Medicine, Machines, and Medical Education.

While advances in science and technology continue to be at the forefront of the evolution of medical practice, the 21st century is also undergoing a unique and profound cultural shift that is changing the very nature of what it means to be a medical professional, namely humankind's transition to an information-based internet society. Medical care will increasingly depend on computer-generated probabilities guided and supported by a growing variety of individuals in health care-related professions, including statisticians, technologists, and information managers. Perhaps the biggest challenge to the profession will come from the erosion of professional autonomy, driven by smart machines, social networks, and internet search engines. As a result of these and other changes, physicians are facing a systematic loss of control, often without the direct input and leadership of the profession itself. In this commentary, the author urges the profession to adopt several strategies, including shifting its focus from reimbursement to the care patients value most, meaningfully addressing critical issues in health policy, becoming the definitive source for publicly available medical information, reimagining medical education, and overhauling the existing accreditation and licensing systems. Medical education must go beyond a focus on physicians whose professional identity revolves around being the exclusive source of medical knowledge. In the digitized 21st century, medical education should emphasize the centrality of the humanistic interface with patients such that the doctor-patient relationship is paramount in the complex medical world of machines and social media. Removing the roadblocks to successful professional reform is no small task, but the process can begin with a grassroots movement that empowers physicians and facilitates organizational and behavioral change. Failure to take action may well hasten the diminishment of patient care and the profession's trusted role in society.

HITECH to 21st century cures: clinician burden and evolving health IT policy.

Adoption and use of health information technology (IT) was identified as 1 solution to quality and safety issues that permeate the United States health care system. Implementation of health IT has accelerated across the US over the past decade, in part, as a result of legislative and regulatory requirements and incentives. However, adoption of these systems has burdened clinician users due to design, configuration, and implementation issues, resulting in poor usability, challenges to workflow integration, and cumbersome documentation requirements. The path to alleviating these clinician burdens requires a clear understanding of the intent and evolution of pertinent regulations and the context in which they exist. This article reviews the Office of the National Coordinator of Health Information Technology's efforts, documents current regulatory actions, and discusses additional policy opportunities that can further improve clinician satisfaction and effectiveness in providing health care with health IT that is an asset, not an obstacle.

Protection of digital health information: Examining guidance from the physician regulatory colleges in Canada.

BACKGROUND: The use of information and communication technology (ICT) has tremendous potential to enhance communication among physicians, leading to improvements in service delivery. However, the protection of health information in digital/electronic format is an ongoing concern. OBJECTIVE: The purpose of this study was to examine guidance for the protection of health information when using ICT from all 10 of Canada's provincial regulatory colleges for physicians and to discuss the potential policy and service delivery implications. METHOD: A search of the regulatory college websites was conducted, followed by a document analysis (content and thematic). RESULTS: The college website search identified 522 documents; 12 of these documents (from 8 of the 10 colleges) met the study criteria. These documents were notable for the considerable variation in the scope and detail of guidance provided across the colleges. CONCLUSION: While the federal-provincial division of powers in Canada enables different jurisdictional approaches to health service delivery and, thus, opportunities for policy learning, this governing structure may also contribute to a lack of incentive for collaboration, leading to an absence of standardised guidance for health information protection when using ICT. This, in turn, may result in unequal and inequitable protection of health information across the provinces. Therefore, a macro-level approach to policy development in this area may hold the greatest promise for enhancing the protection of health information and doing so in a more standardised manner in countries with federal systems of governance.

Privacy and Policy Implications for Big Data and Health Information Technology for Patients: A Historical and Legal Analysis.

The consideration of privacy and policy implications for big data is essential to designing patient-centered health technology. A literature review demonstrated a significant gap to moving forward with information technology in healthcare. Ovid Medline and Google Scholar were searched to identify papers related to health technology, patient outcomes, and policy implications of Big Data. The findings of this research showed that despite a robust legal framework and clear outline of the legislation, there exists an innovative opportunity for health technologies to evolve and become patient-centered by integrating privacy and policy knowledge in health information technology. This historical legal analysis is valuable to health system leaders, decision-makers, health technology companies that are creating innovative platforms, and clinicians in both Canada and the United States.

The 21st Century Cures Act and electronic health records one year later: will patients see the benefits?

While federal regulation provides patients the right to access their electronic health records and promotes increased use of health information technology, patient access to electronic health records remains limited. The 21st Century Cures Act, signed into law over a year ago, has important provisions that could significantly improve access and availability of health data. Specifically, the provisions call for partnerships among health information exchange networks, educational and research initiatives, and health information technology certification requirements that encourage interoperability. The article reviews the potential benefits and concerns regarding implementation of these provisions, particularly the difficulty of aligning incentives and requirements for data sharing and the question of whether currently proposed rules and guidance will support the goal of improved patient access and health information exchange. Researchers, clinicians, and patients have the power to advocate for improved patient access and interoperability as policy development and implementation of the 21st Century Cures Act continues.

Public Policy and Health Informatics.

OBJECTIVES: To provide an overview of the history of electronic health policy and identify significant laws that influence health informatics. DATA SOURCES: US Department of Health and Human Services. CONCLUSION: The development of health information technology has influenced the process for delivering health care. Public policy and regulations are an important part of health informatics and establish the structure of electronic health systems. Regulatory bodies of the government initiate policies to ease the execution of electronic health record implementation. These same bureaucratic entities regulate the system to protect the rights of the patients and providers. IMPLICATIONS FOR NURSING PRACTICE: Nurses should have an overall understanding of the system behind health informatics and be able to advocate for change. Nurses can utilize this information to optimize the use of health informatics and campaign for safe, effective, and efficient health information technology.

HITECH Act Drove Large Gains In Hospital Electronic Health Record Adoption.

The extent to which recent large increases in hospitals' adoption of electronic health record (EHR) systems can be attributed to the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 is uncertain and debated. Because only short-term acute care hospitals were eligible for the act's meaningful-use incentive program, we used national hospital data to examine the differential effect of HITECH on EHR adoption among eligible and ineligible hospitals in the periods before (2008-10) and after (2011-15) implementation of the program. We found that annual increases in EHR adoption rates among eligible hospitals went from 3.2 percent in the pre period to 14.2 percent in the post period. Ineligible hospitals experienced much smaller annual increases of 0.1 percent in the pre period and 3.3 percent in the post period, a significant difference-in-differences of 7.9 percentage points. Our results support the argument that recent gains in EHR adoption can be attributed specifically to HITECH, which suggests that the act could serve as a model for ways to drive the adoption of other valuable technologies.

Meaningful use of health information technology and declines in in-hospital adverse drug events.

OBJECTIVE: Nationwide initiatives have promoted greater adoption of health information technology as a means to reduce adverse drug events (ADEs). Hospital adoption of electronic health records with Meaningful Use (MU) capabilities expected to improve medication safety has grown rapidly. However, evidence that MU capabilities are associated with declines in in-hospital ADEs is lacking. METHODS: Data came from the 2010-2013 Medicare Patient Safety Monitoring System and the 2008-2013 Healthcare Information and Management Systems Society (HIMSS) Analytics Database. Two-level random intercept logistic regression was used to estimate the association of MU capabilities and occurrence of ADEs, adjusting for patient characteristics, hospital characteristics, and year of observation. RESULTS: Rates of in-hospital ADEs declined by 19% from 2010 to 2013. Adoption of MU capabilities was associated with 11% lower odds of an ADE (95% confidence interval [CI], 0.84-0.96). Interoperability capability was associated with 19% lower odds of an ADE (95% CI, 0.67- 0.98). Adoption of MU capabilities explained 22% of the observed reduction in ADEs, or 67,000 fewer ADEs averted by MU. DISCUSSION: Concurrent with the rapid uptake of MU and interoperability, occurrence of in-hospital ADEs declined significantly from 2010 to 2013. MU capabilities and interoperability were associated with lower occurrence of ADEs, but the effects did not vary by experience with MU. About one-fifth of the decline in ADEs from 2010 to 2013 was attributable to MU capabilities. CONCLUSION: Findings support the contention that adoption of MU capabilities and interoperability spurred by the Health Information Technology for Economic and Clinical Health Act contributed in part to the recent decline in ADEs.

Electronic health records in rheumatology: emphasis on automated scoring and additional use.

Electronic health records are increasingly used and frequently required from various regulatory authorities. Apart from their day-to-day use by health care professionals for routine clinical practice and/or the improvement of quality of care processes, patients with chronic inflammatory disease may become increasingly involved in the data retrieval process by self-monitoring and providing patient-reported (outcome) data. Among key features of electronic health records are automated scoring, visualisation of validated measures, and long-term systematic patient-centered data collection in a structured and standardised manner. Data derived from electronic health records are increasingly incorporated into patient-centered research, registries, and other secondary uses. Thus, electronic health records offer opportunities to improve knowledge and to create new process flows in rheumatology health care. The article summarises some of these opportunities in patient care, as well as an overview of secondary use scenarios. In addition, the article focuses on patients' active involvement in the disease management process via health information applications, reports on patients' perspectives, as well as some legal and regulatory matters concerning electronic health records.

Assessing HITECH Implementation and Lessons: 5 Years Later.

POLICY POINTS: The expansive goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, generating points of vulnerability. While federal legislation can be a powerful stimulus for change, its effectiveness also depends on its ability to accommodate state and local policies and private health care markets. Ambitious goals require support over a long time horizon, which can be challenging to maintain. The future of health information technology (health IT) support nationally is likely to depend on the ability of the technology to satisfy its users that its functionalities address the interests policymakers and other stakeholders have in using technology to promote better care, improved outcomes, and reduced costs. CONTEXT: The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned. METHODS: This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act. FINDINGS: Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to interoperability persist, limiting electronic communication across a diverse set of largely private providers and care settings. CONCLUSIONS: Achieving the expansive goals of HITECH required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, some better positioned to move forward than others. To date, it has proven easier to get providers to adopt EHRs, perhaps in response to financial incentives to do so, than to develop a robust infrastructure that allows the information in EHRs to be used effectively and shared not only within clinical practices but also across providers. Effective exchange of data is necessary to drive the kinds of delivery and payment reforms sought nationwide.

Evaluation of Health IT in Low-Income Countries.

Low and middle income countries (LMICs) bear a disproportionate burden of major global health challenges. Health IT could be a promising solution in these settings but LMICs have the weakest evidence of application of health IT to enhance quality of care. Various systematic reviews show significant challenges in the implementation and evaluation of health IT. Key barriers to implementation include lack of adequate infrastructure, inadequate and poorly trained health workers, lack of appropriate legislation and policies and inadequate financial 333indicating the early state of generation of evidence to demonstrate the effectiveness of health IT in improving health outcomes and processes. The implementation challenges need to be addressed. The introduction of new guidelines such as GEP-HI and STARE-HI, as well as models for evaluation such as SEIPS, and the prioritization of evaluations in eHealth strategies of LMICs provide an opportunity to focus on strategic concepts that transform the demands of a modern integrated health care system into solutions that are secure, efficient and sustainable.

2015 Edition Health Information Technology (Health IT) Certification Criteria, 2015 Edition Base Electronic Health Record (EHR) Definition, and ONC Health IT Certification Program Modifications. Final rule.

This final rule finalizes a new edition of certification criteria (the 2015 Edition health IT certification criteria or "2015 Edition'') and a new 2015 Edition Base Electronic Health Record (EHR) definition, while also modifying the ONC Health IT Certification Program to make it open and accessible to more types of health IT and health IT that supports various care and practice settings. The 2015 Edition establishes the capabilities and specifies the related standards and implementation specifications that Certified Electronic Health Record Technology (CEHRT) would need to include to, at a minimum, support the achievement of meaningful use by eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) under the Medicare and Medicaid EHR Incentive Programs (EHR Incentive Programs) when such edition is required for use under these programs.