A number of tools exist (and are being developed) to help health information technology (IT) stakeholders plan for, implement, and evaluate health IT.  These tools are expected to have a wide range of capabilities – some as large as the Federal Health Architecture (FHA) program or the Nationwide Health Information Network (NHIN). Others are smaller in scope and serve to bring health IT to individual stakeholders such as providers, patients, hospitals, pharmacists, and others in this industry.

Following is an overview directly from hhs’s healthIT site.

Clinical Decision Support

Clinical decision support (CDS) provides clinicians, staff, patients or other individuals with knowledge and person-specific information, intelligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses computerized alerts and reminders to care providers and patients, clinical guidelines, condition-focused order sets, patient data reports and summaries, documentation templates, diagnostic support, and other tools that enhance decision making in clinical workflow.

While stand-alone CDS systems exist, the majority of CDS applications operate as components of comprehensive electronic health record systems. Because CDS requires computable biomedical knowledge, person-specific data, and a reasoning or inferencing mechanism that combines knowledge and data to generate “advice” to clinicians, CDS is a sophisticated health information technology component.  Challenges such as expressing clinical guidelines in computable form and avoiding disturbances in workflow and patient-provider communications have delayed the adoption of electronic health records with CDS capabilities.

 Health information technologies designed to improve clinical decision making are particularly attractive for their potential to address the growing information overload clinicians face, and to provide a platform for integrating evidence-based knowledge into care delivery. The use of CDS capabilities within electronic clinical systems holds great potential to improve health care outcomes in the United States. Among many other benefits, CDS has the potential to increase adherence to clinical guidelines, protocols and best practices, help avoid medication errors, and help prevent complications.

Advice generated by CDS resources must fit into health professionals’ workflows.  The advice must arrive “in the right place at the right time” and be delivered to the right person who understands the advice and is in a position to act on it. 

CDS Activities
Recent national CDS activities include the development of a Roadmap for National Action on Clinical Decision Support. Funded by the Office of the National Coordinator (ONC) for Health IT, and conducted by the American Medical Information Association (AMIA), the Roadmap recommends a series of activities to improve CDS development, implementation and use throughout the United States to help enable improvements in health, and the quality, safety and efficiency of healthcare delivery. The key findings of the CDS Roadmap report were presented to the American Health Information Community during a meeting of the Community on June 13, 2006 in Washington, DC. The roadmap identifies three pillars for fully realizing the promise of CDS: having the best available clinical knowledge well-organized for CDS interventions; high adoption and effective use of CDS tools; and continuous improvement of knowledge and CDS methods.  The full text of the CDS roadmap is published on the AMIA website at: http://www.amia.org/inside/initiatives/cds

In 2008, the CDS Ad Hoc Planning Group of the American Health Information Community (AHIC) facilitated the development of a set of CDS recommendations across 5 AHIC workgroups which were accepted by AHIC on April 22, 2008. The CDS recommendations focused on health care quality improvement through effective use of CDS, facilitating collaboration across CDS initiatives, and accelerating CDS development and adoption through federal government programs and collaborations. The full text of AHIC CDS recommendations is located here.

CDS Government Collaboratory

The Federal government can play an important role in promoting the development and adoption of Clinical Decision Support (CDS). Some agencies that deliver patient care utilize CDS functionality within their electronic systems; others support research to design improved CDS systems and evaluate CDS effects; others, through their sponsorship of quality-improvement and other initiatives, can catalyze the use of CDS.

In 2008, a Clinical Decision Support Government Collaboratory was formed to focus on CDS as a key component of health information technology that can improve the quality, safety, efficiency and effectiveness of health care.  Comprised of federal professionals, the CDS Government Collaboratory serves as a forum for sharing CDS-related interests, perspectives and priorities, and fosters communication and collaboration between CDS-related activities across many different agencies.

Electronic Medical Records

An EMR (electronic medical record) is a real-time patient health record with access to evidence-based decision support tools that can be used to aid clinicians in decisionmaking. The EMR can automate and streamline a clinician’s workflow, ensuring that all clinical information is communicated. It can also prevent delays in response that result in gaps in care. The EMR can also support the collection of data for uses other than clinical care, such as billing, quality management, outcome reporting, and public health disease surveillance and reporting.

Furthermore, an EMR may contain  clinical applications that can act on the data contained within its repository; — for example, a clinical decision support system (CDSS), a computerized provider order entry system (CPOE), a controlled medical vocabulary, or a results-reporting system. In general terms, EMRs are clinician-focused in that they enhance or augment the workflow of clinicians or administrators. EMRs are said to be interoperable if they are able to exchange data using standardized data transmission formats.

Implementation of an EMR also creates issues related to identification of stakeholders within a community or region and getting their buy-in, legal issues related to cross-institutional data sharing, security and privacy of shared records over potentially insecure network lines, and patient access to and augmenting their own data in electronic format (using the web, for example).

Electronic Prescribing (AKA: e-prescribing, eRx)

Electronic prescribing refers to the use of either stand-alone software applications or modules integrated in electronic health records (EHRs) to enable clinicians to select and order a prescription, transmit the prescription, dispense the medication for administration and evaluate the effectiveness/outcome.

The Centers for Medicare & Medicaid Services (CMS) issued a definition of e-prescribing in its final regulation in 42 CFR Part 423:

“E-prescribing is the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network. E-prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser.”
The adoption and effective utilization of eRx has been identified as a significant enabler to better, safer and more cost effective health care. The Institute of Medicine (1999) noted that each year seven thousand people die, and 1.5 million are injured from preventable medication errors. They have recommended that by 2010, all prescribers should write and all pharmacies should be able to receive prescriptions electronically. Additionally, they recommend eRx applications should be robust enough to include safety checks for allergies, drug-drug interaction warning, dose appropriateness, drug-clinical condition warning, and drug-laboratory alerts.

Key eRx Adoption Activities
Section 132 of the Centers for Medicare and Medicaid Services, Medicare Improvements for Patients and Providers Act (MIPPA) 2008, authorizes a new and separate incentive program for eligible professionals who are successful e-Prescribers. This program began in Jan 2009. This program initially incentivizes eRx adoption and utilization through 2011 and then results in a fee schedule reduction in 2012+ for non-adopters. The incentive percent amounts for the reporting years are:

 Reporting Year  Incentive Amount for those eRx  Fee scheduled Reduction for non-eRx 
2009-10 +2%   
2011 +1%   
2012 +1% -1%
2013 +.5% -1.5%
2014    -2.0%

Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press, 2007.
Key eRx Reports and Resources
Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press, 2007.
The Center for Improving Medication Management
The Certification Commission for Health Information Technology (CCHIT) – certifies EHRs and eRx applications against criteria for functionality, interoperability, security.
Best Practices and Lessons Learned Related to Electronic Prescribing – A Guide for Health Plans, Employers and Statewide Initiatives eHealth Initiative December 2008
E-Prescribing: Becoming Mainstream Practice , eHI June 2008
A CLINICIAN’S GUIDE TO ELECTRONIC PRESCRIBING , eHI October 2008
Physicians’ Experiences Using Commercial E-Prescribing Systems ; Joy M. Grossman, Anneliese Gerland, Marie C. Reed and Cheryl Fahlman; Health Affairs, 26, no. 3 (2007)
National Progress Report on E-Prescribing ; SureScripts, Dec 2007 
 

Electronic Prescribing (eRx)– A type of computer technology whereby physicians use handheld or personal computer devices to review drug and formulary coverage and to transmit prescriptions to a printer or to a local pharmacy. E-prescribing software can be integrated into existing clinical information systems to allow physician access to patient specific information to screen for drug interactions and allergies.

Personal Health Record (PHR)

Definition
An electronic application through which individuals can maintain and manage their health information (and that of others for whom they are authorized) in a private, secure, and confidential environment.

Understanding a PHR
The most salient feature of the PHR, and the one that distinguishes it from the EMR and EHR, is that the information it contains is under the control of the individual. The concise definition above names the individual as the source of control, but that leaves room for others acting in the individual’s interest—their agent or agents—to have control over access to the PHR. An agent may be expressly designated by the individual but not in all cases; examples of an agent acting for an individual include parents acting for children, or, in the later stages of life, children acting for parents.

Exercising control
The individual is distinctively the guardian of information stored or accessible within a PHR. Similar to the role of a librarian, a person managing a PHR decides what volumes of information to include, how they are maintained and ordered, and who can read them or “check them out.” Standards and policy will need to determine if and how individuals can delete or modify information in a PHR that originated from an EHR and how these modifications are communicated to other providers with whom the data in the PHR are shared.

Portability
Having control also means that an individual’s PHR can exist independently of the entity that sponsors it—the PHR is portable. This requirement for portability excludes models in which sponsors such as health insurers or health care providers give individuals access to health-related information that is dependent on the individual remaining with that sponsor.

Inputs Into the Store of Information
To reiterate, the long-term goal of a PHR is to be a lifelong resource of pertinent health information for an individual. Thus it should have both the depth and breadth of information to enable individuals to become more engaged in their own healthcare as they move from being passive recipients to active participants in their personal health management. The health information in a PHR can be drawn from a broad range of possible sources. Significant sources may include, but are not limited to:

Health care providers—Including hospitals, skilled nursing homes, long term care, and other facilities; pharmacies, lab, and diagnostic facilities reporting test results.
Health care clinicians—Including physicians, nurses, behavioral health professionals, registered dieticians, chiropractors, and other licensed or certified care providers.
Medical devices—Instruments, machines and implanted devices monitoring clinical indices, for immediate use as well as for historical purposes.
Wellness promoters—Entities supplying services or information to generate and maintain good health, such as fitness centers, rehabilitation experts, and complementary/ alternative medicine practitioners.
Individuals—Self-generated information for personal management or information for care providers, including information about allergies, prescribed medications, eating habits, exercise objectives, the progression of an illness or recovery from it, and preferences regarding care in various circumstances.
Health insurers—Information arising from claims for insurance payments, disease management programs recommending certain actions and collecting results, updated information on drugs in a formulary, and other coverage policies specific to an individual.
Public health—Government health departments, disease surveillance and immunization programs, school-based care providers and social workers, and nongovernmental organizations engaged in health and wellness.
Research institutions—Information about opportunities to engage in clinical trials and studies, and recently published results of interest to the individual.
The sum of these and other inputs is a well-rounded picture comprising clinical information, administrative information, and wellness information for individuals to employ and impart to others at their discretion.

Remote Monitoring

Remote monitoring is the electronic transmission of health care data either entered directly by a patient (or his/her caregiver) or through a medical device to a clinician’s Electronic Health Record (EHR) or a patient’s Personal Health Record (PHR). The ability for a clinician to monitor patient information captured remotely in an ambulatory setting, such as physiological, diagnostic, medication tracking, and activities of daily living (ADL) measurements, may be a key enabler for the management of chronic  health problems and initial management of new conditions. Remote monitoring may also be a component of maintaining wellness for the aging population. Remote monitoring could include, but is not limited to, communication of: physiologic measurements (e.g., weight, blood pressure, heart rate and rhythm, pulse oximetry, glucose), diagnostic measurements (e.g., transthoracic impedance) medication tracking device information (e.g., medication pumps, infusion devices, electronic pillboxes), and activities of daily living measurements (e.g., ADL biosensors, pedometers, sleep actigraphy).

Secure Messaging

Secure messaging is the secure and protected transmission of information between patients and their providers, including clinicians and their support staff. This messaging is similar to traditional email where both patients and clinicians can send and respond to communications without having to be on-line at the same time.  Giving patients the ability to compose and send a secure communication to a clinician will, at times, give them access to their clinicians in a more timely, efficient manner than an office visit or a phone call. Similarly, clinicians will benefit from having the ability to respond to or initiate secure communications to facilitate the care process and promote better patient health. This communication will be done in a manner which provides appropriate information to the patient and meets existing needs for clinical documentation. Secure messaging can also serve as a preventive healthcare tool by allowing clinicians to provide clinical reminders to their patients.

ONC: Secure Messaging Pilot
In January 2006, the AHIC advanced a recommendation to the Secretary that originated from the Chronic Care Workgroup, to establish an evidence base for informed reimbursement policy with respect to secure messaging. Upon acceptance by the Secretary, it was determined that this work would be conducted through ONC. The purpose of this project is to identify and work with three pilot sites to test the value of secure messaging between patients and their clinicians. The value of secure messaging technology will be evaluated both qualitatively and quantitatively.

Telehealth

Telehealth is the use of telecommunications technologies to deliver health-related services and information that support patient care, administrative activates and health education.  The technology is a means to improve access to care, while reducing cost of transportation and increasing convenience to patients care.

There are more than 200 telehealth networks connecting some 2,000 institutions across the country. (Reference #2)
 

Telehealth applications
Live videoconferencing: Audio and video feeds used to connect two or more geographically dispersed health care facilities to enable patients, physicians to consult in real time.
Store-and-forward systems (S & F): Digital images and other clinical data are captured at the point of care; they are temporarily stored and later forwarded to another location.
Remote patient monitoring: Home-based monitoring devices are used by patients to easily capture and transmit clinical data over the internet (such as BP and glucose levels). This application is becoming more prominent with the care of chronically ill patients.
E-visits/e-consults: Evolved from secure – email or phone based encounters e-visits can be offered by health insurers through a secure Web portal. 
Telehealth Benefits
Phone visits/e-visits/e-consults and S & F systems
Improved access to care and personal health information
Improved efficiency (most lab results available online within 24 hours)
Decreased costly, unnecessary ER visits due to 24×7 nurse lines
Improved convenience and accessibility for consumers
Improved physician-patient communication
Decreased use of office visits and physician phone calls
Remote patient monitoring
Improved accessibility to specialist care
Reduced hospitalization, resulting in lower treatment costs for chronic patients
Enables early, proactive intervention for follow-up care
Enables caregiver to take a more active role in the care of family members
Improves efficiency by enabling medical professionals to focus on patients who need them most
Live videoconferencing
Reduced wait times
Improved access to specialty care
Improved training and education of medical interns
Telehealth Obstacles
Low consumer awareness
Provider liability concerns
State-specific licensing and regulatory requirements
Traditional provider reimbursements methods
Data interoperability and portability

Low Consumer Awareness Plagues Telehealth Adoption

Base: 5,242 U.S. online consumers