Toward a National Health Information Infrastructure. Interim Report. Opportunities to Improve Health and Health Care


The new century brings with it fresh hope that significant improvements in the public's health and well-being are not only possible, but close at hand. Health, we now realize, is not merely the absence of illness. Nor is health achieved solely by combating disease. Rather, as the World Health Organization puts it, health is a "state of complete physical, mental, and social well-being." Health is also clearly more than an individual matter. Personal and community health are closely connected, and depend on interwoven factors: policies, economics, the environment, housing, and heredity, to name a few. Improvements in both personal and community health are essential for a healthier nation.

The sheer breadth of the challenges facing us as a nation calls for an equally expansive and innovative response. Fortunately, we find ourselves in the midst of a dynamic technological era where dramatic transformations in information and communication technologies offer innovative and unprecedented opportunities for health improvements on a national and global scale. The framework that can link health improvements and information technologies is the National Health Information Infrastructure (NHII).

The NHII does not exist yet in a comprehensive way. Although many pieces of an NHII are well-developed and already in use, others are only now emerging and evolving. As envisioned in this paper, the NHII is the set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health. The broad goal of the NHII is to deliver information to individuals - consumers, patients, and professionals - when and where they need it, so they can use this information to make informed decisions about health and health care.

The NHII is not an effort to collect personal health data from individuals or health care providers. Nor is it the creation of a centralized government database to store personal information about individuals. Rather, the NHII offers a way to connect distributed health data in the framework of a secure network. Comprehensive federal and state health information privacy legislation will ensure that the network will have strict, built-in confidentiality protections for personal health information and tools that individuals can use to protect their information and privacy.

Consumers, patients, health care providers and managers, public health professionals, and policymakers share an interest in promoting equitable access to high-quality health information, available any time, any place. A recent Institute of Medicine report found that up to 98,000 people die unnecessarily each year in U.S. hospitals from preventable medical errors, which makes errors the fifth leading cause of death. A dramatic reduction in such medical mistakes and in other adverse effects of care is one of the most significant benefits that we can expect from the NHII.

The day is not far off when a patient, pharmacy and doctor all communicate routinely through an electronic system. Consider the following story of Sam King and Dr. Jose Hernandez.

Sam: I've had this awful cough that won't go away, so I finally saw Dr. Hernandez, who checked me out and took some tests. He prescribed XX and said I should take it 2 times a day. But as Dr. Hernandez entered the name of the drug into my personal medical record, the computer beeped. My doc told me the computer was warning him that some people with health conditions like mine have developed a rash and muscle cramps when taking the drug he was going to give me. I told him, "Good catch," and was glad he wired a prescription for something else to my drugstore. Before I left, I asked Dr. Hernandez to send the prescription information to my personal health record.

Dr. Hernandez: Mr. Sam King came in last week with a persistent cough. I diagnosed ZZ, and decided to prescribe XX. But when I entered the diagnosis and prescription into Mr. King's electronic medical record, which is part of our Clinical Management System, I was told to link to the drug manufacturer's database to check out an important alert. What I found was an urgent notice about widely scattered reactions in patients with chronic conditions like Mr. King's. I quickly changed his prescription. A short time later, our CMS system got an "all points" bulletin from the manufacturer about this drug. Of course, my practice had learned already about these rare reactions, but I was relieved that providers around the country and the FDA have received the same information.

Through the use of integrated information technologies, it is hoped that different segments of the medical care system will be able to "talk" to one another better and faster, and, in the process, dramatically increase diagnostic accuracy and spot potential errors before they injure patients. For example, some physicians are already using automatic warning systems to alert them to potentially adverse drug interactions or allergic reactions. Even when health care providers administer appropriate medications or treatments, there remain other adverse effects that currently are not efficiently captured, aggregated, and analyzed in ways that could save lives. Among other uses, the NHII will help deliver such alerts in a timely and efficient manner.

The NHII can also deliver other benefits, including enhanced access to consumer health information, peer and support services; greater choice of care; tracking of health histories over a lifetime; and increased accountability for quality and costs. New tools, such as automated reminders and decision-support systems will encourage patient adherence to treatment and health maintenance plans and improve the quality of care. The NHII will also improve community health by taking seemingly isolated events, identifying patterns and trends, and suggesting public health actions to safeguard populations.

A vacation emergency in the not-too-distant future, by Joyce Peters.

When I turned 66 last month, my sister and I took a camping vacation out West. One day as we marveled at a chain of waterfalls, I got severe stomach and chest pains. Luckily, I've subscribed to the Portable Medical Alert System since my first bout of angina five years ago, so I wear patch sensors on my chest and a wrist transmitter with a built-in positioning system. My PMAS sent emergency messages to the closest paramedic team and to my own cardiologist in New York. They both got my vital signs and location. The communications system also linked my doctor to the emergency team. By the time the paramedics reached me, my doctor had sent them relevant parts of my medical history, including previous EKGs. Once at the emergency facility, Dr. Sally Smith took over. She asked my permission to access my online personal health record to get information on previous stomach problems, which didn't show up in my cardiologist's record. I agreed. After a thorough evaluation, including a new EKG for comparison, Dr. Smith told me I probably had viral gastroenteritis. We updated my personal health record at the same time Dr. Smith did hers, and then she discharged me in my sister's care.

The next day I felt much better, but I had lost the written follow-up instructions. No problem. I logged onto my mobile phone and found them where Dr. Smith had entered them the day before: on my personal health home page. My regimen was simple: lots of fluids and watch my diet. The next three days passed without incident, unless you count the elk on the trail.

The day we left, the local paper noted lots of other campers had become sick too. It turns out the local health department has an automated surveillance system that collects anonymous patient data from local health care providers. This system recognized a cluster of tourists with similar symptoms in one part of the park. After a little detective work, they found the culprit. A construction crew had punctured a sewer line, which in turn contaminated a number of wells providing water to park restaurants and other facilities. Come to think of it, my sister and I noticed that the drinking fountains in the park hadn't been working, so I guess park management got the alert.