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Contents

Tables, Figures, and

Exhibits .....................................................................
........... xi

Preface .....................................................................
........................................... xv

Acknowledgments .....................................................
....................................... xxiii

The
Authors .....................................................................
................................. xxv

Part 1 Major Environmental Forces That

Shape the National Health Information

System
Landscape ....................................................... 1

1 The National Health Information

Technology
Landscape ................................................................
..... 3

Learning Objectives

1990s: The Call for HIT

2000–2010: The Arrival of HIT

2010–Present: Health Care Reform and the Growth of

HIT

Summary

Key Terms

Learning Activities

References

2 Health Care
Data .........................................................................
... 21

Learning Objectives

Health Care Data and Information Defned

Health Care Data and Information Sources

Health Care Data Uses

Health Care Data Quality

Summary

Key Terms

Learning Activities

References

3 Health Care Information

Systems ................................................. 65

Learning Objectives

Review of Key Terms

Major Health Care Information Systems

History and Evolution

Electronic Health Records

Personal Health Records

Key Issues and Challenges

Summary

Key Terms

Learning Activities

References

4 Information Systems to Support Population

Health
Management .............................................................
......... 99

Learning Objectives

PHM: Key to Success

Accountable Care Core Processes

Data, Analytics, and Health IT Capabilities and Tools

Transitioning from the Record to the Plan

Summary

Key Terms

Learning Activities

References
Part 2 Selection, Implementation, Evaluation, and

Management of Health Care Information

Systems ....................................................................
139

5 System
Acquisition ................................................................
....... 141

Learning Objectives

System Acquisition: A Defnition

Systems Development Life Cycle

System Acquisition Process

Project Management Tools

Things That Can Go Wrong

Information Technology Architecture

Summary

Key Terms

Learning Activities
References

6 System Implementation and

Support ........................................ 179

Learning Objectives

System Implementation Process

Managing Change and the Organizational Aspects

System Support and Evaluation

Summary

Key Terms

Learning Activities

References

7 Assessing and Achieving Value in Health Care

Information
Systems ....................................................................
215

Learning Objectives

Defnition of IT-Enabled Value

The IT Project Proposal

Ensuring the Delivery of Value

Analyses of the IT Value Challenge

Summary

Key Terms

Learning Activities

References

8 Organizing Information Technology

Services ............................ 251

Learning Objectives

Information Technology Functions

Organizing IT Staff Members and Services

In-House versus Outsourced IT

Evaluating IT Effectiveness

Summary

Key Terms
Learning Activities

References

Part 3 Laws, Regulations, and Standards That

Affect Health Care Information Systems .............. 285

9 Privacy and
Security ....................................................................
. 287

Learning Objectives

Privacy, Confdentiality, and Security Defned

Legal Protection of Health Information

Threats to Health Care Information

The Health Care Organization’s Security Program

Beyond HIPAA: Cybersecurity for Today’s Wired

Environment

Summary

Key Terms

Learning Activities
References

10 Performance Standards and

Measures ....................................... 323

Learning Objectives

Licensure, Certifcation, and Accreditation

Measuring the Quality of Care

Federal Quality Improvement Initiatives

Summary

Key Terms

Learning Activities

References

11 Health Care Information System

Standards .............................. 357

Learning Objectives

HCIS Standards Overview

Standards Development Process

Federal Initiatives Affecting Health Care IT Standards

Other Organizations Infuencing Health Care IT
Standards

Health IT Standards

Vocabulary and Terminology Standards

Data Exchange and Messaging Standards

Health Record Content and Functional Standards

Summary

Key Terms

Learning Activities

References

Part 4 Senior-Level Management Issues Related

to Health Care Information Systems

Management ...........................................................
393

12 IT Alignment and Strategic

Planning ......................................... 395

Learning Objectives
IT Planning Objectives

Overview of Strategy

The IT Assest

A Normative Approach to Developing Alignment and IT

Strategy

IT Strategy and Alignment Challenges

Summary

Key Terms

Learning Activities

References

13 IT Governance and
Management ............................................... 427

Learning Objectives

IT Governance

IT Budget

Management Role in Major IT Initiatives

IT Effectiveness
The Competitive Value of IT

Summary

Key Terms

Learning Activities

Notes

References

14 Health IT Leadership Case

Studies.............................................. 467

Case 1: Population Health Management in Action

Case 2: Registries and Disease Management in the

PCMH

Case 3: Implementing a Capacity Management

Information System

Case 4: Implementing a Telemedicine Solution

Case 5: Selecting an EHR For Dermatology Practice

Case 6: Watson’s Ambulatory EHR Transition

Case 7: Concerns and Workarounds with a Clinical

Documentation System

Case 8: Conversion to an EHR Messaging System

Case 9: Strategies for Implementing CPOE

Case 10: Implementing a Syndromic Surveillance

System

Case 11: Planning an EHR Implementation

Case 12: Replacing a Practice Management System

Case 13: Implementing Tele-psychiatry in a

Community Hospital

Emergency Department

Case 14: Assessing the Value and Impact of CPOE

Case 15: Assessing the Value of Health IT Investment

Case 16: The Admitting System Crashes

Case 17: Breaching The Security of an Internet Patient

Portal

Case 18: The Decision to Develop an IT Strategic Plan

Case 19: Selection of a Patient Safety Strategy

Case 20: Strategic IS Planning for the Hospital ED

Case 21: Board Support for a Capital Project

Supplemental Listing of Related Case Studies and

Webinars

Appendixes

A. Overview of the Health Care IT

Industry................................... 525

The Health Care IT Industry

Sources of Industry Information

Health Care IT Associations

Summary

Learning Activities

References

B. Sample Project Charter, Sample Job Descriptions,

and Sample User Satisfaction

Survey......................................... 539

Sample Project Charter

Sample Job Descriptions

Sample User Satisfaction Survey

Index ........ 559

Part 1: Major Environmental Forces That Shape the

National Health Information System Landscape

Since the early 1990s, the use of health information

technology (HIT) across all aspects of the US health
care delivery system has been increasing. Electronic
health records (EHRs), telehealth, social media,
mobile applica- tions, and so on are becoming the
norm—even commonplace—today. Today’s health
care providers and organizations across the
continuum of care have come to depend on reliable
HIT to aid in managing population health effec- tively
while reducing costs and improving quality patient
care. Chapter One will explore some of the most
signifcant infuences shaping the current and future
HIT landscapes in the United States. Certainly,
advances in infor- mation technology affect HIT
development, but national private sector and
government initiatives have played key roles in the
adoption and application of the technologies in health
care. This chapter will provide a chronologi- cal
overview of the signifcant government and private
sector actions that have directly or indirectly affected
the adoption of HIT since the Institute of Medicine
landmark report, The Computer-Based Patient
Record: An Essential Technology for Health Care,
authored by Dick and Steen and published in 1991.
Knowledge of these initiatives and mandates shaping
the current HIT national landscape provides the
background for understanding the importance of the
health information systems that are used to promote
excellent, cost-effective patient care. 1990s: THE
CALL FOR HIT Institute of Medicine CPR Report The
Institute of Medicine (IOM) report The Computer-
Based Patient Record: An Essential Technology for
Health Care (Dick & Steen, 1991) brought international
attention to the numerous problems inherent in
paper-based medical records and called for the
adoption of the computer-based patient record (CPR)
as the standard by the year 2001. The IOM defned the
CPR as “an electronic patient record that resides in a
system specif- cally designed to support users by
providing accessibility to complete and accurate data,
alerts, reminders, clinical decision support systems,
links to medical knowledge, and other aids” (Dick &
Steen, 1991, p. 11). This vision of a patient’s record
offered far more than an electronic version of existing
paper records—the IOM report viewed the CPR as a
tool to assist the clinician in caring for the patient by
providing him or her with remind- ers, alerts, clinical
decision–support capabilities, and access to the
latest research fndings on a particular diagnosis or
treatment modality. CPR systems and related
applications, such as EHRs, will be further discussed
2000–2010: THE ARRIVAL OF HIT · 5 in Chapter Three.
At this point, it is important to understand the IOM
report’s impact on the vendor community and health
care organizations. Leading vendors and health care
organizations saw this report as an impetus toward
radically changing the ways in which patient
information would be managed and patient care
delivered. During the 1990s, a number of vendors
developed CPR systems. However, despite the fact
that these systems were, for the most part, reliable
and technically mature by the end of the decade, only
10 percent of hospitals and less than 15 percent of
physician practices had implemented them
(Goldsmith, 2003). Needless to say, the IOM goal of
widespread CPR adoption by 2001 was not met. The
report alone was not enough to entice organizations
and individual providers to commit to the required
investment of resources to make the switch from
predominantly paper records. Health Insurance
Portability and Accountability Act (HIPAA) Five years
after the IOM report advocating CPRs was published,
President Clinton signed into law the Health Insurance
Portability and Account- ability Act (HIPAA) of 1996
(which is discussed in detail in Chapter Nine). HIPAA
was designed primarily to make health insurance
more affordable and accessible, but it included
important provisions to simplify adminis- trative
processes and to protect the security and
confdentiality of personal health information. HIPAA
was part of a larger health care reform effort and a
federal interest in HIT for purposes beyond
reimbursement. HIPAA also brought national attention
to the issues surrounding the use of personal health
information in electronic form. The Internet had
revolutionized the way that consumers, providers, and
health care organizations accessed health
information, communicated with each other, and
conducted business, creat- ing new risks to patient
privacy and security. 2000–2010: THE ARRIVAL OF HIT
IOM Patient Safety Reports A second IOM report, To
Err Is Human: Building a Safer Health Care System
(Kohn, Corrigan, & Donaldson, 2000), brought national
attention to research estimating that 44,000 to 98,000
patients die each year because of medical errors. A
subsequent related report by the IOM Committee on
Data Stan- dards for Patient Safety, Patient Safety:
Achieving a New Standard for Care (Aspden, 2004),
called for health care organizations to adopt
information
technology capable of collecting and sharing
essential health information on patients and their
care. This IOM committee examined the status of
stan- dards, including standards for health data
interchange, terminologies, and medical knowledge
representation. Here is an example of the
committee’s conclusions: • As concerns about
patient safety have grown, the health care sector has
looked to other industries that have confronted similar
challenges, in particular, the airline industry. This
industry learned long ago that information and clear
communications are critical to the safe navigation of
an airplane. To perform their jobs well and guide their
plane safely to its destination, pilots must
communicate with the airport controller concerning
their destination and current circumstances (e.g.,
mechanical or other problems), their fight plan, and
environmental factors (e.g., weather conditions) that
could necessitate a change in course. Information
must also pass seamlessly from one controller to
another to ensure a safe and smooth journey for
planes fying long distances, provide notifcation of
airport delays or closures because of weather
conditions, and enable rapid alert and response to
extenuating circumstance, such as a terrorist attack. •
Information is as critical to the provision of safe health
care—which is free of errors of commission and
omission—as it is to the safe operation of aircraft. To
develop a treatment plan, a doctor must have access
to complete patient information (e.g., diagnoses,
medications, current test results, and available social
supports) and to the most current science base
(Aspden, 2004). Whereas To Err Is Human focused
primarily on errors that occur in hospi- tals, the 2004
report examined the incidence of serious safety issues
in other settings as well, including ambulatory care
facilities and nursing homes. Its authors point out that
earlier research on patient safety focused on errors of
commission, such as prescribing a medication that
has a potentially fatal interaction with another
medication the patient is taking, and they argue that
errors of omission are equally important. An example
of an error of omission is failing to prescribe a
medication from which the patient would likely have
benefted (Institute of Medicine, Committee on Data
Standards for Patient Safety, 2003). A signifcant
contributing factor to the unacceptably high rate of
medical errors reported in these two reports and many
others is poor information management practices.
Illegible prescriptions, unconfrmed
2000–2010: THE ARRIVAL OF HIT · 7 verbal orders,
unanswered telephone calls, and lost medical records
could all place patients at risk. Transparency and
Patient Safety The federal government also responded
to quality of care concerns by pro- moting health care
transparency (for example, making quality and price
information available to consumers) and furthering
the adoption of HIT. In 2003, the Medicare
Modernization Act was passed, which expanded the
program to include prescription drugs and mandated
the use of electronic prescribing (e-prescribing)
among health plans providing prescription drug
coverage to Medicare benefciaries. A year later (2004),
President Bush called for the widespread adoption of
EHR systems within the decade to improve ef fciency,
reduce medical errors, and improve quality of care. By
2006, he had issued an executive order directing
federal agencies that administer or sponsor health
insurance programs to make information about prices
paid to health care providers for procedures and
information on the quality of services provided by
physicians, hospitals, and other health care providers
publicly available. This executive order also
encouraged adoption of HIT standards to facilitate the
rapid exchange of health information (The White
House, 2006). During this period signifcant changes in
reimbursement practices also materialized in an effort
to address patient safety, health care quality, and cost
concerns. Historically, health care providers and
organizations had been paid for services rendered
regardless of patient quality or outcome. Nearing the
end of the decade, payment reform became a hot
item. For example, pay for performance (P4P) or
value-based purchasing pilot programs became more
widespread. P4P reimburses providers based on
meeting predefned quality measures and thus is
intended to promote and reward quality. The Centers
for Medicare and Medicaid Services (CMS) notifed
hospitals and physicians that future increases in
payment would be linked to improvements in clinical
performance. Medicare also announced it would no
longer pay hospitals for the costs of treating certain
conditions that could reasonably have been
prevented—such as bedsores, injuries caused by
falls, and infections resulting from the prolonged use
of catheters in blood vessels or the bladder—or for
treating “serious prevent- able” events—such as
leaving a sponge or other object in a patient during
surgery or providing the patient with incompatible
blood or blood prod- ucts. Private health plans also
followed Medicare’s lead and began denying payment
for such mishaps. Providers began to recognize the
importance
adopting improved HIT to collect and transmit the
data needed under these payment reforms. Offce of
the National Coordinator for Health Information
Technology In April 2004, President Bush signed
Executive Order No. 13335, 3 C.F.R., establishing the
Offce of the National Coordinator for Health
Information Technology (ONC) and charged the offce
with providing “leadership for the development and
nationwide implementation of an interoperable health
information technology infrastructure to improve the
quality and effciency of health care.” In 2009, the role
of the ONC (organizationally located within the US
Department of Health and Human Services) was
strengthened when the Health Information Technology
for Economic and Clinical Health (HITECH) Act
legislatively mandated it to provide leadership and
oversight of the national efforts to support the
adoption of EHRs and health informa- tion exchange
(HIE) (ONC, 2015). In spite of the various national
initiatives and changes to reimbursement during the
frst decade of the twenty-frst century, by the end of
the decade only 25 percent of physician practices
(Hsiao, Hing, Socey, & Cai, 2011) and 12 percent of
hospitals (Jha, 2010) had implemented “basic” EHR
systems. The far majority of solo and small physician
practices continued to use paper- based medical
record systems. Studies show that the relatively low
adoption rates among solo and small physician
practices were because of the cost of HIT and the
misalignment of incentives (Jha et al., 2009). Patients,
payers, and purchasers had the most to gain from
physician use of EHR systems, yet it was the physician
who was expected to bear the total cost. To address
this misalignment of incentives issue, to provide
health care organizations and providers with some
funding for the adoption and Meaningful Use of EHRs,
and to promote a national agenda for HIE, the HITECH
Act was passed as a part of the American Recovery
and Reinvestment Act in 2009.

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below:
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