Health information terms

In 2004, United States President George Bush called for most Americans to have electronic health records by 2014. While few would have imagined what that really could mean to the providers of health care, patients and consumers, and those dependent on gathering health-related information from multiple sources, one thing was certain: he was not referring to electronic versions of the paper records used in most clinical settings at the time.

The types of electronic records that would support the outcomes that were and are still anticipated are part of a health information technology infrastructure that will ultimately allow authorized access to fully comprehensive patient and consumer health related information for multiple appropriate activities: patient care, consumer self-management of health, and a multitude of research, emergency response, and public health initiatives. Another part of that infrastructure is the system of health information exchange networks that can support secure and reliable information exchange within their constituency, and with other similar networks. Both the electronic records and the system of networks must, however, have incorporated recognized standards for interoperability and for the secure and reliable exchange of health information.

As of today, we do not have all the critical pieces in place to realize the vision. They are, however, just around the corner. The Certification Commission for Health Information Technology has incorporated basic interoperability standards for patient care as part of its 2008 certification criteria. Nine sites implementing the core specifications for health information exchange are the first of many that will constitute the Nationwide Health Information Network. We are on the cusp of a cataclysmic change in how health and care will be managed into the future as more and more information becomes available through expanded adoption of interoperable technologies.

Realizing the vision is not, however, just about the enabling technology. It’s also, to quote Secretary Michael Leavitt in his keynote address at the February 2008 HIMSS Annual Conference & Exhibition in Orlando, very much about sociology and culture change. Both clinicians and consumers need to feel that privacy and security needs are addressed appropriately. Everyone must see the value in creating, exchanging, and using electronic health information, and contribute to its investment. And, as in any culture, we need to clearly communicate with one another, so that our health policies are well informed, products can be marketed with transparency, and protections can be applied to well-defined situations.

Culture change requires a consistent language that can support a system of public policies, private development, and outreach/educational initiatives that will allow the majority of Americans to experience the actual value of an electronic health information infrastructure. Our next step, then, is to assure that this language is in place and represents a consensus on how terminology and definitions should be used as we move toward the 2014 goal. I am pleased that The National Alliance for Health Information Technology has convened this public dialogue and presents here the results.

Costs and Benefits of Health Information Technology

The United States health care system is at risk due to increasing demand, spiraling costs,  inconsistent and poor quality of care, and inefficient, poorly coordinated care systems. Some  evidence suggests that health information technology (HIT) can improve the efficiency, costeffectiveness, quality, and safety of medical care delivery by making best practice guidelines and evidence databases immediately available to clinicians, and by making computerized patient records available throughout a health care network. However, much of the evidence is based on a small number of systems developed at academic medical centers, and little is known about the organizational changes, costs, and time required for community practices to successfully implement off-the-shelf systems. An analysis of the usefulness of implementing HIT must take into consideration several

factors: 

• ·         The potential of this technology to improve health care quality, safety, and patient satisfactionand how this potential has been demonstrated.The cost-effectiveness of the technology—the business case for adoption of the technology including the total costs of implementation (both financial and in terms of resources) and any cost savings that accrue. Concerns exist that those who bear the greatest share of such costs are not able to recoup those costs.  

• ·         The ability to generalize the effects of an HIT intervention on costs and benefits in existing systems (using published experience with or research on these systems) to the technology’s use by other health care organizations. The Leap Frog Group and a number of components of the U.S. Department of Health and Human Services (HHS)—the Centers for Medicare & Medicaid Services (CMS), the Office of the Assistant Secretary for Planning and Evaluation (ASPE), the Office of Disease Prevention and Health Promotion (ODPHP), and the Agency for Healthcare Research and Quality (AHRQ)—requested a review of the research on HIT to compile and evaluate the evidence regarding the value of discrete HIT functions and systems in various health care settings. This  Evidence-based Practice Report on the costs and benefits of health information technology systems, along with an accompanying interactive database that catalogs and assesses the existing evidence was prepared by the Southern California Evidence-based Practice Center (EPC). This report systematically reviews the literature on the implementation of HIT systems in all care settings and assesses the evidence in four specific circumstances: 

1.  The costs and benefits of HIT for pediatric care.
2.  The ability of one aspect of HIT, the electronic health record (EHR), to improve the quality of care in ambulatory care settings.
3. The costs and cost-effectiveness of implementing HER.
4. The effect of HIT on making care more patient-centered.

Pharmacology and formulation

Buprenorphine acts as a partial opioid agonist by attaching tightly to the same receptors in the brain as other opioids, such as oxycodone, heroin, or methadone, blocking their effects and preventing withdrawal symptoms. Buprenorphine produces only weak morphinelike effects, without the euphoria triggered by full opioid agonists in opioiddependent individuals. Buprenorphine carries a lower risk of abuse, dependence, and overdose compared to full opioid agonists.However, a fatal overdose is still possible if patients combine buprenorphine with other central nervous system (CNS) depressants, such as sedative-hypnotics (e.g., benzodiazepines) or alcohol.

Effectiveness of Buprenorphine office-based treatment 

A 2006 evaluation of buprenorphine office-based treatment showed it to be effective. Most physicians surveyed (74%) found one or more months of buprenorphine treatment to be effective for their patients, with 60% of patients abstaining from all drugs and 84% from opioids (except buprenorphine) after a one-month period.

Slightly more than half the physicians (53%) had no previous experience with medication-assisted treatment (MAT) for opioids. (MAT is the use of medications, in combination with counseling and behavioral therapies, to treat substance-use disorders). At a six-month follow-up, 81% of patients said they had abstained from opioids, and 59% said they had abstained from all drugs.

Recognizing opioid abuse and dependence 

Clinicians should be alert to potential signs of substance abuse during routine and urgent visits, or while taking the patient history. Asking nonjudgmental, open-ended questions about a patient’s functioning with his or her family, at work or school, and in social situations may reveal a drug problem. It is important to avoid stigmatization. Primary care physicians can use screening tools such as the CAGEAID (Table 2), which are effective in identifying substance abuse problems. If the substance abuse screen is positive, be aware of signs associated with opioid intoxication such as drowsiness, slurred speech, memory impairment, and pupillary constriction.

After a thorough assessment, a formal diagnosis of either opioid dependence or abuse should be made. Substance dependence or abuse is based on a cluster of behaviors and physiological effects occurring within a specific time frame. The diagnosis of dependence is more severe and therefore supersedes one of abuse if the person meets the criteria for both abuse and dependence listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR).

City Health Information

A ddiction to narcotic pain relievers and heroin (opioids) is a major health problem in the United States (US). Rates of abuse and dependence for opioid pain relievers such as Vicodin® (hydrocodone bitartrate and acetaminophen) and OxyContin® (oxycodone HCl controlled-release) have increased during the past several years, and opioids are now second only to marijuana as drugs of abuse.

However, fewer than 20% of Americans who are dependent on opioids (narcotic pain relievers and heroin used intravenously and intranasally) are in drug treatment programs. Drug overdose is one of the leading causes of death in New York City (NYC). In 2006, more than 900 people died of drug overdoses in NYC; heroin and other opioids were involved in the majority of these deaths. Buprenorphine is the only approved officebased treatment for opioid dependence. Buprenorphine makes treatment for opioid dependence more readily available, and patients can have their buprenorphine prescriptions filled at a pharmacy. Opioid addiction treatment in a primary care setting also allows for increased clinical attention to other health conditions amongopioid-dependent individuals.

Framework and Standards for Country Health Information System

The Health Metrics Network (HMN) was launched in 2005 to help countries and other partners improve global health by strengthening the systems that generate health-related information for evidence-based decision-making. HMN is grateful for funding support from the Bill and Melinda Gates Foundation, the Uk Department for International Development (DFID), the Danish International Development Agency (DANIDA), the Netherlands Ministry of Foreign Affairs, the United States Agency for International Development (USAID), the European Commission (EC) and the World Health Organization (WHO), which also serves as host to HMN.

HMN is the first global health partnership that focuses on two core requirements of health system strengthening in low and low-middle income countries. First, the need to enhance entire health information and statistical systems, rather than focus only upon specific diseases. Second, to concentrate efforts on strengthening country leadership for health information production and use. In order to help meet these requirements and advance global health, it has become clear that there is an urgent need to coordinate and align partners around an agreed-upon “framework” for the development and strengthening of health information systems.

It is therefore intended that by 2011, this Framework and Standards for Country Health Information Systems (the “HMN Framework”) will be the universally accepted standard for guiding the collection, reporting and use of health information by all developing countries and global agencies. This will only be achieved by fostering agreement on the goals and coordinated investments now needed by country health information systems.

The HMN Framework will serve two broad purposes. Firstly, at country level, it will focus investment and technical assistance on standardizing health information system development, and serve as a benchmark for baseline system assessments. As part of this, a roadmap is described for strengthening health information systems, and putting in place on going monitoring and evaluation. Second, the HMN Framework will permit access to and better use of improved health information at the country and global levels.

The HMN Framework is not intended to replace existing guidelines that provide detailed information on health information system elements. Instead it will seek to identify appropriate and existing standards and promote them. This dynamic approach is expected to evolve over time as it incorporates new developments, country experiences and partner inputs. This second edition has already been informed by a wealth of input on different aspects of health information systems obtained through consultative meetings and country visits. Its adaptation is intended to be iterative as HMN progresses and country health information systems mature. It is intended that the HMN Framework will be instrumental in forging consensus around the vision, standards and processes required of a health information system.