Running head: HEALTH INFORMATION TECHNOLOGY 1
Health Information Technology: Current Topics
Kristi Coe, MS, RN
Kent State University
HEALTH INFORMATION TECHNOLOGY 2
Health Information Technology: Current Topics
Week 1: Health information technology AND patient outcomes OR quality of care
Weigel, F. K., Switaj, T. L., & Hamilton, J. (2015). Leveraging Health Information Technology to Improve
Quality in Federal Healthcare. US Army Medical Department Journal.
The federal health care system is comprised of the Veterans Administration (VA), Department of
Defense, and the Indian Health Service. This article examined ways in which increased use of health
information technology (HIT) may be of benefit to this health system. A comprehensive literature search
was done with 11 articles identified as relevant to the research question. The review was not limited to
studies that applied only to the federal health system, but included studies that could be generalized to
this setting. The purpose of the study was to evaluate the impact of HIT in terms of improving quality in
light of the 2009 Agency for Healthcare Research and Quality (AHRQ) framework. The reviewers noted
that medication dosing accuracy has improved with computerized physician entry. Direct patient
outcomes (rather than provider adherence studies) and mortality reduction were noted to be a
weakness in the current literature. While this is helpful to point out, the reviewers did not provide
concrete examples of how this may be addressed in the future. Two special notes of concern were
“alert fatigue” in which providers stop paying attention to system alerts due to sheer volume as well as
workarounds that are devised in part to avoid these alerts. While workarounds can be beneficial in
some cases, they also can serve to be a dangerous step in terms of quality of care. The majority of
reviewed studies were able to find at least “one positive outcome” from the implementation of HIT.
Similarities between challenges such as interoperability, data mining, and usability that the federal
system faces and the private sector faces were noted. It was found that focusing on the advantage of
the HIT system and allowing experimentation by end users may help in the implementation and
adoption of new systems. This could be an important finding in helping managers to limit opportunity
cost and increase clinician buy-in. Of particular note was the fact the VA was the only federal entity to
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have published research related to HIT and quality outcomes. The article had many valuable
observations that were gleaned from the review. In general, the lack of specificity regarding the “one
positive impact” of HIT was a limitation of the study. The results would be more useful if they were
arranged by measures of impact rather than addressed in general terms. In conclusion, the authors
found that only part of the 2009 AHRQ framework had been adopted and that works remains in terms of
full integration of HIT in the federal healthcare system. This study can be helpful as the federal health
care system is a closed system in which data regarding regulatory measures, integration, and quality
measures may be more readily accessible and could then be translated into more complex and
fragmented systems in the public and private sector.
Week 2: accountable care organizations AND health information technology
Walker, D. M., Mora, A. M., & Scheck, A. M. (2016). Accountable care organization hospitals differ in
health IT capabilities. The American journal of managed care, 22(12), 802-807.
In a statistically robust study, the authors set out to examine the difference between accountable care
organizations (ACOs) and non- ACO hospitals in regards to adoption of health information technology
(HIT). ACOs differ somewhat in their adoption strategies in that many HIT initiatives are often driven by
by cost and quality goals rather than meaningful use (MU) incentives. The authors wanted to investigate
the HIT capabilities of ACOs and compare those to the non-ACO hospitals in regards to 1) MU
achievement, 2) patient engagement, and 3) health information exchanges. The study was a cross-
sectional design which will give a “snapshot in time” of the situation in regards to the research
questions, but will not provide longitudinal data to measure changes over time. Follow up studies
should perhaps implement a methodology that would allow for assessment of this dynamic. The analysis
in the study was detailed as the authors statistically accounted for response bias inherent in their data
source (2013 American Hospital Association Annual Survey IT Supplement and the 2013 AHA Survey of
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Care Systems and Payment) by applying a weighted model to responses based on hospital
characteristics. This approach allowed greater reliability in the validity of the results. Further limitations
regarding this bias were addressed as well. In the unadjusted comparison, ACO hospitals were
significantly more likely to meet MU Stage 1 and 2. However, when adjusted for hospital characteristics,
no difference was noted. Even in the adjusted model, however, ACO hospitals were found to more likely
than non-ACO hospitals to participate in an HIE and achieve a level of 4 out of 7 indicators of patient
engagement. This may give rise to the idea that ACO are heavily invested in technology that leans
toward patient centered care. This may have future implications for MU incentives and how to align
these two approaches. This study is significant in that it helps to establish a baseline of information
regarding the difference between both philosophy and adoption of HIT in ACO and non-ACO hospitals.
More specific studies with longitudinal data collection, a focus on strategic vision and IT alignment of the
ACO organization, and higher levels of research methodology should follow up on these early indicators
of HIT use.
Week 3: eICU and impact on cost
Kumar, S., Merchant, S., & Reynolds, R. (2013). Tele-ICU: efficacy and cost-effectiveness approach of
remotely managing the critical care. The open medical informatics journal, 7, 24.
The United States healthcare system if facing two difficult realities. First, the population is aging and
requiring more intensive healthcare interventions. Second, the number of intensivists available to
provide care is not meeting the demand. This article examines both the efficacy and cost effectiveness
of implementing an eICU in order to meet these demands. A review of the literature was conducted
with 189 articles returned in the initial search that were evaluated for relevance to the research
question. 25 articles were retained for analysis regarding efficacy and return on investment
(ROI). Efficacy was operationally defined in most studies as length of stay (LOS) and decreased
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mortality. In some studies, results were reported in absolute terms which made interpretation more
clear; conversely, in many studies, results were reported in relative terms which made determining
efficacy more difficult. In both cases, the research demonstrated mixed results on both outcome
measures. Not insignificantly, some studies did measure nurses’ attitude toward eICU and in general
found that under staffed units could benefit from the eICU support. One caution in interpreting results is
the disparity between the types of ICUs that were included. Urban centers that treat hundreds of high
acuity patients are included with studies of more rural health systems that treat far fewer and lower
acuity patients. This discrepancy would need to be addressed before the results could be accurately
translated to any particular clinical setting. As expected, eICU units have considerable startup costs as
well as maintenance costs once established. Any savings is thought to be directly derived from the
outcome measure of decreased LOS and mortality. A formula was provided that may help to determine
the financial viability of eICUs, but it does not appear that the formula was applied to the studies in
question. This would have been a helpful step to complete if not already provided in the publication
and would have provided more robust comparators for the reader. While overall ROI seemed difficult to
determine, it does appear that variable costs are better contained with eICU. Barriers to wider
implementation (only 5-7% of US hospitals use eICU) are thought to be connected to staff resistance
related to patient control issues, interoperability of established healthcare IT systems and the eICU, and
the lack of documented results related to financial saving and improved outcomes. This study was at
attempt to address the latter barrier. It is a helpful start, but the lack of definitive data, lack of
homogeneity between clinical settings, and the lack of consistent operational definitions between
studies indicated that this is an area that would benefit from additional rigorous research.
Week 4: Health information exchange AND interoperability
Adler‐milstein, J., & Pfeifer, E. (2017). Information Blocking: Is It Occurring and What Policy Strategies
Can Address It?. The Milbank Quarterly, 95(1), 117-135.
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This study addresses a particular challenge of interoperability known as information blocking. This
challenge was brought to the forefront of interoperability discussions following a 2015 report by the
Office of the National Coordinator for Health IT (ONC) that examined the issue in depth. This study
sought to follow up on that report and explore the nature of information blocking by addressing three
research questions: 1) To what extent do electronic health records (EHR) vendors and providers engage
in information blocking? 2) When information blocking occurs, what are the most common forms that it
takes? 3) What policy strategies are perceived as most effective in curbing information blocking? Third
party Health Information Exchange (HIE) organizations were surveyed regarding these questions. Of the
105 HIE leaders that were included in the survey request, 60 responded which yielded a 57% response
rate. 83% of respondents indicated strong familiarity with information blocking which indicates in some
measure the scope of the issue as it relates to interoperability. 83% also reported that EHR vendors
engage in information blocking routinely (50%) or occasionally (33%). When hospitals and health
systems were extracted from the data (as compared to EHR vendors), these percentages dropped
(routinely: 25%; occasionally: 34%). Promoting products that offer limited interoperability was the
primary method of information blocking followed by high fees unrelated to cost, and making third-party
access to data difficult. In most cases, the motivation for information blocking is perceived to derive
from a desire to gain or maintain a competitive advantage in the marketplace. 3 potential policy
solutions were expressed that may help to address the problem. First, prohibiting gag clauses and
allowing public reporting for comparison of vendors and products may help to reduce information
blocking. Second, demonstrations of product interoperability in the clinical setting was thought to be
beneficial. Finally, stronger state or federal regulations regarding HIE standards would be helpful. Of
those that supported policy initiatives regarding EHR vendors, making information blocking illegal was
the policy choice that was most supported (67%). Among hospital and health systems, policy initiatives
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centered on increased incentives from the Centers for Medicare and Medicaid Services (CMS) and
increased transparency accompanied calls for making information blocking illegal.
One considerable limitation was the sample itself. HIE leaders may perceive information blocking at a
higher rate than actual as their primary goal is to better implement and enable HIE efforts and any
barriers to that would be negative. However, even with accepting this limitation, the consistency of the
data with other documented barriers lends importance and validity to the findings. Targeted policy
efforts that directly address information blocking may be best as broader, non-specific regulations could
serve to unintentionally thwart the industry. Studies such as this that address specific interoperability
barriers seem to be very helpful in crafting comprehensive policies that can help to improve processes
and effectiveness in this vital area of HIE.
Week 5: Implementing EHR
Yanamadala, S., Morrison, D., Curtin, C., McDonald, K., & Hernandez-Boussard, T. (2016). Electronic
health records and quality of care: An observational study modeling impact on mortality,
readmissions, and complications. Medicine, 95(19).
Electronic health record (EHR) implementation has a fairly strong research record in terms of improving
billing mechanisms and tracking physician performance. What has been less clear is the measurable
impact EHRs may have on patient outcomes. This study sought to clarify the relationship between EHR
implementation and patient outcomes of mortality, readmissions and patient safety indicators (PSI). The
study evaluated patient outcomes (mortality, 30 day all cause readmission, length of stay and PSI) in two
intervention groups (full adoption of EHR and partial adoption of EHR) compared to a control group of
no EHR adoption for medical surgical patients across a 6 state region. Data was extracted from the 2011
State Inpatient Database (SID) that was linked to the 2011 American Hospital Association annual survey
database.
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Using both univariate analysis and regression models as compared to the level of EHR implementation,
the study found that patients treated at hospitals with full EHR implementation had the lowest rates of
inpatient mortality, readmissions, and PSI. This was followed by hospitals with partial EHR adoption and
the poorest outcomes were for hospitals with no EHR adoption. This trend, however, was not
statistically significant after controlling for other patient and hospital factors. In the difference on
difference analysis looking at medical and surgical patients separately compared to EHR implementation
level on patient outcomes, only three cases were found to be statistically significant.
This study gives increased evidence that EHR adoption may not impact patient outcomes to the level
that many perceive. The fact that many EHR systems primarily serve as a “recording function after an
intervention” rather than a “checking mechanism” during the actual patient care phase may be part of
the lack of impact noted in studies. For example, other concurrent studies have shown that EHR
adoption may increase the rate of cholesterol testing without demonstrating an improvement in
patient’s cholesterol levels. It would seem that clear expectations for both the function and reasonable
clinical endpoints that EHR may influence may help to avoid unrealistic expectations and also guide
efforts to use the EHR to the fullest extent possible.
Unfortunately, the authors in this study did not include the specific patient and hospital factors for
which they controlled and which may play a significant part in determining when and where EHR
implementation is the most effective. Further research into the factors that particularly influence the
role of EHR in patient outcomes is needed.
Week 6: provider attitudes AND computerized order entry
Simon, S. R., Keohane, C. A., Amato, M., Coffey, M., Cadet, B., Zimlichman, E., & Bates, D. W. (2013).
Lessons learned from implementation of computerized provider order entry in 5 community
hospitals: a qualitative study. BMC medical informatics and decision making, 13(1), 67.
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A multi-disciplinary team of physicians, nurses, pharmacists conducted a qualitative inquiry into the
lessons learned from providers in a community hospital setting that had recently completed
computerized provider order entry (CPOE) implementation. The setting of the study was key in that
much of the research on this issue has focused on academic medical centers or with hospitals that used
self-developed CPOE systems. These results are not always transferable to the community hospital
setting that is implementing commercial CPOE systems. The researchers used multiple data collection
methods including both field observation and in-depth interviewing. The field visits focused on both
structured data (% of orders entered directly by physician providers) and unstructured data (typical
workflow of observed unit). The team met to compare notes and validate findings frequently. The in-
depth interviews examined specifically attitudes of providers prior to implementation, barriers to
implementation, facilitators of implementation, goals for advanced use of CPOE, and finally advice for
other hospital systems that are considering CPOE. Interviews were done by phone and were recorded
and transcribed.
Five themes emerged from the study: 1) Governance 2) Preparation 3) Support 4) Perceptions and 5)
Consequences. Governance was conceived as the acknowledgement that clinical staff had to be present
throughout the planning and implementation phase of the project. Although all participants recognized
that the information technology (IT) department shouldered much of the planning load, having a variety
of stakeholders at the table was seen as absolutely necessary to the success of the project. Preparation
had more variance in results with some participants indicating that advanced preparation was a key
factor while others felt that no amount of advanced training would suffice compared to “going live”. The
emotion of fear was also brought into focus as many interviewees stated that older providers, in
particular, expressed fear during this stage in relation to the workflow change. Support was defined by
most participants as the necessary follow up to preparation with “at the elbow” support more beneficial
than advance preparation in many cases. All hospitals trained their own “super-users” from current
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staff rather than utilize outside experts. In most cases, this “at the elbow” support lasted for at least a
month. Managing perceptions of change was seen as common barrier across all hospitals. Anxiety and
fear were common and were disproportionately aimed at the older providers although could be felt
across all providers. A “one size fits all” approach to this problem did not emerge, but strong leadership,
clinical champions, and approachable liaisons were all key factors in managing the perceptions prior to
implementation. Consequences were categorized as both expected and unexpected. Expected
consequences included a focus on patient safety and a commitment to CPOE by the staff. Unexpected
consequences included the strain on nursing staff as they compensated for super-users who were not
available for regular staffing for a period of time, the communication breakdowns regarding the use of
hybrid systems where some providers were complying directly and some were not or were changing
orders remotely without notifying nursing staff, and the accelerated retirement of some experienced
providers that simply choose not to learn the system (or turned their inpatient rounds over to
hospitalists).
This article is extremely helpful for mid-size community hospitals that are contemplating CPOE. The
adherence to qualitative research methodology is a key factor in gaining reliable results that can be
transferred to other similar setting. The discussion section in particular could provide a very helpful and
straightforward guideline for other organizations.
Week 7: Provider attitudes toward patient portals journal articles
Kruse, C. S., Argueta, D. A., Lopez, L., & Nair, A. (2015). Patient and provider attitudes toward the use of
patient portals for the management of chronic disease: a systematic review. Journal of medical
Internet research, 17(2).
This systematic review set out to investigate the aspects of portals that are favorable to patients and
providers as well as the aspects that are identified as needing improvement. The literature review
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provided an operational definition for portals and highlighted the characteristics of portals that have
been found to be helpful in past research. These included patient-provider communication, better
disease management and empowerment, and decision making support. Barriers to portal
implementation mentioned in the literature review included security, workload for providers, and cost.
The authors searched PubMed and CINAHL and identified 27 studies that met the inclusion criteria as
well as addressed the research question. Multiple chronic diseases were represented in the patient
sample. As expected, positive and negative attitudes overlapped on several portal characteristics. Of
note, 41% of articles reported improvement in patient-provider communication, however, 19% of
articles also mentioned provider concerns with messaging due to security issues and time
management. Providers were concerned about workflow in terms of answering messages while
simultaneously seeing patients in the clinical setting. 33% of articles mentioned better disease
management of chronic conditions due to educational resources present in the portal. In 3 articles,
patients had difficulty understanding the resources even if they were present. Only 2 (7%) articles
mentioned any negative medical outcomes as a result. Unexpectedly, only 3 (11%) mentioned cost as a
barrier. This is a departure from most literature that involves health IT. It was not stated if factor of
cost was due to initial startup cost, ongoing maintenance cost, or lost costs in billable clinical care due to
increased communication with patients. In summary, portals are generally viewed favorably by both
patients and providers, however, work on interpreting the meaning of posted results, expectations
regarding patient/provider communication, and support for those with limited internet or technology
experience are still areas of concern. The article did not distinguish well between those results that
applied only to patients, those that applied only to physicians and any differences between the two
groups. This added information would be useful in identifying where areas of agreement are and where
there is differing opinions in relation to portal functions between patients and providers. Further
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research on these differences may help in supporting areas of agreed upon value and re-designing area
of concern.