The Digital Age has made access to high-speed broadband services as necessary as telephone service has been for decades. High-speed telecommunications services are now a basic communication tool for education and health, banking, for access to government services, for work-related and marketing activities as well as for leisure activities, games, entertainment and even news (1).
Technology and, in particular, Internet technology are transforming the academic medical landscape. Clinical faculty increasingly use electronic medical record (EMR) systems as they perform clinical duties. A large number of institutions are moving to digital-only radiography. House staff now come to rounds armed with a vast array of reference information stored in handheld personal digital assistants (PDAs). The iPod has recently become a platform for lectures as “podcasts” (2), and the feasibility of using an iPod as a mobile X-ray image viewer has been recently demonstrated (3). Continuing education is also increasingly available through the Internet (4). The digital revolution has greatly altered how academic health systems pursue education, research, and clinical care.
One of the most fundamental transformations is occurring in the area of health care delivery. The provision of clinical care is changing rapidly as eHealth technologies become increasingly used and accepted (5–7), with a move away from episodic care to a concentration on continuity of care, especially for patients with chronic diseases (8), who will create the greatest disease burden in the future (9). Care is gradually moving away from a focus on the service provider to that of the informed patient and from an individual approach to treatment to a team approach. Increasingly, less focus is placed on treating the illness and more is placed on wellness promotion and illness prevention: the model of the “information age care” described by Ferguson (10). To move to this future of information age health care (11), the availability and use of information must be strengthened to facilitate changes in health service delivery, and a much greater focus must be placed on developing and refining the information technology infrastructure.
Distributed academic networks of like-minded researchers and clinicians are starting to emerge under the guise of regional health information organizations (RHIOs) to:
The single most important technical innovation making these RHIOs possible is broadband distribution, which enables the development of sophisticated multi-media-based applications, particularly on the doctor’s desk. The increasing availability of broadband systems, whether satellite-based, cable, fiber, or digital subscriber lines (DSL), means that, with their reduced prices, there is simply more opportunity to provide effective e-health services through these academic networks.
Major medical centers are now using Telemedicine and eHealth technologies in a variety of ways to benefit their residents. The continuing wired and wireless integration of clinical data and systems at the point of care will result in better treatment and reduced medical errors. The next logical step is to expand the networks and to be able to link them in a secure, affordable, and effective environment to support health, education, and economic vitality in rural communities (1).
Whatever technological changes occur, the major challenge will be to make relevant information available at the point of care with the patient. Here, access to broadband networks is key. Northern California has recently become the epicenter of an emerging RHIO. In Northern California, high-speed networks, such as internet2 (www.internet2.edu) and CENIC (www.cenic.edu), facilitate the development and interconnection of participants in the RHIO. Northern California, as a center of commerce, technology, and education incorporating the state’s capital city, Sacramento, is an ideal venue for such an RHIO. A small number of technically highly evolved regional health care organizations serve a large proportion of the total health care customer base. From an information technology perspective, these organizations already have many similarities.
In our experience, establishing a successful RHIO among diverse health care organizations requires reconciling multiple cultural, logistical, technical, and communications policies and practices. At the same time, it offers major long-term academic and clinical advantages to all concerned. These policies and practices may be broadly categorized into five principal areas:
All members must agree on the extent of clinical and academic information to be made available among the partners. In particular, the interchange of selected medical records is an issue because creating a comprehensive record delivery system could be prohibitively costly, especially during early stages of the initiative. From a clinical perspective, only occasionally are complete clinical notes required, such as when a patient is transferred from one hospital to another. Most often, relatively small amounts of key clinical information are sufficient to ensure good clinical care, such as that found in recent clinical summaries or in laboratory and pharmacy reports. Research data needs vary with differing projects, but “minimum data sets” would allow core regional research programs to be developed.
2. Privacy, Security, and Confidentiality
To engender mutual confidence and trust among the participants, as well as to meet regulatory requirements, RHIO security and privacy policies and practices must be carefully defined and enforced. The HIPAA regulations serve as a useful and necessary framework for developing the RHIO privacy and security principles.
3. Data and Coding Standards
Uniform standards among the participants are essential at all technical and operational levels (12). All RHIO partners must adopt a range of industry standards, such as Health Level-7 (HL-7) for data exchange, the Systematized Nomenclature of Medicine (SNOMED) for common vocabulary, the International Classification of Disease (ICD) for morbidity and mortality coding, and the Veteran’s Administration RxNORM as a common representation of drug information (13). The availability of standards is necessary but not sufficient for health care system interoperability. The ability to integrate hospital systems will depend on integrating the clinical nomenclature into data exchange standards (14). Uniform standards of practice for medical records need to be established. Establishing a common directory architecture among the participants is also essential for seamless interoperability.
4. Telecommunications Infrastructure
Each participant in the RHIO must maintain extensive and sophisticated computer network facilities to communicate effectively with other RHIO partners. The interconnection should be a straightforward technical task and can be almost immediately accomplished using the CENIC Network, the Internet, or both. In either case, privacy and security would be maintained using Virtual Private Network (VPN) encrypted connections.
5. Change Management and Training
All partners need to encourage the use and uptake of information technology in their various systems as they implement an electronic health record. Substantial gains can be made by collaborating in training and education activities and in workflow redesign for an electronic information environment across the partner groups.
A collaboration between the University of California, Davis, and the four other University of California academic medical centers is in the planning stages. The goal of this collaboration is to develop a statewide RHIO using CENIC and linking some Kaiser-Sutter hospitals and telemedicine networks, as described in a recent report from the California Telemedicine and eHealth Center (www.cteconline.org).
The University of California, Davis, Health System (UCDHS), as an academic medical center with substantial interests in clinical effectiveness, distributed research, and education, is ideally positioned to be involved in these Californian RHIO initiatives because of a long association and great credibility with the legislature and with state health care agencies. Within California, the UCDHS’s sophisticated Information Services infrastructure has a growing reputation for the development and maintenance of cutting-edge, state-wide information management applications (such as projects involving the University of California’s incident reporting, California’s death certificate registration system, telemedicine, and bioterrorism). The UCDHS has plans to become a “distributed regional” health provider (using its information technology infrastructure as its foundation), has the only medical school with a marked impact in Northern and Central California, and is developing relationships with commercial companies to foster biomedical research.
Academic centers and the functions of schools of medicine will be linked with the network in several ways. Education at medical school will be different in the future as the schools themselves increasingly become distributed virtual academic environments, available wherever or whenever students need them. Teaching and supervision may be done by specialists from afar who have particular skills or expertise and who are linked to these distributed academic networks. This linking is already happening in some commercial university programs where individual professors, mainly in areas such as business and economics, have become educational “superstars.”
The future may bring students who will enroll in a school for basic, hands-on training but who will also enlist in remote lectures for a particular course. Teachers could be sought to “headline” programs and attract students, in the same way that sports teams hire particular individuals with special talents to ensure success, both on the field and in promoting the brand. The distributed virtual environments of the future could transmit these teachers easily into prearranged courses, programs, institutions, and countries, anytime and anywhere. Health education programs may, as a consequence, become more flexible and could become available anywhere. As noted by Stead (15), the “Networked Health Enterprise” is increasingly possible as the informatics community creates environments that allow information to reach across the network while adhering to standards of privacy and intellectual property.
With advancements in broadband technologies, we will likely move to global health care systems where doctors and patients interact in electronically distributed environments around the world, either wired or wireless. These global delivery environments, formed as “networks of networks” amalgamating and linking RHIOs from different states and countries, could incorporate a variety of features, including video technology, to allow video consultations in real-time or video e-mail for store-and-forward programs, as well as electronic consumer-owned or provider-shared voice-driven health records. On the doctor’s desktop, appropriate practice management and communications software will be serviced either from central servers or from the doctor’s own local network and that will allow him or her to link seamlessly in peer-to-peer relationships with colleagues. Health care professionals will be able to receive continuing health education for professional credits and reaccreditation needs via their desktop.
The development of distributed academic networks should lead to substantial epidemiological and biodefense-related research opportunities. The research possibilities can be divided into two areas: an expansion of present research programs, with new partners and more patient access; and the development of new research programs among RHIO partners, and evaluation of the effectiveness of the RHIO itself as a process supporting “distributed health care.”
The implementation of an RHIO should lead to exploring specific research hypotheses, about both patient outcomes and system outcomes, such as better regional cooperation. A comprehensive evaluation of the process of moving toward a distributed health network itself must be implemented from the beginning. With the expanded patient base it provides, an RHIO could encourage commercial partnerships between the information technology and pharmaceutical industries.
Although the technology revolution has altered many areas in health care, several challenges remain. Despite the proven benefits of electronic medical record systems, their use is surprisingly low among U.S. physicians. Upwards of 90% of U.S. physicians access the Internet for personal use, yet less than 20% of office-based practices use electronic medical records (16, 17). Despite the proven benefits of physician order entry systems, less than 8% of physicians use one routinely (18). Ignorance of the benefits of computerization is unlikely to explain the lack of adoption. Among nonusers of electronic medical record systems, more than 50% of physicians recognize that these systems could reduce their risk of making medical errors and improve the quality of care in their offices (19).
Frequently, the focus of the investment made in health care information technology is not optimal. An astonishing $20 billion is spent annually by health care providers on information technology, but over two-thirds of this money is used to upgrade and maintain billing systems and only one-third is used for hospital clinical information systems (16). Understanding the barriers to adopting health care information systems and developing strategies to overcome them are critical for realizing their full benefits. Regional health information organizations that involve academic medical centers promise to promote the use of health care information systems and effective informatics practices through education and community outreach.
Even if health care enterprises were to purchase a prevailing commercial health care information system, lack of interoperability (the ability to seamlessly link data from disparate systems) continues to be a major limitation to the regional use of computerized clinical data (20). The lack of interoperability among systems means that these digital resources are “silos” of information living separately without the ability to link together effectively. Without interoperability, data exchange between and data aggregation across them is not possible. Interconnecting information across systems requires overcoming some formidable challenges, such as instituting the widespread use of data exchange standards and standardized coding systems.
The ability to influence a physician when he or she is executing a care plan can alter clinical outcomes. Not surprisingly, some of the most compelling data regarding the benefits of clinical information systems come from studies of computerized physician order entry (CPOE) systems (21). However, CPOE systems have also been implicated as the causes of errors (22). Thus, CPOEs do not guarantee better decisions by clinical users. Success requires careful attention to how the system is configured and a thorough understanding of how it influences the user on a cognitive level (23).
Overcoming these challenges is essential to improving the widespread adoption of computerized clinical systems and evolving toward a truly integrated, 21st-century eHealth environment with its attendant benefits to patients and society.
All of these developments will mean a major emphasis on distributed or enterprise systems of information and communications technology and on the benefits that they can bring to patients, providers, and the community at large.
The health system has to meet the challenges contained in the recent crucially important report from the Committee on Quality Health Care in America published by the Institute of Medicine (24). This influential report notes that “information technology must play a central role in the redesign of the health care system” and suggests that the United States needs a renewed national commitment to build an information infrastructure to support health care delivery. In addition, that commitment should lead to the “elimination of most hand written clinical data by the end of the decade.” For this change to occur, the health system has to think seriously about its basic infrastructure requirements, and in the next century, these will increasingly involve close collaboration with telecommunication providers.