The responsibility for assuring America’s health has historically been assigned to governmental public health agencies at the local, tribal, state, and national departments of health. But while the government has the responsibility to promote and protect the health of the people, The Future of Public Health in the 21st Century1 reported that public health agencies alone cannot assure the nation’s health. Public resources are finite and democratic societies limit the actions that can be taken by government. Many determinants interact to create health and there is a growing recognition that individuals, communities, and institutions can form powerful relationships that governments cannot replicate alone.1 Therefore, the definition of public health asserted by the Institute of Medicine, “what we as a society do collectively to assure the conditions in which people can be healthy,”2 is viewed as the responsibility of each of us, especially the largest group of healthcare professionals—nurses.
Public health functions and informatics needs
While we look to assure the conditions in which people can be healthy, it is noted that information shortcomings affect our ability to serve the public’s health.1 Despite advances in science and technology in many other industries, information systems and technologies in health care are outdated and inadequate to support the information needed in health care. Assessment of the public’s health involves collection, analysis, interpretation, and communication of information. Currently, this information comes from a wide variety of sources, yet suffers with problems of fragmentation, redundancy, and lack of standardization. In most communities we lack interoperable networks to share or aggregate information to support policy efforts and consumer involvement. Electronic record systems offer the infrastructure to collect and manage information in a meaningful way, but this technology has not diffused into society quickly enough.
National initiatives in informatics
While the US healthcare system has a long and distinguished history of innovation, health care faces major challenges including high costs, medical errors, variable quality, administrative inefficiencies, and lack of coordination. These challenges are often connected to inadequate use of health information technology (HIT) as an integral part of medical and nursing care.3 In 1998, the National Committee on Vital and Health Statistics affirmed that the nation’s information infrastructure could be an essential tool for promoting the nation’s health.3 In April 2004, President Bush issued an Executive Order calling for widespread adoption of interoperable electronic health records within 10 years. This Order established the Office of the National Coordinator for Health Information Technology (ONCHIT) to coordinate the development and implementation of interoperable HIT in both the public and private sector.3, 4 The goals and initiatives of the ONCHIT are important to nursing, as they will form the strategic information infrastructure on which the future of health care will be built.5, 6
Goals for the HIT decade
Within the context of a strategic framework, 4 goals were asserted for the HIT Decade, each with specified strategies intended to contribute to the vision for improved health care. The goal of informing clinical practice is directed to reduce medical errors and duplicative work to allow clinicians to work on improved patient care. Strategies here include creating incentives to implement the electronic health record, decreasing the risk of investment, and diffusing technology to rural and underserved areas. The goal of connecting clinicians is directed at creating interoperable records so that data are portable and can follow patients as they move through the care settings. Strategies here include fostering regional collaborations, developing a nationwide health information network (NHIN), and coordinating federal health information systems so that federal care delivery, reimbursement, and oversight are more efficient and cost effective. The goal of personalizing care focuses on helping individuals manage their own wellness. The strategies for this goal are to encourage the use of personal health records, enhance informed consumer choice, and promote the use of telehealth systems. Finally, the goal of improving population health fosters the collection of timely, accurate clinical information that allows for evaluation of care, public health surveillance, clinical research, and feedback to clinicians. Strategies for this goal are to unify public health architectures, to streamline quality health status monitoring, and to accelerate research and the dissemination of evidence.3
Public-private partnerships
The vision for consumer-centric and information-rich care requires a joint effort between the federal, state, and local governments, and the private sector. Federally funded contracts are directed toward creating an interoperable information infrastructure referred to as a nationwide health information network (NHIN). The NHIN is to be designed to operate with systems that have been certified to meet functionality requirements and comply with harmonized interoperability standards. Current partnership activities include efforts to: (1) evaluate the state of adoption of electronic health records and effectiveness of policies to support this; (2) harmonize interoperable standards for healthcare systems; (3) develop criteria and an evaluation process for certifying electronic records in ambulatory and inpatient areas and the networks they use to operate; (4) pilot in local markets the architecture and network for sharing information securely among hospitals, providers, pharmacies, and laboratories with technology developers and providers working together; and (5) assess and develop plans to address privacy and security practices related to interoperable electronic health information exchange.3, 5, 6
The American Health Information Community
Whereas the HIT implementation approaches are directed at the IT industry, a federally chartered commission known as the American Health Information Community7 (referred to as “the Community”) guides the policy and requirements for the health care industry. The Community provides input and recommendations to the Department of Health and Human Services on how to make health records digital and interoperable, and assure that the privacy and security of those records are protected, in a smooth, market-led way. The Community identified “breakthrough” projects that are to be completed in 2–3 years in 4 targeted areas. In the area of biosurveillance, the breakthrough is to support public health monitoring by the transmission of ambulatory and emergency utilization and lab system data to public health agencies in a standardized and anonymous way in 24 hours. In the area of consumer empowerment, the breakthrough is to have a pre-populated consumer-directed registry summary that is easy, portable, and longitudinal and can follow the patient across settings. This includes the capacity to link registration data to a patient’s medication history data. The breakthrough in electronic health records is to have standardized, secure access to lab results and interpretations available to clinical authorized parties. And, finally, in the area of chronic care monitoring, the breakthrough is to have secure messaging available between patient and provider.
The nursing challenge
It is critical for members of the Academy as well as all other nurses to be aware of HIT initiatives that will transform and shape the future of care delivery. Basic informatics competencies and understanding of the information requirements of nursing, as well as the information requirements of the patients we serve, are essential. As HIT becomes more widely adopted and used as an essential tool in the care-delivery process, it is imperative that nursing concepts and utilities are components of these tools. There are many forums for nurses to get involved in the policy and implementation activities of HIT initiatives. Activities of the Office of the National Coordinator provide open forums for nurses to participate in the Community and its 4 workgroups. National HIT organizations also offer forums in which to speak as well as listen and learn. These include the American Nursing Informatics Association (ANIA) (http://www.ania.org/), and the nursing informatics workgroups of the Healthcare Information Management and Systems Society (HIMSS) (http://www.himss.org/ASP/index.asp) and the American Medical Informatics Association (AMIA) (http://www.amia.org). At the state level, one can become active in state nursing organizations to ensure they are involved in HIT initiatives to represent the needs of nurses and patients. One can connect with the state’s Quality Improvement Organization (QIO) or investigate a state’s/region’s efforts in establishing a Regional Health Information Organization (RHIO). At a local level, one can influence the selection and implementation of electronic health records through participation on information systems panels within work settings or become a “champion” to others as they consider/move to HIT adoption. Nurses also need to continue to advocate for patient protections of privacy and be mindful of unintended consequences of electronic systems that threaten their safe use. And, finally, we are challenged to help guide consumers into the electronic information age to enhance their access to health information and independence in managing their care. We can work to improve the health of the nation by staying informed and by improving our management of health information as we care for the public’s health one person at a time.
This article was written as part of official government duties and is therefore identified as in the public domain. No copyright can be assigned to it.
References
1. 1Institute of Medicine of the National Academies. The Future of the Public’s Health in the 21st century. Washington, (DC): The National Academies Press; 2003;.
2. 2Institute of Medicine of the National Academies. The Future of Public Health. Washington, (DC): The National Academies Press; 1988;.
3. 3Thompson TG, Brailer DJ. The Decade of Health Information Technology: Delivering Consumer-centric and information-rich Health care. Washington, DC: US Department of Health and Human Services; 2004;.
5. 5Office of the National Coordinator for Health Information Technology (ONCHIT). http://www.hhs.gov/healthit/ (accessed July 6, 2006).
6. 6Office of the National Coordinator for Health Information Technology (ONCHIT). HHS Announces New Regulations that support e-prescribing and EHR adoption: Press Release and Regs. Available at: http://www.hhs.gov/healthit/e-prescribing.html. Accessed July 6, 2006.
7. 7Office of the National Coordinator for Health Information Technology (ONCHIT). American Health Information Community (the Community). Available at: http://www.hhs.gov/healthit/ahic.html. Accessed July 6, 2006.
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