Health information technology in hospitals: current issues and future trends

Strategic context

UK hospitals are large organisations that are part of an even larger system that is governed centrally – the NHS, which is further divided into NHS Wales, NHS England, NHS Scotland and NHS Northern Ireland. Although aims are similar, HIT implementation strategies and the associated involvement of governments vary. For example, England has now moved from an initially ‘top-down’ implementation model through a national programme characterised by central procurement of standardised technological systems, to a model that allows more local input in decision making among implementing hospitals.^16,17 However, the consequences of the previously centralised procurement model are still widely experienced, particularly where organisations are continuing to implement solutions that they have not selected themselves. This can have disastrous consequences for not only the acceptability of systems among users (they are more likely to reject a system that they feel has been forced upon them), but also the strategies used by managers to initiate and sustain organisational transformations (they might not support the implementation and, therefore, behave in a way that conveys doubt to users).¹⁸

A particularly important factor that can to some extent facilitate adoption is the existence of financial incentives.¹⁹ For example, the USA has been successful in stimulating HIT use through the use of a centrally administered stimulus package.²⁰

Organisational approach

For implementing organisations, strategy is just as important, but unfortunately not more straightforward. Radical organisational changes are often necessary as part of implementations,²¹ but these are complicated by the complexity of the hospital environment.²² Many teams work together often over great distances to deliver care – a carefully choreographed act. When new ‘off-the-shelf’ technology is introduced, the dynamics change and hospital staff have to learn new ways of working.²³ This is not always easy for individuals and extremely difficult to manage. For example, there is a risk that organisational processes are simply automated, as opposed to redesigned, which then results in a lack of the desired benefits.^17,24 In addition, there is commonly little appreciation that benefits might take a long time to materialise (because they are, to a large extent, dependent on efficient health information exchange (HIE)) and that desired safety and efficiency savings are hard to attribute.^17,25,26 As a result, financial risks are a real threat, particularly within the first few years of adoption. Therefore, it is important not to overestimate early benefits and to appreciate that these are likely to have diffuse effects that are difficult to measure.^17,25,26

Technical characteristics

It has also frequently been found that technical characteristics can influence the implementation of HIT.^16,17 Key challenges include poor usability, functionality and performance (which can introduce new threats to patient safety).^27–29 Issues here can range from long system response times to long-winded data entry, which can mean that information cannot be accessed when needed and/or recorded by users.^16,17 In addition, system design can mean that certain errors are more likely. For example, selection errors can occur when users unintentionally click on the wrong medication because it is in close proximity to the intended drug on the list.^16,17 Such technical issues often emerge not only because system development lacks end-user input, but also because of the difficulty in customising systems to suit the needs of different professional groupings operating within hospitals.^16,17

Other repeatedly found technical characteristics that can hinder implementation progress include the lack of HIE and interoperability within and across organisations, as well as the marginalisation of patients and carers.^26,30

Social consequences

As already alluded to above, system implementation can have various unintended and undesired consequences. Some of these are social in nature, with various potentially adverse effects on clinical workflows and collaborative working.^16,17,23,31 For instance, it has been found that, in some cases, systems can reduce face-to-face contact within teams and between healthcare professionals and patients, and shift the focus of healthcare professional work to increased data entry activities.^16,17 This in turn can lead to resistance to use HIT or the development of ‘workarounds’, where the technology is used in ways other than intended.³²

To ensure that system design reflects different needs, it is important that efforts are made to understand and take account of the broad range of stakeholders who are using HITs.³³ Admittedly, the range of users in hospitals is large, but some successes have been recorded through strategies including: close working relations with developers, clinical champions and leadership, and continuous engagement and evaluation activities.^25,26,34 Meaningful and ongoing evaluation is particularly important to promote more clinically relevant technologies and ensure continued engagement of users (Fig 2).^35,36

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Fig 2.

Catwell and Sheikh's simplified evaluation process model.³⁵ Adapted from Catwell and Sheikh 2009.³⁵

Interfacing and HIE on a larger scale

Many of the benefits of HIT are dependent on sharing of information – be it across devices and equipment or across healthcare organisations.^37,38 Therefore, one important development that is likely to see increasing attention is HIE, the electronic exchange of information relating to health. The Holy Grail of HIE is the so-called ‘HIMSS Level 7’, a state of seamless electronic information exchange that enables using data to improve processes of care, quality, and safety (see the discussion surrounding secondary uses below).³⁹ This includes a fully functional electronic health record used to exchange information across the local health community, with access for health professionals and patients. Stages of adoption are tracked by HIMSS Analytics, a USA-based not-for-profit organisation that helps organisations to work through eight stages towards an electronic care environment. Currently, 190 US hospitals, three European hospitals, three Asian hospitals and one Canadian hospital have achieved HIMSS Level 7.

On a small scale, the more consistent use of standards will pave the way for HIE with ‘smart’ devices that are able to respond to electronic signals. This includes, for example, wearable technology, such as wristbands that contain wireless communication devices and can exchange information with hospital computers. Benefits here include not only instant access to patient-specific information for healthcare professionals, but also (depending on the ability of the device) potentially monitoring of vital signs.⁴⁰

Similarly, there is likely to be greater use of robots in hospitals that are part of a larger HIE system, such as those that dispense medications to reduce dispensing errors, or those that clean hospitals to reduce healthcare-associated infections.^41,42

Looking ahead, the drive towards integrated health and social care and the availability of cloud-based data management means that we are likely to see greater developments surrounding sharing of data with community providers and, indeed, directly with patients themselves. As a result of these developments, data management, security, storage, analysis and interpretation are likely to be core future missions for hospitals.⁴³

The beginnings of seamless integration can already be seen in some local health communities. For example, the Indiana Health Information Exchange is the oldest health information exchange network in the USA. It uses electronic data interchange for healthcare transactions between hospitals, community care facilities and other healthcare organisations. Run by the Regenstrief Institute, it now holds data on more than 7 million patients.⁴⁴ Similarly, the Andalucian health system has been using a Cerner integrated regional EHR and electronic prescribing system spanning public health, primary, secondary, emergency and social care since the 1990s.^45,46

However, although already bringing significant local benefits because data are seamlessly shared between electronic devices, humans and locations; current tools that have emerged with a discrete focus, often on particular functions within hospitals, have limited capacity for HIE and interoperability, and are not designed to support transitions between home-, community- and hospital-based care. Existing HIE initiatives also tend to use an integrated system by one designated supplier. Potential issues might emerge when organisations using different systems are required to interface, and there is a risk of commercial monopolies.

Patient-centric architectures – patients as the new users

Although myriad HIT users are currently problematic, this is likely to become more complicated in the future, because patients are likely to have increased control over their records. Although patients’ ability to edit health information will facilitate involvement in care, the implications for working practices of healthcare professionals could be significant. At best, increased patient involvement will result in more targeted and efficient care with patients as active participants, whereas at worst, patients might be viewed as interfering, resulting in adverse effects on relations with healthcare professionals.

Nevertheless, some successful examples exist, although these do not allow patients to enter information electronically, but focus on facilitating communication between healthcare professionals and patients at a distance, and patient access to their records. For example, The National Shared Care Plan in New Zealand is a programme sponsored by the National Health IT Board and the Auckland Regional District Health Boards. It allows communication between patients with long-term conditions and between different healthcare providers through a coordinated electronic care plan.⁴⁷

Similarly, OpenNotes allows patients to access and read their medical notes electronically. It is a national initiative in the USA aiming to promote patient access and active involvement in care activities and, in due course, the co-authoring of records.⁴⁸

The Blue Button initiative allows patients online access to their own health information, including medications, allergies and lab results. It is widely used in the USA in the Veterans Health Administration and the Center for Medicare and Medicaid Services (the main US national social insurance program), among others. The scheme is expanding rapidly with numerous public and private sector organisations implementing the Blue Button and expanding Blue Button capabilities nationwide.⁴⁹

Innovative secondary uses of data

Another promising development relates to the increasing secondary uses of data held within electronic systems. Currently, some of the benefits are derived from analysing data within organisations,^16,17 but the future is likely to be characterised by aggregating data in a way that transcends organisational boundaries. Potential benefits exponentially increase with scale, although so do organisational challenges, because of the increasing number of health- and social care organisations involved. Moreover, key challenges are likely to include continuing debates surrounding patient confidentiality and consent, and the capacity to meaningfully analyse data that become available.

Again, some international examples of routine secondary uses on larger scales that transcend organisational boundaries exist. These already bring significant organisational benefits. For instance, Kaiser Permanente provides care for 8.6 million members in California and parts of Colorado. In 2002, the organisation began working with Epic Systems Corporation to create and implement an integrated EHR (KP HealthConnect). Although centrally governed, the system is configured in line with the needs of different localities. An in-house analytics team routinely draws on data to improve the quality and efficiency of care provided. This includes data warehousing, and both operational analytics (clinical and financial) and research analytics (to support research into for example health disparities and comparative effectiveness research).⁵⁰

Geisinger Health System provides for over 2.6 million people in Pennsylvania. It began implementation of EpicCare, an integrated EHR, in 1996. Having collaborated with IBM to create an integrated data warehouse, the system now supports a range of research projects drawing on EHR data. As part of this, the organisation is able to simulate re-engineering of care processes, and allows for testing of new software tools in clinical environments and then commercialisation of these (xG Health Solutions).⁵¹