Advances in electronic health record (EHR) systems and health information exchange (HIE) are shifting efforts in public health toward greater use of information systems to automate disease surveillance, but a study from the Indianapolis-based informatics and healthcare research organization Regenstrief Institute has found that these technologies' capabilities are underutilized by those on the front lines of preventing and reporting infections.
The study measured the awareness, adoption, and use of EHR systems and health information exchange by hospital-based infection preventionists (IPs) to report and share information critical to public health. IPs are often responsible for reporting information on patients diagnosed with healthcare-acquired infections like methicillin-resistant staphylococcus aureus, or MRSA, as well as sexually transmitted diseases such as chlamydia.
Unfortunately, says Brian Dixon, Ph.D., Regenstrief Institute investigator and assistant professor in the School of Informatics and Computing at Indiana University-Purdue University Indianapolis, IPs are often left out of the processes by which hospitals are acquiring, implementing, and developing their EHR strategies. “Informatics tools offer a lot of promise for IPs, but if they are not involved in those processes, then it’s unlikely that the tools will be selected, designed, or implemented to support their workflow.”
Regenstrief’s research seems to back up Dixon’s concern. To measure awareness and engagement in EHR and HIE activities, the online survey of IPs was conducted in states with HIE networks. A total of 63 IPs were invited to participate; 44 (69 percent) responded. The survey asked about the adoption and use of EHR systems, participation in regional HIE initiatives, and IP needs with respect to EHR systems and public health reporting.
While 70 percent of IPs surveyed reported access to an EHR system, less than 20 percent were involved in the design, selection or implementation of the system. Without such involvement, those surveyed indicated the information systems often did not include modules or components that supported infection control activities.
A NEED FOR SUPPORT
Prior research has shown that health information exchange can increase the completeness and timeliness of infection reporting to local and state health agencies. In this study, the researchers found that half of the IPs surveyed were unaware of whether their hospital or health system participated in a health information exchange. Only 10 percent of IPs indicated that their organizations were formally engaged in health information exchange activities.
When asked what functionality they needed most from EHRs, IPs said that they needed decision support. A lot of the comments from the study centered around the idea that when their facility required an EHR system, they were handed the keys to the car but were not given modules that supported their workflow, says Dixon. “So now, rather than sifting through a bunch of paper reports, IPs are sifting through electronic ones. Sure that’s different, but it’s not an improvement. Better decision support will help them better indentify things they need to pay attention to report to public health as opposed to paging through the electronic version of the chart.”
Hospital IPs are also frustrated with inefficient lists of patients whose electronic medical charts they must examine individually. They say they want electronic alerts and reminders when the system detects something of potential importance. There needs to be concerted R&D to meet this gap in decision support, Dixon says.
Recently, there has been a push from the Centers for Medicare & Medicaid Services (CMS) to reduce hospital-acquired infections and increase the use of EHR systems, says Dixon. “The Centers for Disease Control and Prevention (CDC) are encouraging local and state health departments to use health information technologies to improve infectious disease reporting and prevention activities. I think some of the newer meaningful use criteria might be helpful to bring IPs into the equation and into the dialogue.”
According to the CDC, at any given time, about one in every 20 patients acquires an infection related to their hospital care. Healthcare-associated infections not only affect patient lives, but also add to the nation’s growing healthcare costs.
To that end, informatics tools can be effective in a number of ways. One way is to identify individuals who have a previous history of a disease when they come into the institution, so you can immediately get them into isolation, says Dixon. Another is to alert clinicians when a patient whose prior history is unknown but his or her culture comes back positive from the lab. Again, isolation protocols can be implemented, says Dixon.
There are also technologies out there for tracking healthcare workers and their interactions with patients to look at how the workers can be carriers for some of these diseases. “ID solutions can help us identify patterns of diseases spreading through an organization and how they can be reduced through improved campaigns for hand hygiene or other types of activities,” Dixon says.
The bottom line is, when you’re making a multimillion dollar investment in a software application or enterprise system for your hospital or network of hospitals, you want to make sure you will have maximal use of this tool among folks across your enterprise, Dixon says. One strategy that would be help this cause would be to have the CIO or CMIO of a facility engage with the hospital epidemiologist or frontline IP and try to understand what his or her needs are when it comes to the EHR, he advises.
“Lots of IPs have access [to EHRs], but it’s not really well understood how they are using it or what specific functions would be most useful to them. Those needs have not been documented very well. Once the CIO or CMIO understands the needs of his or her department better, he or she can then identify the right solution that may be available or partner with a vendor that could meet the needs of the organization and be useful to others as we keep our eye towards the future where there will be greater integration between hospital information systems and public health systems.”
At the end of the day, says Dixon, infection control often gets thrown into the same bucket as quality improvement, so it is not something that is always on the forefront. Instead, the primary users of clinical information systems are frontline clinicians, so they’re the ones who are often the focus for implementation and processes. “But the other services and users within the hospital are important to include as well,” Dixon stresses. "When you make this big kind of investment, you want to leverage it for a number of things your organization has to do.”