Learning Objectives
By the end of this section, you will be able to:
- Discuss the impact of health informatics
- Identify the legal boundaries on health informatics, communications, and technology
- Differentiate between electronic health records and electronic medical records
Health-care informatics is focused on the applications of the massive quantities of data generated by the health-care industry. These data are used to develop strategies to positively influence and improve the delivery of health care. Legislation and governing institutions provide legal boundaries around health informatics by developing guidelines, regulations, and initiatives to support national adoption and acceptance of health informatics. Many of these initiatives have supported the elimination of electronic medical records and the widespread adoption of electronic health records (EHRs).
Health Informatics
Informatics is the science of information. When we talk about informatics, we are talking about the use of technology and computer systems to process data and information. Informatics is a broad term that can be applied to many disciplines. Within health care, the concept can be further broken down by specialty area, such as biomedical, clinical, medical, nursing, population health, and public health informatics. These specialized fields collectively form the broader domain of health informatics.
The field that integrates information science with health care is called health informatics (Saba & McCormick, 2015). In other words, it is a specialized field within health care that combines information, technology, and health-care knowledge to improve patient care. Through health informatics, care may be streamlined and coordinated so that quality care can be delivered in the most efficient and cost-effective manner.
Health informatics helps to identify, define, manage, and communicate data, information, knowledge, and wisdom within health care. It creates information structures, processes, and technologies that can be used to support nurses, providers, consumers, patients, and the interdisciplinary teams that guide decision-making. Additionally, informatics enhances collaboration, communication, safety, satisfaction, efficiency, and effectiveness within the delivery of health care.
Information and Communications Technology
All communication technologies that enable users to access, retrieve, store, transmit, and manipulate digital information make up information and communications technology (ICT) (Figure 37.6). A broader term for information technology (IT), ICT includes technologies such as the internet, wireless networks, computers, cell phones, software, and other media applications such as videoconferencing and social networking. ICT allows for remote care, interdisciplinary clinical support, and knowledge support. The use of ICT has the potential to promote patient-centered care at a lower cost, improve quality of care and information sharing, educate patients and health professionals, encourage relationships between patients and their health providers, and reduce travel time.
Predictive Medicine and Precision Health
The use of laboratory and genetic tests to determine an individual’s probability of developing a disease is called predictive medicine. The goal of predictive medicine is to use biomarkers to predict an individual’s risk for developing a clinical disorder, predict the most effective treatment, and then intervene before the patient develops the condition. While genetics-based predictive medicine has been used for quite some time, the scope of this field is expanding to include conditions beyond those solely reliant on genetic predictions.
Considering the massive amounts of health-care data that are collected, stored, and processed, and the new analytical techniques available, predictive medicine is one of the most promising applications of informatics. Using its power, providers may soon be able to individualize the risk for a variety of health outcomes and determine individualized treatment options for patients. For predictive medicine to be successful, however, significant efforts will be needed to purchase, develop, and refine the necessary information technology infrastructure. Furthermore, predictive medicine has its limitations: in particular, its reliance on stored data for predictive modeling means its accuracy is limited to the quality of the data available; 100 percent precision cannot be guaranteed. Therefore, it becomes vital for nurses and all health-care providers to prioritize accurate and appropriate data collection, maintain proper assessment techniques, and comprehend the potential impact of the data they enter on a patient’s chart—not only on the patient’s immediate needs but on future applications throughout health care.
In comparison, precision health refers to an innovative approach to health care that considers individual differences in genetics, environment, and lifestyle. The goal of precision health is to tailor medical care and treatment plans to the unique characteristics of each patient, with the aim of achieving the best possible outcomes. At the core of precision health is the integration of genomic information, where an individual’s genetic makeup is analyzed to unveil insights into disease susceptibility, response to medications, and inherent genetic factors influencing health. Precision health allows health-care professionals to develop personalized treatment plans that consider not only genetic factors but also environmental and lifestyle influences. This approach is particularly promising in areas such as cancer treatment, where targeted therapies based on genetic profiles can lead to more effective and less toxic interventions.
By tailoring interventions to the specific needs of each patient, precision health aims to optimize treatment effectiveness, minimize adverse effects, and improve overall health outcomes. However, precision health also presents challenges, including the need for robust and secure data management systems, ethical considerations related to privacy and consent, and the integration of this approach into routine clinical practice. Additionally, disparities in access to genetic testing and other precision health tools must be addressed to ensure equitable health-care outcomes for diverse populations. Despite these challenges, precision health holds great promise in revolutionizing health care, moving away from the traditional, one-size-fits-all model toward a more individualized and targeted approach to medical care.
Epidemic Tracking
The field that applies science and technology to meet the needs of public health is called public health informatics. This specialized field encompasses population health, policy development, and the accessibility of public health services; however, its main focus is to promote health and prevent diseases within populations and communities.
The public health domain of informatics is responsible for several functions, including the surveillance and prevention of epidemics and the spread of diseases. Collecting, analyzing, and disseminating data related to diseases, health outcomes, and injuries is called surveillance; through careful surveillance, public health officials can reduce the spread of disease and other poor health outcomes and injuries. Incidence and prevalence are two key epidemiological concepts used within surveillance measures to quantify and describe the occurrence of diseases or health-related events within a population. The number of new cases of a specific disease or health-related event that occur within a defined population during a specified time period is called incidence; it measures the risk of developing a condition. In comparison, prevalence represents the total number of cases (both new and existing) of a particular disease or condition in a population at a specific point in time or over a specific period; it indicates how widespread the condition is within the population (Arnold et al., 2020).
A recent example of surveillance is the contact tracing conducted by state and local health departments, the Centers for Disease Control and Prevention (CDC), and other public health agencies during the COVID-19 pandemic. Incidence and prevalence measures were constantly evaluated to determine the risk of developing COVID-19 and the extent of the virus’s spread by region. By tracking reports of positive COVID-19 cases and conducting follow-ups, officials documented the movements, interactions, and duration of contact of positive cases. This enabled the mapping of cases and facilitated the implementation of quarantine measures to slow the spread of the virus (Ibrahim, 2020).
Legislation and Governing Institutions
Legislation and governing institutions play a significant role in the development of health informatics, communications, and technology. They create organization, structure, and policy, while also offering support for ongoing advancements and improvements. It is crucial for nurses to comprehend the legal framework that underpins health informatics so they can advocate for changes that promote safer, more effective, and more efficient information technologies in health care.
Legislation
There are several important pieces of legislation that impact health-care informatics. Perhaps the best known is the Health Insurance Portability and Accountability Act (HIPAA), passed in 1996 to curtail health-care fraud and abuse, enforce standards for health information, guarantee the security and privacy of health information, and ensure health insurance portability for employed persons (Office of the National Coordinator for Health Information Technology [ONC], n.d.-b). The law also identifies consequences for any health-care providers who violates its provisions. Nurses should be familiar with the following main components of HIPAA:
- The Privacy Rule describes what information is protected and how the protected information can be used or disclosed.
- The Security Rule describes who is protected and what safeguards must be in place to protect electronic protected information.
- The Enforcement Act describes what compliance consists of, when and how investigations must occur, how to report noncompliance, and how consequences for privacy and security breaches should be enforced (ONC, n.d.-b).
Another piece of legislation that has shaped nursing informatics is the American Recovery and Reinvestment Act (ARRA), which was passed in 2009 to stimulate the economy following the Great Recession of 2007–2009. Lawmakers identified the economic value of health information technology and the related need to improve health-care delivery. As such, concepts of health-care informatics are embedded throughout the act. The act is divided into two parts:
- Part A addresses health information technology policies and standards, as well as privacy and security.
- Part B addresses Medicare and Medicaid health information technology, as well as incentives to providers and organizations that adopt EHRs and meaningful use (which will be defined later in this section) (Federal Communications Commission, n.d.).
Within the American Recovery and Reinvestment Act is the Health Information Technology for Economic and Clinical Health (HITECH) Act. The act’s purpose is to improve health-care quality by preventing errors and assisting with patient-centered decisions at the point of health-care delivery. The act also seeks to lower costs by reducing inefficiencies and service duplication, promote health through prevention and early detection, and improve the management of chronic diseases (Peterson & Holman, 2018). Moreover, it facilitates clinical research, works toward reducing health disparities, ensures the security of patient information, and strives to bolster public health by enabling early detection and response to infectious diseases and bioterrorism.
Overall, the HITECH Act has increased the adoption rate of EHRs and has contributed to a national health information infrastructure in which an individual EHR can be accessed by any provider (ONC, n.d.-c; Peterson & Holman, 2018). While the adoption of EHRs across the United States has increased significantly in recent years, not all Americans have access to these digital health records. The associated costs and complexities of implementing EHR systems pose barriers, particularly for smaller health-care providers in underserved areas that may face financial constraints. Additionally, the infrastructure and readiness for adopting EHRs vary across regions, with rural areas often encountering difficulties due to limited access to high-speed internet and advanced technology. Resistance to change, concerns about data privacy and security, and disparities in resources further contribute to uneven EHR adoption rates. Regulatory hurdles, including variations in state-level regulations and a lack of standardization in EHR systems, also impede the seamless exchange of health information. Achieving universal EHR coverage will require continued concerted efforts to address these multifaceted challenges and promote a more integrated and accessible digital health infrastructure.
The Medicare Access and CHIP Reauthorization Act (MACRA), enacted in 2015, fundamentally transformed the way Medicare pays health-care providers. MACRA repealed the Sustainable Growth Rate formula and introduced the Quality Payment Program (QPP). This program established two tracks for provider reimbursement: the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). MIPS consolidates existing quality reporting programs into a unified framework, tying reimbursement to performance on measures related to quality, cost, improvement activities, and the promotion of interoperability. APMs provide financial incentives for practices to participate in innovative payment models designed to improve care quality and reduce costs. MACRA aims to shift the health-care system toward value-based care, emphasizing quality and outcomes while incentivizing providers to embrace new payment models that prioritize patient-centered, efficient, and coordinated care (ONC, n.d.-a).
The Food and Drug Administration Safety and Innovation Act (FDASIA) of 2012 developed “a report that contained strategies and recommendations for a risk-based regulatory framework for health IT, including medical mobile applications, which promoted innovation, protected patient safety, and avoided regulatory duplication” (FDA, 2020). The recommendations were a collaborative effort from the Food and Drug Administration (FDA), the Office of the National Coordinator for Health Information Technology (ONC), and the Federal Communications Commission (FCC).
The 21st Century Cures Act (Cures Act) was signed into law in 2016. It was developed to promote and fund the acceleration of research to prevent and cure serious illness, accelerate drug and medical device development, address the opioid crisis, and improve the delivery of mental health services. The Cures Act Final Rule, a set of regulations issued by the ONC in the United States as a part of the 21st Century Cures Act, supports seamless and secure access, exchange, and use of electronic health information and is designed to give patients and their health-care providers secure access to health information (ONC, n.d.-b).
Finally, the Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed in 2020 at the start of the COVID-19 pandemic, has significant implications for health care. The CARES Act highlighted the need to modernize public health data surveillance and infrastructure. The onset of the pandemic quickly demonstrated the deficiencies of the United States’ current health-care system, which proved to be outdated and unable to keep up with patient needs. Modernizing the surveillance infrastructure would enable users to automatically obtain real-time data that is coordinated across the health-care system’s various subsystems. The CARES Act also expanded access to telehealth and other connected health technology capabilities and supported the application of Smart health IT technologies and systems. Additionally, the act provided federal grants to evaluate and address the risks associated with cyber threats in remote customer service or telework practices (U.S. Department of the Treasury Office of Recovery Programs, 2023).
Link to Learning
The Office of the National Coordinator for Health Information Technology (ONC) provides information about health IT laws, regulations, and policies on its website.
Governing Institutions
Governing institutions are critical for maximizing the potential of health informatics at both the national and global levels. They can assist by promoting the adoption of electronic health records, encouraging interoperability, providing incentives to improve quality and efficiency, and fostering technical advancements. Financial support is essential to aid the adoption of health information systems, facilitate information exchange, support research and development, and ensure robust information security measures.
The most notable U.S. agency at the forefront of informatics is the Office of the National Coordinator for Health Information Technology (ONC), which is a division of the Office of the Secretary for the U.S. Department of Health and Human Services (HHS). HHS is responsible for national health-care regulation. The ONC is responsible for delivering provisions of the Cures Act, including regulating health information technology, advancing interoperability, prohibiting information blocking, and enhancing the usability, accessibility, privacy, and security of health information technology. Its employees coordinate national efforts related to the access, exchange, and use of data, with the goal of advancing the development and use of health information technology capabilities and establishing expectations for data sharing (ONC, n.d.-a) (Figure 37.7).
The Health Informatics and Interoperability Group (HIIG) within the Office of Burden Reduction & Health Informatics (OBRHI) oversees interoperability efforts by the Centers for Medicare and Medicaid Services (CMS), another division of HHS. The HIIG promotes the secure exchange, access, and use of electronic health information. This group plays a significant role in publishing policies and establishing a governance framework for interoperability (CMS, 2023b).
Another key institution is the Office of Health Informatics within the U.S. Food and Drug Administration (FDA). This agency provides health informatics tools, solutions, and expertise to enhance the ability of the FDA to promote public health. Some of its functions include developing and implementing health initiatives, promoting effective use of informatics, creating open-source informatics platforms, implementing standardized vocabularies, standardizing data collection and analysis, and researching informatics solutions (FDA, 2019).
The International Organization for Standardization (ISO) is a global federation that works to establish consensus standards globally. The American Health Information Management Association (AHIMA) has been leading the development of health information management standards at the ISO. Together, the ISO and AHIMA have been working to develop shared rules, content, and infrastructure. They are focused on developing standards for rules, guidelines, practice, data, information exchange, safety, privacy, and security (Orlova et al., 2017).
Electronic Health Records
An electronic health record (EHR) is a digital version of a patient’s comprehensive medical history. EHRs are transportable, moving with the patient, and accessible by everyone involved in the patient’s care—including the patient. They allow health-care information to be shared across practice settings, connecting providers both within a particular organization and between organizations, and have built-in tools that assist with decision-making. EHRs provide enhanced communication and coordination of care that can result in increased efficiency, cost savings, and a seamless delivery of care.
Providing patients with access to their health information empowers them to have more control over their health-care decisions. According to the HIPAA Privacy Rule, patients have a right to access and obtain their own medical records. This right is a legal and enforceable right, encompassing both paper and electronic formats (DHHS, 2022).
While the adoption of EHRs is intended to create a seamless delivery of care, they do not always support interoperability, the ability of different systems to “talk” to each other. According to the Healthcare Information and Management Systems Society, interoperability is “the ability of different information systems, devices and applications (systems) to access, exchange, integrate and cooperatively use data in a coordinated manner, within and across organizational, regional and national boundaries, to provide timely and seamless portability of information and optimize the health of individuals and populations globally” (HIMSS, n.d., para. 1).
Recognizing the importance of an electronic health record that moves with the patient, Congress created the Meaningful Use Electronic Health Record (HER) Incentive Program as an attempt to modernize the managing and sharing of health-care information. This program, which stemmed from the HITECH Act, was established in 2011 with the intent to increase the adoption of electronic health record usage within the United States. Under the meaningful use program, health-care providers must demonstrate the meaningful use of certified EHR technology to qualify for financial incentives provided by Medicare and Medicaid. The program is part of broader efforts to promote the adoption of EHRs, enhance health-care quality, and improve patient outcomes through the effective use of health information technology (Anumula & Sanelli, 2012).
Using the EHR in a “meaningful” way—that is, to its full extent—facilitating the electronic exchange of information so that quality of care may be improved is considered meaningful use. Examples of meaningful use include structuring data entry to ensure all pieces of critical information are captured, ensuring computerized provider order entry is occurring in practice, e-prescribing, capturing vital signs within the EHR, and ensuring medications are being reconciled at every visit (or, in an acute care setting, upon admission and discharge). Meaningfully implementing EHRs has the potential to improve quality, safety, and efficiency; reduce health disparities; engage patients and families; coordinate care; enhance privacy and security; and improve population and public health—all of which are priorities for health-care providers in the United States.
The Meaningful Use EHR Incentive Program was designed so that meaningful use would be achieved within three stages(Table 37.1) (Anumula & Sanelli, 2012; ONC, 2013).
| Stage | Date Implemented | Purpose | Outcomes |
|---|---|---|---|
| 1 | 2011 | To facilitate data gathering and sharing | Providers tasked with transferring data to EHRs and sharing health information: e.g., by printing after-visit summaries to send home with the patient |
| 2 | 2014 | To advance clinical processes | Built on Stage 1 by adding new standards, such as online access for patients to their health information, electronic health information exchange between providers, and emphasis on utilizing the clinical decision support tools within EHRs |
| 3 | 2017 | To improve outcomes and demonstrate improvements in quality of care | Built on Stage 2 by using health information technology for population health management, clinical quality measurement, and public health reporting; ensures data is stored according to data regulations; improves care through implementation of electronic prescribing, clinical decision support systems, computerized provider order entry, and patient access to electronic records; emphasizes coordination of care through patient engagement with patient portals; supports health information exchange by implementing electronic summaries of care |
Once Stage 3 was introduced, the term “meaningful use” was officially replaced with “advancing care information,” although the concept is often still referred to as meaningful use.
While the EHR Incentive Program made great strides in achieving meaningful use of EHRs, the U.S. health-care system continued to struggle with interoperability. Therefore, in 2018, the program was renamed the Promoting Interoperability Program. The Promoting Interoperability Program was intended to look beyond the original intent of the EHR Incentive Program by creating new measurements of EHR implementation and increasing the focus on interoperability and improving access to health information (CMS, 2023a).
Nevertheless, interoperability continues to lag within the U.S. health-care system due to the high volume of health information and the variety of EHR systems that use different techniques for programming and formatting. Because of the global nature of EHR systems—working together, talking together, and transcribing information to and from each other—standardization will be key to achieving interoperability. An important goal is to standardize terminology so that concepts are presented in an unambiguous manner between a sender and receiver of information; it is also important to standardize the format of how the information is transported, the privacy and security measures in place, and the identifiers used to identify individual patients and providers. With all these features in place, any record could be read by anyone with the assurance that the same message is being sent and received.
Another strategy is to investigate how AI and machine learning can be used to transcribe data that have been programmed using different formats. AI and machine learning are already used to process large amounts of data, which can then be used to identify common trends, but they might also be used to pull information from various systems into a unified format. Strategies for achieving interoperability are managed by the Office of Interoperability and Standards (OIS), which is a division of the ONC (ONC, n.d.-a).
Electronic Medical Records
When talking about electronic patient records, you will likely encounter two important terms: electronic health record (EHR) and electronic medical record (EMR). While sometimes used interchangeably, these are very different terms with quite different implications for health care as we move into the digital future of health-care delivery.
Recall that EHRs are digital versions of a patient’s complete medical history; they are intended to move with the patient from provider to provider. In contrast, an electronic medical record (EMR) is a digital form of a paper chart for use by one medical practice. The distinguishing factor to remember is that the digital chart is stored for use only by the respective practice. For the patient or another provider to access the chart, one must physically print it or save it to a digital storage device. This lack of portability decreases communication between providers and across health systems; it also makes it more difficult for patients to make informed decisions about their care. Other key differences between EMRs and EHRs are summarized in (Table 37.2). Due to government regulations and technological innovations, EMRs have largely been phased out and replaced with EHRs, allowing for a more seamless delivery of care.
| Electronic Medical Record (EMR) | Electronic Health Record (EHR) |
|---|---|
| A digital version of a paper chart from one provider only | A digital version of a patient’s overall health history from various health-care providers |
| Cannot be shared with another health-care provider | Designed to easily share health information across various health-care settings |
| Not intended to allow patient information to move outside one health-care setting | Designed to allow medical information to move with the patient to various health-care settings |
| Used for diagnosis and treatment only | Includes various built-in tools for supporting medical decision-making |
Patient Portals
A patient portal is a secure online platform that provides patients with twenty-four-hour access to their personal health information. By connecting to the internet and logging in with their secure username and password, patients may access information such as recent health-care visits, discharge summaries, medications, immunizations, allergies, procedure results, and lab results. Some portals even allow the patient to securely message their provider, request prescription refills, schedule appointments, check insurance benefits and coverage, update contact information, make payments, download and complete medical forms, and view educational materials. Not only do patient portals save time, enhance communication between patients and providers, and provide support to patients, they also allow patients to become more engaged and in control of their own health and care.