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Information technology control and audit Fifth Edition

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INFORMATION TECHNOLOGY
FOR THE

HEALTH PROFESSIONS
LILLIAN BURKE BARBARA WEILL FIFTH EDITION
Information Technology for
the Health Professions
This page intentionally left blank
Information Technology for
the Health Professions
Fifth Edition

Lillian Burke
Barbara Weill

330 Hudson Street, NY, NY 10013

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Library of Congress Cataloging-in-Publication Data

Names: Burke, Lillian, author. | Weill, Barbara, author.
Title: Information technology for the health professions / Lillian Burke,
Barbara Weill.
Description: Fifth edition. | Boston: Pearson, [2019] | Includes
bibliographical references and index.
Identifiers: LCCN 2017047044 | ISBN 9780134877716 | ISBN 0134877713
Subjects: LCSH: Medical informatics.
Classification: LCC R858 .B856 2019 | DDC 610.285—dc23 LC record
available at https://lccn.loc.gov/2017047044

1 18

ISBN-13: 978-0-13-487771-6
ISBN-10:     0-13-487771-3
 To our families, for their inspiration, understanding,
patience, faith in us, and love.

Molly and Harry, Richard, Andrea and Jason, and Sadie, Daniel and Mandy
—L.B.

Hazel and Rob, Mike, Buffy and Jon and Mikey, Joanne and Melissa
and Sarah and Emma
—B.W.
 Contents
Preface xii Computer Information Systems in
Reviewers xv Health Care 10
Medical Office Administrative
Software: An Overview 11
Chapter 1
Coding and Grouping 11
An Introduction to Scheduling 12
Medical Informatics: Accounting 12
Administrative Uses of Insurance 12
Computers in the Claims 14
Medical Office 1 Accounting Reports 14
Chapter Outline 1 Does Computerization Improve
Learning Objectives 2 Patient Outcomes? 20
Clinical/Medical Informatics 2 In the News 21
The American Recovery and Chapter Summary 22
Reinvestment Act (ARRA), Key Terms 23
the Health Information Review Exercises 24
Technology for Economic Notes 26
and Clinical Health Act (HITECH), Additional Resources 29
and the Health Information
Technology Decade 3
The Patient Protection and Affordable Chapter 2
Care Act (ACA) (2010) 4
Telemedicine 33
Administrative Applications of
Chapter Outline 33
Computer Technology in the
Medical Office 5 Learning Objectives 34
The Patient Information Overview 34
Form 6 Store-and-Forward Technology and
The Paper Medical Record 7 Interactive Videoconferencing 35
The Electronic Medical Teleradiology 36
Record 7 Telepathology 37
The Personal Health Record 7 Teledermatology 38
The Electronic Health Record 7 Telecardiology 38
The eHealth Exchange 9 Teleneurology 39
The EHR and Big Data Telestroke 39
Analytics 9 Epilepsy 41

vi
 CONTENTS vii

Parkinson’s Disease 41 The Emergence of Diseases in

E-mail and Digital Cameras in the Late 20th and Early
Teleneurology 42 21st Centuries 85
Telepsychiatry 42 AIDS 85
Remote Monitoring SARS 86
Devices 43 Ebola Virus 86
Telewound Care 45 Antibiotic Resistance 86
Telehome Care 46 MRSA 87
Telemedicine in Prison 47 CRKP 88
Other Telemedicine NDM-1 88
Applications 48 Vector-Borne Diseases 88
The Telenurse 50 West Nile Virus 88
Smartphones and Tablet Zika Virus 88
Computers 51 Using Information Technology to
Is Telemedicine Track and Combat a 21st Century
Effective? 53 Epidemic: Cholera 89
Issues in Telemedicine 55 Information Technology—Collection,
Modeling, and Surveillance
In the News 57
of Disease Agents 89
Chapter Summary 57
Computer Modeling of Disease:
Key Terms 58 Health Statistics and Infectious
Review Exercises 58 Disease 91
Notes 60 Models of Infectious Disease
Additional Resources 68 Agent Study (MIDAS) 91
Related Websites 76 Climate Change: Global
Warming 91
Chapter 3 The Public Health Response to
Hurricane Katrina 93
Information Technology The BP Deepwater Horizon Oil
in Public Health 77 Spill 94
Chapter Outline 77 A Note on the Earthquake,
Learning Objectives 78 Tsunami, and Radiation Disaster
Introduction 78 in Japan 96
Definition 78 The Opioid Overdose
Epidemic 97
Social Inequality, Poverty,
and Health 79 Discussion 98
Using Computers to Study In the News 99
Disease 81 Chapter Summary 99
Statistics and Epidemics: Key Terms 99
A Historical Overview 82 Review Exercises 100
viii CONTENTS

Notes 102 Chapter 5

Additional Resources 109
Related Websites 117 Information Technology
in Surgery—The Cutting
Chapter 4 Edge 146
Chapter Outline 146
Information Technology Learning Objectives 147
in Radiology 118 Overview 147
Chapter Outline 118 Computer-Assisted Surgery 147
Learning Objectives 119 Computer-Assisted Surgical
Introduction 119 Planning 147
X-Rays 120 Minimally Invasive
Ultrasound 121 Surgery 148
Digital Imaging Techniques 122 Computer-Assisted Surgery and
Computed Tomography 122 Robotics 148
Magnetic Resonance Imaging 123 ROBODOC, AESOP, ZEUS,
Positron Emission Tomography 126 da Vinci, MINERVA, NeuroArm,
and Other Robotic
Single-Photon Emission Computed
Devices 149
Tomography Scans 127
Functional Near-Infrared Issues in Robotic Surgery 154
Spectroscopy (fNIRS) 128 Augmented Reality 155
Bone Density Tests 128 Telepresence Surgery 156
Other Imaging Technology 128 NASA Extreme Environment
Nanotechnology 129 Mission Operation 157
Computer-Aided Detection 129 The Operating Room of the
Future 158
Picture Archiving and
Communications Systems 130 Lasers in Surgery 158
Interventional Radiology: Bloodless Discussion and Future
Surgery 130 Directions 159
The Dangers of Medical Nanotechnology 160
Radiation 132 Conclusion 160
In the News 134 In the News 161
Chapter Summary 134 Chapter Summary 161
Key Terms 134 Key Terms 162
Review Exercises 135 Review Exercises 162
Notes 137 Notes 163
Additional Resources 141 Additional Resources 166
Related Websites 145 Related Websites 169
 CONTENTS ix

Chapter 6 Chapter Summary 188

Key Terms 189
Information Technology Review Exercises 189
in Pharmacy 170 Notes 190
Chapter Outline 170 Additional Resources 195
Learning Objectives 171
Overview 171 Chapter 7
The Food and Drug
Administration 171 Information Technology
Uncertified Medicines 172 in Dentistry 199
Biotechnology and the Human Chapter Outline 199
Genome Project 173 Learning Objectives 200
Rational Drug Design 173 Overview 200
Bioinformatics 173 Education 200
The Human Genome Project 174 Administrative Applications 201
Developments in Biotechnology 175 The Electronic Dental Chart 204
Computer-Assisted Drug Demographics and the Transformation
Trials 177 of Dentistry 207
Computer-Assisted Drug Computerized Instruments in
Review 178 Dentistry 208
The Computerized Pharmacy 178 Endodontics 208
Computers and Drug Errors 178 Periodontics 209
The Automated Community Cosmetic Dentistry 210
Pharmacy 180 Diagnosis and Expert Systems 210
Automating the Hospital Diagnostic Tools 211
Pharmacy 181 X-Rays 211
The Hospital Pharmacy—Robots Digital Radiography 211
and Barcodes 181
Cone Beam Computed
Point-of-Use Drug Dispensing 181
Tomography Scanner 211
Computerized IVs and
Barcodes 184
Electrical Conductance 213
Radio Frequency Identification Other Methods 213
Tags 185 Light Illumination 214
Telepharmacy 185 Lasers in Dentistry 214
Drug Delivery on a Chip 186 Minimally Invasive Dentistry 214
Nanotechnology and Pharmacy 187 Surgery 215
The Impact of Information Technology Teledentistry 215
on Pharmacy 187 In the News 216
In the News 187 Chapter Summary 216
x CONTENTS

Key Terms 216 Conclusion 243

Review Exercises 217 In the News 244
Notes 218 Chapter Summary 244
Additional Resources 219 Key Terms 245
Related Websites 221 Review Exercises 245
Notes 247
Chapter 8 Additional Resources 250
Related Websites 254
Informational Resources:
Computer-Assisted Chapter 9
Instruction, Expert
Information Technology
Systems, Health
in Rehabilitative
Information Online 222
Therapies: Computerized
Chapter Outline 222
Learning Objectives 223
Medical Devices,
Overview 223 Assistive Technology,
Education 223 and Prosthetic
The Visible Human Project 223 Devices 255
Computer-Assisted Chapter Outline 255
Instruction 225 Learning Objectives 256
Simulation Software 225 Overview 256
Virtual Reality Simulations 226 Computerized Medical Instruments
Patient Simulators 228 and Devices 256
Distance Learning 232 Computerized Devices in
Decision Support: Expert Optometry/Ophthalmology 258
Systems 233 Assistive Devices 260
Health Information on the Augmentative Communication
Internet 234 Devices 262
Medical Literature Databases 235 Electronic Aids to Daily
E-Mail 237 Living 263
Self-Help on the Web 238 Prosthetic Devices 263
Support Groups on the Web 239 Computerized Functional Electrical
Judging the Reliability Stimulation Technology 267
of Health Information on the Risks Posed by Implants 269
Internet 240 Computers in Rehabilitative
Health-Related Smartphone Therapies 269
and Tablet Computer Apps 240 Conclusion 270
Computers and Psychiatry 242 In the News 270
 CONTENTS xi

Chapter Summary 270 Databases and the

Key Terms 271 Internet 293
Review Exercises 272 Privacy, Security, and Health
Care 293
Notes 273
Health Insurance Portability and
Additional Resources 277
Accountability Act of 1996
Related Websites 281 (HIPAA) and HITECH 293
Privacy of Medical Records Under
Chapter 10 HIPAA, HITECH, and the USA
Patriot Act 295
Security and Privacy in
Telemedicine and Privacy 296
an Electronic Age 282 E-Mail and Privacy 296
Chapter Outline 282 Privacy and Genetic Information 296
Learning Objectives 283 Privacy and Electronic Health
Security and Privacy—An Records 297
Overview 283 In the News 298
Threats to Information Chapter Summary 298
Technology 284 Key Terms 299
Computer Technology and Review Exercises 299
Crime 284
Notes 301
Security 286
Additional Resources 305
Privacy 289
Related Websites 310
Databases 290
Government Databases 290 Glossary 311
Private Databases 292
Index 324
 Preface: An Introductory Note
on Computers
Information Technology for the Health Professions is not a book about computers, but rather
a look at the myriad uses of computers and information technology in health care. A brief
overview of a few basic computer terms will be helpful in understanding these concepts.
Today, computers are used in every aspect of our lives. You have a small computer
called a smartphone or a tablet in your pocket or a larger desktop computer on your desk.
Whatever their size be and whatever they look like, all computers have some things in
common. The tangible parts of the computer you can touch are called hardware: Input
devices (a mouse, keyboard, touch screen, or microphone) let you enter data into your
computer; output devices (a screen, printer, or speaker) let you get information from your
computer. Inside your computer is some processing hardware (a central processing unit
or CPU in a desktop computer), which turns the data into information, that is, adds 3 plus 4
and gets 7 as an answer. All computers have some storage to hold information and instruc-
tions and some memory to hold current work. On a desktop computer, the storage is called
a hard drive. All computers need instructions to tell them how to perform tasks. These
instructions are called software programs and are usually stored in the computer. The
instructions that tell the computer how to run are called system software. The most impor-
tant system software is the operating system. Application software tells the computer how
to perform specific tasks. Word processing software for text, spreadsheets for numbers,
database management software for organized lists, graphics software that allows you to
create presentations using images, and communications software that allows you to con-
nect to the Internet are common examples of application software.
Almost all computers are connected to a large World Wide Web of interconnected
computers called the Internet. Some computers, such as the Chromebook, use the Internet
to store much of its software, information, and data. But all of us, if we use a smartphone,
are connected. We use a wireless connection like Wi-Fi. When you access data and pro-
grams from the Internet and save information on the Internet, that is called cloud comput-
ing. The part of the Internet that is easiest to navigate is called the World Wide Web and is
organized as pages and stored on websites. The Internet of Things (IoT) refers to intercon-
nected devices. Devices can refer to almost anything that can electronically share data.
They include cars, smart TVs, heart monitors, and buildings, to name a few.

NEW TO THIS EDITION

Chapter 1
• Updated material regarding the administrative uses of computers in health care that
includes: administrative tasks in medical offices and hospitals, computers storing
­electronic medical records, doctors’ notes, and creating bills
• Updated material regarding the American Recovery and Reinvestment Act, HITECH,
and the Patient Protection and Affordable Care Act (ACA)
xii
 PREFACE: AN INTRODUCTORY NOTE ON COMPUTERS xiii

• Updated information regarding medical office practice management software, which

describes patient and professional scheduling, accounting, and insurance
• New article for “In the News”
“Doctors Find Barriers to Sharing Digital Medical Records,” by Julie Creswell
published on September 30, 2014 in The New York Times
Chapter 2
• Updated studies on the effectiveness of telemedicine
• Updated material on the myriad health-related applications used with smartphones
and tablet computers
• New article for “In the News”
“Tackling Weight Loss and Diabetes with Video Chats,” by Anahad O’Connor
published on April 11, 2017 in The New York Times
Chapter 3
• New material on the Ebola virus
• New material on the Zika virus
• New material on the current epidemic of opioid addiction
• New article for “In the News”
“Why the Menace of Mosquitoes Will Only Get Worse,” by Maryn Mckenna
published on April 20, 2017 in The New York Times
Chapter 4
• New material on light imaging technology used in radiology
• New article for “In the News”
“Why Big Liars Often Start Out As Small Ones,” by Erica Goode published on
October 24, 2016, in The New York Times
Chapter 5
• New material on the negative effects of robotic surgery
• New article for “In the News”
“Robotic Surgery for Prostate Cancer May Offer No Benefits over Regular
Surgery,” by Nicholas Bakalar published on July 28, 2016 in The New York Times
Chapter 6
• New material regarding CRISPR, a technology that makes gene editing easier
• New article for “In the News”
“Uncle Sam Wants You—Or at Least Your Genetic and Lifestyle Information,” by
Robert Pear published on July 23, 2016 in The New York Times
Chapter 7
• Updated material regarding teledentistry
• New article for “In the News”
“The Unexpected Political Power of Dentists,” by Mary Jordan published in the
Washington Post on July 1, 2017
Chapter 8
• Updated material regarding informational resources available on the Internet and the
many health-related apps available for smartphones and tablet computers
xiv PREFACE: AN INTRODUCTORY NOTE ON COMPUTERS

• New article for “In the News”

“Using the Web or an App Instead of Seeing a Doctor? Caution Is Advised,” by
Austin Frakt published in The New York Times on July 11, 2016
Chapter 9
• New material regarding developments in computerized devices
• New article for “In the News”
“A Talking Teddy Bear Practicing in the Pediatric Hospital,” by Emma Cott and
Taige Jensen published in The New York Times on June 3, 2015
Chapter 10
• New information pertaining to new laws about security, ransomware, and other issues
• New article for “In the News”
“The Health Data Conundrum,” by Kathryn Haun and Eric J. Topol published in
The New York Times on January 2, 2017
A note on our point of view: Over the last several years, politics and science have clashed
over many issues including climate change and whether human action is responsible. This
is not a debate within the scientific community, which has achieved consensus. We take
the consensus of the scientific community as our point of view.

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This book has the following student resources.
• Self-Study Assessment
• Flashcards
• Glossary

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• TestGen™
Reviewers
Reviewers of the Fifth Edition Reviewers of Previous Editions

Tandra Archie James Bonsignore, RHIA

Florida Technical College William Rainey Harper College
Orlando, Florida Palatine, Illinois
Lori Bennett, ABD Mary Beth Brown, MRC, BM
Colorado Technical University Sinclair Community College
Colorado Springs, Colorado Dayton, Ohio
Mary Beth Brown, MRC, BM Michelle Buchman MA, BSN, RN
Sinclair Community College Cox College
Dayton, Ohio Springfield, Missouri
Elizabeth Hoffman, MA Ed, CMA, Michelle Cranney
(AAMA), CPT, (ASPT) Virginia College, Online Division
Henry Ford College Birmingham, Alabama
Dearborn, Michigan
Tricia Elliott, MBA, CSHA
Jacqueline McNair, MA, RHIT William Rainey Harper College
Baltimore City Community College Palatine, Illinois
Baltimore, Maryland
Jeri Layer, AS
Roberta Taylor, BS Sinclair Community College
Sinclair Community College Dayton, Ohio
Dayton, Ohio
Deborah L. Weaver, RN, PhD
Valdosta State University
Valdosta, Georgia

xv
This page intentionally left blank
 1
CHAPTER
An Introduction to Medical
Informatics: Administrative
Uses of Computers in the
Medical Office
CHAPTER OUTLINE
• Learning Objectives
• Clinical/Medical Informatics
• The American Recovery and Reinvestment Act (ARRA), the Health Information
Technology for Economic and Clinical Health Act (HITECH), and the Health Information
Technology Decade
• The Patient Protection and Affordable Care Act (ACA) (2010)
• Administrative Applications of Computer Technology in the Medical Office
• The Patient Information Form
• The Paper Medical Record
• The Electronic Medical Record
• The Personal Health Record
• The Electronic Health Record
• The eHealth Exchange
• The EHR and Big Data Analytics
• Computer Information Systems in Health Care
• Medical Office Administrative Software: An Overview
• Coding and Grouping
• Scheduling
• Accounting
• Insurance
• Claims
• Accounting Reports
2 Chapter 1 • AN INTRODUCTION TO MEDICAL INFORMATICS

• Does Computerization Improve Patient Outcomes?

• In the News
• Chapter Summary
• Key Terms
• Review Exercises
• Notes
• Additional Resources

LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
• Define medical informatics, also known as clinical informatics.
• Discuss the American Recovery and Reinvestment Act (ARRA) and the Health Information
Technology for Economic and Clinical Health Act (HITECH) and their effects on health information
technology (HIT).
• Define the decade of HIT.
• Discuss the Patient Protection and Affordable Care Act (Obamacare).
• Define the electronic medical record (EMR) and electronic health record (EHR), and discuss the
differences between the two.
• Define interoperability.
• Define the eHealth Exchange.
• Describe computer information systems used in health care settings.
• Hospital information systems (HIS)
• Financial information systems (FIS)
• Clinical information systems (CIS)
• Pharmacy information systems (PIS)
• Nursing information systems (NIS)
• Laboratory information systems (LIS)
• Radiology information systems (RIS)
• Picture archiving and communication systems (PACS)
• Discuss the issues raised by several studies of the computerization of health records.

CLINICAL/MEDICAL INFORMATICS Medical informatics is “the application

of . . . information technology to . . . health-
Clinical informatics or medical informatics is a
care. . . .”2 Traditionally, the application of com-
rapidly expanding discipline. It has a long history
puter technology in health care is divided into
in which it has sought to improve the way medical
three categories. The clinical use of computers
information is managed and organized. In 2011,
includes anything that has to do with direct patient
clinical informatics became a board-certified spe-
care, such as diagnosis, monitoring, and treat-
cialty; the first exam was given in 2013. Doctors in
ment. Special-purpose applications include the
any medical field can become certified in informat-
use of computers in education, research, and some
ics by taking an accredited course and an exam.1
 THE AMERICAN RECOVERY AND REINVESTMENT ACT 3

aspects of pharmacy. Administrative applica- Currently, one important focus of medical

tions include office management, scheduling, and informatics is the integration of hospital infor-
accounting tasks. Many programs are specifically mation systems (HIS), so that radiological
designed for medical office practice manage- images, for example, are available in real time in
ment, which refers to all the business-related the operating room. Once the system in one insti-
aspects of a medical practice. Telemedicine—the tution is integrated, another important focus of
delivery of health care over telecommunications medical informatics is creating regional and then
lines—includes clinical, special-purpose, and national (and even international) interoperability
administrative applications. (diverse computer systems that can communicate
Clinical informatics has many definitions. with one another). The application of computer
The common emphasis in all definitions is on the technology continues to contribute to the achieve-
use of information technology to organize infor- ment of these goals.
mation in health care. That information includes This entire book is about clinical or medical
patient records, diagnostics, expert or decision informatics; in this chapter, we will focus on the
support systems, and therapies. The stress is not administrative applications of information tech-
on the actual application of computers in health nology in the medical office. This includes the
care, but the theoretical basis. Medical informat- health information technology (HIT) decade,
ics is an interdisciplinary science “underlying the electronic medical record (EMR), electronic
acquisition, maintenance, retrieval, and applica- health record (EHR), and various computer
tion of biomedical knowledge and information to information systems used in hospitals. We will
improve patient care, medical information, and discuss accounting in a health care environment.
health science research.”3 The tool used to per- In the rest of the book, specific clinical and spe-
form these tasks is the computer. Clinical infor- cial-purpose applications will be emphasized. All
matics focuses on improving all aspects of health of these applications are the focus of medical
care. Some of the aspects it focuses on include informatics. Part of the context of the expansion
improving the clarity of diagnostic images, of clinical informatics is formed by a series of
improving image-guided and minimally invasive laws and executive actions.
surgery, developing simulations that allow health
care workers to improve treatments without prac-
THE AMERICAN RECOVERY AND
ticing on human subjects, developing low-cost
diagnostic tests, treating physical handicaps, REINVESTMENT ACT (ARRA), THE
providing consumers with information, coordi- HEALTH INFORMATION
nating international medical reporting, develop- TECHNOLOGY FOR ECONOMIC
ing and improving information systems used in AND CLINICAL HEALTH ACT
health care settings, and developing decision (HITECH), AND THE HEALTH
support systems.
There are several subspecialties of clinical
INFORMATION TECHNOLOGY
informatics. A few are bioinformatics, which DECADE
uses computers to solve biological problems; A major impetus for the introduction of EHRs
dental informatics, which combines computer came from several federal laws: the Health
technology with dentistry to create a basis for Information Technology for Economic and
research, education, and the solution of real- Clinical Health Act (HITECH), part of the
world problems in dentistry; and nursing infor- American Recovery and Reinvestment Act
matics, which uses computers to support nurses.4 (ARRA), signed into law on February 17, 2009,
Public health informatics uses computer technol- by President Barack Obama, and the Patient
ogy to support public health practice, research, Protection and Affordable Care Act (ACA), also
and learning.5 known as Obamacare.
4 Chapter 1 • AN INTRODUCTION TO MEDICAL INFORMATICS

The Health Insurance Portability and The ONCHIT is in charge of promoting the
Accountability Act of 1996 (HIPAA) was passed universal adoption of HIT in the United States.
by the U.S. Congress and signed into law by The system will include an EHR for each person
President Bill Clinton in 1996. It established pri- and a nationwide system in which every health
vacy and security rules for EHRs: “A major goal care institution can communicate seamlessly with
of the Security Rule is to protect the privacy of every other health care institution.11 As of 2017,
individuals’ health information while allowing this goal had not been met.
covered entities to adopt new technologies to When the ARRA was signed into law on
improve the quality and efficiency of patient care.”6 February 17, 2009, by President Obama, it
HIPAA’s goal was to make health insurance por- included billions of dollars for the expansion of
table from one job to another and to secure the HIT. Through Medicare and Medicaid, monetary
privacy of medical records. Its privacy provisions incentives would be offered to doctors and hospi-
went into effect gradually in 2003, and the tals to adopt EHRs. By January 2015, 87 percent
Enforcement Rule went into effect in 2006. Its pri- of office-based doctors and “96 percent of all non-
mary purpose is to protect the privacy of individu- federal acute care hospitals possessed certified
ally identifiable health information. Basically, health IT.”12
patients must be aware of the privacy policy of the
health care provider and be notified when their THE PATIENT PROTECTION
information is shared (with major exceptions
detailed in the Patriot and Homeland Security
AND AFFORDABLE CARE ACT
Acts). Patients are guaranteed the right to see and (ACA) (2010)
request changes and corrections in their medical On March 23, 2010, the ACA, also known as
records. The information may be used for Obamacare, was signed into law by President
research, but software exists to remove all per- Obama. However, in December of 2017, Congress
sonal identifiers. Staff must be trained to respect repealed the individual mandate of the ACA; peo-
the privacy of patients; they should not discuss ple are no longer required to buy health insurance.
patients in a public area. Measures must be taken It is estimated that this will lead to 13 million
to ensure that only authorized people in the office fewer people having health insurance and raise
see the record. These measures may include bio- premiums by about 10 percent. Among other
metrics (using body parts to identify the user), things, the ACA had expanded health insurance
encryption, and password protection. When data coverage to millions more people by requiring
are sent over the Internet, they are encrypted using them to buy health insurance. It also expands
software; that is, they are scrambled; the data can Medicaid coverage and reforms insurance prac-
only be seen by someone with a decryption key.7 tices. If your employer does not offer insurance,
HITECH increases the penalties for violating the the insurance can be bought through state health
HIPAA Privacy Rule.8 (For a more detailed dis- insurance exchanges (HIEs). An HIE is a mar-
cussion of HIPAA and HITECH’s privacy and ketplace where you can buy insurance. The
security provisions, see Chapter 10.) exchanges are supposed to lower the price of
In 2004, President Bush established the insurance by allowing people to band together to
Office of the National Coordinator of Health get lower prices than an individual would have to
Information Technology (ONCHIT). Its mis- pay. The exchanges are state-based, but estab-
sion is to “promote a national health Information lished with federal start-up funds. The exchanges
Technology infrastructure and oversee its devel- have the power to require that the plans sold are
opment.”9 ONCHIT was funded by HITECH, part “in the interest” of purchasers. Although the
of the American Recovery and Reinvestment Act exchange cannot set premiums, it can require
signed into law on February 17, 2009, by President insurers to justify rate hikes, and if the exchange
Barack Obama.10 is not satisfied with the reason, it can refuse to
 Administrative Applications of Computer Technology in the Medical Office 5

sell that plan. The exchanges are not open to all pre-existing condition like diabetes or cancer
customers. You can buy from an exchange if you before you buy insurance coverage. There are no
work for a company with fewer than 100 employ- lifetime limits on your health benefits.21
ees, if you are unemployed, or if you are retired and Between 2010 and 2016, the number of
not eligible for Medicare. The exchanges are not Americans without health insurance declined
monopolies. An individual can buy insurance on sharply from 48 million to 28.6 million. Twenty
the open market, but the insurer has to charge the percent of those with insurance had public plans;
same price within and outside of the exchange.13 69.2 percent had private coverage. Of those with
Under the ACA, millions qualify for subsi- private plans, 11.6 million had bought their insur-
dies. Anyone with an income below four times the ance through the exchanges established by the
federal poverty level (federal poverty level: ACA. States that expanded Medicaid cut their
$24,600 for a family of four, $12,060 for an indi- uninsured rates in half from 18.4 percent in 2013
vidual; four times the federal poverty level: to 9.2 percent in 2016.22
$98,400 for a family of four, $48,240 for an indi- The ACA recognizes how important informa-
vidual in 201714) is eligible for some sort of sub- tion technology is in helping to improve both
sidy. In 2016, “the vast majority of ACA enrollees quality and efficiency. The Centers for Medicare
[were] still receiving subsidies.”15 Although the and Medicaid Innovation tests different ways of
Trump Administration stopped paying the subsi- delivering care: “Many of the payment and care
dies in October 2017, insurers still have to provide delivery model opportunities in the legislation,
the discounts required by the ACA. and in the initial projects specified by the
Under the ACA, Medicaid can be extended Innovation Center, require an information tech-
by the states to those who earn less than 133 per- nology infrastructure to coordinate care.” Some of
cent of the poverty level, although because of a the demonstration projects require both EMRs
Supreme Court decision, the expansion of and e-prescribing.23
Medicaid is up to each state.16 In a summary
of 108 studies of the effects of the expansion of ADMINISTRATIVE APPLICATIONS OF
Medicaid between 2014 and 2017, significant
increases in coverage and access to health care
COMPUTER TECHNOLOGY IN THE
and decreases in hospitals providing uncompen- MEDICAL OFFICE
sated care were found. “. . . [E]xpansion states Beginning with the computerization of hospital
have experienced greater reductions in unmet administrative tasks in the 1960s, the role of digi-
medical need because of cost than non-expansion tal technology in medical care and its delivery has
states.”17 Not only did individual health improve expanded at an ever-increasing pace. Today, com-
in states that expanded Medicaid, but the eco- puters play a part in every aspect of health care.
nomic health of the states improved, too. “[S] Administrative applications include office
tates expanding Medicaid under the ACA have management tasks, scheduling, and accounting
realized budget savings, revenue gains, and over- functions. These are tasks that need to be per-
all ­economic growth.”18 Through 2016, the fed- formed in any office. However, some of these
eral government paid all costs for those newly activities are slightly different in a health care
eligible for Medicaid.19 environment, so programs are needed that take
The bill reforms some of the practices of pri- into account the special needs of a medical office.
vate insurance. Children can stay on their parents’ Many programs are specifically designed to
insurance plans until age 26.20 Under the ACA, computerize basic administrative functions in a
insurance companies are prohibited from discrim- health care setting—the coding systems, insur-
inating against people with pre-existing condi- ance information, and payment information. Such
tions. Insurance companies cannot deny you programs allow the user to organize information
insurance or charge you more money if you have a by patient, by case, and by provider. These
6 Chapter 1 • AN INTRODUCTION TO MEDICAL INFORMATICS

programs enable the user to schedule patient information in a database file stored on a com-
appointments with a computer; take electronic puter. Within the file, there can be several tables.
progress notes; create lists of codes for diagnosis, Each table holds related information; for exam-
treatment, and insurance; submit claims to pri- ple, one table might hold information on the doc-
mary, secondary, and tertiary insurers; and receive tors working for the “Doctors’ Practice of
payment electronically. These programs must Anywhere,” another holds information on its
allow the bucket (balance) billing that medical patients, and another holds information on its
offices must use to accommodate two or three insurance carriers. All of the tables are stored in
insurers, who must be billed in a timely fashion the practice’s file. A table is made up of related
before the patient is billed. Moreover, because records; each record holds all the information on
these programs establish relational databases one item in the table. Each patient has a record in
(organized collections of related data), informa- the practice’s patient table. In a medical office or
tion input in one part of the program can be linked hospital, each record is a medical record. All the
to information in another part of the program. information on one patient makes up that patient’s
Billing information and financial status are easily record. Each record is made up of related fields.
available. Tables can be searched for any informa- One field holds one piece of information, such as
tion, and this information can be presented in fin- a patient’s last name, Social Security number
ished form in one of the many report designs (SSN), or chart number. One field—the key
provided, including various kinds of billing field—uniquely identifies each record in a table.
reports. If no report design meets the user’s need, The information in that field cannot be duplicated.
a customized report can easily be designed and Social Security number is a common key field
generated by the user. Medical accounting soft- because no two people have the same SSN. Chart
ware can be used by medical administrators and number uniquely identifies each patient’s chart. In
office workers, doctors and other health care a relational database, related tables are linked by
workers, and students. It can ease the tasks of sharing a common field. If a practice is completely
administering a practice using a computer. The computerized, a patient’s electronic record may
amount of data and information a modern practice contain several pages for personal information,
has to collect and organize is overwhelming. medical history, insurance information, notes,
These programs allow the user to computerize appointments, radiological images, alerts and
tasks performed every day in any medical envi- reminders, and allergies. The structure of a data-
ronment. All the disparate tasks and pieces of data base makes it possible to enter information in one
and information need to be well organized, acces- table (say, the appointments table), and that
sible, and easily linked. The user may quickly and appointment is automatically entered into the
easily organize, access, and link information from patient’s electronic record. The related files in a
one part of the program to information in any database can be used to generate structured
other part of the program. reports.
A database is an organized collection of
information. Database management software
(DBMS) allows the user to enter, organize, and THE PATIENT INFORMATION FORM
store huge amounts of data and information. The At or before a patient’s first visit, he or she fills
information can be linked, updated, sorted, out a patient information or registration form. It
resorted, and retrieved. To use DBMS efficiently, includes personal data like name, address, home,
the user should be familiar with certain concepts cell and work phones, date of birth, SSN, and stu-
and definitions. A database file holds all related dent status. The patient is also asked to fill in
information on an entity, for example, a medical information about his or her spouse or partner.
practice. For instance, the “Doctors’ Practice of Medical information is required: allergies,
Anywhere” would store all of its data and medical history, and current medications. The
 The Electronic Health Record  7

patient is also asked for the reason for the visit, such THE PERSONAL HEALTH RECORD
as accident or illness, and the name of a referring
Patients may establish their own records with the
physician.
help of several platforms, including Microsoft
In addition, the patient is asked to provide
HealthVault. An electronic personal health record
insurance information for himself or herself and a
(PHR) is a person’s health information in elec-
spouse or partner. This information includes the
tronic form. It belongs to the individual and is
names of the primary, secondary, and tertiary
available to him or her on any Web-enabled device.
insurance carriers; name and birth date of the poli-
It may include any relevant health information,
cyholder; the co-payment; and policy and group
including the primary care doctor’s name and
numbers.
phone number; allergies, including drug allergies;
medications, including dosages; any chronic health
THE PAPER MEDICAL RECORD problems, such as high blood pressure; major sur-
The information on the patient information forms geries with dates; and the patient’s living will and/
will then be entered in the patient’s record. The or advance directive. The PHR can be used in
traditional patient record was on paper, stored in emergencies to alert emergency personnel to neces-
one doctor’s office. One of the problems with sary information, as well as during routine doctor
paper records is that they may be illegible, which visits. The patient is in control of his or her PHR
can lead to serious errors in diagnosis, treatment, and can share it with whomever he or she chooses.
and billing. There is only one copy of a paper The patient can also add information that he or she
record, leading to difficulty in sharing patient gathers between doctor visits on blood pressure,
information and the possibility of misplacing the exercise habits, and smoking. It can help the patient
record. There can be a time delay between the keep track of appointments, necessary vaccinations
examination and the completion of the doctor’s and screening tests, and preventive services.26 As
notes on the record. A transcribed record or a of August 2, 2010, veterans were able to download
record typed using a word processor may include their PHRs from their MyHealthVet accounts,
human errors also. A paper record is hard to search allowing them to both control the information and
for specific information. The use of electronic share it with health care providers.27
records may help solve some of these problems.
THE ELECTRONIC HEALTH RECORD
THE ELECTRONIC MEDICAL
The information on a patient’s EMR will form the
RECORD basis of the EHR (Figure 1.1 ▶). Although the
In a computerized office, the information that was terms EMR and EHR are used interchangeably,
gathered and entered onto a patient information their meanings are not the same. According to the
form will then be entered into a computer into Healthcare Information Management Systems
EMRs. This will form the patient’s medical Society, an organization that promotes the expan-
record. Encouraged by HIPAA and the federal sion of the use of information technology in health
government, the EMR has gradually replaced the care, “[t]he Electronic Health Record (EHR) is a
paper record. The EMR may be stored in a hospi- longitudinal electronic record of patient health
tal’s private network, but it may also be kept on information generated by one or more encounters
the Internet.24 in any care delivery setting. Included in this infor-
Software has been developed that makes it mation are patient demographics, progress notes,
possible to store medical information on smart- problems, medications, vital signs, past medical
phones and tablet computers. The records include history, immunizations, laboratory data, and radi-
prescribed medications, insurance, and names of ology reports. The EHR automates and stream-
doctors, among other relevant data. It may also lines the clinician’s workflow. The EHR has the
contain digital photo identification.25 ability to generate a complete record of a clinical
8 Chapter 1 • AN INTRODUCTION TO MEDICAL INFORMATICS

▶ Figure 1.1 Electronic health record.

Source: U.S. Department of Veterans Affairs, www.va.gov.

patient encounter, as well as supporting other These certification criteria were developed by the
care-related activities directly or indirectly. . . .”28 Secretary of Health and Human Services. The mean-
There are specific differences between the ingful use criteria were adopted over a 5-year period.
EMR and EHR. The EMR belongs to one health The record must include the following: demograph-
care institution—a doctor’s office or hospital; it ics, vital signs, problem list, electronic notes, family
must be interoperable (be able to communicate health history, advance directive, and emergency
and share information with the other computers access, among others. The EHR must be encrypted,
and information systems) within that institution control access, and provide audit reports.31
only. Ideally, the EHR is not the property of any There are many benefits predicted from the
one institution or practitioner. Eventually, it must EHR: As records become interoperable, the
be interoperable nationally and internationally. It patient’s record will be available anywhere there
is the property of the patient who can access the is a computer on the network; this helps guarantee
record and add information. It must include infor- continuity of care. Each of the patient’s health
mation from all the health care providers and care providers will know the patient’s full medical
institutions that give care to the patient. It thus history and can therefore provide better care. If
eases communication among many practitioners the patient is in an accident in New Jersey, for
and institutions. It is a source for research in clini- example, but lives in California, the patient’s
cal areas, health services, patient outcomes, and record is a click away. The EHR is legible and
public health. It is also an educational source.29 complete. The EHR may also allow the patient to
Meaningful use of EHRs is defined by be more in control of his or her health care: By
ONCHIT. It refers to meeting several criteria.30 2015, 64 percent of doctors could securely
 The EHR and Big Data Analytics 9

exchange messages with patients, 63 percent of hasn’t gotten his recommended pneumonia
doctors’ EHRs allowed patients to view their elec- shot. Or, perhaps he was taken off his beta-
tronic records, 41 percent of doctors could let blockers during a recent hospitalization and
patients download their records, and 19 percent needs to start them again.” The study found that
allowed patients to electronically send their doctors’ performances were significantly
records to another doctor. Sixty-nine percent of improved. According to the study, simply using
hospitals allowed patients to view, download, and EHRs does not automatically improve care. For
send their records.32 However, despite its benefits, example, simple reminders on prescribing pro-
the EHR raises serious privacy issues. Any net- duce small improvements.37
work can be broken into, and the medical infor-
mation can be stolen and misused; a great deal of THE eHEALTH EXCHANGE
medical information is private. HIPAA provides
To be effective in improving care, EHRs have to
the first federal protection for medical records. In
be fully interoperable nationally. The first step
2015, data breaches affected more than 113 mil-
toward national interoperability is regional
lion people.33 (See Chapter 10 for a full discus-
interoperability. Regional cooperation is being
sion of HIPAA and HITECH and the privacy of
fostered through the establishment of regional
medical information.)
health information organizations (RHIOs) in
The information on the EHR is also available
which data are shared within a region. The
for studies of public health and can be used to
eHealth Exchange, formerly the Nationwide
collect data that will help improve health out-
Health Information Network (NHIN), is the
comes. By 2015, hospitals were required to report
infrastructure that would allow communication
certain public health data including immuniza-
between RHIOs. Finally, a nationally interopera-
tions, some lab results, and syndromic surveil-
ble system would be established, where any
lance to a public health agency. 34 Syndromic
patient record would be available anywhere on the
surveillance means tracking health and disease
national network.
patterns in a community. In 2015, Congress
By 2015, the eHealth Exchange encom-
passed the Medicare Access and CHIP
passed 40 percent of U.S. hospitals, more than
Reauthorization Act of 2015 (MACRA). One of
8,000 pharmacies, and 100 million patients.
its aims is to move Medicare and CHIP payments
Networks of providers, hospitals, regional health
to quality of care or outcomes instead of the
information exchanges, and federal agencies are
amount of care, that is, the number of procedures
participants. It is the largest health information
performed. MACRA is trying to move from fee-
network in the United States and includes all 50
for-service to value-based care.35
states.38
One study (2015) of 47 articles on the
effects of EHRs on patient outcomes found that
EHRs improve health care, improve efficiency, THE EHR AND BIG DATA ANALYTICS
reduce medication errors, and reduce adverse One of the things made possible by the EHR is the
drug events (ADEs).36 There are some studies gathering of huge amounts of health-related and
indicating that this is true. In 2010, a study was lifestyle-related data. The Internet of Things (IoT),
done on 40 Northwestern Medicine primary made up of connected devices such as heart moni-
care physicians using smart EHRs that alerted tors, Fitbits, scales, and other wearable and non-
doctors during exams when something was wearable electronic devices, can add to these data.
wrong with the patient’s care: “[A] . . . yellow When collected in data warehouses, these data can
light on the side of the . . . computer alerts him be mined for trends, and predictions can be made.
or her that something is awry. . . . When the The right analytic software can show a practice
doctor clicks on the light, she may learn that which patients need to be watched for coronary
Mr. Jones, who has congestive heart failure, artery disease, which for diabetes. Treatment plans
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