Informatics in Emergency Medicine: A Brief Introduction (Paper)
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Informatics in Emergency Medicine: A Brief Introduction (Paper)

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Theera-Ampornpunt N. Informatics in emergency medicine: a brief introduction. In: The International Conference in Emergency Medicine: Challenges in Emergency Medicine: It’s Time for Change!; 2012 ...

Theera-Ampornpunt N. Informatics in emergency medicine: a brief introduction. In: The International Conference in Emergency Medicine: Challenges in Emergency Medicine: It’s Time for Change!; 2012 Jan 30 - Feb 1; Bangkok, Thailand. Bangkok (Thailand): Mahidol University, Faculty of Medicine Ramathibodi Hospital; 2012 Feb.

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Informatics in Emergency Medicine: A Brief Introduction (Paper) Informatics in Emergency Medicine: A Brief Introduction (Paper) Document Transcript

  • Informatics in Emergency Medicine: A Brief Introduction Nawanan Theera-Ampornpunt, M.D., Ph.D. Health Informatics Division Faculty of Medicine Ramathibodi Hospital Mahidol University, Bangkok, ThailandAbstract Patient care in any specialty requires good information, which is the focus of biomedicaland health informatics. Emergency medicine presents challenges for informatics that are distinctfrom other specialties. This paper discusses roles informatics can play in emergency medicineand offers examples of how common informatics solutions will be key toward high-qualityemergency medicine in the future. Technologies introduced include electronic health records,personal health records, health information exchange, mobile health and social media, and finallythe future of biosurveillance.Introduction As in any other medical specialties, emergency medicine provides care to patients inneed, and the quality of care unavoidably hinges on the quality of the information.[1] This is atthe heart of biomedical and health informatics (previously known as “medical informatics”), aninterdisciplinary field that is concerned with “the optimal use of information, often aided by theuse of technology, to improve individual health, health care, public health, and biomedicalresearch.[2] Unlike other specialties, however, emergency medicine presents unique challengesfor informatics. The urgency of its patients, with limited time and resource constraints,oftentimes compounded by severely restricted and scattered information makes it difficult foremergency physicians to make quick and appropriate decisions without errors.[3] The scale andunpredictability of mass casualties and disasters complicate the matter even further. Athoughtful, comprehensive, and well-executed informatics approach, therefore, is critical toemergency medicine. Such an approach must not interfere or slow down the providers in thissetting where every second matters, but instead should aim to improve how providers performand allow them to do their job more efficiently. The purpose of this paper is to introduce emergency medicine providers to the field ofinformatics by offering perspectives on how some informatics solutions can help them performbetter. While it is impossible for any single paper to cover the breadth and depth of growinginformatics knowledge bases, I hope that this paper will open the doors for emergencyphysicians and “informaticians”[2] to work together in finding the most appropriate solutionsthat will maximize values toward our mutual goal—the patients’ health and wellbeing.
  • Roles of Informatics in Emergency Medicine With the literature noting information gaps prevalent in emergency visits,[4] it is notdifficult to imagine the inherent values of patient’s health information an information system canbring, especially in the emergency settings where self-reported information is usually unavailableor unreliable. In fact, there exists literature evidence for the values of such information in thequality and efficiency gains in the emergency settings, at least for some medical conditions andin some health care organizations.[5-7] These documented benefits highlight the roles of “healthinformation exchange” (HIE),[8] an electronic intermediary platform that serves as informationbrokers between health care organizations as well as with other parties (including governmentalagencies and patients). While it is natural to think of informatics as the deliverer of patient information to healthcare providers, informatics in fact has much more to offer. Any well-designed informationmanagement approach, paper or electronic, must integrate well with the user’s workflow andprovide tangible values to the care process. An information system that simply digitizes theexisting workflows without adequately considering the workflow implications, therefore, notonly demonstrates the failure to recognize the “transformational” opportunities informaticssolutions can bring, but could also hinder high-quality care because of inherent problems in theexisting care processes. Good information systems, therefore, not only provide information thatare easily accessible by their users, but also seize the opportunity to redesign and add values tothe work processes by leveraging the technologies. This section discusses the potential roles ofinformatics in transforming the care processes that will set the stage for other sections thatfollow. The Institute of Medicine, in its “Crossing the quality chasm” landmark report, identifiessix aspects of quality health care—safety, timeliness, effectiveness, efficiency, equity, andpatient-centeredness.[9] This serves as a useful framework in identifying roles informatics canplay in emergency medicine. The availability of patient health information, offered by HIE andother technologies, provides a clearer picture of the patient’s health status, allowing emergencyphysicians to make more effective decisions in a timely manner. Knowledge of the patient’s drugallergies and current medications also provides patient safety benefits, whereas prior laboratoryresults may prevent unnecessary or redundant testing (i.e., making care more efficient). Apart from these simple information broking roles, health information technology (IT)can also be leveraged in other ways that further improve care quality. Consider first the safetyaspect. Computerized physician order entry (CPOE) systems, where physicians enter medicationorders directly into the system, prevent medication errors resulting from poor handwriting. Theyalso enable the use of clinical decision support systems (CDSSs) features such as alerts andreminders that warn the users about certain drug allergies or potential drug-drug interactions that
  • busy and overworked clinicians could have missed otherwise. The effects of these technologieson patient safety have been noted,[10] although the presence and degree of specific benefits stillvary from one study to another.[11,12] As previously noted when discussing HIE, theimportance of timely information can never be overstated in emergency medicine. Apart fromHIE, several other technologies also help deliver timely information or offer timely care to thosein need, including personal health records, telemedicine, and mobile health (mHealth)technologies. Several of these also make health care more equitable and patient-centered byreducing barriers to care of disadvantaged populations and empowering patients in their self-care. While health IT has great potential to improve health care, it is also important to note, asinformatics experts have rightly pointed out, that health IT is not a panacea to cure all problemsin the health care systems.[13,14] Risks of health IT in facilitating errors and other unintendedconsequences have been documented.[15,16] This underscores the need to balance the technicalfocus on health IT with the equally important “people and organizational issues” as repeatedlynoted by informatics experts.[17-20] It is important not only to develop a good informationsystem, but also to manage the IT implementation appropriately, with attention to projectmanagement, change management, communication, training, and workflow implications.[21] In short, there are several undeniable roles for health IT in improving patient care inemergency medicine, but in order to maximize benefits and minimize unintended consequences,it is necessary to view health IT not just as a technological innovation but also as an agent fororganizational and work process transformations. The following sections discuss in more detailhow some health IT solutions of today can transform care in emergency medicine of tomorrow.Electronic Health Records and Health Information Exchange Many providers may have heard of “electronic health records” (EHRs) or “electronicmedical records” (EMRs). Among informatics professionals, EHRs often refer to electronicrecords of a patient’s health information that are documented by and accessible to health careproviders. EHRs are often housed within the walls of health care organizations, but to maximizecontinuity of care across settings, EHRs from one health care organization should ideally beaccessible to other health care organizations through HIE or other mechanisms when providingcare to the patients, with appropriate privacy protections. Since different organizations often usedifferent EHR solutions, the need to use agreed-upon information standards is paramount to aninteroperable health information infrastructure that shares and processes electronic informationacross different technologies. As discussed in the last section, availability of patient health information can reduceerrors and improve quality of care in the emergency settings. An HIE infrastructure that
  • integrates data from disparate EHR systems provides a more complete picture of a patientpresenting to the emergency department. Consider, for instance, a diabetic patient from Bangkokwho visits Phuket as a tourist and happens to lose his consciousness during one of his tours.Without additional information, an emergency physician in Phuket may be forced to use her bestjudgment uninformed to treat the patient to the best of her ability. With an interoperable HIE, thephysician may be able to access the patient’s history from a Bangkok hospital’s EHR system(assuming that the patient could be identified, say, based on an identification card in his wallet).The doctor may notice from the records that the patient has missed an appointment and likely ranout of his oral hypoglycemic agents. Alternatively, she may realize that the patient has severeallergies to penicillin, which would be of critical importance if sepsis is suspected. The value ofinformation in the EHRs to the emergency physician will vary depending on clinicalpresentations and the information in the records, but having an access provides potentiallyvaluable information that might not be available otherwise. For this scenario to become a reality,there is a need to have a public policy that facilitates widespread adoption of EHRs and aninfrastructure for an interoperable HIE. The United States is moving in this direction, with itsHITECH Act and “Meaningful Use” efforts.[22,23] Several European countries also have a highadoption rate of ambulatory EHRs as well as facilitative public policies and social contexts,[24]all of which are key ingredients to a successful HIE. Although electronic documentation of clinical care provided to patients is a necessaryelement of any EHR system, it is not sufficient to bring about quality benefits we endeavor.Experts have identified other important functionalities that an EHR system should have,including order entry and electronic viewing of laboratory and radiology results.[25] Recentstudies of EHR adoption in the United States have used these functionalities to assess how muchprogress has been made toward widespread adoption.[26-28] This reinforces the point madeearlier that health IT should not be viewed simply as an information provider but instead as anagent of work process improvements that accompany its implementation. These work processimprovements could include, for example, “meaningful” use of computerized order entry toreduce medication errors and streamline the entire medication management process; use ofclinical decision support features to alert users to potential errors; and electronic viewing oflaboratory results to provide timely reporting, to bring abnormal results to the clinicians’attention, and to plot the results on a chart that makes it more easily for clinicians tocomprehend. In short, to delivery substantial benefits, EHR implementation needs to movebeyond electronic documentation of clinical care.Personal Health Records A less familiar technology that nevertheless has a potential to improve emergency care ispersonal health records (PHRs). While EHR systems target at health care providers as the mainusers, PHR systems focus on the individual patients.[29] Patients can access, enter, and update
  • their personal health information in a PHR system, though the architecture of the system canvary depending on who provides the services and whether the PHRs are standalone or integratedwith provider-managed EHRs. A PHR system can serve as a patient’s personal informationmanagement tool, and it may also offer health care professionals access to the patient’sinformation when it is needed to provide care. When a patient presents to the emergencydepartment, emergency physicians may be able to access a patient’s PHRs which may containtheir underlying conditions, current medications, allergies, laboratory results, among others.While this sounds similar to accessing the patient’s electronic records residing in other healthcare organizations through an EHR system and an HIE platform, the key difference betweenPHRs and EHRs is on who primarily manages the information (patient vs. provider). Like EHRs,quality gains in PHRs lie not only on the information provided, but also on other functions thathelp transform the care process. These include reminding diabetic patients about annual eyeexaminations or providing personalized access to online resources related to smoking cessation(improving both the effectiveness and patient-centeredness aspects of care). The current PHR landscape is still relatively immature, especially after Google Healthclosed its services,[30] and more research is needed on various aspects of PHRs.[31]Nevertheless, with the society increasingly moves toward more consumer empowerment andonline presence, PHRs are expected to play an integral role to the future of health care and itspotential benefits to emergency medicine are obvious.Mobile Health While traditional telemedicine technologies that connect providers and patients separatedphysically or chronologically have been known for decades, use of mobile technologies forhealth-related purposes has received much attention in the past few years. The exponentialincrease in mobile device adoption creates a large, enthusiastic consumer base. The rise of socialmedia in the recent years also offers convenient and appealing platforms for social interactionsand online information seeking. These recent advances in mobile health (mHealth) bringubiquitous access to health information and health care resources into the hands of not onlyconsumers worldwide but also the rural populations where traditional telephone lines andInternet may still be out of reach. It changes the way consumers communicate about health issuesthat undoubtedly will influence how they expect health care services will be delivered in the nearfuture.[32] A study by the World Health Organization also shows that mHealth is a globalphenomenon that has the potential to benefit not only high-income countries but also low-incomeones.[33] One area in emergency medicine where mHealth is particularly helpful is disastermanagement. From the 2004 Indian Ocean tsunami to the 2010 Haiti earthquake to the 2011Japan earthquake and tsunami, mobile devices and social media have provided new ways for
  • victims, relief workers, and disaster managers to communicate and coordinate.[33,34] The rolesof mHealth were evident during the 2011 record flooding in Thailand. In that disaster, socialmedia including Twitter, Facebook, and YouTube were used along with many other public andprivate online resources to help assess the situation, spread the words, and coordinate reliefefforts, among others. Mobile devices were predominantly employed to communicate via voice,text messages, and social media, as well as many more innovative uses of IT tools. The need formHealth technologies becomes especially important when traditional telephone lines andelectricity are disrupted by the disasters. Nevertheless, the use of these mHealth technologiesduring disasters is still mostly scattered and unorganized, with many lessons to be learned.[35] Itremains a challenge for emergency and disaster management specialists to recognize the fullpotential of these technologies and leveraging them to prepare us for future disasters.Biosurveillance The last informatics solution to be discussed that has a direct implication on emergencymedicine is biosurveillance. This encompasses a group of technologies used to electronicallymonitor the trends in health status of a population so that a timely investigation or interventioncan be made if necesary. The pandemic influenza in the past few years and the rising threat ofbioterrorism are two apparent scenarios where biosurveillance can make a difference. Severalapproaches to biosurveillance exist today, from the active use of IT by a group of users to reportthe newly identified cases for a disease of interest (e.g., malaria) in a particular location, to thepassive monitoring of the current trends using data from various sources. The timeframe ofreporting also varies depending on the purpose and nature of the surveillance, from days ormonths after the case identification to real-time monitoring. The Google Flu Trends,[36] whichuses keywords from the popular online search engine in near real-time to predict with aconsiderable degree of accuracy the likely presence of influenza epidemic in a geographic area,demonstrates the utility of biosurveillance not only to epidemiologists and public healthadministrators but also to the general public.[37-39] With EHRs widely adopted and connectedby many emergency departments in a community, one can imagine a powerful biosurveillancesystem that monitors the chief complaints (e.g., flu-like symptoms), laboratory results (e.g.,laboratory-confirmed cases of influenza), and clinical diagnoses of emergency patients visitingone of such the emergency departments through their interconnected EHR systems and providesa real-time situational awareness (e.g., a rising trend of possible influenza cases that mightindicate an ongoing epidemic) that would allow governmental agencies responsible for diseasecontrol and prevention to act fast in assessing and controlling the situation. Although thisscenario is currently not achievable in most communities due to a lack of widespread adoption ofinterconnected EHR systems, the landscape is changing and such biosurveillance tools areexpected become a reality of emergency patient care in the coming years.
  • Conclusion The roles of biomedical and health informatics in emergency medicine were reviewed.Examples of how informatics tools can lead to safe, timely, effective, efficient, equitable, andpatient-centered care have been offered. Important informatics solutions that have great potentialto improve patient care in the emergency settings have been discussed, including the electronichealth records, personal health records, health information exchange, mobile health, andbiosurveillance. it is my hope that these discussions have provided you a brief introduction intothe field of informatics and encouraged you to explore ways informatics can help improve howemergency medicine functions.References 1. Shortliffe EH. Biomedical informatics in the education of physicians. JAMA. 2010 Sep 15;304(11:1227-8. 2. Hersh W. A stimulus to define informatics and health information technology. BMC Med Inform Decis Mak. 2009 May 15;9:24. 3. Fordyce J, Blank FS, Pekow P, Smithline HA, Ritter G, Gehlbach S, Benjamin E, Henneman PL. Errors in a busy emergency department. Ann Emerg Med. 2003 Sep;42(3):324-33. 4. Stiell A, Forster AJ, Stiell IG, van Walraven C. Prevalence of information gaps in the emergency department and the effect on patient outcomes. CMAJ. 2003 Nov 11;169(10):1023-8. 5. Theera-Ampornpunt N, Speedie SM, Du J, Park YT, Kijsanayotin B, Connelly DP. Impact of prior clinical information in an EHR on care outcomes of emergency patients. AMIA Annu Symp Proc. 2009 Nov 14;2009:634-8. 6. Overhage JM, Dexter PR, Perkins SM, Cordell WH, McGoff J, McGrath R, McDonald CJ. A randomized, controlled trial of clinical information shared from another institution. Ann Emerg Med. 2002 Jan;39(1):14-23. 7. Connelly DP, Park YT, Du J, Theera-Ampornpunt N, Gordon BD, Bershow BA, Gensinger RA, Shrift M, Routhe DT, Speedie SM. The impact of electronic health records on care of heart failure patients in the emergency room. J Am Med Inform Assoc. Forthcoming 2011. 8. Shapiro JS, Kannry J, Lipton M, et al. Approaches to patient health information exchange and their impact on emergency medicine. Ann Emerg Med. 2006 Oct;48(4):426-32. 9. Institute of Medicine, Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. 337 p. 10. Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA. 1998 Oct 21;280(15):1311–6.
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