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What are a few of the many ways that Health Information System (HIS) data can be used not only for supporting the delivery of healthcare services, but for additional purposes such as protecting the public’s health?

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Printing and Binding: Edwards Brothers Malloy To order this product, use ISBN: 978-1-284-0-3611-4 Library of Congress Cataloging-in-Publication Data Balgrosky, Jean A., author.

Essentials of health information systems and technology / Jean A.



; cm.

Includes bibliographical references and index.

ISBN 978-1-4496-4799-5 I.


[DNLM: 1.

Health Information Systems.


Medical Informatics.

W 26.55.I4] R858 610.285—dc23 2014011074 6048 Printed in the United States of America 18 17 16 15 14 10 9 8 7 6 5 4 3 2 1 Dedication This book is dedicated to the information technology professionals working day after day in and on behalf of healthcare organizations across the country without whose work, nothing described in this book would be possible.

Table of Contents Preface Prologue Acknowledgments About the Author Contributors Section I Understanding Health Information Systems and Technology Chapter 1 Alignment: Health Information Systems and Current Challenges in Health Care Learning Objectives Introduction Healthcare Cost and Quality Issues Motivation HIS and the U.S.

Government’s Role and Goals in Health Care The Quality Crisis Furthers U.S.

Government Involvement in HIS Consumer Expectations and Engagement Uses of HIS in Other Countries Protecting the Public’s Health Summary Key Terms Discussion Questions References Chapter 2 HIS Scope, Definition, and Conceptual Model Learning Objectives Introduction HIS Uses in Organizational and Community Settings Summary Key Terms Discussion Questions References Section II Systems and Management Chapter 3 HIS Strategic Planning Learning Objectives Introduction HIS Strategy: Organizational Strategy as Its Roadmap HIS Strategy: Where Do We Begin? Why HIS Strategy Matters HIS and Technology Strategy: Advancing Public Health HIS and Technology Strategy: Architecture Builds a Strong House HIS and Technology Support of Organizational Goals HIS and Technology Strategy and Plans: Follow-up with Tactical Details Issues of Change and the Need for Governance Summary Key Terms Discussion Questions References Chapter 4 HIS Application Systems and Technology Learning Objectives Introduction HIS Applications Technology Summary Key Terms Discussion Questions References Chapter 5 Managing HIS and Technology Services: Delivering the Goods Learning Objectives Introduction Managing Process Managing People Summary Key Terms Discussion Questions References Chapter 6 Implementation Learning Objectives Introduction Stages in Implementation Reasons for HIS and Technology Project Successes and Failures Summary Key Terms Discussion Questions References Chapter 7 Leadership and Adoption of HIS and Technology Learning Objectives Introduction HIS Leadership from an Organizational Perspective Realizing the Value from HIS and Technology Investments Presidential/Political/National Leadership Perspective in HIS and Technology Leadership from Public Health Researchers and Scientists Leadership of Professional Organizations in HIS and Technology Adoption of HIS and Technology Summary Key Terms Discussion Questions References Section III Health Informatics Chapter 8 Health Informatics Learning Objectives Introduction Health Informatics Definition and Purpose Additional Motivation to Pursue Health Informatics Relationship of Health Informatics to Donabedian’s Healthcare Quality Framework Informatics Capabilities and Disciplines Unintended Consequences of Current Uses of HIS and Technology Summary Key Terms Discussion Questions References Section IV Data, Analytics, and Business Intelligence/Clinical Intelligence (BI/CI) Chapter 9 Data Learning Objectives Introduction Data Sources Velocity, Volume, and Variety (Three V’s) and Big Data Data Challenges Data Security and Protection Summary Key Terms Discussion Questions References Chapter 10 Business and Clinical Intelligence Learning Objectives Introduction Healthcare Business and Clinical Intelligence History of BI and CI Current Challenges for Analytics Models for Data Architecture and Strategy Examples of BI/CI at Work The Future of BI/CI Summary Key Terms Discussion Questions References Section V Research, Policy, and Public Health Chapter 11 HIS and Research, Policy, and Public Health Learning Objectives Introduction HIS Model: Research, Policy, and Public Health Relationships to HIS Types of Research and Sources of Data from HIS Areas Deserving Special Attention That Rely on HIS Management Summary Key Terms Discussion Questions References Section VI New Directions for HIS and Technology Chapter 12 What Lies Beyond the Current State of HIS and Technology? Learning Objectives Understanding the Future of HIS and Technology eHealth, mHealth, Social Media, and Telemedicine Emerging HIS Technologies and the Human–Machine Relationship Future Directions in Informatics, Data, and Analytics The Effect of New Technologies on Public Health Alignment Between HIS and Technology and the Future Challenges in Health Care and Public Health Issues and Ethics to Consider as the Future of HIS and Technology Unfolds Future Impact of HIS and Technology on Research, Policy, and Public Health Summary Key Terms Discussion Questions References Glossary Index Preface We simply have to look around at our immediate surroundings to see how our world is evolving due to the introduction of disruptive technologies, practically before our very eyes.

Health care, the practice of medicine, public health, and health in the lives of individuals are no different—and information technologies (IT) have a lot to do with these changes.

This text addresses health information systems (HIS) and technology, and it is intended to take the mystery out of this subject, which can be daunting to even the most knowledgeable and talented around us—healthcare experts, physicians, nurses, and public health professionals alike.

Why? Because unless something that appears foreign or complex or unusual has been carefully and simply explained to us, it remains a mystery, and we tend to avoid the subject, which prompts us to sidestep taking the dive into the world of health information systems and technology.

But what a loss, to avoid one of the most interesting, creative, ever-changing topics on the planet! No healthcare professional in any discipline can do her or his work without health information systems and technology.

In this text, we dig in and explore together the simple truths and principles about this technical and disruptive subject.

When we break it down into basics and principles that apply to any technology or any situation, suddenly what can be an intimidating, seemingly complex subject becomes much clearer.

What qualifies me to write about this topic? I have spent my career in the fields of health care, medical records science, health information systems and technology, innovation, and public health.

As a chief information officer (CIO) for 20 years in two large, complex health systems, I learned tough lessons about health information technology, planning and managing systems, people, and change, and introducing disruptive technologies into healthcare organizations in a variety of markets across the United States.

I learned how to develop HIS strategic plans, negotiate with and manage IT vendors, and implement new systems.

In pursuing my PhD, I have learned the art and science of research; as an educator for the past 7 years, I have learned to teach graduate students pursuing their master of public health (MPH), master of science (MS), or PhD in health policy and management degrees.

A good deal of my career has been spent explaining health information systems and technology to healthcare professionals, people, and students—those proficient in elements of technology as well as those completely unfamiliar with HIS and technology but expert in their chosen domain of health care such as nursing, medicine, management, quality, laboratory science, finance, or other disciplines.

My favorite discipline has always been the clinical side of health care, because, well, that is what health care is all about—caring for people who at a point in their lives find themselves vulnerable and in need of support, care, therapy, and maybe a little education about how to better take care of themselves.

This is my bias.

As my dear mentor, Dr.

Paul Torrens, taught us at UCLA in the introductory course on the U.S.

healthcare system, everyone has a bias, and it is important to state what that is at the outset of a conversation, writing, or lecture, so that people can take that perspective into consideration.

The clinical side of health care is why healthcare organizations exist; the prevention of disease and harm is the mission of public health.

Such organizations do not exist to provide fabulous billing services to the world or terrific strategic plans as a product.

These functions in healthcare organizations are important, but they are support roles, intrinsic to success but ancillary to the real purpose of healthcare organizations and public health—namely, to provide high-quality health care to patients in the practice of medicine as well as public health services to citizens and populations in the pursuit of health.

This text, then, is about HIS and technology for health care and public health.

It is also about making this complex, potentially overwhelming topic simple.

Because curricula in universities and training programs for the health sciences, medicine, nursing, computer science, and other disciplines that lead to careers in health care, medicine, and public health have not included information technology courses until very recently, most people working in healthcare organizations and public health institutions today had absolutely no education or formal training in HIS.

And yet, these are exactly the same people who are being asked to make the transformative change using HIS—to take the big leap into implementing disruptive technologies into their clinical and business environments, all while taking care of sick and injured people.

This is a tall order, and it can be very stress inducing without proper support and clarification along the way of “what we are doing and why we are doing it.” In fact, computerization of healthcare organizations and public health entities does not need to be a mystery, nor does it need to be as high risk as is it when those entering the process do so without education in the fundamentals of planning, selecting, implementing, using, and reaping the benefits of HIS and the data, information, and knowledge it can produce.

My goal in this text is to give you a fundamentals playbook, thereby making HIS and technology more than the “black box” that it seems to so many otherwise highly qualified healthcare professionals or students whose goal it is to understand and work in health care, health policy and management, and public health someday.

This text is also intended for those new students who are just preparing for their careers, as they launch into whatever orbits their professional life takes them.

Younger students, of course, have the advantage of having grown up with technology as part of their everyday existence, which definitely gives them a leg up in learning about it.

But readers should not think that just because smart phones or laptop computers are easy and intuitive for them to use, they do not need to learn the fundamentals of planning, selecting, implementing, managing, and using the large HIS that guide organizations small and large.

The disciplines of HIS, informatics, and data management are essentials of healthcare management, the new practice of medicine, and public health initiatives, and these are quite different from using personal computing devices whose applications and functions are integrated at the factory.

We are counting on you! Young people starting out in their careers—along with experienced professionals broadening their perspectives, knowledge, and marketability—can carry the day into a better, more costeffective healthcare and public health future.

This future will be enabled by innovative uses of HIS and emerging health technologies that can help us take care of patients more effectively in our hospitals, clinics, and physician practices, and help people stay healthier and safer in their daily lives.

Industry by industry, segment by segment, and organization by organization, the key principles of HIS strategy, planning, management, and implementation (and key principles for computer systems) are very nearly the same, no matter which types of systems or technologies or organizations are involved.

By focusing on fundamentals, guiding principles, management issues, and proven methods, you will be well equipped to deal with HIS selection and implementation projects in your department or organization.

My goal is for you to feel confident with your grasp of this subject—HIS—and the health information systems and technology aspects of your professional role.

Whether HIS is your primary focus or is secondary to your role, you will need it to do any job in health care and public health.

The firmer your command of the basics of HIS and technology, the more qualified you will be for any new job or opportunity in which you find yourself and that ignites your professional passion.

This is true regardless of the specialty, domain, department, function, or type of healthcare organization in which you work.

The truth is that no matter which area of healthcare practice you enter—such as project management, nursing, medicine, finance, operations, public health programs and outreach, health education and health promotion, policy, or another role—your job will include health information systems–based and technology-related responsibilities.

It will be incumbent upon you to implement systems in your department, function, or organization throughout your career.

It is much better to have a handle on the basics and key principles of HIS, so that you will be confident and proficient in those duties.

By knowing these principles, you will be able to volunteer for the next HIS implementation project in your organization with conviction—and know that by understanding the basics of technology, you will be able to quickly pick up the technology specifics relevant to each new project.

Some readers may become so enamored with HIS at this level that they are spurred to go further and specialize in this area.

I am here to share a simple message: You can do it! With emerging education and training programs in IT and a growing number of programs specializing in HIS, plus growing numbers and types of professional and entrepreneurial opportunities, you can make this your career if you so choose.

The sky is the limit.

Opportunities abound for productive, exciting, and well-paying careers in HIS for the long haul.

In whatever area you choose to invest your education and training, HIS and technology will simply make you more proficient in that discipline, better able to innovate compete and reinvent yourself, more valuable to the organization, and more qualified for a wider range of opportunities and responsibilities.

The more you know about HIS and technology, the better.

Now that you’ve had this heartfelt pep-talk, we will move on to a quick review of the key topics of Essentials of Health Information Systems and Technology.

ORGANIZATION OF THIS TEXT This text is organized into sections that follow the HIS model presented in the HIS Scope, Definition, and Conceptual Model chapter and used throughout the text as a conceptual model for framing and organizing the materials and principles introduced.

With a picture in your mind of how the various pieces and principles fit together, you will gain confidence in your overall understanding of the many facets of HIS and technology, which in turn will make a lifetime of learning about this area much easier for you from this point forward.

I guarantee you will understand something that the majority of people in your organization do not, which provides you with a tremendous opportunity to be a leader in your healthcare career no matter where it takes you.

The first section, Understanding Health Information Systems and Technology, begins with the Alignment: Health Information Systems and Technology and Current Challenges in Health Care chapter, which explains why HIS and technology matter so much in health care and public health today.

Topics include HIS’s relationship to primary issues in health care today, health care cost and quality, motivations for today’s emphasis on HIS, the role of the U.S.

government in HIS in health care and public health today, changing consumer expectations, uses in other countries, opportunities for research and policy making, and relevance to the public’s health.

The HIS Scope, Definition, and Conceptual Model chapter presents the HIS model and lays out the types of settings in which HIS and technology are used.

The second section, Systems and Management (the first sphere of the HIS model), addresses planning, managing, and implementing HIS and technology.

It begins with the Health Information System Strategic Planning chapter, which presents a conceptual HIS planning framework.

I had the good fortune to be introduced to this planning tool early in my career, thanks to the transformative work of Jay McCutcheon and Bart Neuman, pioneers in HIS planning and strategy.

I have used this HIS planning framework during my entire career, including now as I teach what I have learned over the years.

It seldom fails to make the proverbial light bulb come on for my students, as I explain it and their eyes brighten and they smile, which tells me they now grasp a clarifying construct for understanding how all these different types of systems and technologies fit together, just as I did when I learned this timeless concept early in my career.

The HIS Application Systems and Technology chapter walks you through the basics of software systems and technology.

It was written by the skillful hand of James Brady, a stellar expert in the technology and security of HIS.

This chapter covering the basics of technology may seem a bit daunting but take a deep breath and jump in—you will gain so much by doing so.

The Managing HIS and Technology Services: Delivering the Goods chapter teaches you about managing people, projects, and processes of HIS and technology.

The Implementation chapter introduces you to the exciting and challenging world of selecting and implementing systems—a topic essential to anyone who actually wants to put these new systems to work in an operational environment.

Implementation is exciting work, but definitely not for the faint of heart; it is rewarding because you will use everything you have ever learned every single day of an implementation project.

The last chapter in this section is Leadership and Adoption of HIS and Technology, in which you are introduced to HIS leadership methods and roles, and the interesting tale of adoption of new technologies in health care and generally in organizations of any type.

The third section, Understanding Health Informatics, begins with the Health Informatics chapter.

This chapter familiarizes you with various types of health informatics and roles for informaticists, such as in medicine and nursing; relates HIS and technology to Donabedian’s health care quality framework including structure, process, and outcomes; and delves into the unsettling but important topic of unintended consequences of implementing HIS in healthcare organizations.

Penned by the pragmatic and knowledgeable Ric Speaker, the Data chapter explores the vital world of data, and discusses sources and characteristics of data, “Big Data,” data stewardship and management, data challenges, and data security and protection.

The importance of understanding and appreciating the essential topic of data when learning about HIS and technology cannot be overemphasized—at the end of the day, it is always about the data.

The Business and Clinical Intelligence chapter covers an area of enormous interest—the use of systems and their data for secondary uses that give us insight into the details and evidence regarding what we do clinically and in the business of health care.

This exciting world of analytics—retrospective, real time, and predictive—creates new knowledge for the purpose of improving health outcomes.

The next section, Research, Policy, and Public Health, contains the HIS and Research, Policy, and Public Health chapter.

It discusses uses of HIS for research, including roles of universities, government, private foundations, and reporting organizations in that worthy cause.

The relationships of HIS and technology to policy and public health are examined as well.

The final section, New Directions for HIS and Technology, includes the What Lies Beyond the Current State of HIS and Technology? chapter, which explores the trajectory and potential future paths of emerging technologies and their application and use in health care and public health.

eHealth, mHealth, uses of social media, personalized health care and medicine, and telemedicine are discussed, followed by an introduction to some of the issues and ethical dilemmas associated with ubiquitous use and access to data for purposes of health care and public health, including the dynamic tension between security and privacy of information versus access.

I have put my heart and soul into Essentials of Health Information Systems and Technology, just as I always have into the work experiences, mistakes, and lessons learned that are contained within this text.

I hope you like it; but more importantly, I hope you find it useful and can apply what you learn here as you pursue the path in health care that ignites your passions.

As I tell my students in the classroom, I share the mistakes I have made and the lessons learned from those experiences, so you can go into your careers equipped with that knowledge—and make new mistakes and learn a fresh set of lessons on your own! Jean Balgrosky Prologue Essentials of Health Information Systems and Technology is intended as a basic but thorough introduction to a complex and intimidating topic.

It is intended to take the mystery out of a subject that some people find exciting but others feel they cannot master because it is too highly technical.

Jean Balgrosky brings to health information systems (HIS) and technology her extensive experience implementing health information systems at Scripps Health and Holy Cross Health System (now Trinity Health) and her ongoing experience studying and teaching about health information systems at the University of California, Los Angeles.

Her experience places her in a unique position to understand and teach both the theory and the practice of health information systems and technology.

As she writes in the Preface: “A good deal of my career has been spent explaining health information systems and technology…”.

This will be obvious as you read the book.

Essentials of Health Information Systems and Technology is an important addition to our Essential Public Health series.

This text emphasizes key concepts as well as many specifics about health information systems and technology.

Once these concepts are understood, such as the need to match the structure of the HIS to the structure of the organization, the architecture of the HIS system becomes much easier to understand.

It is then far easier to “get it” in terms of the types of technology that are a “fit” for various organizational or information scenarios.

This text provides substantial information about and clear explanations of the key technologies used to create systems and networks for healthcare and public health purposes.

The concepts are presented without assuming extensive background, using an easily accessible approach.

The text is ideal for use in introductory courses without prerequisites.

Understanding the concepts is key because the applications are sure to change—and change rapidly—in the coming years.

If you understand the essential components of technology such as hardware, software, networks, and mobile devices, you do not need to be a technical expert.

You can focus on the basics, and then learn the technology specifics necessary for each project.

Therefore, the key principles are the focus of this text, which highlights HIS and technology planning and strategy, architectures, implementations, and uses, with accessible explanations and examples.

Successful systems implementations are the result of cooperation and collaboration between the many different types of expertise found in any health enterprise.

This is true whether one is selecting and implementing a new electronic health record system for a community clinic or a complex multihospital system, or designing and implementing new earlywarning surveillance capabilities for public health agencies around the country, or using social media and smart phones to reach out with important health-related information to difficult-toaccess rural areas.

The world of HIS and technology is an exciting, interesting, sometimes frustrating, and hopefully rewarding arena of possibilities and promise for making health care and public health safer, more accessible, and more effective.

But it is not without its risks and unintended consequences.

The proper attention is needed to determine the appropriate amount of change introduced at once.

In addition, a balance must be struck between offering access to information and protecting the privacy and security of sensitive information on individuals.

This text addresses these more caution-laden concepts so as to develop a realistic perspective of what it takes to implement systems and technology successfully.

New systems are not magic, and the benefits we hope to achieve from their use do not happen just by pushing a button.

These systems and the data they produce must be carefully stewarded to ensure positive results and the avoidance of new problems that can result from improperly implemented or managed systems.

The future of HIS and technology is unfolding, limited only by our imaginations and our will to adapt our systems and work methods carefully, creatively, and productively.

Essentials of Health Information Systems and Technology will guide your way into this emerging world and help you cope and contribute.

Richard Riegelman MD, MPH, PhD Series Editor Acknowledgments Essentials of Health Information Systems and Technology is a labor of love stemming from the challenging, exciting, complex area in which I have spent my career.

As a chief information officer (CIO), educator, and bootstrap entrepreneur doing and managing information systems and technology in health care, sharing what I have learned over the years has always been a goal of mine.

I have had the privilege and pleasure of teaching this subject for the past 6 years to the outstanding graduate and extension students at University of California, Los Angeles’s Fielding School of Public Health, who have provided valuable feedback and input regarding ways to introduce key HIS concepts and subject matter.

These students and colleagues, along with the many people with whom I had the privilege of working throughout my career at Scripps Health, Holy Cross Health System, Peat Marwick, and UCLA, have been instrumental in shaping the approach I have taken in explaining the essential elements of this complicated topic, any one of which could be a book in itself.

I am grateful for these many experiences and interactions, just as I am for the encouraging words from my students, colleagues, and mentors.

I have attempted to weave connections between all types of health information, whether initially produced in a healthcare organization, for public health purposes, or by an individual.

Previously separate areas of our health world are converging as we embrace use of mobile technologies, the Internet, and e-commerce in healthcare and information technology innovation.

This brings hospitals, physician offices, and other healthcare delivery settings in touch with public health needs, prevention, and population health management, reflecting the true focus of our greatest needs in health care today: improving quality and health status, becoming more cost-effective, and preventing and reversing troubling trends of increasing epidemics of illness associated with behaviors, the environment, and daily lifestyle habits.

I owe my passion for connecting these two worlds to my education and training at UCLA’s Fielding School of Public Health, and to several people in particular.

In my early days as an undergraduate, Miss Olive Johnson, a health information leader with a vision that was well before her time, provided me with mentorship and foundational education in medical record science as an undergraduate, then welcomed me back as a graduate student during a challenging time in my life to get my master’s degree in health information systems management.

She gave me an opportunity that forever favorably altered my life.


Ray Goodman awarded me a scholarship that sustained me and my daughter through my days as a graduate student and single parent.

He had the foresight to anticipate the emerging importance of health information systems and the need to prepare qualified graduates in this area.

I would also like to thank Dr.

Jonathan Fielding, who sponsored me in my Masters internship into the PhD program and who has been an advocate for my studies and work ever since.

Since my undergraduate days, Dr.

Paul Torrens has provided me with enthusiastic encouragement in my studies and work in health information systems and technology as well.

To this day, Drs.

Fielding and Torrens are my mentors, colleagues, and friends.


Jack Needleman has served as the chairperson of my PhD committee and provided the guidance I have needed through the dissertation research process.


Diana Hilberman has been my mentor in teaching and provided important opportunities for me to integrate the discipline of health information systems and technology into the graduate programs in health policy and management at UCLA.

All these people have made huge differences in my life, education, and career, and I am eternally grateful to them.

I would also like to thank Drs.

Leah Vriesman, Fred Zimmerman, Robert Kaplan, Tom Rice, Paul Fu, Doug Bell, and the members of the Fielding School of Public Health’s Department of Health Policy and Management faculty for their support of and interest in my PhD studies and teaching.

I am grateful for their enthusiastic support of developing an HIS curriculum for the department and the opportunity to develop and teach classes on this topic, which has provided me with the testing ground for much of this text’s content.

Another early lucky break in my career trajectory is owed to Sister Geraldine M.

Hoyler, C.S.C.

She plucked me out of a crowd of more typical candidates at the time and gave me my first job as a CIO at the age of 32.

My work in those days was fueled by insights and innovations of Jay McCutcheon and Bart Neuman, inventors of the HIS planning model that I use to this day, and which provides a key framework for the concepts presented in this text.

My friends and colleagues Dr.

Neetu Chawla and Jessie Chatigny have provided valuable advice and encouragement, acting as expert sounding boards as I waded through the challenges of structuring and writing chapters.

I’d like to thank my Bootstrap Incubation colleagues Kyle, Brandy, Sonya, Wyatt, Courtney, Melanie, Seth, CJ, Chris, Mannix, Brian, Kevin, and Bryce, who have picked up the slack and patiently waited as I went through spurts of writing and revising.

Thank you for keeping my knowledge current as every day we strive to create innovations in health information technology together.

I am ever so grateful for my new friends and colleagues—in particular, Dr.

Samir Damani and his team, who inspire me and many others in the pursuit of digital health, population health management, and personalized medicine.

I owe special thanks to my author comrades and contributors, Jim Brady and Ric Speaker.

They threw their hats willingly into the ring to help get this text written, tackling incredibly vital and challenging chapters.

Bravo to their contributions and commitment to the text, among all their other responsibilities.

We all have agreed: It was the hardest thing we have ever done! Jim and Ric, this text would not be here without you.

I am lucky to have loyal friends and brilliant colleagues such as you.

I also owe a debt of gratitude to Danny Boye Meyers, genius at the Apple Store genius bar in La Jolla, California, who rescued my raw, original Chapter 8 from the jaws of the asterisks bug in a split second, nimbly outsmarting my laptop, making it think it had crashed before it dissolved the chapter before our very eyes, ultimately and amazingly recovering the chapter at a critical time in the schedule to compose this manuscript.

I am humbled by his adept brilliance.

Further, I want to acknowledge all the hard-working information technology professionals I have been privileged to call my colleagues throughout my career.

You have taught me everything about HIS and service to the mission of health care.

Through the several years-long process from conceptualizing through writing and revising this text, Dr.

Dick Riegelman, editor of the Essentials of Public Health series, has provided me with the extraordinary combination of opportunity, guidance, constructive feedback, support, and enthusiasm for this volume.

I hope Essentials of Health Information Systems and Technology matches his hopes and expectations for a topic so relevant to a complete education in public health and health management.

I appreciate his vision and believe students will benefit greatly as a result.

I would like to thank Mike Brown of Jones & Bartlett Learning for his vision and excitement about adding this title to the series, and Chloe Falivene for her organized, professional, and energetic approach to getting this text from outline to manuscript to published product.

Sarah Bayle has provided stalwart and focused editing leadership, along with copyeditor Jill Hobbs and permissions expert Ashley Dos Santos, whose discipline ensures a properly referenced and cited book.

I always felt as if my hard work was very important to each of them and, along with Dr.

Riegelman, they provided me with a fantastic, professional support team.

Last and most importantly, to my family—nothing in my life is possible without you.

I am eternally grateful to you for your love and patience while I spent weeks at a time holed up writing.

To my dear husband Parker, thank you for your support and encouragement to write this text, and for understanding how important it was to me to do this.

(And thank you for handling family responsibilities during those days on end I was writing.) To my children Melissa, Jessica, Seth, Sarah, Wyatt, CJ, and Steven, thank you for being here—you and your families are my inspiration for everything I do.

I also want to express my love and gratitude to my parents, who, although no longer with us, instilled in me the value of education and the importance of books, and provided me with unending motivation to strive to do something good with my life.

This text is for you.

And to my sister Wendy and brother Steve, thank you for your constant love and support, which has always provided such great comfort to me.

About the Author Jean Balgrosky, MPH, RHIA, teaches Health Information Systems and Technology at UCLA Fielding School of Public Health, where she also received her MPH in health information management and BS in health services with a specialization in medical record science.

She is currently a PhD candidate in health policy and management and is completing her dissertation, Adoption of Health Information Technology by Physicians for Use in Their Practices.


Balgrosky’s career in health information systems and technology has included the role of chief information officer (CIO) in large, complex healthcare organizations for more than 20 years, consulting, and teaching at the graduate level.

More recently, she has become an entrepreneur, mentor, and board member for start-up companies in the life sciences, digital health, softwareas-a-service, and healthcare analytics arenas.

She is also CIO of a digital health company.

Essentials of Health Information Systems and Technology is Ms.

Balgrosky’s first book, for which she draws largely from her 30-year career in health information systems and technology as well as from teaching graduate courses at UCLA the past 5 years.

She has authored numerous papers and articles over the course of her career, is a frequent speaker, moderator, and panelist at health information technology conferences, and plans to publish the results of her dissertation research regarding physician adoption of electronic health records.


Balgrosky has provided leadership throughout her career to the evolving health information systems and technology industry, maintaining her accreditation as a Registered Health Information Administrator as the foundation of her knowledge of medical record management and electronic health records.

Her goal in writing this and subsequent books is to develop courses and resource materials for health information systems curricula, as well as to infuse necessary information technology topics into other courses taught in schools of public health and health management.

Examples of courses that now require information technology components include financial and human resources management, quality, organizational behavior, strategic planning, marketing, and medical and nursing educational programs.


Balgrosky lives in Del Mar, California, with her husband Parker.

They have seven children and, at current count, nine grandchildren.

Contributors James W.

Brady, MEd, PhD, CISSP, CISM, CRISC, PMP, CSM, CPHIMS, FHIMSS Area Chief Information Officer Kaiser Permanente Orange County Anaheim, CA Adjunct Faculty National University San Diego, CA Ric Speaker Entrepreneur and Health Information Systems Executive Bear Creek Works, LLC Heber City, UT SECTION I Understanding Health Information Systems and Technology CHAPTER 1 Alignment: Health Information Systems and Current Challenges in Health Care LEARNING OBJECTIVES By the end of this chapter, the student will be able to: • Identify the major reasons for the increase in health information systems (HIS) activity in U.S.

health care.

• Describe current healthcare challenges such as cost and quality issues and explain how HIS initiatives might help.

• Explain the U.S.

government’s role in and goals for health care, including the aims of legislation such as HIPAA, ARRA, and HITECH.

• Describe evolving consumer expectations regarding automation of healthcare processes and ways that HIS uses enable patients to become more engaged in their health care.

• Identify ways HIS is used in other countries.

INTRODUCTION Why Is HIS Getting So Much Attention Today? It makes great sense to automate health care using modern information technology and systems, but currently an inordinate amount of attention is focused on the rapid introduction of health information systems (HIS), especially electronic health records (EHRs), into healthcare organizations of all shapes and sizes throughout the United States.

Hospitals, clinics, physician practices of all sizes, public health organizations, and other settings in which health care is delivered have put HIS implementation high on their priority lists.

This is because patients, physicians and nurses, managers of these healthcare organizations, the government, public health organizations, policy makers, and quality improvement organizations have an extreme sense of urgency about implementing HIS as a means of improving the quality and efficiency of health care.

Traditional paper-based records and work processes are inadequate for addressing the complexities of medical care and the interactions between healthcare organizations involved in the care of patients, particularly as many require a variety of care settings and services.

Administrative processes in health care have also increased in volume and complexity.

Done properly, computerization of these tasks relieves people of many mundane manual tasks and also improves efficiencies.

Health care innovations today commonly incorporate new technologies such as mobile devices, genomic capabilities, and high-speed networks.

Infrastructure spans from organizations to personal computing devices and smartphones.

The field of health care seeks to improve cost and quality performance by adopting these new technologies and HIS in new ways across the care continuum.

Any student preparing to work in health care in any capacity is compelled to understand the basics of HIS and its use in health care now and into the future.

This need was the motivation for this text, the Essentials of Health Information Systems and Technology.

What Else Is Happening in HIS That Students Must Be Aware of? Every student needs to be aware of the powerful roles that government and the free market play in influencing how HIS is used in health care.

The government regulates and passes laws concerning proper implementation and use of HIS and health information technology (HIT), while the free market encourages commercialization of HIS products and services to enhance vendor company stock prices and dividends for shareholders.

Both of these forces are changing the way health care is delivered and how the U.S.

health system functions, but their efforts often push in different directions or collide with opposing interests.

How Can a Student Begin to Understand HIS? This text is designed to take the mystery out of understanding HIS.

Computer systems can be complicated.

This text describes how HIS is used in organizations and throughout the U.S.

health system by healthcare and public health professionals—but not how such systems are built, programmed, or technically developed.

Those areas are better addressed in schools of computer science and engineering.

The text matches different types of HIS to different purposes within healthcare organizations and health care in general, such as to meet clinical, financial management, and public health reporting needs.

It also covers the innovative ways HIS is expanding its reach through mobile devices, social networking, digital health and wellness, predictive analytics, and convergence with entire areas such as the biotechnology and pharmacology fields.

HEALTHCARE COST AND QUALITY ISSUES In 2012, health care accounted for 17.2% of the U.S.

gross domestic product (GDP); this is equal to $2.8 trillion, or $8915 per person, and with an average annual projected growth rate of 6.2% per year for 2015 through 2022, health spending could comprise 19.9% of the GDP by 2022.1 Health care in all its related parts is undergoing massive change and experiencing numerous challenges in the process.

The drivers of change are inadequate quality and the unsustainably high costs of health care.

The Institute of Medicine (IOM) published two watershed reports, To Err Is Human (1999) and Crossing the Quality Chasm (2001), which provide solid evidence of alarming quality problems and make suggestions for improvement.

To Err Is Human describes high levels of avoidable medical errors in U.S.

hospitals that result in as many as 98,000 patients dying every year—patients who should have been discharged from the hospital successfully.2 Crossing the Quality Chasm outlines six key aims necessary to improve the quality of care3: • Safe: Ensuring care helps and does not harm patients.

• Effective: Providing services based on scientific evidence to all who could benefit, and refraining from providing services to those not likely to benefit.

• Patient centered: Providing respectful and responsive care according to patient preferences, needs, and values.

• Timely: Reducing delays for those who receive and those who give care.

• Efficient: Avoiding waste of materials and resources in patient care processes, including equipment, supplies, ideas, and energy.

• Equitable: Providing care that is consistent in quality regardless of a patient’s characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Unfortunately, despite significant efforts on many individuals’ and organizations’ parts, the U.S.

health system remains inefficient and ineffective compared to the health systems of other developed nations by the majority of standard population-based outcome measures.4 Sadly, these numbers have not improved since the two seminal IOM reports were published more than a decade ago.

An updated evidence-based analysis estimates the number of deaths due to medical errors in U.S.

hospitals to be more than 400,000 per year; the same analysis cites poor incident reporting processes (only 14% of total adverse events) as contributing to this phenomenon and appeals for greater patient involvement in identifying errors and preventable harmful events.5 Given this background, what does HIS mean to health care? Is HIS just a collection of computers and technologies used by those practicing modern medicine and delivering healthcare services to automate their work? Or is HIS a transformative force that can radically alter and improve the work processes by which health care is delivered? The answer to both questions is “yes.” HIS can both speed up existing processes and enable brand new ways of delivering health care to people.

It is also important, as we delve into the complex world of HIS, to always ask the question, “What are the benefits and what are the risks of adopting any new technology?” New and computerized is not always better than how things have been done traditionally, if they have been done safely and in a well-organized fashion.

Another key question for understanding HIS is, “How prevalent is HIS use?” Today, we are in the midst of a growing, massively transitional phase of healthcare delivery, moving toward greater use of computers in delivering, managing, and studying health care.

It is much more difficult to transition from traditional paper-based processes to computerized information processes than it is to begin a new health-related activity or process that uses automation from the beginning.

The fact that our society is in the throes of such massive, disruptive change in the way we do our work in health care has added an ever-present element of risk and uncertainty to the exact end point of this journey to automate and improve health care.

We can envision a better health system and enhanced health for all people through the use of technology and HIS.

But getting there will be a long journey, fraught with missteps and difficulty because these changes rely on technology innovation and human behavior, and the end point of such change is not defined.

In addition, the introduction of HIS into health care is creating many unintended consequences, both good and bad, that are not yet fully understood.6 Thus, when we move to computerize health care, we must constantly ask the question, “What are we trying to accomplish and why?” We must evaluate whether we have achieved what we set out to and make necessary adjustments along the way as we make sweeping changes throughout the U.S.

health system, including computerizing our systems and processes.

From the broadest perspective, the future of HIS in health care will entail the automation of processes we know and the adoption of new processes that have yet to be created.

It is difficult to predict whether this transition will be truly disruptive or simply innovative, and to evaluate the difference between those two.

The net effect of HIS, however, must be positive—the health of people depends on it.

MOTIVATION The IOM’s watershed report To Err Is Human studied 33.6 million hospitalizations in the United States.

Based on the resulting data, the IOM estimated that each year an estimated 44,000 to 98,000 patient deaths occur during hospitalizations, not because of the patient’s condition, but rather due to mistakes occurring in hospitals.

This number was greater than the number of deaths per year due to motor vehicle accidents, breast cancer, and AIDS combined.2 This devastating statistic translates into 1310 to 2917 deaths per 1 million hospitalizations due to medication errors every year, year after year.

If the Six Sigma level of reliability is applied, that ratio translates into 114 avoidable deaths per 1 million hospitalizations due to medication errors.

(Six Sigma is a quality improvement methodology that strives to eliminate errors in processes to a near-perfection level through data analysis techniques.7) Unfortunately, if any one of those persons included in the avoidable death statistics is you or a loved one, this is 100% of what matters to you.

The To Err Is Human report provides all the motivation needed to improve quality and outcomes and to increase the focus on patient safety.

It sheds light on the whole U.S.

healthcare system, rather than focusing on any one caregiver or provider.

The bottom line is that the costs of health care continue to rise, and quality problems have persisted.

But what is the connection to HIS? The answer lies in the IOM’s second watershed report, Crossing the Quality Chasm.

This report identified four key reasons for the significant gap in the U.S.

health system between reality and ideal quality: • The growing complexity of science and technology, with delays between innovation and implementation.

Modern medicine is becoming increasingly multifaceted, with increasingly specialized areas of practice emerging.

Also, new biomedical equipment and information technologies are being developed at an exponential rate, all of which make the access to complete and current information and the interaction between the various new technologies equally complex.

This trend has been relentless for decades, as expressed more than 30 years ago by David Eddy: “The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.”8 HIS initiatives must target this gap and help close it.

• The increase in chronic illness burden with a system centered on acute illness.

The aging demographics of the U.S.

population and the increasing incidence of chronic illnesses such as obesity, cancer, diabetes, and heart disease occurring within a health system that emphasizes the “medical model” of care have resulted in a lack of effectiveness in dealing with the majority of today’s illnesses.

The mismatch between an epidemic of chronic illness and settings oriented toward acute care dominates the U.S.

health system, resulting in failure to successfully address these conditions.

By the time a person with diabetes is sick enough to come to the hospital, it is too late to treat that condition in a way that addresses the root cause of the illness.

All that can be done in a hospital setting is address the symptoms and outcomes of this condition.

Such chronic illnesses require access to patients in less costly settings such as clinics and doctors’ offices, and importantly, in their homes and everyday lives.

The inpatient hospital setting is ill equipped to deal with these prevalent chronic conditions; hospitals are set up to cure acute illness, not manage chronic illness or prevent it in the first place.

• The inadequate use of information technology (IT).

The IOM report asserts that IT can be instrumental in preventing or catching many types of medication errors that cause avoidable deaths and countless injuries or near misses each year.

Many HIS capabilities contained within EHRs are designed with capabilities to prevent such errors, such as drug–drug interaction alerts, allergy alerts, computerized physician order entry (CPOE), and others.

Also, the IOM report indicates that many of the errors responsible for avoidable patient deaths occur in “hand-offs” of patient information between caregivers, between departments of the hospital or clinics such as the laboratory and nursing, or between physicians in their offices and the hospital settings.

These paper or verbal hand-offs can be eliminated or reduced through the use of computer systems such as EHRs that transmit information electronically, greatly reducing the risk of errors in the information as it is transmitted.

• A payment system that provides conflicting incentives and does not reward quality improvement.

For decades, doctors and hospitals have not been paid based on the quality of their services or on patient outcomes.

Instead, they are paid just for providing those services and properly documenting this care.

Thus there is a low correlation between how well patients do and how well the provider is paid.

This translates into a lack of financial incentives for quality outcomes and instead provides incentives for utilization of services, regardless of the outcome for the patient.

Quality improvement is not “baked into” the processes surrounding patient care, but rather is seen as occurring at additional effort and expense to the physician and hospital organizations (providers).

This results in quality improvement being viewed as an add-on or separate activity in these organizations and discourages efforts to interweave quality improvement into the fabric of the care provided.2 HIS AND THE U.S.

GOVERNMENT’S ROLE AND GOALS IN HEALTH CARE Several seminal laws and research reports have marked the U.S.

government’s current involvement in the evolution of HIS activities and in response to the unsustainable escalation of healthcare costs.

These important elements include the following: • The Health Insurance Portability and Accountability Act (HIPAA) of 1996 • The IOM reports To Err Is Human and Crossing the Quality Chasm • The IOM report Health IT and Patient Safety: Building Safer Systems for Better Care • President George W.

Bush’s and President Barack Obama’s healthcare initiatives • The American Recovery and Reinvestment Act (ARRA) of 2009: Title IV—Health Information Technology for Economic and Clinical Health (HITECH) Act • The Affordable Care Act (ACA) of 2010 The Health Insurance Portability and Accountability Act Initially introduced to ensure that individuals’ insurance would be portable across states and jobs, HIPAA had far greater impact through its “administrative simplification” (Title II) elements.

HIPAA requirements for electronic data interchange (EDI) anticipated the need for data standards for electronic claims in health care, in addition to seeing that electronic records required standards for privacy and security.

These standards, originally targeting the Medicare claims processes, introduced far-reaching administrative simplification attributes, including the following: • Standards (the first mandate for electronic HIS standards for data transmission protocols) • Requirement that providers and health plans participating in Medicare participate • Privacy and security of protected health information (PHI) • Preempted state laws, thus reducing fragmentation across the United States • Imposed penalties for noncompliance, giving these regulations and laws teeth9 Title II Administrative Simplification Act The Title II Administrative Simplification Act aimed to improve the U.S.

health system’s efficiency by introducing standards governing the use and communication of healthcare information.

The rules include protection of identifiable PHI and apply to all provider and payer organizations, called “covered entities” by the legislation.

Covered entities include health plans, healthcare billing services, and healthcare providers (hospitals, clinics, and physician practices) that transmit healthcare data, submit claims, and receive reimbursement from Medicare.

While the scope of these regulations refers to organizations participating in Medicare, the impact reaches far beyond Medicare to virtually all healthcare entities, because Medicare standards and practices set the benchmark standards for all payers.

HIPAA’s administrative simplification rules include the following: • Privacy Rule: Regulates the use and disclosure of PHI, laws implemented in 2003.

It mandates that a person’s medical information with identifying information attached to it cannot be used, viewed, or shared by anyone in a healthcare organization other than a healthcare professional or public health practitioner who has the need to look at that information for the purposes of taking care of or addressing the business needs of that person.

The privacy rule applies to PHI on any medium—electronic or paper.

• Transactions and Code Sets Rule: Establishes EDI standards for healthcare claims.

Claims sent to payers for reimbursement, and subsequent reimbursement to the providers, must be sent electronically in a certain technical format, standardizing electronic claims processing and thus making it more efficient.

• Security Rule: Defines administrative, physical, and technical security safeguards.

This rule establishes specifics for ensuring secure transmission of data through systems and over the Internet, so that even though HIS and the Internet are used, the data traveling on these networks and in these systems are secure.

• Unique Identifiers Rule: Establishes National Provider Identifier (NPI) standards for providers.

This rule establishes unique identifiers for providers, ensuring accuracy of electronic provider payments.

• Enforcement Rule: Defines civil financial penalties for HIPAA violations.

This rule provides the teeth of the HIPAA regulations.

If providers violate HIPAA rules, they face significant financial and other penalties.9 HIPAA rules and regulations have set a new bar for government participation in defining the way forward in automating healthcare administrative and clinical processes while protecting individuals’ privacy and allowing for public health issues to be addressed to prevent disease, injury, or disability.

Driven initially by the need to ensure portability by establishing standards for electronic claims transactions for Medicare, HIPAA standards for electronic data transmission, privacy, and security of PHI have redefined HIS’s and the U.S.

healthcare system’s norms and practices.


GOVERNMENT INVOLVEMENT IN HIS Responding to the findings outlined in the To Err Is Human and Crossing the Quality Chasm reports, the federal government established two waves of policies intended to encourage the implementation of HIS in the U.S.

health system.

With added emphasis on improving quality and cost-effectiveness in health care, the federal government identified the implementation of HIS initiatives as a priority, particularly the implementation of EHRs for all U.S.

patients by 2014, first by President George W.

Bush and then by President Barack Obama.10 President Bush signed several initiatives into law to provide “seed grants” to fund pilot projects testing various uses of IT in healthcare settings.

One of these initiatives was the Medicare Prescription Drug Improvement and Modernization Act of 2003; it included provisions for the development of standards for electronic prescribing, an initial step in the implementation of EHRs.

This move precipitated the establishment of a Commission on Systemic Interoperability to plan the establishment of technical interoperability standards for eprescribing systems.11 Also under executive authority of President Bush, the Office of the National Coordinator of Health Information Technology within the Department of Health and Human Services (HHS) was established.

Next, also under the administration of President Bush, came Executive Order 13335 of April 27, 2004, titled “Incentives for the Use of Health Information Technology and Establishing the Position of the National Health Information Technology Coordinator,” as well as the “President’s Health Information Technology Plan,” calling for a 10-year plan to get EHRs online for all Americans.12,13 These national policy interventions built upon other major national initiatives, including the Consolidated Health Informatics initiative in 2003 involving HHS, the Department of Defense, and Veterans Affairs, which established the goal of uniform standards for electronic exchange of clinical health information across all federal healthcare entities.14 While these national and presidential initiatives provided encouragement and incentives for hospital and physician providers to invest the money and time in the daunting task of automating their organizations and practices using HIS, the stimulus with the greatest impact has been ARRA, the legislation that includes the HITECH Act.

This act greatly expanded the resources available for HITECH activities.

First, it created a strategic plan for a nationwide interoperable HIS, a plan that is required by this act to be updated annually.

Second, it called for a leadership structure consisting of two committees to advise the coordinator: a Health Information Policy Committee and a Health Information Standards Committee.

As part of the $787 billion ARRA stimulus package, the HITECH Act requires the government to lead the development of standards that allow for nationwide electronic exchange and use of health information to improve the quality and coordination of care.15 Through the HITECH Act, the government is investing about $30 billion in HIT infrastructure and Medicare and Medicaid incentives to encourage doctors and hospitals to use HIS to electronically exchange patients’ health information.16 The Congressional Budget Office calculated that this investment will save the government $10 billion and will generate additional savings throughout the health sector through improvements in quality of care and care coordination, reductions in medical errors, and duplicative care.

The HITECH Act also strengthens federal privacy and security laws to protect identifiable health information from misuse as the healthcare sector increases the use of HIS.

The Congressional Budget Office estimates that as a result of this legislation, approximately 90% of physicians and 70% of hospitals will be using comprehensive EHRs by 2020.17 These standards are having a seismic effect on vendor products for EHRs and other HIS software, which must now meet these standards or else face quick elimination from the marketplace because they will not qualify organizations to receive their incentives based on meeting these standards.

TABLE 1.1 Summary of Meaningful Use Criteria Stages 1, 2, and 3 The meaningful use criteria, objectives, and measures will evolve in three stages over the next 5 years: 1.

Stage 1, 2011–2013: Data capture and sharing 2.

Stage 2, 2014–2015: Advance clinical processes 3.

Stage 3, 2016–2017: Improved outcomes Stage 1: Meaningful Use Criteria Focus on… Stage 2: Meaningful Use Criteria Focus on… Stage 3: Meaningful Use Criteria Focus on… Electronically capturing health information in a standardized format More rigorous HIE Improving quality, safety, and efficiency, leading to improved health outcomes Using that information to track key clinical conditions Increased requirements for eprescribing and incorporating lab results Decision support for national highpriority conditions Electronic transmission of patient Communicating that information for care care summaries across multiple coordination processes settings Patient access to self-management tools Initiating the reporting of clinical quality measures and public health information Access to comprehensive patient data through patient-centered HIE Using information to engage patients and their families in their care More patient-controlled data Improving population health HIE, health information exchange.

Reproduced from healthit.gov.


EHR incentives & certification: How to attain meaningful use.

http://www.healthit.gov/providers-professionals/how-attain-meaningful-use HITECH establishes “meaningful use” criteria for EHR implementations that must be met for hospitals and physicians (provider organizations) to receive incentive payments (for Medicare patients).

Meaningful Use criteria are features, functions, and capabilities of EHRs shown to improve care (Table 1.1).

The meaningful use criteria measure EHR adoption of these capabilities, such as the percentage use within an organization of EHR capabilities such as CPOE, as a way of encouraging EHR adoption.

Although many specifics are laid out in the Stages 1 and 2 criteria (followed by Stage 3, the criteria and dates of which are being set), generally speaking, through 2016, if a provider organization meets these criteria for implementing specified levels of EHR system functionality, that qualifying provider receives an incentive payment through a slight increase in payment for Medicare patients.

After 2016, if these criteria are not met, a penalty is levied in the form of reduced Medicare reimbursement for services provided by those noncompliant hospitals and physicians.

Financial penalties for physicians not using EHRs meaningfully by 2016 include a loss of 1% of their Medicare payments, a loss of 2% in 2017, and a loss of 3% in 2018.

Hospitals will lose percentages of their annual updated reimbursements from Medicare under the diagnosis related groups (DRGs) system (which is used for calculating payments for various conditions and treatments) if they do not meet the meaningful use criteria by 2017.18 These increases (incentives) or reductions (penalties) in Medicare payments will significantly impact the financial well-being of these provider organizations, as Medicare patients account for a major proportion of patients and participation in Medicare is the only realistic course for the vast majority of provider organizations to remain viable.

The HITECH Act paves the way for increased demand associated with the ACA, making available major training grants to stimulate the establishment of university- and community college–based HIS training programs as a means of addressing the current shortage of approximately 60,000 HIS professionals needed to support implementation of EHR systems and other HIS activities called for in the HITECH program.

CONSUMER EXPECTATIONS AND ENGAGEMENT Emerging research and common sense tell us that if patients—people—are more engaged in their healthcare processes and in maintaining their health, their health status outcomes will improve.

Of course, personal responsibility is a strong determinant of health and well-being, and the more attention paid to one’s health and the health of one’s family members, the better.

Clinicians are adapting their practice of medicine and healthcare services in ways that engage and involve patients in the process.

HIS in its many forms—including the Internet, secure email, smart devices, machine-to-machine (M2M), and social media—will play a part in the integration of people and providers in the care process.

In addition to information being available to caregivers and providers through components of HIS such as EHRs and other robust capabilities such as clinical decision support, direct interaction between patients and clinicians is now becoming the norm.

While the infrastructure necessary to accomplish this communication between organization-based providers and patients in their homes is not available everywhere, healthcare delivery organizations are earnestly building out these systems and connectivity in a wave of innovation characteristic of today’s evolving healthcare landscape.

If you do not yet communicate with your doctor using computer technology, you soon will.

These new uses of intersecting HIS and social media are also placing new demands on HIS in healthcare organizations, because any transmission of PHI (as defined by HIPAA) must take place securely and in ways that ensure privacy and the confidentiality of that information.

As you will recall, providers who violate HIPAA face stiff penalties.

Organizational models are also changing rapidly in response to the evolution of technology.

Through IT, families can now be connected to their loved ones who may be in the hospital.

Likewise, care settings can be connected across the continuum of care, from the hospital, to the physician’s office, to the imaging center, to home health, to the workplace, and to schools, to name a few of the various settings in which health care happens.

Myriad new devices have been devised to facilitate this connection: In addition to mainframe computers, desktops and laptops, tablets, iPads, smartphones and smart, mobile, biomedical devices can be used by people wherever they are to test blood sugar or capture other important health symptom data.

Clearly, paper medical records will no longer suffice—they do not have the capacity to house the data and information that originate far and wide about a patient who traverses this range of care settings in the normal course of care and life, let alone genomic data and customized cancer care, and medical home frameworks.

These new types of data, care, and organizational structures require new ways of handling information.

People must be connected to their healthcare providers and medical information in new ways.

All this means healthcare providers must learn to think “horizontally” in terms of clinical workflows and the movement of important information about patients among all these cross-continuum settings; they must collaborate across and between vertical settings (e.g., different offices, specialties) to optimize the new flows; and they must provide increasingly efficient patient care processes and better outcomes, improved patient experiences and involvement, and improved satisfaction for providers as well.

USES OF HIS IN OTHER COUNTRIES HIS activity is an international affair, with many countries engaged in activities of information infrastructure establishment, especially EHRs and health information exchange initiatives (efforts to automate, streamline, and innovate within their unique healthcare systems).

In a recent study funded by the Commonwealth Fund, HIS and technology plans and projects in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States were examined.

More than 90% of general practitioners in Australia, New Zealand, the Netherlands, and the United Kingdom reportedly used EHRs, whereas only 10% to 30% of practitioners in ambulatory settings in the United States and Canada used EHRs.

A striking finding of this study is that only 10% of hospitals in the seven countries studied met the criteria for major elements of an EHR.19 Massive but varied investments of financial resources and organizational energy are being made country by country, and the results are largely the same internationally—HIS adoption is slow and painstaking work.

While national systems that are based on a single payer—that is, “closed” health systems in which providers, hospitals, and the payer are all part of the same unified health system, such as in the United Kingdom—have a shot at pulling together a consistent effort to implement HIS initiatives nationwide, this is still incredibly difficult work for many reasons.

First, the financial resources required to both start up and then maintain EHRs and HIS infrastructure are of such magnitude that if other major priorities such as economic crises or changes in national leadership emerge at the same time, progress can be slowed.

Also, as in the United States, political, popular, and professional energy and will must align to muster the resources and commitment to initiate and implement the HIS infrastructure required to support a health system nationally.

Unfortunately, sometimes one of these pillars of progress may falter.

For instance, in Germany, a setting in which EHRs and “smart cards” for 80 million citizens’ personal health records made major headway in the past decade, more recent times have seen mounting concerns about privacy on the part of the citizenry, slowing momentum and progress toward EHR adoption in that country.20 The United Kingdom, Denmark, Australia, the Netherlands, and Taiwan also have encountered major difficulties in adopting electronic systems for health care.

Major transformational systems such as EHRs and the infrastructure they require are accomplished slowly, and while such change is desired, the obstacles associated with their implementation are felt in all types of health systems, whether national or free market in philosophy.21 In addition to the software, hardware, and network infrastructures needed to support these systems, the difficulties of other changes such as the establishment of technical standards and discipline in the management of data have proved enormously challenging to health systems in countries around the world.

PROTECTING THE PUBLIC’S HEALTH All of these HIS initiatives on the part of healthcare organizations, the government, consumers, and health IT professionals have an additional purpose: to make data available, using appropriate safeguards to ensure data integrity and protect citizens’ privacy, for purposes of protecting the public’s health.

Public health officials and organizations can benefit from HIS data made available by healthcare providers; such data may provide alerts to outbreaks of disease, aid in preventing injury, or provide tip-offs to bioterrorism.

These data may also be used to conduct comparative studies of the effectiveness of different types of therapies across groups or populations and thereby determine which might be better to use under various circumstances.

It is most efficient, from the entire health system’s perspective, for healthcare data to be coordinated, protected, consistent, and used for multiple purposes, each with the intent of providing health care, improving the public’s health, and improving the overall quality of health services in the United States.

This understanding is reflected in the HIS model that forms the conceptual foundation for this text.

SUMMARY Motivation for recent significant increases in HIS initiatives in the United States centers largely on deepening concerns regarding the cost and quality of health care.

HIS initiatives, including EHRs and health information exchanges, are seen as key ingredients in improving the efficiency and effectiveness of health care.

The U.S.

federal government has included HIS initiatives in its economic stimulus legislation, intended to update the nation’s aging infrastructure and elevate the technical sophistication of the healthcare system.

Major regulations and policy interventions by the federal government include HIPAA and ARRA, which established the HITECH Act.

Consumers of healthcare services have come to expect the same level of automation and convenience in health care as they experience in other segments of the U.S.

economy and consumer services.

The United States is one of many countries internationally that are striving to implement comprehensive HIS to improve the efficiency and effectiveness of their health systems.

KEY TERMS Affordable Care Act (ACA) of 2010 American Recovery and Reinvestment Act (ARRA) of 2009 Computerized physician order entry (CPOE) Diagnosis related groups (DRGs) Electronic data interchange (EDI) Electronic health record (EHR) Health information exchange (HIE) Health information systems (HIS) Health information technology (HIT) Health Information Technology for Economic and Clinical Health (HITECH) Act of 1996 Health Insurance Portability and Accountability Act (HIPAA) Meaningful Use National Provider Identifier (NPI) Protected health information (PHI) Discussion Questions 1.

Which current challenges in health care are primary drivers of HIS adoption in the United States? How might HIS initiatives help the U.S.

health system address these issues? 2.

Do you think that the federal government needed to establish regulations and enforce laws regarding privacy, security, and confidentiality of PHI? What about policies and regulations intended to stimulate adoption of HIS, including EHRs? Why or why not? 3.

Should the government mandate capabilities of EHRs intended to improve quality of care or should quality initiatives be left to providers and provider organizations? Explain your response.


Are consumer expectations capable of influencing HIS adoption in the United States? In which ways should patients/consumers engage in their care using HIS? 5.

Which lessons can U.S.

providers draw from the experiences of other countries in implementing HIS? 6.

What are a few of the many ways that HIS data can be used not only for supporting the delivery of healthcare services, but for additional purposes such as protecting the public’s health? REFERENCES 1.

Centers for Medicare & Medicaid.


National health expenditure projections 2012–2022 Forecast Summary.


http://www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/NationalHealthExpendData/downloads/proj2012.pdf 2.

Committee on Quality of Health Care in America, Institute of Medicine.


To err is human.


Kohn, J.

Corrigan, & M.

Donaldson, Eds.

Washington, DC: National Academy Press.


Committee on Quality of Health Care in America, Institute of Medicine (IOM).


Crossing the quality chasm: A new health system for the 21st century.

Washington, DC: National Academy Press.


McCullough, J.

C., Zimmerman, F., Fielding, J.

E., & Teutsch, S.



A health dividend for America: The opportunity cost of excess medical expenditures.

American Journal of Preventive Medicine, 43(6), 650–654.


James, John T.

(2013, September).

A new, evidence-based estimate of patient harms associated with hospital care.

Journal of Patient Safety, 9(3), 122–128.


Committee on Patient Safety and Health Information Technology, Institute of Medicine.


Health IT and patient safety: Building safer systems for better care.

Washington, DC: National Academy Press.


Definition: Six Sigma.


http://searchcio.techtarget.com/definition/Six-Sigma 8.

Congressional Budget Office.


Evidence on the costs and benefits of health information technology.

http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/91xx/doc9168/maintext.3.1.shtml 9.

HIPAA privacy rule and public health guidance from CDC and the U.S.

Department of Health and Human Services.


http://www.cdc.gov/mmwr/preview/mmwrhtml/m2e411a1.htm 10.

Bush, G.


http://www.whitehouse.gov/news/release/2004/04/20040427-4.html 11.

O’Sullivan, J., Chaikind, H., Tilson, S., Boulanger, J., & Morgan, P.


Overview of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (2004).

http://royce.house.gov/uploadedfiles/overview%20of%20medicare.pdf 12.

Executive Order: Incentives for the use of health information technology and establishing the position of the National Health Information Technology Coordinator.


http://georgewbushwhitehouse.archives.gov/news/releases/2004/04/20040427-4.html 13.

Thompson, T.

G., & Brailer, D.



The decade of health information technology: Delivering consumer-centric and information-rich health care: Framework for strategic action.

http://www.providersedge.com/ehdocs/ehr_articles/The_Decade_of_HIT-Delivering_Customercentric_and_Info-rich_HC.pdf 14.



Consolidated health informatics http://searchhealthit.techtarget.com/definition/Consolidated-Health-Informatics-CHI 15.

Health Information Technology for Economic and Clinical Health Act or HITECH Act.


http://waysandmeans.house.gov/media/pdf/110/hit2.pdf 16.

Blumenthal, D., & Tavenner, M.


The “Meaningful Use” regulation for electronic health records.

New England Journal of Medicine, 363, 501–504.

http://www.nejm.org/doi/full/10.1056/NEJMp1006114 17.

CBO letter estimating federal direct spending and revenues of HITECH to Honorable Charles B.

Rangel Chairman Committee on Ways and Means U.S.

House of Representatives.


http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/99xx/doc9966/hitechrangelltr.pdf 18.

HITECH Answers.


EP meaningful use objectives.

http://www.hitechanswers.net/ehradoption-2/meaningful-use/ep-meaningfuluse-objectives 19.

Jha, A.

K., Doolan, D., Grandt, D., et al.

(2008, December).

The use of health information technology in seven nations.

International Journal of Medical Informatics, 77(12), 848–854.


Versel, N.


Germany halts smart card program for security review.

Fierce Mobile Healthcare.

http://www.fiercemobilehealthcare.com/story/germany-halts-smart-card-program-security- review/2010-01-26 21.

Anderson, G.

F., Frogner, B.

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(2006, May).

Health care spending and use of information technology in OECD countries.

Health Affairs, 25(4), 819–831.

http://content.healthaffairs.org/content/25/3/819.full Discussion Questions CHAPTER 2 HIS Scope, Definition, and Conceptual Model LEARNING OBJECTIVES By the end of this chapter, the student will be able to: • Describe the purpose, definition, and scope of health information systems (HIS) using a conceptual model.

• Define the components of HIS according to the conceptual model, including systems and their management, health informatics, data and analytics, research, policy, and public health.

• Explain the progression and maturation of HIS, beginning with the foundation of core HIS and their management; the use of HIS embodied in the discipline of informatics in key functions such as medicine, nursing, and public health; the use of HIS to learn and create information and knowledge through data analytics and research; and the use of HIS to improve health outcomes and the way healthcare work is done through research, policy, and public health.

• Describe organizational and community settings in which HIS and informatics can be used.

INTRODUCTION Before delving into the depths of health information systems (HIS), it is important to lock in some key concepts regarding the scope of HIS and take the mystery out of computer systems by reviewing the overall structure of how systems and their uses fit together.

The conceptual model adopted in this text provides an understanding of the relationships among the major elements of HIS—not just the “systems” of HIS, but also the art and science of making use of systems and information (informatics), the data created and captured in these systems, and the variety of uses that the data can be put to work to do, such as research, policy, and public health.

Each of these uses of data depends on the foundational HIS that create and capture data through the applied use of systems to do clinical and administrative work in healthcare organizations of all types, shapes, and sizes.

This chapter describes and builds the layers that comprise the entire HIS model.

Definition of Health Information Systems In this text, we will define the scope of HIS as including all computer systems (including hardware, software, operating systems, and end-user devices connecting people to the systems), networks (the electronic connectivity between systems, people, and organizations), and the data those systems create and capture through the use of software.

Each key layer of this progression through the totality of HIS relies on the foundation of core systems, and requires professionals who specialize in that layer’s work.

Next, we look at the various layers of HIS one at a time—systems; health informatics; data and analytics; and research, policy, and public health.

Systems and Their Management Well-architected, properly managed computer systems are the foundation of the ability to create, transmit, and use information.

As obvious as this sounds, with availability of the Internet, development of cool new devices such as iPhones and Androids, and advertisements everywhere from vendors touting the ease of “cloud computing,” it is sometimes tempting to think that access to high-quality, useful systems and information is as easy as 1-2-3—that all that is necessary is to “plug into” one of these devices or some other easily accessible computing modality.

The hard truth is that the myth of “plug-and-play” simply delays the realization that meaningful health information and data—whether available via the Internet, over a secure internal network, or through the use of an iPad or another innovative device—are only as good as the HIS platform that serves as the data source.

In other words, the access devices and networks do not actually create data; instead, data are created and captured by painstakingly and properly implemented HIS that provide features and functions to support the workflow (sequence of common tasks) and processes (end-to-end methods) of healthcare providers and organizations, patients, and public health professionals.

These HIS that create and capture data (which can then be coalesced into meaningful information) serve as the foundation upon which all other information- and data-related capabilities depend.

It might seem old-fashioned, but the source systems and devices that support the work of providers and healthcare organizations remain the essential building blocks of all other advanced uses of data and information and computerized workflow support modalities such as health informatics, data analytics and outcomes analysis, research and public health data surveillance, and predictive modeling techniques.1 We will talk more about these source systems and their management in the HIS Strategic Planning, HIS Application Systems and Technology, and Managing HIS and Technology Services chapters.

The HIS model in Figure 2.1 depicts this relationship: HIS and their management form the footing for health informatics, data and analytics, and research, policy, and public health uses of HIS.

These components of the total scope of HIS, in turn, rely on the fundamental HIS for the capabilities and data the HIS create and capture so that these spheres can exist.

For example, without the foundational HIS, informatics would have no systems capabilities and features and functions to work with in redesigning workflows and calculating rules and alerts, or clinical decision support and artificial intelligence aids to help in the advancement of the practice of medical, nursing, or other health-related professions.

FIGURE 2.1 HIS Scope Model Likewise, without well-managed HIS used to support key work processes such as clinical care and administrative functions (e.g., billing and payroll), no data would be created and captured for use in databases for analytical and business intelligence purposes.

In addition, without these HIS, no data would be created and captured for research, policy, and populationbased public health purposes.2 Data to be used for research, policy analysis, and public health surveillance need to come from somewhere—they need to be real data values, emanating from real healthcare processes and patients, which are then made available for these secondary purposes on any large scale.

Health Informatics Informatics is the use of information systems and technology to redesign, improve, and recreate the way work is done in disciplines such as the practice of medicine, nursing, medical imaging, and public health.

In most cases, informatics focuses on certain quality or process improvement objectives, but this varies based on the setting in which the informatics activities take place.

Informatics comprises the “use” of the computer capabilities that HIS provide to end users.

In health care, this includes the activities of physicians, nurses, and other clinicians in the various settings in which they do their work, as well as professionals working in public health in its various environs, such as community settings, public health clinics, and other public health organizations.

HIS are expected to enable improvements in the efficient delivery of health care, the quality of services provided, and health outcomes across the U.S.


Data and Analytics Much of the value of systems is locked up in their data—a resource created only as systems are used and data captured in those systems’ databases.

Creating this resource can yield additional value, the rewards of which are reaped at an exponential scale through secondary uses of this data treasure trove.

While primary uses of data involve the transactions that support day-to-day activities of professionals and organizations, the only way to create information is through the aggregation and compilation of these data to create something greater than the single units of data—in other words, to create meaningful information that is relevant to someone who is doing the work of health and health care.

Thus the creation of information and the ability to conduct analysis and gain knowledge are completely dependent upon the creation and capture of the data in the first place.

If someone attempts to create information out of proxied, extrapolated, or estimated data for a certain purpose, the only fruit of those data will be educated guesses.

With real data, emanating from real activities conducted in real organizations through real processes, real analysis and research drawing real inferences, associations, outcomes, and evidence can be accomplished.

Data created and captured in systems represent a treasure trove to be carefully stewarded and valued every step of the way.

Everything else in the conceptual model displaying the progression of information from HIS relies on these data.

The importance assigned to real data is not unique to the healthcare field.

“Business intelligence” is a popular term for the value realized by flexibly analyzing comprehensive stores of data representing the totality of an organization or provider’s scope of activity.

In other words, data from various systems that support clinical and financial transactions can be combined to enable analysis that reveals insights into the entirety of the activities within the scope of that entity.

In health care, this concept leads to the notion of “clinical intelligence.” Research, Policy, and Public Health At the pinnacle, data created and captured in HIS become available for research.

These data fuel the work of university researchers—with their inherent expertise, curiosity, and desire for insight—and they enable analysts to measure the health of patient populations and provide evidence for improving efficiency and effectiveness of healthcare processes and outcomes.

Policy makers rely on research that predicts the long-term implications of steps taken in the delivery of health care and implementation of healthcare laws and regulations; that is, they rely on researchers’ findings, such as studies carried out in university settings, or analyses performed by governmental agencies and organizations dedicated to health care and public health.3–5 The simple data captured, one patient at a time, in EHRs designed to support individual workflows at separate organizations are ultimately aggregated into databases that can be made available to researchers and analysts.

These aggregated data for research and analysis—the proverbial acorn—ultimately guide the work of policy makers and public health professionals responsible for governmental, political, and legal decisions about healthcare directions, policies, programs, and investments—the mighty oak tree (see Figure 2.2).

Public health officials are in a position to harvest the bounty of the entire HIS data chain, as the scope of their work expands from the purview of a person, an organization, or group of patients, to the entire country, ultimately reflecting an international scope.

As data are aggregated from systems that support clinical care or business activities across organizations and geographies, they can be analyzed according to many dimensions, such as demographic characteristics (e.g., female versus male, age groups, or race or ethnicity), pathogen (e.g., tuberculosis or anthrax), disease (e.g., cancer, heart disease, or acute illnesses), providers (e.g., hospitals, primary care physicians, or specialists), payment mechanisms (e.g., fee-forservice, health maintenance organization [HMO], preferred provider organization [PPO], Medicare, Medicaid, or uninsured), or other characteristics to better understand trends across an entire population.

Such analysis of population-wide characteristics and activities is not confined to the boundaries of an organization (e.g., a hospital) or a segment of the population (e.g., patients insured by a certain carrier or analyses pre- and post-healthcare reform).

Rather, inquiries and reports of interest to public health officials reflect the full expanse of their responsibility or perspective, such as a county, region, nation, or the world, as opposed to a subset consisting of those persons who are covered by insurance, are cared for at a particular institution, or live in certain geographies that may be over-represented by the available data.

The options or variations available for a particular scope are completely determined by the data available for such analyses and the generalizability of those data to an appropriate population.

Elsewhere in this text, we consider the types and sources of data that can be used for these analyses.

FIGURE 2.2 Data Creation/Data Aggregation Progression and Maturation of HIS through the HIS Conceptual Model We can outline the steps in the progression of the use of HIS and HIS data according to the HIS conceptual model.


Foundation (HIS) The progression begins with core HIS and their effective and proper management.

None of the subsequent layers of HIS can exist without the foundational, core systems and infrastructure.


Use (Informatics) HIS software system capabilities support clinical and business transactions, and enable redesign and improvement of healthcare workflow and processes, a discipline referred to as health informatics.

The automated support of daily activities carried out in a healthcare organization—and use of HIS by the professions of medicine, nursing, and public health to develop new, streamlined, and more effective workflows in the care of patients, with the intention of improving health care—is the unique discipline of informatics.

The term “informaticist” has emerged as our world has become automated; this role is found at the intersection of computers and the work of professionals using those systems, such as physicians, nurses, and public health officers, and the work of IT professionals designing, building, and implementing those systems, such as computer systems engineers, systems analysts, programmers, trainers, and testers.


Learning/Knowledge (Business/Clinical Intelligence, Data, and Analytics) The use of data for learning and gaining new knowledge begins when transactional data are created and captured in HIS through the use of HIS software, then coalesced into databases and analytics platforms.

Subsequently, these data are used for analysis and creation of information, including clinical decision support (CDS), business intelligence (BI), and clinical intelligence (CI), ultimately leading to enhanced knowledge about health care and public health.

This newly gained knowledge and the analytical capabilities represent secondary uses of data, which can reveal ways to improve healthcare processes, health outcomes, population health, and overall efficiency and effectiveness in health care.6 4.

Change Eventually the progression and maturation of the use of HIS and the data they produce will improve our ability to conduct research, create effective policy, and improve the public’s health through change.

The path to change for the better is illuminated by evidence produced through use of systems, analytics, and research using data created and captured in HIS.

HIS USES IN ORGANIZATIONAL AND COMMUNITY SETTINGS With so many different types of organizations and players using health data, the answer to the question “What does this organization or entity use HIS for?” will differ for each type of organization or entity.

Likewise, the mission, vision, and goals of each

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