Anticipating and addressing the unintended consequences of health IT and policy: a report from the AMIA 2009 Health Policy Meeting

Federal legislation (Health Information Technology for Economic and Clinical Health (HITECH) Act) has provided funds to support an unprecedented increase in health information technology (HIT) adoption for healthcare provider organizations and professionals throughout the U.S. While recognizing the promise that widespread HIT adoption and meaningful use can bring to efforts to improve the quality, safety, and efficiency of healthcare, the American Medical Informatics Association devoted its 2009 Annual Health Policy Meeting to consideration of unanticipated consequences that could result with the increased implementation of HIT. Conference participants focused on possible unintended and unanticipated, as well as undesirable, consequences of HIT implementation. They employed an input–output model to guide discussion on occurrence of these consequences in four domains: technical, human/cognitive, organizational, and fiscal/policy and regulation. The authors outline the conference''s recommendations: (1) an enhanced research agenda to guide study into the causes, manifestations, and mitigation of unintended consequences resulting from HIT implementations; (2) creation of a framework to promote sharing of HIT implementation experiences and the development of best practices that minimize unintended consequences; and (3) recognition of the key role of the Federal Government in providing leadership and oversight in analyzing the effects of HIT-related implementations and policies.     

美国主要电子病历系统应用评价项目综述

电子病历系统评价是医疗卫生信息化发展研究的一个重要方面。美国近年来在电子病历系统的采纳和应用评价以及效果评价方面都有着相关的研究项目，相关资料也比较丰富。简要概述了美国电子病历系统应用评价项目的研究现状，对我国开展类似的评价研究有着重要的借鉴意义。     

Phased implementation of electronic health records through an office of clinical transformation

Evidence suggests that when carefully implemented, health information technologies (HIT) have a positive impact on behavior, as well as operational, process, and clinical outcomes. Recent economic stimulus initiatives have prompted unprecedented federal investment in HIT. Despite strong interest from the healthcare delivery community to achieve ‘meaningful use’ of HIT within a relatively short time frame, few best-practice implementation methodologies have been described. Herein we outline HIT implementation strategies at an academic health center with an office of clinical transformation. Seven percent of the medical center''s information technology budget was dedicated to the Office of Clinical Transformation, and successful conversion of 1491 physicians to electronic-based documentation was accomplished. This paper outlines the process re-design, end-user adoption, and practice transformation strategies that resulted in a 99.7% adoption rate within 6 months of the introduction of digital documentation.     

试谈中国医院信息化事业发展的激励因素和历经阶段

在查阅、收集了30多年来有关医院信息化发展的资料并进行梳理、分析归纳和基础上,以“我国HIT事业是如何发展过程,形成今天这样繁荣的建设热潮的”为主题,针对激励、推动医院信息化建设的各项因素和发展过程,结合亲身经历,进行总体性回顾、探讨。认为国家和卫生部在14个方面的重大举措是发展的最根本激励因素和原动力,历经6个阶段发展到今天,并期望此文对HIT发展历程的总结和今后进一步发展起到抛砖引玉的参考作用。     

Unintended Consequences of Information Technologies in Health Care—An Interactive Sociotechnical Analysis

Many unintended and undesired consequences of Healthcare Information Technologies (HIT) flow from interactions between the HIT and the healthcare organization’s sociotechnical system—its workflows, culture, social interactions, and technologies. This paper develops and illustrates a conceptual model of these processes that we call Interactive Sociotechnical Analysis (ISTA). ISTA captures common types of interaction with special emphasis on recursive processes, i.e., feedback loops that alter the newly introduced HIT and promote second-level changes in the social system. ISTA draws on prior studies of unintended consequences, along with research in sociotechnical systems, ergonomics, social informatics, technology-in-practice, and social construction of technology. We present five types of sociotechnical interaction and illustrate each with cases from published research. The ISTA model should further research on emergent and recursive processes in HIT implementation and their unintended consequences. Familiarity with the model can also foster practitioners’ awareness of unanticipated consequences that only become evident during HIT implementation.     

医院信息安全体系设计方法

医院信息化发展对提高医疗服务效率和工作质量产生了重要的作用，医疗业务活动对信息系统依赖程度日益加深。安全性问题越发引起大家的关注和重视。但是如何按照国家信息安全管理规范和技术标准，开展医院信息安全体系设计。需要一个正确的理论和方法指导。     

Clinical decision support: progress and opportunities

In 2005, the American Medical Informatics Association undertook a set of activities relating to clinical decision support (CDS), with support from the office of the national coordinator and the Agency for Healthcare Research and Quality. They culminated in the release of the roadmap for national action on CDS in 2006. This article assesses progress toward the short-term goals within the roadmap, and recommends activities to continue to improve CDS adoption throughout the United States. The report finds that considerable progress has been made in the past four years, although significant work remains. Healthcare quality organizations are increasingly recognizing the role of health information technology in improving care, multi-site CDS demonstration projects are under way, and there are growing incentives for adoption. Specific recommendations include: (1) designating a national entity to coordinate CDS work and collaboration; (2) developing approaches to monitor and track CDS adoption and use; (3) defining and funding a CDS research agenda; and (4) updating the CDS ‘critical path’.The quality and safety of medical care in the United States have drawn increased attention in the past decade. Studies suggest many errors could be avoided with the use of health information and communications technology (HIT).^{i 1–4} Such improvements have been facilitated by the adoption of computerized provider order entry systems, electronic medical records that improve accessibility to clinical data, and a variety of approaches loosely grouped together and referred to as clinical decision support (CDS) systems. To foster better health processes, better individual patient care, and better population health, CDS systems intelligently provide, at appropriate times, knowledge or information (person-specific or population-specific). Clinicians, patients and individuals thus benefit from CDS.⁵ Clinical decision support interventions may include alerting and reminder systems, dosing calculators, and order sets and tools that provide access to medical knowledge at the point of care. Evidence suggests that computerization of medical record systems and even implementation of provider order entry systems may not be sufficient to ensure high quality care.⁶ Rather, CDS represents the effecter arm for clinical process improvement,^2–4 provided that it is effectively utilized and implemented with careful consideration of clinical workflow.In the summer of 2005, the Office of the National Coordinator for Health Information Technology (ONC), along with the Agency for Healthcare Research and Quality (AHRQ) asked the American Medical Informatics Association (AMIA) to develop a plan to guide federal and private sector activities to advance CDS. In response, AMIA established the CDS roadmap development steering committee to lead this effort. A set of meetings and consensus panels led to the production of the roadmap for national action on CDS (the ‘CDS roadmap’) in 2006.⁵ This report recommended activities to facilitate CDS development, implementation and use throughout the United States to improve the quality, safety and efficiency of healthcare. The roadmap included a critical path that recommended activities in the three-year timeframe following the report''s publication.Since then, significant effort by numerous stakeholders, including federal agencies, quality organizations, informatics groups, healthcare systems and individual researchers have devoted effort to CDS. To assess national progress in CDS, we conducted an environmental scan, reviewing published literature, white papers, reports by multiple stakeholders and recent legislation. Using the critical path activities as a framework, our report presents a synthesis of progress to date. We discuss future directions and recommend specific next steps, taking into consideration trends in clinical computing and increased availability of funds to support HIT as part of the recent US federal stimulus package.     

Understanding the acceptability of a computer decision support system in pediatric primary care

Objective

Individual users’ attitudes and opinions help predict successful adoption of health information technology (HIT) into practice; however, little is known about pediatric users’ acceptance of HIT for medical decision-making at the point of care.

Materials and methods

We wished to examine the attitudes and opinions of pediatric users’ toward the Child Health Improvement through Computer Automation (CHICA) system, a computer decision support system linked to an electronic health record in four community pediatric clinics. Surveys were administered in 2011 and 2012 to all users to measure CHICA''s acceptability and users’ satisfaction with it. Free text comments were analyzed for themes to understand areas of potential technical refinement.

Results

70 participants completed the survey in 2011 (100% response rate) and 64 of 66 (97% response rate) in 2012. Initially, satisfaction with CHICA was mixed. In general, users felt the system held promise; however various critiques reflected difficulties understanding integrated technical aspects of how CHICA worked, as well as concern with the format and wording on generated forms for families and users. In the subsequent year, users’ ratings reflected improved satisfaction and acceptance. Comments also reflected a deeper understanding of the system''s logic, often accompanied by suggestions on potential refinements to make CHICA more useful at the point of care.

Conclusions

Pediatric users appreciate the system''s automation and enhancements that allow relevant and meaningful clinical data to be accessible at point of care. Understanding users’ acceptability and satisfaction is critical for ongoing refinement of HIT to ensure successful adoption into practice.     

Empowering physicians with health information technology: An empirical investigation in Chinese hospitals

ObjectiveFew studies examine physicians’ use of different features of health information technology (HIT) in relation to their psychological empowerment and stress, especially in China, where many hospitals are being pushed to share digitized medical information. Further, there are mixed findings about the impact of HIT on stress, with some studies suggesting that HIT increases stress and others suggesting no effect. Hence, there is a need for a nuanced view of HITs to incorporate different features, regions, and outcomes. This work seeks to extend the existing body of knowledge on HIT by assessing the effects of basic (data-related) and advanced (clinical) HIT features on physician empowerment, stress, and ultimately, job satisfaction in Chinese hospitals.Materials and MethodsWe surveyed 367 physicians at 5 class 3 hospitals (ie, regional hospitals that provide specialist medical and healthcare services and carry out high levels of teaching and scientific research tasks) in 5 provinces in China. We specified and estimated a structural equation model using partial least squares.ResultsPhysicians who used advanced features experienced improvement in all dimensions of physician empowerment and significant reduction in stress. Physicians who used basic technology, however, experienced improvement in fewer dimensions of physician empowerment and no significant change in stress. Except for efficacy, all dimensions of physician empowerment and stress predicted job satisfaction.ConclusionsHealthcare professionals should assess the purpose of HIT features and expect different effects on intermediate and ultimate outcomes. The nuanced view of HIT features and processes leading to outcomes sheds light on their differential effects and resolves inconsistencies in prior findings on HIT effects.     

快速微粒凝胶免疫测定法与酶联免疫吸附测定法检测HIT抗体的临床应用比较

目的比较快速微粒免疫凝胶法（PaGIA）和酶联免疫吸附测定法（ELISA）检测HIT抗体在诊断肝素诱导的血小板减少症（HIT）中的应用。方法选取应用肝素制剂患者197例,男性120例、女性77例,根据4 Ts评分系统临床诊断HIT,所有患者均应用ELISA法进行HIT抗体检测,对ELISA法检测阳性及出现血小板减少的患者再次应用PaGIA法进行检测,并对两次HIT抗体检测结果进行比较。结果 4 Ts评分临床诊断HIT患者6例,两种检测方法分别检测出5例抗体阳性。24例ELISA法检测阳性患者中的19例非HIT患者,应用PaGIA法再次检测仅有3例阳性。结论4 Ts评分系统仍是目前临床诊断HIT的重要依据,联合HIT抗体检测可提高确诊和除外HIT诊断的准确性。PaGIA法检测HIT抗体与临床符合度更高,优于ELISA法。     

抗CD_3单克隆抗体HIT3aⅠ.制备和特异性鉴定

利用鼠—鼠杂交技术获得1个单克隆抗体(McAb)HIT3a。经免疫学、细胞化学和生物化学分析,证实HIT3a是抗入成熟T细胞表面CD_3抗原McAb,具有亲和力高、活性稳定、能激活T细胞、在补体存在下溶解T细胞等特性,是1个理想的可用于免疫学研究和临床治疗的CD_3类McAb。     

The Use of Autonomic Modulation Device to Control Training Performance after High-Intensity Interval Training Program

The aim of the present research was to analyze the autonomic response in a group of trained swimmers before and after conducting a 4-week period of high-intensity interval training (HIT). Heart rate variability was analyzed in 14 swimmers (16.2?±?2.6 years, 169.1?±?10.2 cm and 61.3?±?9.9 kg) in basal condition and during a HIT session before and after completing a training period. The HIT session that was evaluated consisted of: 16?×?25 m maximum speed, resting 30 s between sets. Participants combined aerobic training with tethered swimming and HIT sessions three times per week in a period of 4 weeks. Results showed a significantly decrease (p?<?0.05) of the standard deviation of the NN intervals (SDNN), the standard deviation of differences between adjacent NN intervals (SDSD), the number of successive difference of intervals which differ by more than 50 ms (NN50), after the training period. Results showed a higher parasympathetic activation besides improvements in autonomic adaptation after HIT training period.     

HIT Implementation in Critical Access Hospitals: Extent of Implementation and Business Strategies Supporting IT Use

Small rural hospitals face considerable financial and personnel resource shortages which hinder their efforts to implement complex health information technology (HIT) systems. A survey on the use of HIT was completed by 85% of Iowa’s 82 Critical Access Hospitals (CAH). Analyses indicate that low IT staffing in CAHs is a barrier to implementing HIT solutions. CAHs with fewer staff tend to employ alternative business strategies. There is a clear relationship between having IT staff at a CAH and the types of technologies used. Many CAHs report having difficulty expanding upon HIT functionalities due to the challenges of finding IT staff with healthcare expertise. Most CAHs are in the transition point of planning for or beginning implementation of complex clinical information systems. Strategies for addressing these challenges will need to evolve as the HIT investments by rural hospitals race to keep pace with the goals for the nation.     

HIT抗体检测对血小板减少症的临床诊断意义

目的探讨HIT抗体在肝素诱导的血小板减少症(HIT)中的诊断价值,使其作为1项有价值的指标,较早诊断HIT,减少HITTS的发生。方法选择2007-02~2007-12间,随机连续观察在哈尔滨医科大学第二临床医学院血管外科应用普通肝素治疗的46例住院患者。结果实验组中HIT抗体阳性例数为21例,对照组HIT抗体阳性例数为2例。实验组中有7例患者血小板减少(血小板下降范围25%~53.4%),且HIT抗体阳性,该7例患者后经功能性检查确诊为HIT患者。结论HIT抗体检测的实验敏感性较高,且不涉及放射性,操作简单。该方法可在实验室开展,与血小板计数检测结合可对应用肝素的患者进行初筛,防止HITTS的发生。     

心脏手术患者围术期肝素诱导的血小板减少症

目的：了解心脏手术患者围术期肝素诱导的血小板减少症(heparin-induced thrombocytopenia,HIT)发生率 及其抗体阳性率,探索HIT发病及其抗体产生的影响因素。方法：检测连续的315例心脏手术病例手术前后血小板计 数、HIT抗体、血小板因子4(platelet factor 4,PF4)。按4Ts评分诊断HIT。按性别、年龄、病种等分别统计发生率及其 抗体阳性率并分析影响因素。结果：HIT发生率3.5%(11/315),HIT抗体阳性率36.5%(115/315)。其中冠心病患者HIT 发生率(17.1%)高于心脏瓣膜病患者(1.9%,P<0.05)和先天性心脏病患者(0.8%,P<0.05)。先天性心脏病患者HIT抗体阳 性率(51.7%)高于心脏瓣膜病患者(30.5%,P<0.05),心脏瓣膜病患者HIT抗体阳性率高于冠心病患者(14.6%,P<0.05)。 HIT患者术后严重并发症发生率(36.4%)高于非HIT患者(10.5%,P<0.05)。Logistic回归示HIT发病的影响因素为年龄, HIT抗体产生的影响因素有年龄和体外循环。结论：心脏手术患者围术期HIT发生率较低,但易产生严重并发症,致 残致死率高,应警惕HIT发病的危险因素。     

Development and Psychometric Evaluation of the Impact of Health Information Technology (I-HIT) Scale

Objective

The use of health information technology (HIT) for the support of communication processes and data and information access in acute care settings is a relatively new phenomenon. A means of evaluating the impact of HIT in hospital settings is needed. The purpose of this research was to design and psychometrically evaluate the Impact of Health Information Technology scale (I-HIT). I-HIT was designed to measure the perception of nurses regarding the ways in which HIT influences interdisciplinary communication and workflow patterns and nurses’ satisfaction with HIT applications and tools.

Design

Content for a 43-item tool was derived from the literature, and supported theoretically by the Coiera model and by nurse informaticists. Internal consistency reliability analysis using Cronbach’s alpha was conducted on the 43-item scale to initiate the item reduction process. Items with an item total correlation of less than 0.35 were removed, leaving a total of 29 items.

Measurements

Item analysis, exploratory principal component analysis and internal consistency reliability using Cronbach’s alpha were used to confirm the 29-item scale.

Results

Principal components analysis with Varimax rotation produced a four-factor solution that explained 58.5% of total variance (general advantages, information tools to support information needs, information tools to support communication needs, and workflow implications). Internal consistency of the total scale was 0.95 and ranged from 0.80-0.89 for four subscales.

Conclusion

I-HIT demonstrated psychometric adequacy and is recommended to measure the impact of HIT on nursing practice in acute care settings.     

对健康信息技术试验用于中低收入国家呼吸系统疾病管理的建议:从高收入国家可以学到什么？

 当人类的健康系统面临来自于医疗资源和经济等多方面的挑战时,健康信息技术(health information technology,HIT)有时可以帮助我们解决问题。然而,关于广泛应用HIT的相关证据仍不全面。中低收入国家的医疗基础设施和医疗保健水平相对薄弱,因此我们希望能从有着良好医疗保健基础的发达国家获取在呼吸病领域的应用经验,总结其失败的教训,为如何使HIT应用利益最大化提供建议。高收入地区研究应用HIT给我们的启示就是应在疾病负担适当的人群中开展低成本且技术成熟的研究,同时仔细评估其安全性。     

美国医疗信息技术教育概述及其启示

本文阐释了医疗信息技术教育(health information technology education,HIT教育)的概念,并在调查美国医疗信息技术教育的基础上,分别从学位教育及认可机制、知识群与知识单元、市场对HIT专业人员需求及政府对HIT教育资助等方面对美国医疗信息技术教育进行了详细论述.

Abstract：

This paper first explores the scope and the meaning associated with the concept of the health information technology education (HIT education). It then presents an intensive and comprehensive analysis on different aspects of HIT education in the United States, including its academic degree structure, the features demonstrated by education programs at different levels of academic degrees, the accreditation mechanism and programs, the design of knowledge cluster and knowledge unit, requests for HIT professionals from society and market, and the government funding for HIT education.