Information for Health: A Strategy for Building the National Health Information Infrastructure Report and Recommendations From the National Committee on Vital and Health Statistics

3. TECHNICAL AND FUNCTIONAL BUILDING BLOCKS OF THE NHII

A number of existing technologies, applications, and standards have the potential to be part of the NHII and, with adequate coordination, to serve the goal of providing timely health information to all who need it. The healthcare sector, for example, has been investing in specific applications, such as electronic medical records, digital imaging systems, and personal digital assistants. Consumers can use personal health records systems on Web sites to manage their information. Public health officials are using geographic information systems to enhance surveillance capabilities. For the most part, however, the three dimensions of the NHII have been evolving on separate technical and functional tracks and at an uneven pace. Moreover, according to the National Research Council (NRC) and the President's Information Technology Advisory Committee, the right technologies and functions have not been developed to support the demanding circumstances of health decisionmaking and health care. ^6,13 One overarching problem is the slow development and uneven implementation of standards that allow technologies and information to be linked effectively. This has hindered private-sector innovation and public-sector responsiveness.

The Internet is the network platform for the NHII, and it will support functions and applications across the personal health, healthcare provider, and population health dimensions. The NRC has identified many of the applications and technical challenges for the three dimensions. (See Table 2.)

Many pieces of the NHII are already well-established parts of the information and communication infrastructure in the United States. These technical pieces are not necessarily health-sector specific. They are technologies that are already available to, affordable for, and widely used in multiple sectors of U. S. society. These core technical components include, among others, the Internet and the World Wide Web, e-mail, databases, search engines, listservs, electronic data interchange (EDI), and encryption and authentication technologies. In many cases, the technologies have already been adapted to health-specific applications and functions and are being used extensively by consumers, clinicians, and public health officials for information, education, and data management. However, the full potential of even these fundamental technologies for decision support, coordination of care, and public health improvement is far from realized. ^6,13,14

In other cases, the health-specific applications and functions of technical components are only now taking shape or they may be utilized by only a few organizations and individuals. Examples of applications and functions that are only partially disseminated in the health sector include broadband; geographic information systems; remote video, sensing, and monitoring; customized computer interfaces and tailored Web pages; digital signatures and certificates; and wireless technologies. Pockets of users exist, but their activities and their ability to exchange information are constrained by lack of resources, organizational and professional boundaries, and traditional ways of communicating and doing business. Fuller use of these — and established — technologies can support telemedicine, electronic health records (clinical or consumer), integrated clinical information systems, disease management, digital prescribing, provider-patient e-mail, cross-database searching, and timely public health alerts.

Table 2 — Selected Health Applications of the Internet
Application Domain	Real-Time Video Transmission	Static File Transfer	Remote Control	Information Search and Retrieval	Real-Time Collaboration	Primary Technical Challenges
Consumer Health	Remote medical consultations to the home, office, or wherever the patient is located.	Accessing personal health records online. Downloading educational videos. Sending periodic reports on health conditions to a care provider.	Remote control of patient monitoring equipment.	Online searching for health information or self-assessment guides. Looking for a doctor or hospital.	Collaboration with care providers. Participation in chat groups and support groups.	Protection of sensitive patient information from breaches of confidentiality and from corruption. Ubiquity of access so that all healthcare consumers can be reached at the location at which care is needed. Tools and policies for validating the quality of online information.
Clinical Care	Remote medical consultations between clinician and patient or between two clinicians.	Transfer of medical records and images (e.g., X-rays, MRI, CT scans).	Remote and virtual surgery (a long-term possibility being examined by the defense and space communities).	Practice guidelines. Searches of professional medical literature.	Consultation among care providers, such as for surgical planning, which may involve manipulation of digital images.	Access to sustained bandwidth and low latency for remote consultations and collaboration. Security of clinical records. Network reliability. Ubiquity of access for care providers.
Public Health	Videoconferencing among public health officials during emergency situations, such as chemical or biological attacks by terrorists.	Incident reporting. Collection of information from local public health departments and laboratories. Surveillance for emerging diseases or epidemics. Transfer of epidemiology maps or other image files for monitoring the spread of a disease.	N/A	Access to published literature and research results as well as epidemiologic data. Delivery of alerts and other information to practitioners or other health workers.	Videoconferencing among public health officials during emergency situations, such as chemical or biological attacks by terrorists.	Security to ensure confidentiality and integrity of laboratory reports and other public health information that may contain personal identifying information. Network reliability. Security from information warfare or attacks on the network's physical infrastructure.
Adapted with permission from Computer Science and Telecommunications Board, Commission on Physical Sciences, Mathematics, and Applications, National Research Council. 2000. Networking health: Prescriptions for the Internet. Washington, DC: National Academy Press.

There are no authoritative national reports on technology adoption in healthcare organizations. Industry surveys have found uneven diffusion of technologies and functions, although organizations report that they recognize the administrative and clinical factors that drive the need to share health information. ¹⁵ In 2001, provider organizations report that the technologies they most widely use include high-speed networks (83 percent), data security systems (78 percent), client-server systems (75 percent), and intranets (75 percent). Thirteen percent of providers have a fully operational Computerized Patient Record (CPR) system in place, virtually unchanged from 2 years ago, although another 53 percent report that they are either beginning to install the hardware and software for CPRs or have planned CPR implementation. Thirty-one percent are using handheld PDAs, and 37 percent currently employ wireless information appliances. Almost all organizations have a Web site, which is used overwhelmingly for marketing and promotion but will soon provide more functions, such as patient scheduling and electronic patient-physician communication. ¹⁶ Twenty-five percent of provider organizations already have an installed base for patient-provider e-mail. ¹⁵

These same surveys indicate that if healthcare organizations follow through on their plans, the picture may change rapidly in the next 2 years. A survey of 44 practice group managers found that 80 percent expect to do electronic charting by 2003, compared with 25 percent today. And 82 percent expect to automate prescription writing by 2003, compared with 16 percent today. ¹⁷ A variety of wireless appliances and applications also will support clinicians, consumers, and public health officials in the NHII. For example, Harris Interactive estimates that 50 percent of the country's physicians will be using handheld devices by 2005. But that could change markedly if insurers, employers, hospitals, and other providers mandate physician usage for prescription writing, charge capture, and results and order verification. ¹⁸ Public health workers are pilot-testing wireless systems for data transfer and communication from distant sites. ¹⁹

This picture of current and planned use of technology does not give a definitive view of which technologies will be implemented and for what purposes. Many implementation challenges confront organizations and end-users. Some problems will require changes to the technology; others will require changes to processes and practice. Research on the ultimate cost effectiveness of the new technologies is similarly uneven. ^14,20

To support the multifunctional environment described above, the Internet, which is the backbone of NHII connections and communications, must be strengthened. It is relatively stable for some functions, such as unsecured e-mail and the exchange of small text-based files, but unstable for other functions, such as real-time telemedicine consultations and remote multimedia simulations. ¹³ The Internet and connected devices remain vulnerable to attack and disruption of service. ¹³ As mentioned throughout this report, though, the limitations of the infrastructure are not just technical. New policies and practices will be required to achieve the infrastructure's fullest use.

One of the ways the NHII could be strengthened is through more rapid adoption of and compliance with existing standards and accelerated development of other needed standards. As the Committee has noted on numerous occasions, standards are an essential component of the NHII. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides a platform for the exchange of financial, clinical, and administrative information in healthcare transactions. The HIPAA financial and administrative transaction standards were released as regulations by HHS on August 17, 2000. These regulations will serve as a catalyst to move the healthcare industry to use more efficient and standardized electronic communications for communicating health claims, enrollment, eligibility, remittances, and related transactions. HIPAA includes not only financial and administrative transaction standards but also standards for privacy and security. Eventually, standards should make it possible to have a network architecture that is all but invisible to end users.

Along with the HIPAA financial and administrative transaction standards, a comprehensive set of Patient Medical Record Information (PMRI) standards can move the Nation closer to a healthcare environment where clinically specific data can be captured once at the point of care with derivatives of this data available for meeting the needs of payers, healthcare administrators, clinical research, and public health. This environment could significantly reduce the administrative and data capture burden on clinicians; dramatically shorten the time for clinical data to be available for public health emergencies and for traditional public health purposes; profoundly reduce the cost for communicating, duplicating, and processing healthcare information; and, last but not least, greatly improve the quality of care and safety for all patients. NCVHS issued preliminary recommendations in 2000 and will recommend HIPAA PMRI standards in 2002.

The Committee also recommended standardizing a core set of data elements for enrollment and encounter in a 1996 report on Core Health Data Elements. Uniform collection of these elements would enhance administrative as well as clinical data. ²¹

A number of U. S. standard development organizations have developed clinical transaction standards for various purposes (ASTM, HL7, DICOM, OMG, IEEE, NCPDP) ^a and some of these, HL7 and DICOM, are in widespread use in the United States, Europe, and the Pacific Rim. However, substantial standardization work remains. Compliance testing is needed to ensure a uniformity in the adoption of these standards. Standards for codes that give specific meaning to the content of these messages also are needed. A number of medical terminologies with important levels of usage and utility already exist for various domains, including the Systematized Nomenclature of Medicine (SNOMED), the Logical Observation Identifiers Names and Codes (LOINC), and the Medical Collaborations Interactive Network (MEDCIN), but the adoption of these is limited. ^b Existing codes for some subject domains do not meet the needs of clinical records. For example, the National Drug Code does not include all drugs, and it is suitable only for inventory control of packages, not for prescribing where the active ingredients, dosage, and manner of administration need to be identified.

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