You are attending your departmental monthly team meeting where you are all discussing your emergency department’s (ED) plan to switch to an electronic healthcare record (EHR) system in the coming months. There is also a lot of discussion about utilizing more health informatics tools to improve patient care. The presenter discusses the emerging role of health informatics in the ED, as well as the utility of connecting to regional health information exchanges. You start to wonder about the implications for your ED practice in the future.
In this month’s post we provide an introduction to the Hi in HiQuiPs! We discuss key terms and concepts within Health Informatics, and try to build a foundation for future health informatics-related posts as we delve deeper into various aspects that relate to the ED.
Health Informatics and the ED
You may be asking yourself why is this information relevant to my ED practice? Well, with the emergence and proliferation of healthcare technologies, vital day-to-day ED activities rely on health informatics to function. A basic understanding of the field is therefore essential for the following reasons:
- Health informatics technology design needs domain experts (i.e. from the ED). Rather than relying on designers outside the field, ED clinicians can take charge of designing features that are more fitting for their environment workflow and needs to avoid solutions that are not helpful or create onerous workarounds.
- A basic knowledge of the field enables a common language while interacting with informaticians, technologists, and health informatics designers.
- ED clinicians equipped with a health informatics foundation can help create better policies of technology integration. Instead of reacting to technologies that appear in the ED, we can lead efforts to regulate, and improve these technologies.
- Quality improvement efforts are enabled through understanding the different levels of health informatics interaction and the contexts which comprise them to select appropriate interventions.
Biomedical and Health Informatics
I hope we have convinced you with the importance of having some basic knowledge in this field. Now what does this field really entail?
Arguably the most encompassing term to describe the field is Biomedical and Health Informatics (BMHI), which is defined as “a field that is concerned with the optimal use of information, often aided by the use of technology, to improve individual health, health care, public health, and biomedical research”.1 Health Informatics is part of BMHI and is more focused on the application domains such as with clinical care, public health and prevention, and you will see the terms used interchangeably. 2
The field itself has several interrelated components that are worth mentioning. A summary of these components is presented in Figure 1.
The figure has several elements that are illustrated as follows:
Imaging informatics include the use of medical images for example from picture archiving and communication systems (PACS), while research informatics focuses on clinical research applications. Clinical field informatics can be specified per field, such as dental, pathology, nursing, etc. Consumer health informatics may include wearables and other consumer-oriented applications. Bioinformatics often focuses on genomics, and public health informatics focuses on elements of population surveillance, reporting and health promotion. Also, as you may have noticed, “people” are highlighted at the bottom of the figure, as the field of health informatics encompasses stakeholders include patients, clinicians, administrators, and policy makers.
There a multitude of conceptual frameworks to help understand health information technology (HIT). The Informatics Stack is one of the frameworks that describes HIT through successive levels in a hierarchy of interdependence, with each level building on, and encompassing the preceding one.3 This is illustrated in Figure 2 below, where you will see each HIT is interdependent with many different levels that may influence outcomes of using it. For example: An EHR can be viewed as an information system comprising many different modules (each with a different purpose) and built on specific algorithms with specific data elements. The EHR also fits within a specific workflow of health care providers, which have different goals depending on their roles, and which fit within a unique organization, situated in a specific general context (world) such as the national health policy. Understanding these different levels and their influence on HIT enables a directed response to quality improvement efforts in the BMHI field.
Health Information Technologies (HITs)
Now that we’ve got a bird’s eye view of the BMHI field, we will mention some important HITs that are related to the ED environment.
Electronic Health Records
EHRs refer to an electronic system that comprise a secure and private lifetime record of a person’s health and healthcare history.4 EHRs go beyond just data collection, they also enable data storage, analysis and exchange. Currently, EHR data for 94.6% of Canadians is available to authorized healthcare clinicians.5 This number however maybe lower in EDs due to scanned paper charts that are added to the EHR.
Computer Physician Order Entry
Computer physician order entry (CPOE) refers to the management system that allows the ordering of medications, investigations and imaging electronically.6 This can be a separate system or part of a larger electronic ecosystem that includes the EHR.
Health Information Exchanges
With the growth of the ability to capture information in a timely manner and store it, the need for integrating and transferring information across boundaries has emerged through the use of health information exchanges (HIEs). HIE is the process of sharing patient-level electronic health information between different organizations.7 An example of an HIE is ConnectingOntario, which enables over 117,000 clinicians to access components of patient digital health records.8 Other HIEs include Dossier santé Québec, ConnectCare Alberta, and Pharmanet in British Columbia.9–11 To the users, they are web-based portals that provide real-time access to health information such as lab tests, medications, and diagnostic imaging results that are used in clinical care.
HIEs are somewhat different in their function and architecture than databases, repositories or warehouses such as the Canadian Institute for Health Information (CIHI), which is a national repository of 28 Pan-Canadian Databases.12 The latter is primarily for storage of large amounts of data that may be used for aggregate and/or patient level analyses rather than day-to-day access for individual level patient information for clinical use with HIEs.
A new class of HITs are emerging and will inevitably affect ED care. These include patient apps and wearable technologies which collect real-time information from patients, and enable the transmission of this information to care providers. These technologies are already gaining acceptance in ED settings.13 Moreover, they have shown accuracy with certain ED assessments such as ED heart rate in arrhythmias.14 Other examples include continuous glucose monitoring devices, air quality sensors, and temperature monitors. However, there is much debate on the potential adverse effects on using these technologies including increasing care seeking behaviour. Please stay tuned for a future post to discuss wearable technologies and the ED!
Several national organizations are worth noting in our discussion that affect the world level in the framework presented in Figure 2.These organizations have more in depth information for interested readers.
- In terms of regulation, Health Canada is the regulatory body for new healthcare technologies.15
- Digital Health Canada is the national health informatician association which assists in certification and education of digital health professionals.16 This is in parallel to the Healthcare Information and Management Systems Society (HIMSS), which is similar to Digital Health Canada on an international level. Moreover, the latter also assists in public policy, workforce development, research and analytics.17
- The Canada Health Infoway is worth noting as it seeks to accelerate the development, adoption, and effective use of digital health solutions in Canada.18
- Finally, given the current increase in healthcare technologies, the Canadian Agency for Drugs and Technologies in health (CADTH) provides health care decision-makers with objective evidence to help make informed decisions about the optimal use of health technologies. 19
I hope we have given you a flavour of the BMHI world and what it encompasses, some basic terminology, and relevant organizations to the Canadian context. Now that you have gained a better understanding of the field, join us in our next post where we dive deeper into a BMHI tool that has been a game changer for Quality improvement efforts: CPOE.
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- 2.Shortliffe E, Cimino J. Biomedical Informatics: Computer Applications in Health Care and Biomedicine. 3rd ed. Springer; 2006.
- 3.Lehmann H. The Informatics Stack: A Heuristic Tool for Informatics Teaching. Methods Inf Med. January 2017:e129-e133. doi:10.3414/me16-01-0152
- 4.Understanding EHRs, EMRs and PHRs. Canada Health Infoway. https://www.infoway-inforoute.ca/en/solutions/digital-health-foundation/understanding-ehrs-emrs-and-phrs. Accessed 2019.
- 5.Highlights from 2016-2017. Canada Health Infoway. https://www.infoway-inforoute.ca/en/95-about-infoway/accountability/7546-annual-report-highlights-2016-2017. Published 2018. Accessed March 13, 2019.
- 6.Healthcare Information and Management Systems Society Staff. HIMSS Dictionary of Healthcare Information Technology Terms, Acronyms and Organizations. 3rd ed. HIMSS Publishing; 2013.
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- 8.ConnectingOntario ClinicalViewer. eHealth Ontario. https://www.ehealthontario.on.ca/en/for-healthcare-professionals/connectingontario. Published 2018. Accessed March 13, 2018.
- 9.Quebec. Quebec Health Record. https://www.quebec.ca/en/health/your-health-information/quebec-health-record/. Published January 28, 2019. Accessed 2019.
- 10.Connect Care. Alberta Health Services. https://www.albertahealthservices.ca/info/cis.aspx.
- 11.Chee E, Schneberger S. British Columbia’s PHARMANET Project. Ontario: University of Western Ontario; 2003.
- 12.About CIHI. Canadian Institute for Health Information. https://www.cihi.ca/en/about-cihi. Published 2018.
- 13.Claudio D, Velázquez MA, Bravo-Llerena W, Okudan GE, Freivalds A. Perceived Usefulness and Ease of Use of Wearable Sensor-Based Systems in Emergency Departments. IIE Transactions on Occupational Ergonomics and Human Factors. September 2015:177-187. doi:10.1080/21577323.2015.1040559
- 14.Koshy AN, Sajeev JK, Nerlekar N, et al. Smart watches for heart rate assessment in atrial arrhythmias. International Journal of Cardiology. September 2018:124-127. doi:10.1016/j.ijcard.2018.02.073
- 15.Notice: Health Canada’s Approach to Digital Health Technologies. Government of Canada. https://www.canada.ca/en/health-canada/services/drugs-health-products/medical-devices/activities/announcements/notice-digital-health-technologies.html. Published April 10, 2018.
- 16.About Us. Digital Health Canada. https://digitalhealthcanada.com/about-us/.
- 17.About HIMSS. HIMSS. https://www.himss.org/about-himss.
- 18.About Canada Health Infoway. Canada Health Infoway. https://www.infoway-inforoute.ca/en/about-us.
- 19.About CADTH. CADTH. https://www.cadth.ca/about-cadth.