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- Healthcare information management systems: Cases, strategies, and solutions: Fourth edition
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Book Shelf - Healthcare Information Management Systems Books
Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. Technology and Tools in the Diagnostic Process.
A wide variety of technologies and tools are involved in the diagnostic process see Figure , but the primary focus of the chapter is on health information technology health IT tools. Health IT covers a broad range of technologies used in health care, including electronic health records EHRs , clinical decision support, patient engagement tools, computerized provider order entry, laboratory and medical imaging information systems, health information exchanges, and medical devices.
The committee concluded that health IT has the potential to impact the diagnostic process in both positive and negative ways. When health IT tools support diagnostic team members and tasks in the diagnostic process and reflect human-centered design principles, health IT has the potential to improve diagnosis and reduce diagnostic errors.
Despite this potential, however, there have been few demonstrations that health IT actually improves diagnosis in clinical practice El-Kareh et al. Indeed, many experts are concerned that current health IT tools are not effectively facilitating the diagnostic process and may be contributing to diagnostic errors Basch, ; Berenson et al.
This chapter discusses the design of health IT for the diagnostic process, the interoperability of patient health information, patient safety issues related to. The committee makes one recommendation aimed at ensuring that health IT tools and technologies facilitate timely and accurate diagnoses. In addition, this chapter briefly reviews the use of mobile health mHealth and telemedicine in the diagnostic process.
Other technologies, such as diagnostic testing, are discussed in Chapter 2. That report emphasized that health IT functions within the context of a larger sociotechnical system involving the technology itself, the people who work within the system, the workflow or actions and procedures clinicians are anticipated to perform as they deliver care , the organization using the technology, and the external environment.
The design of health IT has the potential to support the diagnostic process. In particular, by supporting the individuals involved in the diagnostic process and the tasks they perform, health IT may improve diagnostic performance and reduce the potential for diagnostic errors. The increasing complexity of health care has required health care professionals to know and apply vast amounts of information, and these demands are outstripping human cognitive capacity and contributing to challenges in diagnosis see Chapter 2.
El-Kareh et al. Although health IT interventions are not appropriate for every quality-of-care challenge, there are opportunities to improve diagnosis through appropriate use of health IT. For instance, a well-designed health IT system can facilitate timely access to information; communication among health care professionals, patients, and their families; clinical reasoning and decision making; and feedback and follow-up in the diagnostic process El-Kareh et al.
Table describes a number of opportunities to reduce diagnostic errors through the use of health IT. A number of researchers have identified patient safety risks that may result from poorly designed health IT tools Harrington et al. Recommendation 1: The Secretary of Health and Human Services HHS should publish an action and surveillance plan within 12 months that includes a schedule for working with the private sector to assess the impact of health IT [health information technology] on patient safety and minimizing the risk of its implementation and use.
The plan should specify:. Recommendation 2: The Secretary of HHS should ensure insofar as possible that health IT vendors support the free exchange of information about health IT experiences and issues and not prohibit sharing of such information, including details e.
Recommendation 3: The ONC should work with the private and public sectors to make comparative user experiences across vendors publicly available. This council should operate within an existing voluntary consensus standards organization. Recommendation 5: All health IT vendors should be required to publicly register and list their products with the ONC, initially beginning with EHRs certified for the meaningful use program. Recommendation 6: The Secretary of HHS should specify the quality and risk management process requirements that health IT vendors must adopt, with a particular focus on human factors, safety culture, and usability.
Recommendation 7: The Secretary of HHS should establish a mechanism for both vendors and users to report health IT—related deaths, serious injuries, or unsafe conditions. Recommendation 8: The Secretary of HHS should recommend that Congress establish an independent federal entity for investigating patient safety deaths, serious injuries, or potentially unsafe conditions associated with health IT. This entity should also monitor and analyze data and publicly report results of these activities.
Recommendation 9a: The Secretary of HHS should monitor and publicly report on the progress of health IT safety annually beginning in If progress toward safety and reliability is not sufficient as determined by the Secretary, the Secretary should direct the Food and Drug Administration FDA to exercise all available authorities to regulate EHRs, health information exchanges, and personal health records.
Recommendation 9b: The Secretary should immediately direct FDA to begin developing the necessary framework for regulation. Such a framework should be in place if and when the Secretary decides the state of health IT safety requires FDA regulation as stipulated in Recommendation 9a above.
Recommendation HHS, in collaboration with other research groups, should support cross-disciplinary research toward the use of health IT as part of a learning health care system. Products of this research should be used to inform the design, testing, and use of health IT. Specific areas of research include. New England Journal of Medicine, G. Schiff and D. Can electronic clinical documentation help prevent diagnostic errors?
Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society. If health IT products do not have these features, it may be difficult for users to effectively interact with the technology, contributing to workarounds alternate pathways to achieve a particular functionality or unsafe uses of the technology, as well as errors associated with the correct use of the technology. Although many of these risks apply to health care broadly, the committee concluded that health IT risks are particularly concerning for the diagnostic process.
Poor design, poor implementation, and poor use of health IT can impede the diagnostic process at various junctures throughout the process.
For instance, a confusing or cluttered user interface could contribute to errors in information integration and interpretation that result in diagnostic errors. Poor integration of health IT tools into clinical workflow may create cognitive burdens for clinicians that take time away from clinical reasoning activities.
To ensure that health IT supports patients and health care professionals in the diagnostic process, collaboration between the federal government, the health IT industry, and users is warranted.
The IOM report concluded that the safety of health IT is a shared responsibility and described the ways in which health IT vendors, users, governmental agencies, health care organizations, and others can collaborate to improve the safety of health IT.
Users include a wide variety of clinicians such as treating health care professionals, clinicians with diagnostic testing expertise, pharmacists, and others , as well as patients and their families HIMSS, For example, by working with users, health IT vendors.
In line with these recommendations, the committee recommends that health IT vendors and ONC should work together with users to ensure that health IT used in the diagnostic process demonstrates usability, incorporates human factors knowledge, integrates measurement capability, fits well within clinical workflow, provides clinical decision support, and facilitates the timely flow of information among patients and health care professionals involved in the diagnostic process.
Collaboration among health IT vendors, ONC, and users can help to identify best practices in the design, implementation, and use of health IT products used in the diagnostic process. Further research in designing health IT for the diagnostic process is also needed see Chapter 8. The sections below describe the importance of these various features in the design of health IT for the diagnostic process.
The committee did not want to impose specific requirements for how this recommendation is implemented, because the approach would be too proscriptive. The potential benefits of health IT for improving diagnosis cannot be realized without usable, useful health IT systems.
It is intuitive, forgiving of mistakes and allows one to perform necessary tasks quickly, efficiently and with a minimum of mental effort.
Tasks which can be performed by the software. Recent discussions of usability have focused on the importance of incorporating design principles that take human factors 1 into account. Middleton et al. A number of terms have been used to describe the optimal design approach, including human-centered design, user-centered design, use-centered design, and participatory design. The committee opted for the more inclusive term, human-centered design, to describe how the involvement of all stakeholders, rather than just users, is affected by the health IT system.
A human-centered design approach balances the requirements of the technical system of computers and software with those of the larger sociotechnical system Gasson, Although some health IT vendors have adopted human-centered design principles, the practice is not universal AHRQ, Furthermore, usability challenges may only become evident after the system has been implemented or after it has been in widespread use.
Accordingly, it is important to make continuous improvements to the design, implementation, and use of health IT Carayon et al. Opportunities to assess the effects of technology on the diagnostic process are discussed in Chapter 3. Although clinicians have reported a high level of use and satisfaction with certain health IT features, such as electronic prescribing Makam et al.
Health IT that is not designed and implemented to support the diagnostic process can increase vulnerability to diagnostic errors. Future research on health IT usability will be important see Chapter 8. As mentioned in Box , a major issue related to health IT is how it will affect the patient—clinician relationship. The hope is that health IT will enhance patient and clinician communication and collaboration by, for example, facilitating patient access to health information see Chapter 4.
However, this needs to be facilitated by health IT tools that assist patients and their families in engaging in the diagnostic process such as patient access to clinical notes; see Recommendation 1. Patient portals provide patients with access to their medical information, but poor usability—including navigational problems and unmet expectations about functionality—can hinder adoption of such tools among patients Greenhalgh, Additional patient-facing health IT tools include mHealth applica-.
In addition, there are concerns that clinicians may be unwilling or not know how to act on information collected by patients though mHealth, wearable technologies, or other forums Dwoskin and Walker, ; Ramirez, One article suggested that the EHR has negatively affected the clinician—patient bond by prioritizing the computer above the patient.
An important component of usability is whether it supports teamwork in the diagnostic process. Health IT has the potential to strengthen intra- and interprofessional teamwork by providing structural support for enhanced collaboration among the health care professionals involved in the diagnostic process.
Reducing the cognitive burdens on clinicians is another key feature of usable health IT systems. Health IT has the potential to support clinicians in the diagnostic process by managing information flow and filtering and presenting information in a way that facilitates decision making. The problem list derives from the problem-oriented medical record, developed by.
Lawrence Weed Jacobs, The problem list includes all past and present diagnoses, as well as the time of occurrence and whether the problem was resolved, and links to further information on each entry in the list AHIMA, ; Weed, Although studies have shown that use of high-quality problem lists is associated with better patient care Hartung, ; Simborg et al.
To encourage this change, meaningful use criteria require that participants maintain an up-to-date, coded problem list for at least 80 percent of their patients AHIMA, Unfortunately, poorly designed health IT systems, such as those with confusing user interfaces and disorganized patient information, may contribute to cognitive overload rather than easing the cognitive burden on clinicians. Poorly designed systems can detract from clinician efficiency and impede information integration and interpretation in the diagnostic process.
A recent analysis of the graphical display of diagnostic test results in EHRs found that few of the current EHRs meet evidence-based criteria for how to improve comprehension of such information Sittig et al. For example, one EHR system graphed diagnostic testing results in reverse chronological order; none of the EHRs in the analysis had graphs with y-axis labels that displayed both the name of the variable and the units of measurement. Human factors engineering approaches, such as a heuristic evaluation or an assessment of how well a particular interface design complies with established design principles for usability, could help identify usability problems and guide the design of user interfaces CQPI, One key feature of an effective user interface is simplicity.
Clinicians have expressed dissatisfaction about EHR screens being too busy due to a high degree of display clutter or the high density of objects. Clinicians need to be able to complete a task without having to undergo extra steps, such as clicking, scrolling, or switching between a keyboard and mouse; however, many health IT tools are cumbersome to navigate.
One study of emergency department clinicians found that inputting information consumed more of their time than any other activity, including patient care Hill et al. Hill and colleagues estimated that a clinician could make 4, clicks in one hour shift.
[PDF] Healthcare Information Management Systems: Cases, Strategies, and Solutions (Health
Health information technology HIT is being sought as one of the key elements to streamline the process of providing healthcare to improve quality and harness cost. It is hoped that HIT will lead to a more cost-efficient healthcare system than the current one. Surprisingly, there is no agreed definition of HIT in academic literature or government documentation. An information system consists of four interrelated components—data, information technology, process, and users. With the digitizing of information systems in healthcare organizations, the roles of HIM professionals have expanded into information technology IT and user support, which usually are the functions of IT supporting services. For example, HIM educational programs usually do not provide courses in computer science theories such as algorithms or formal methods. The delineating line between traditional HIM and HIT professionals has been blurred by the convergence of their functions and reporting structures in the electronic healthcare environment.
It seems that you're in Germany. We have a dedicated site for Germany. Editors: Weaver , C. Healthcare Information Management Systems, 4th edition, is a comprehensive volume addressing the technical, organizational and management issues confronted by healthcare professionals in the selection, implementation and management of healthcare information systems. With contributions from experts in the field, this book focuses on topics such as strategic planning, turning a plan into reality, implementation, patient-centered technologies, privacy, the new culture of patient safety and the future of technologies in progress. With the addition of many new chapters, the 4th Edition is also richly peppered with case studies of implementation.
Healthcare information management systems: Cases, strategies, and solutions: Fourth edition
Learn what a health information system is, benefits, best practices, and more in Data Protection , our series on the fundamentals of information security. A health information system HIS refers to a system designed to manage healthcare data. Health information systems also include those systems that handle data related to the activities of providers and health organizations. As an integrated effort, these may be leveraged to improve patient outcomes, inform research, and influence policy-making and decision-making. Because health information systems commonly access, process, or maintain large volumes of sensitive data, security is a primary concern.
It seems that you're in Germany. We have a dedicated site for Germany. Editors: Ball , Marion J. With contributions from experts in the field, this book focuses on topics such as strategic planning, turning a plan into reality, implementation, patient-centered technologies, privacy, the new culture of patient safety, and the future of technologies in progress. With the addition of 28 new chapters, the Third Edition is also richly peppered with case studies of implementation, both in the United States and abroad.
It seems that you're in Germany. We have a dedicated site for Germany.
Strategic Roles of HIM Professionals for National Health Information Infrastructure
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Not a MyNAP member yet? Register for a free account to start saving and receiving special member only perks. Technology and Tools in the Diagnostic Process. A wide variety of technologies and tools are involved in the diagnostic process see Figure , but the primary focus of the chapter is on health information technology health IT tools. Health IT covers a broad range of technologies used in health care, including electronic health records EHRs , clinical decision support, patient engagement tools, computerized provider order entry, laboratory and medical imaging information systems, health information exchanges, and medical devices. The committee concluded that health IT has the potential to impact the diagnostic process in both positive and negative ways.
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