The Underserved and Health Information Technology: Issues and Opportunities. What Role Can Health IT Play?

11/01/2008

Researchers have struggled to definitively characterize all the factors associated with disparities in health and health care for the underserved and assign appropriate importance to each factor. There is, however, a consensus regarding the significance of these problems and a solid interest among program and policy leaders to understand the manner in which advances in public health, health care delivery and health care financing can work to address these disparities. While it is clear that these disparities are a result of a complex network of factors including personal, family, cultural, neighborhood and economic variables in addition to those associated with the direct provision of necessary health care services, many have identified health IT as a means to facilitate behavioral and organizational changes to improve the health and health care of the underserved.

For the purpose of this paper we define health IT as technology that enables patients and providers to support better health and health care by providing targeted information meant to inform, educate or generally allow for improved decision making. In some cases, the information provided by these technologies is traditionally accessed by other means such as paper patient charts, evaluations and clinical summaries transferred via fax or by hand between providers or even clinical flow sheets that outline appropriate care for specific clinical situations based on accepted clinical guidelines.

Exhibit 1: Health IT Applications 10

Health IT Applications
Product or Functionality Description
Electronic Health Record (EHR) An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across more than one health care organization.
Electronic Medical Record (EMR) An electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one health care organization.
e-Prescribing (eRx) Enables a physician to transmit a prescription electronically to the patient’s choice of pharmacy. It also enables physicians and pharmacies to obtain information about the patient’s eligibility and medication history from drug plans. Often comes with built in alerts for drug-drug, drug-allergy and drug-disease interactions.
Personal Health Records An electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be drawn from multiple sources while being managed, shared, and controlled by the individual.
Computerized Physician Order Entry (CPOE) Refers to a computer-based system of ordering medications and often other tests. Physicians directly enter orders into a computer system that can have varying levels of sophistication. Basic CPOE ensures standardized, legible, complete orders, and thus primarily reduces errors due to poor handwriting and ambiguous abbreviations.
Clinical Decision Support (CDS) Any system designed to improve clinical decision making related to diagnostic or therapeutic processes of care. CDS addresses activities ranging from the selection of drugs (e.g., the optimal antibiotic choice given specific microbiologic data) or diagnostic tests to detailed support for optimal drug dosing and support for resolving diagnostic dilemmas. Often incorporated as part of CPOE or EMR/EHR systems.
Disease Registries A database feature that includes key clinical data on a subset of chronically ill patients for the purpose of tracking their condition and managing treatment.

In other cases, health IT enables providers and patients to access information that they otherwise would not be able to access. Exhibit 1 above outlines some basic definitions of health IT applications. Implemented properly, these technologies can create tremendous efficiencies and improvements in health and health care by providing “the right information to the right person at the right time”. This results in benefits such as greater adherence to evidenced based guidelines for screenings and vaccinations, better patient compliance with treatment instructions, reductions in medication errors and improved patient education.

As noted above, specific technologies that are most commonly referred to as health IT include electronic health records (EHRs) and personal health records (PHRs), the former being the systems used by providers to electronically record and maintain patient demographic information and information on activities, diagnoses and orders associated with a clinical episode, and the latter being an application for use by patients to access and update information related to their own health and health care or that of a family member or loved one. One key distinction between EHRs and PHRs lies in defining the locus of usage and control. EHRs are controlled and used primarily by the provider whereas PHRs are used and controlled by patients and their surrogates.
Additional applications include functionalities that may be considered add-ons to these core concepts, including clinical decision support (CDS) which in the context of an EHR would provide patient specific information on an appropriate course of treatment based on clinical effectiveness research; issue alerts if an order entered by the clinician is counter-indicated based on the patient’s profile; or provide reminders regarding the need to order specific interventions such as screenings, vaccinations, blood tests or foot exams. 

In addition to PHRs, other health IT applications aimed at patients include health kiosks, where patients could obtain information on health conditions or access to information on their own health and health care using publicly available computer terminals set up within the community. These may also include messaging systems that allow transmission of reminders, information to guide healthful behavior, or even direct communication with providers through email or short message service (SMS) messaging accessed via cell phones or personal digital assistants (PDAs). In a 2006 report entitled, “Expanding the Reach and Impact of Consumer e-Health Tools”, the Office of Disease Prevention and Health Promotion at HHS identified a series of functions that might be considered some of the key potential benefits to patients using health IT. These functions included provision of health information to patients in a searchable format to help with researching treatment options; support for behavior modification and self management of a healthy lifestyle; access to online communities for interacting with others on health issues; and functions that allow joint management and tracking of treatment involving online collaboration between patients and clinicians.11

Another use of health IT involves health information exchange (HIE) which refers to the electronic exchange of data on a particular patient in a secure format between relevant administrative and clinical stakeholders such as other clinicians, payers and patients themselves. HIE can enable more efficient exchange of data between different types of providers (e.g., ambulatory and acute care providers or between primary care and specialty care) or between providers and patients (EHRs to PHRs). Some HIE functionality can also be built into PHRs and EHRs to enable specific services such as electronic prescribing (eRx) and refilling of prescription medications, ordering tests, receiving results from clinical laboratories, and maintaining ready access to radiology reports and results from tests conducted in an inpatient environment.

A central premise of our paper is that health IT applications such as the ones described in Exhibit 1 represent potentially effective mechanisms for achieving basic goals associated with improving health, health care and access to care for the underserved. As has been often noted, there is no evidence to suggest that health IT adoption in and of itself will transform the health or health care of the underserved. However, if based in broader initiatives for increasing enrollment in public programs, improving quality of care, empowering patients through improved access to information and streamlining and simplifying health care delivery, health IT may be a critical ingredient to achieving important changes.

In particular, because all IT and systems initiatives are designed around managing information in a standardized and efficient manner, these technologies can play an important role in assuring that the right information, in the right format is available to the right person and the right time to improve family and provider decision making, improve access to care and better target resources. Over time, health IT applications may lead to a richer set of data from which population health care trends can be assessed, thereby contributing to the development of better knowledge on the causes of disparities affecting health and health care for the underserved, getting a better sense of the barriers to improving their status relative to those disparities and contributing to programmatic and policy initiatives informed by a richer set of data than are currently available.

In the remainder of this paper we describe in greater detail opportunities and challenges associated with the use of health IT to improve health and health care of the underserved. For the sake of simplicity, in some places we organize this discussion between those technologies that can be considered primarily provider facing, such as EHRs, and those technologies that are primarily patient facing, such as PHRs. We note however that this is a somewhat artificial distinction as effective approaches to improving health may need to take advantage of technologies that enable direct electronic communication between providers and patients through direct messaging and are, in that sense, both provider and patient facing. We end the paper with summary conclusions for different health care sector stakeholders and address areas that merit further exploration through research and evaluation.

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