Introduction:
Information technology (IT) has been successfully integrated into many different sectors of the American economy. However, one area where IT has not had much influence until recently is the field of medicine. Due to the rising cost of healthcare and increasing demands by patients and insurers for better quality care, healthcare organizations are being driven to implement IT to improve results (Powner, 2003, p. 2). In 2003, the United States General Accounting Office (GAO) released a report on the benefits that can be achieved in healthcare through IT. This study analyzed ten private and public hospitals, three healthcare insurers, and one community network to identify cost savings and other benefits associated with investments made in technology. Several of these benefits and cost savings will be cited throughout this text.
David Powner (2003), Director of Information Technology Management Issues for the United States Government, states in a letter to Senator Edward M. Kennedy:
According to the Institute of Medicine and others, health care is an information-intensive industry that remains highly fragmented and inefficient. Hence, the use of information technology in delivering clinical care and performing administrative functions has the potential to yield both cost savings and improvements in the care itself. (p. 4)
Healthcare is certainly an “information-intensive industry.” One example of a significant advancement IT provides hospitals is the development of electronic medical records. This technology can condense medical information into a single database. Not only does this technology reduce paper costs, it allows healthcare providers to access pertinent patient information (such as medical history, medications, insurance information, etc…) with just the click of a mouse. During its exhaustive study, the GAO encountered a teaching hospital that realized savings of $8.6 million dollars a year by replacing paper medical charts with electronic medical records (Powner, 2003, p. 2). Though these savings are impressive, they do not come without opposition from healthcare ethicists.
At what costs do electronic medical records save time and money? Patient privacy rights advocates argue that this “highly sensitive medical information is routinely shared by third parties not involved in patient care” (Yeo, 2003, p. 141). In addition to privacy violations that occur within the walls of a healthcare organization, privacy violations can also occur outside the medical setting by computer hackers breaking into medical databases. In January of 2001, the University of Washington Medical Center had its administrative database broken in to. This database contained confidential information on over 5,000 patients (Yeo, 2003, p. 141). What is needed is a balance between improved care through IT and the potential hazards it can create. J.J. Chin (2003), a Healthcare Ethics Consultant suggests the following:
It is clear therefore that the use of IT in medicine should always be based on whether the benefits to the patients exceed the anticipated hazards, and whether risks to the patient’s privacy and confidentiality can be reduced to an acceptable level through regulation and education. (p. 149)
There will always be conflicts regarding how IT should be implemented in the medical field but IT is improving the quality of care patients receive. The potential benefits IT presents to healthcare organizations are numerous and expanding everyday. Healthcare currently accounts for 15 percent of the United States economy which amounts to $1.7 trillion per year (Mullaney, 2005). Dr. David Brailer, President Bush’s top ranking health-information official, suggests that medical IT practices could save $140 billion a year by 2014 (Mullaney, 2005). These types of potential savings are why so many healthcare facilities are investing in IT now more than ever. In 2004, hospitals spent $25.8 billion on IT and that number is expected to grow to over $30.5 billion by the end of 2005 (Mullaney, 2005).
Advantages of IT in Medicine
Medical data in the Information Technology field poses many rewarding advantages to physicians, doctors, patients and facilities. Implementing modern day software allows nurses and doctors to create a paper trail on a patient’s history with ease. A medical record is defined as a “confidential record that is kept for each patient by a healthcare professional or organization” (Primer, n.d.). These records include a patient’s personal information, medical history and events documentation, such as an illness.
Transforming medical records from paper to electronic files is cost-effective and more advantageous to patients, nurses, doctors, hospitals, and other healthcare organizations. Medical records have been created and maintained in paper form for decades. However, many smaller and rural hospitals are just beginning the adjustment and conforming to Electronic Medical Records (EMR). Advantages of having an Electronic Medical Record include “lower development cost, multiplatform design, and ease of integrating dynamic data with static documents” (Detmer, 1994). Electronic medical record systems are designed to exchange data that conforms to public standards for web use. Due to this, security is considered another benefit to healthcare organizations. When medical data is displayed on the World Wide Web, the Uniform Resource Locater (URL) is listed under a Secure Hypertext Transfer Protocol (HTTP).
This means that web addresses that contain a patient’s medical history have enhanced security. Having information stored in a computer system enables healthcare providers to save valuable time. This time can then be directed toward personal contact with their patients. Employees who are currently using these systems have adjusted to the change in a positive manner.
The medical profession is a lucrative one in bigger hospitals located in metropolitan areas and medical information technology is a large part of the process. In the smaller, more rural healthcare facilities IT is just beginning to create positive results. Smaller hospitals do not usually have the capital necessary to hire a large staff and maintain a “sophisticated health system” (MEDITECH, 2005). With the assistance of IT software, a small hospital can have an organized health system and fewer worries within a more stable and controlled environment. Medical software “unites all facilities within an organization for efficient, high-quality care that reaches an extensive patient base. With a reliable, integrated system, tasks can be performed quickly with fewer employees, while maintenance costs are reduced, and savings can grow” (MEDITECH, 2005).
In addition to handling integrative systems, medical information technology can also communicate effectively and efficiently with other external sources. According to George Masiello, CIO of Children’s Hospital in Richmond, VA, medical information technology software is “’an excellent core system, with terrific cost ownership…It exchanges information with our homegrown system and third-party systems” (MEDITECH, 2005). Medical Information Technology not only organizes internal work, but can be conjoined with other online records to give consumers a real time effect.
Another advantage of medical IT is online access to insurance organizations. Insurance companies now have resources available to individuals 24 hours a day, 7 days a week. United Healthcare (2005) offers medical tips, online nurse chat, and personal insurance coverage information to their clients and gives them the authority to view claims, co-pay, and deductibles information online. Accounts can be accessed by policy holders through the internet and registration is confidential. Insurance cards can also be ordered online and shipped to a policyholder’s home in less than one minute. Other online features offered by United Healthcare (2005) include doctor finder, preference search, and medical advice. Although it is strongly recommended that clients speak with a physician in terms of personal health, United Healthcare offers general information and assistance regarding health care and illness (United Healthcare, 2005).
An additional advantage to offering online access to insurance information is giving clients an alternative to staying on hold for long periods of time to speak with a live professional. Some people do not have the time or patience to stay on hold for long periods of time, especially during peak periods, to ask questions. Having questions and answers online, in the Frequently Asked Questions section of a website, enables customers to access information online in a few minutes. EHealthInsurance (2005), another health insurance provider, offers prospective and current individuals, families, and small businesses the ability to request a quote, compare plans, and apply for health, dental, and vision insurance coverage online. This online insurance company offers insurance from a large selection of the top insurance coverage companies in addition to “unbiased advice from licensed professionals” (EHealthInsurance, 2005).
As with online insurance, medical information technology has permitted the expansion of online healthcare coverage to include e-prescriptions. “Hospitals and physicians have been slowly turning to technology to make healthcare safer and more convenient. E-prescribing, which allows healthcare providers to transmit prescriptions electronically to a pharmacy rather than write them on paper, is attracting interest and gaining support from the government and major insurers and healthcare providers around the country” (Symantec, 2005). As with any other technological advance, e-prescribing offers its advantages. Some advantages include cost savings and time benefits. E-prescribing can also improve communication and simplify processes among patients, doctors, pharmacies, and insurers. Procedures involved in prescription renewals, checking formularies, and benefit eligibility are just a few processes that be streamlined. Additional benefits of e-prescriptions noted on Symantec’s Enterprise Solution’s (2005) website include:
• Decreases administrative costs. According to a Medco study reductions could reach 42 percent in the number of pharmacy calls to the physicians' office and 30 percent in calls related to prescription illegibility.
• Reduces potentially harmful drug interactions by alerting physicians of possible risks.
• Increases the use of generic and preferred drugs by providing physicians with formulary information when writing a prescription.
• Decreases medication errors due to hard-to-read physician handwriting.
• Automates the process of checking for drug interactions and allergies.
• Reduces patient wait time at the pharmacy. (Symantec, 2005)
Symantec’s (2005) website also notes that makers of e-prescribing software state the security used for e-prescribing is similar to that used in typical banking transactions. Some security details are:
• The handhelds or PCs used to access the e-prescribing system is password-protected and utilizes a screen locking feature. If the device is lost or unattended, the device is locked. Anyone using the device at another time must login into the system again using a logon ID and password.
• Encryption is used to protect the information being transmitted. Should the information be intercepted, it would be unreadable.
• Access rights are assigned so personnel can access only the information that pertains to his or her job responsibilities.
• Transaction activities can be traced to individuals by their unique user ID. This allows greater control over user activities and security.
• Secure Internet connections and private network connections work to protect information as it passes from one location to another.
• Because there is so much sensitive information being stored, measures to protect the integrity and availability of that information must be implemented. Symantec’s Information Integrity is an ideal approach to this situation – it is designed to simultaneously provide for the security and the availability of network resources – ensuring e-prescribing systems are always up and running, and the sensitive remains data intact.
• Pharmacies must maintain Health Insurance Portability and Accountability Act (HIPAA) compliance, including keeping their terminals and other access points in private locations.
• When a patient meets with the physician, he or she can get a paper copy of the prescription to take to the pharmacy so the pharmacist can compare the print version to the e-version to make sure the correct person is receiving the prescription. Pharmacies will also use other means to identify the patient picking up the prescription, such as requesting ID, an insurance card, or Social Security number.” (Symantec, 2005)
Disadvantages of IT in Medicine
Although the advantages that medical IT can offer healthcare providers and patients through shared information and expedited care in an emergency are noteworthy, there are disadvantages. Issues of privacy and ethics are common. Doctor-patient confidentiality gives patients the freedom to share personal information at the deepest level. If this confidential information is entered into a database, how can a private individual be guaranteed it will not end up in the wrong hands? The President’s Commission on Cyber Security readily admits that electronic information systems are “highly vulnerable” to unauthorized intrusions (Meyer & Pyles, 2005). This vulnerability has been recognized globally and the global community is appealing for medical IT to be handled in an ethical manner.
Doctors have been sworn to the Hippocratic Oath for centuries. In the Singapore Medical Journal, two authors address “some of the ethical problems and hazards faced in adopting IT in a profession based on human interaction” (Chin, 2003, p. 149). One of the authors, C.J.J. Yeo, uses the “Hippocratic tradition to assess if the use of IT is beneficial or potentially harmful to medicine” (Chin, 2003, p. 149).
In an editorial published in the Berita Malaysia Medical Association Newsletter, Dr. David Quek (1999), council member of the Malaysia Heart Association, states:
It is timely to reflect upon the Hippocratic Oath even as some of its tenets have been replaced and updated in the International Code of Medical Ethics and the Geneva Declaration. I believe the spirit of the Hippocratic tradition still lives on in all of us as medical practitioners.
In light of this, Medical IT “must therefore be applied as an instrument subject to the goals of medicine and appraised in the context of whether it promotes or impedes the attainment of these medical goals” (Chin, 2003, p. 149).
In 1996, Congress passed a bill known as the Health Insurance Portability and Accountability Act (HIPAA). Changes in health care delivery, technology, and a number of other factors created a need for legislative changes. One of the most important pieces of this legislation is the additional rights given to patients with regard to the privacy of their medical information. Although the Hippocratic Oath is still in place, legislation was necessary in order to provide individuals this protection (Pheley & Dudley, 2005).
“Now the drive to apply Information technology to medicine threatens to undermine the ethical foundation of quality healthcare in a way that Hippocrates could understand, but to a degree that he probably could not have imagined.” (Meyer & Pyles, 2005) The new HIPAA legislation of 2003 has now replaced federal “regulatory permission” for the patient’s informed consent in the disclosure of medical records for most purposes (Meyer& Pyles, 2005). Astonishingly, organizations are campaigning for the implementation of a nationwide “interoperable” electronic health information network that would make a patient’s health information widely available without the patient’s informed consent (Meyer & Pyles, 2005). This request seems to be financially motivated because this type of network would offer increased efficiency and lower health care costs.
Another disadvantage to medical IT is that the system is not flawless. Human error is involved at the data entry and communication levels. Much is at stake when doctors need to interpret information provided by a computer. Misinterpreted information can hinder a patient’s decision making capabilities as well as affect the doctor-patient relationship in some settings.
“The use of IT in medicine should always be based on whether the benefits to patients exceed the anticipated hazards, and whether risks to patient’s privacy and confidentiality can be reduced to an acceptable level through regulation and education” (Chin, 2003, p.149) “The medical profession must insist and persuade medical IT companies to focus their R&D efforts beyond mere capacity, power and speed, but instead on systems that are also safe and more controllable from patients’ perspectives.” (Chin, 2003, p. 150)
Training and education are a must if ethics, medicine, and information technology are to coexist. An example of such training is the HealthSec 2005 Conference & Expo scheduled for September 28-30, 2005. Co-chairperson, Micki Krause, a recognized leader in the health care information security industry states, “Health care information security professionals are under pressure to comply with HIPAA and other regulations, utilize the latest e-health technologies, and maintain a topnotch security program under tight budget constraints.” The keynote speaker will be addressing information technology and the ethical challenges (BW, 2005).
IT and Emergency Medical Care During Disasters
As noted by authors Theodore Chan, Jim Killeen, William Griswold, and Leslie Lenert (2004), in an article published in the Academic Emergency Medical Journal (AEMJ):
Disaster response to mass-casualty incidents (MCIs) represents one of the greatest challenges to a community’s emergency response system. Rescuers, field medical personnel, regional emergency departments, and hospitals must provide care to a large number of casualties in a setting of limited resources, inadequate communication, misinformation, damaged infrastructure, and great personal risk. Emergency care providers and incident managers attempt to procure and coordinate resources and personnel, often with inaccurate data regarding the true nature of the incident, needs, and ongoing response.
New technologies in communications, the Internet, computer miniaturization, and advanced “smart devices” have the potential to vastly improve an emergency medical response to such mass-casualty incident disasters. Next generation wireless Internet and geopositioning technologies may have the greatest impact on improving communications, information management, and overall disaster response and emergency medical care (p.1229).
The United States currently faces several new, concurrent, large-scale health crises as a result of terrorist activity. Three major health issues have risen in urgency and public consciousness: bioterrorism, the threat of widespread delivery of agents of illness, mass disasters, localized events that produce large numbers of casualties and overwhelm the usual capacity of health care delivery systems, and the delivery of optimal health care to remote military field sites (Teich, Wagner, Mackenzie, Schafer, 2002, p.97).
Chan, et all (2004) also noted in their AEMJ article:
Recent acts of mass terrorism, such as the World Trade Center (WTC) and Pentagon attacks on September 11, 2001, the release of sarin in a Tokyo subway in 1995, and the Madrid train station bombings have called attention to the urgent need to improve disaster response for mass-casualty incidents (p.1229).
More recently, the natural disaster of Hurricane Katrina affected thousands of people in Louisiana, Mississippi, and Alabama.
A disaster imposes many challenges for a community’s emergency response system due to its size, scope, and intensity. It can be characterized by many people trying to respond quickly to unusual situations in an unfamiliar environment. Traditionally, a lack of communication results in more problems than all other factors combined. Critical infrastructure such as public transportation and communications may be disabled, yet coordination and management of cross-jurisdictional agencies is necessary to respond as needed. Emergency department (ED) and hospital availability, resources, and staff must also be mobilized and coordinated under chaotic, stressful situations and with great urgency (Chan, et all, 2004, p. 1229).
Communication and information management is a constant challenge during times of disaster. The need for accurate and up-to-date information from the field about the incident itself, casualties, medical needs, triage, and treatment can significantly impact the use and preparedness of community resources, such as ambulances, EDs, and hospitals (Chan, et all, 2004, p. 1229). Many of the logistical problems faced during a disaster are not caused by shortages of medical resources, but rather from failures to coordinate their distribution using manual systems.
An integrated system is essential for communication from the field to the hospital and should be designed to provide seamless connectivity across an array of networks with different performance characteristics based on “always best connected” principles for maintaining quality of service. Disaster communications and connectivity networking have the potential to improve acute medical care from the field to emergency department (ED) continuum by facilitating response coordination, information transfer, and overall “situational awareness” during a disaster. Geolocation strategies should focus on an “always best located” or “location stack” utilizing multiple geopositioning technologies (Chan, et all, 2004, p.1231).
Basic telecommunication pathways include landlines, airwaves (radio, microwave), and satellite media. Current standard communications rely heavily on landlines and airwaves that are subject to many limitations; particularly radio communication on frequencies reserved for emergency personnel. Landlines are immobile, often damaged at the disaster site, and difficult to establish quickly. Radio airwaves can become inoperable due to excessive congestion as well as infrastructure damage to towers, base stations, and repeaters. An example of which is the 1995 bombing of the Murray Federal Building in Oklahoma City. The telephone lines were overloaded and hampered communications in the field and hospital radio systems failed to operate in 12 of 15 receiving hospitals. Similarly, following the World Trade Center attacks, chaos and confusion were a result of radio frequency incompatibilities and congestion, the loss of local telephone services, and overwhelming cellular phone traffic (Chan, et all, 2004, p.1230).
The advent of computer miniaturization, also called “smart devices”, the Internet, third generation wireless connectivity, and positioning technologies are advanced applications that will help to improve communication in the event of a disaster. Geoposition tracking and miniaturized medical monitoring equipment have been tested on soldiers and medics in the military battlefield. These technologies are being evaluated to improve and enhance patient care and tracking, foster greater provider safety, enhance incident management at the scene, and to coordinate a community’s emergency medical services (EMS), ED, hospital resources. This technology will greatly enhance informatics support at the scene and at receiving EDs and hospitals.
The development of wireless technologies also provides avenues to improve telecommunication capabilities during a disaster. Third generation wireless networks such as 1x Evolution-Data Optimized technology with unified standards along with the ability to provide high-speed broadband connectivity are now being explored for multidirectional rapid and real time audio, video, and other high density data transmission between users simultaneously. These new technologies can serve as the basis for a rapid, integrated, wireless communication system for disaster response (Chan, et all, 2004, p.1230).
Triage tagging technology focuses on the use of bar coding and mobile wireless data acquisition to individually identify and track victims of disaster.
Triage Tracker and the Patient Barcode Registration system are examples of this new technology. However, there is one disadvantage to using bar coding systems. These systems require the presence of providers with scanning devices to obtain tracking data (Chan, et all, 2004, p.1230). Another option being tested is the Wireless Internet Information System for Medical Response to Disasters (WIISARD) project. This project recently tested the ability to collect patient vital signs continuously in the field that were then relayed through a mobile field LAN to a secure Internet database site that allowed simultaneous access by providers and hospitals (CALIT2, 2003).
Computer miniaturization, wireless technologies, bar code patient tracking, global positioning, and the use of handheld PDAs have allowed the development of mobile data acquisition and monitoring capabilities. Many organizations are also outsourcing or replicating much of their data in order to protect it in the event of a disaster that may affect their servers (Burton, 2005). These types of new information technologies are helping to improve communication by providing real time information that will ultimately improve emergency medical care and save lives during a disaster.
Conclusion
As with anything in life, there are two sides to every story. The advantages and disadvantages of using IT in the medical field have been debated for quite some time and will continue to be debated into the future. However, as our technology improves and our healthcare system evolves, it seems unreasonable not to implement the many benefits gained by technology.
In reviewing the advantages of IT in the medical field, Detmer (1994) and MEDITECH (2005) both discuss the efficiencies and cost savings associated with medical IT. Health care providers can substantially decrease costs and improve information access with the implementation of IT systems such as electronic medical records and integrated networks. These systems allow information to be quickly accessed by health care professionals as well as quickly and efficiently transferring information to third party health care organizations such as insurance companies. Powner (2003) also notes the cost savings that can be generated with medical IT systems.
As health care costs increase for health organizations as well as patients, more efficient ways of transacting business within the health care system is necessary. Powner (2003) states that IT contributed to nearly $850,000 in savings for one rural community hospital by preventing errors in drug administration and dosages by “using bar code technology and wireless scanners to verify both the identities of patients and their correct medications.” (p. 5). These types of systems are not only reducing costs, but improving medical care by reducing the number of human errors occurring at health care facilities.
Even those criticizing the use of IT can not deny that this technology is improving the health care system overall. Criticism is being raised over the security of these systems, not their ability to enhance health care. With the passing of the Health Care Portability and Accountability Act in 1996, Congress shed light on the fact that IT has made doctor-patient confidentiality harder to maintain. HIPAA tries to address the fact that health care facilities are transmitting confidential patient information to third party organizations such as insurance companies. Electronic claims processing is quick and efficient but how much information is really necessary for an insurance company to process a claim? By processing claims electronically, patients have no direct knowledge of what information is being submitted or if their privacy rights are being violated.
Another concern for IT critics is the security of health care information networks. Powner (2003) acknowledges that “security, and thus privacy, has not yet been assured-authentication of users and data encryption need to be more effectively implemented” (p. 15). There are many IT companies working to place more safeguards on all IT systems but hackers continue to break in to databases at an alarming rate and identity theft is on the rise.
Proponents for medical IT are also vigorously pursuing better, more interoperable communications for use during disasters. Current systems allow for quick responses during events such as minor traffic accidents or small fires. However, catastrophic events, such as Hurricane Katrina, shed a new light on emergency communications networks. When large events such as this occur, it becomes painfully obvious that more interoperability is needed for first responders such as fire, police and emergency medical personnel. Many of these departments have their own radio networks and have little to no capabilities for transmitting vital information to other department networks. Although security and privacy issues arise over the use of linked networks between different departments and localities, there is little argument to the fact better communications are necessary and IT is working to provide those communication networks.
J.J. Chin explains the current dilemma best in his article published in the Singapore Medical Journal. Chin (2003) states:
The debate on the safe and appropriate use of IT in medicine will continue to evolve as the capabilities of the technology are progressively being developed at a hurried pace. Only by returning to the fundamental precepts of medical ethics can we continue to meet new challenges posed by new inventions in order to preserve the ideals and aspirations of the profession, and society (p. 151).
Regardless of the IT advancements available now or in the future, the health and well-being of individual patients should always be the number one priority of health care providers.
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