture have been significant barriers to the development of an informatics infrastructure within health care organizations.
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From page 87... ...
When the clinical information system and clinical improvement processes were transferred from LDS Hospital to other institutions, one of the greatest challenges was to transfer the continuous improvement mind-set (e.g., emerging deficiencies in information technology systems were often viewed as "works in progress" rather than failures)
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From page 88... ...
, data standards (e.g., data interchange, terminologies, and knowledge representation) , and patient safety reporting systems (e.g., organizational, state, national)
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From page 89... ...
. The conference focused on several key topics, including data standards and vocabulary, as well as financial incentives.
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From page 90... ...
Given recent events and the current climate, moreover, the federal government may have an interest in extending its scope as a resource in handling sensitive situations and Internet-related problems that may affect health information systems.
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From page 91... ...
the implementation of common data standards for interoperability and comparability of health information. Although a health information infrastructure that supports learning and accountability systems for patient safety has not been implemented in most organizations to date, the barriers involved are not primarily technological.
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1998b. Upgrading clinical decision support with published evidence: What can make the biggest difference?
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2000. A clinical decision support system for prevention of venous thromboembolism: Effect on physician behavior.
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1998. Respiratory isolation of tuberculosis patients using clinical guidelines and an automated clinical decision support system.
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2001. Clinical decision support systems for the practice of evidence-based medicine.
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