Page 81 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 8: Principles of Medical Informatics and Clinical Informatics in the ICU 49

CHAPTER Principles of Medical USA, implementation of HIT is supported by the HITECH provisions of
the American Recovery and Re-investment act of 2009. Central to the
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8 Informatics and Clinical release of funding, the concept of “meaningful use” has been adopted as
a mechanism to ensure government funding is directed toward technol-
Informatics in the ICU ogy that enhances the quality of care delivered to patients. The defini-
tion of meaningful use of EHR has only recently been agreed upon by
Vitaly Herasevich the Center for Medicare and Medicaid Services and is expected to shape
Ognjen Gajic the core functionality of HIT in the USA for the foreseeable future.
Brian W. Pickering The adoption of HIT has been advocated on the basis that an overall
increase in the quality of care delivery will follow. The major areas of
positive impact are reported to include increased adherence to protocol-
https://kat.cr/user/tahir99/
KEY POINTS based care, reduction in medication errors, and lower cost. 4,5
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Despite the potential benefits, the complexity of the effect that
• Development of data integration platforms, Clinical Decision widespread adoption of EHR will have on processes of care is largely
Support Systems (CDSS), telemedicine, and mobile computing unknown. Significant knowledge gaps currently exist and are underlined
applications are rapidly changing the acute hospital environment. by a number of studies that report a negative impact of HIT on patient-
• The widespread adoption of health information technology (HIT) centered care. These negative effects include disruptions to established
is being actively promoted as a tool to facilitate quality and safety workflow, increased time spent in documentation and away from patient
of health care. care, and information overload. The care of patients in the ICU gener-
• High cost, indiscriminate data presentation, information overload, ates vast quantities of data. A significant advantage of a HIT-enabled
and a lack of human factor consideration present significant barri- ICU is that these data are available in a digital form. Digital signatures
ers to wider HIT adoption. of patient characteristics, disease state, physician and nursing actions,
• Although HIT adoption improved some elements of quality and as well as operational data such as time stamps or entity location offer
safety, there is currently little evidence to prove that HIT adoption an unprecedented opportunity to capture data, which facilitates system
is associated with improved patient-centered outcomes. understanding as well as the development of applications which nudge
it toward an optimized state.
• To get the most from the digitalization of the ICU environment, ICU patients, however, by virtue of their severity of illness and the
an integrated and multidisciplinary approach is required. Medical large number of processes of care, team members, and technology, may
informatics and human factor engineering provide a core method- be particularly vulnerable to the potentially disruptive effects of HIT
ology and tools for meaningful use of HIT to optimize quality and adoption. For example, the implementation of a commercially available
safety of critical care delivery computerized physician order entry (CPOE) system in a pediatric ICU
was associated with a doubling of adjusted mortality. In many cases,
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technology buries useful information in noise. The hopelessly inadequate
It has been estimated that ICU patients are exposed to an average of 178 performance of bedside alarms manifest as unnecessary interruptions to
processes of care every 24 hours. Each process is an opportunity for the workflow, frequent manual override without action, and provider fatigue.
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system of health care delivery to fail. The same study estimated that the In order to realize the “meaningful use” of EHR, it is essential that
rate of failure, in the form of errors, which caused or had the potential to hospital managers, clinicians, systems engineers, cognitive scientists,
cause harm, was about 1%, or just fewer than 2 per patient per day. This and information technology and informatics experts work together to
may seem a small number of failures but when one considers severity of understand how health care providers can best be enabled to provide
illness of ICU patients, it is not surprising that they are particularly vul- safe care and improve patient-centered outcomes. In other industries,
nerable to those errors. With the declaration of Vienna, the elimination this multidisciplinary approach has been adopted very successfully and
of error in the ICU has been determined to be the single most important has led to increased reliability, system optimization, and innovation.
priority of the critical care societies of all major developed and develop- In a similar manner to a state-of-the art navigational aid, future HIT
ing nations including the Society of Critical Care Medicine in the USA applications should guide the ICU patient safely from one health state
and European Society of Intensive Care Medicine. The combination of to the next.
health information technology, medical informatics, and an invested
team of frontline providers has the potential to play an important role in BIG PICTURE: WHAT IS MEDICAL INFORMATICS?
the redesign of ICU systems of health care delivery. In this chapter, we
outline the application of medical informatics in the acute care setting. Informatics and computers in medicine mean different things to dif-
With examples, we illustrate some of the challenges and opportunities ferent people depending on their roles and responsibilities. For policy
that exist for acute care settings equipped with a comprehensive elec- makers, they may facilitate access to benchmark public health data. For
tronic health record. hospital administrators, they may provide resource utilization oversight
and reportable indicators of quality. For the hospital or community
HEALTH INFORMATION TECHNOLOGY AND practitioner, they may be used for documentation, patient scheduling,
ELECTRONIC HEALTH RECORD prescribing, and billing. For the patient, they may offer access and the
ability to share their own medical data. For researchers, they may pro-
Health care providers and policy makers already support the use of vide access to raw data and the tools to analyze it.
health information technology (HIT) as a tool for providing efficient, Medical informatics is defined by American Medical Informatics
high-quality patient care. HIT has been defined as “the application of Association as, the application of “the principles of computer and infor-
information processing involving both computer hardware and software mation science to the advancement of life sciences research, health pro-
that deals with the storage, retrieval, sharing, and use of health care fessions education, public health, and patient care” and is described as
information, data, and knowledge for communication and decision a “multidisciplinary and integrative field focused on health information
making.” Electronic health record (EHR) is one application of HIT and and communication technologies, and involves computer, cognitive,
is perhaps the one most familiar to bedside providers. and social sciences.” The growing importance of this field of practice is
Widespread adoption of interoperable HIT has become a top priority such that there are ongoing efforts to establish clinical informatics as a
for health care systems in both developed and developing nations. In the formally recognized medical subspecialty. 7

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