US Pharm. 2012:37(11):Epub.
As pharmacists we strive to ensure quality improvement in
health care practices. Hence, it is important for us to be aware of
advances in health information technology (IT) as they relate to
specialty areas, including infectious disease. Clinicians and public
health professionals have made great strides in incorporating into
infectious disease practice the various technology enhancements on the
market today, resulting in improved delivery of clinical and public
health services. Learning how to integrate advances in health IT with
more traditional practices to improve quality and promote a culture of
health care excellence is a cornerstone of pharmacy practice.
Pharmacists can accomplish this by understanding how policy decisions
regarding health IT impact the quality of health care and learning how
the best available technological resources can be applied to clinical
practice. It is also important to note that as these applications
continue to evolve in the next few years in support of quality
improvement, we will need to understand when and where these
technologies can be used to optimize the overall process and delivery of
excellent health care.
Health IT offers great promise in the arena of infectious
disease and microbiology. We have seen over the years the continued use
and misuse of antimicrobials, and we have seen resistant bacterial
strains emerging because of antibiotic misuse. Thus, technologies to
better manage and track best practices in infectious disease are
welcome. This column will address some key considerations regarding the
use of technology in support of infectious disease best practices, in
both the public health and clinical realms.
There are three major areas of technology application
advances with respect to infectious disease today. They include public
health, computer decision support for antibiotic prescribing, and
delivery of up-to-date research results to the point of care.
Public Health: Disease Surveillance and Monitoring
The application of health IT in the public
health community for infectious disease surveillance and for monitoring
the immunization status of the population is an increasingly important
function for protecting the health of the population. Many state and
local health departments, as well as the CDC, have taken the initiative
in this area. In addition, the American Recovery and Reinvestment Act
(ARRA) of 2009 has stimulated further progress under its provisions in
the Health Information Technology for Economic and Clinical Health Act
(HITECH), which established an incentive program for both hospitals and
eligible professionals to encourage the adoption and meaningful use of
certified electronic health records (EHRs). In addition, HITECH provided
funds through the CDC to “establish activities to support meaningful
use of electronic health records through two-way communications between
clinicians and national, state and local public health entities.”1
The Department of Health and Human
Services, with the Centers for Medicare and Medicaid Services (CMS) as
the lead agency, released the final regulations regarding phase I
meaningful use in 2010.2,3 Under these regulations, which
governed the meaningful use EHR incentive program in 2011 and 2012,
eligible professionals and hospitals had the option to submit electronic
immunization data to immunization registries or immunization
information systems. In addition, eligible professionals and hospitals
had the option to submit electronic syndromic surveillance data to
public health agencies. Furthermore, hospitals had the option to submit
electronic data on reportable laboratory results to public health
agencies. These incentivized activities were intended to strengthen
electronic public health reporting activities that were already
occurring in some states.
For example, in New York State, an electronic system of
childhood immunization reporting, hospital laboratory reporting, and
emergency department syndromic data reporting to the New York State
Department of Health (NYSDOH) has been in place for nearly a decade.4
The NYSDOH relies on hundreds of thousands of clinical laboratory
results reported annually via New York’s Electronic Clinical Laboratory
Reporting System (ECLRS) to trigger field investigations of communicable
diseases and to determine the source of the infection and prevent
further spread.4 New York also collects syndromic data
electronically from emergency rooms, allowing detection of epidemics and
pandemics; a recent example of this was the tracking of the H1N1
influenza pandemic. Finally, New York’s Immunization Information System
(NYSIIS) is used by over 90 percent of pediatric practices in the state
to electronically record childhood immunizations.4 With the exception of the immunization reporting, the other two systems had not been directly linked to patient-specific EHRs.
The state of Massachusetts likewise uses
an electronic laboratory reporting (ELR) system that has been certified
by the Department of Health and Human Services, Office of the National
Coordinator, as meeting meaningful use requirements for public health
reporting.5 The system is now in use by 65 of 72 hospitals to
report infectious disease test results to the Massachusetts Department
of Public Health Bureau of Infectious Disease in real time.5
The system automatically converts all reported messages into the
required data format to facilitate interoperable data exchange and to
meet meaningful use requirements.
Public health departments often rely on a
geographic information system (GIS) to track syndromic and laboratory
data regarding emerging infections. These systems are usually
interactive and can integrate data from a variety of sources into a map
project. GIS technology can be used to track the spread of disease, to
localize vulnerable populations, and to assess the availability of
resources to deal with the infection. For example, GIS was used by the
Norwegian Institute of Public Health to study an outbreak of
legionnaires' disease that was related to industrial air scrubbers.6
Locations of patients both at home and at work were mapped, and their
movements were tracked. Attack rates and risk ratios were calculated
with respect to different possible sources. Patients living within 1 km
of a particular air scrubber had the highest risk ratios, and the risk
decreased with increasing distance. This allowed identification of the
most likely source, which was then confirmed with cultures and molecular
Computer Decision Support for Antibiotic Prescribing
Evans and colleagues first described the
use of computerized clinical decision support in the management of
patients in the intensive care unit at a hospital in Utah.7
The authors demonstrated improved selection of appropriate antibiotics
with better outcomes and reduced cost in the ICU setting. Personal
digital assistants (PDAs) and hand-held devices are now being tested in
critical care settings to assist clinicians in the appropriate
prescribing of antibiotics. The advantage of this approach is that
up-to-date data can be supplied to clinicians in real time at the point
of care so that more informed antibiotic choices can be prescribed. A
large number of authoritative sources such as the Sanford Guide to
Antimicrobial Therapy are now available for PDAs and other hand held
devices such as the Blackberry and the iPad.
Delivery of Up-to-Date Research Results to the Point of Care
Electronic technologies have the
opportunity to deliver the latest research and treatment information in
real time today, versus just a few years ago, when less easily
accessible sources such as textbooks, literature reviews, and white
papers provided guidance on diagnosing and treating infectious disease
states. The introduction of electronic decision making in infectious
disease creates a very dynamic process. With the power of the Web,
virtually any new treatment plan or diagnostic approach can be retrieved
and reviewed immediately at the point of care. The Internet, along with
pocket devices, provides easy access to point-of-care tools, including
high quality Web sites specializing in antibiotic management, such as
the Johns Hopkins ABX Guide.8 Some available
technologies include electronic mailing lists, (e.g., LISTSERV), drug
databases, and links to technology tools that are custom designed for
the latest research from nearly anywhere around the globe can be quickly
accessed at the bedside. This quick turnaround of multiple pieces of
information proves invaluable when diagnosing and treating infectious
disease processes, thereby supporting best practices with appropriate
treatment plans. For example, Web-based decision support tools, as well
as hand-held phones, can provide the necessary support and structure for
virtual on-the-spot diagnosis and treatment of an infectious process.
Hence, more appropriate antimicrobial agents can be selected at the
beginning of therapy based on best evidence, thereby eliminating the
need for broad-spectrum coverage protocols previously instituted prior
to results and diagnosis. Online sites also provide invaluable
information about dosing and potential side effects.8
Technological advancements in diagnosis
and treatment of infectious disease highlight the need for clinicians to
understand the technologies and how and when to best use them to create
a seamless process for diagnosing, managing and prescribing.
Pharmacists will play a key role in these efforts, as they will have the
same real-time accessibility as clinicians to online information to
support best practices. Pharmacists will likewise be able to review
nuances in the diagnosis, monitoring, and prescribing of infectious
disease protocols, and this in turn should save valuable time for
pharmacists, who previously had to search and investigate new dosing
regimens and protocols for various disease states. Finally, many of
these decision support tools now easily interface with EHRs and
e-prescribing platforms, making the cross-check and review of a
patient’s profile much less labor intensive than previous efforts when
reviewing physician orders.
We are realizing in this era of health
care reform that a significant amount of data and tracking is generated
during the delivery and practice of health care. Data that were
previously static and sometimes were out-of-date or difficult to verify
are now being replaced with dynamic information to support the
best-practice prescribing of the various antimicrobial categories.
Infectious disease prescribing, sometimes cumbersome, is now better
enabled with the infusion of technology support. Thus, technologies such
as the hand-held devices that we see in our day-to-day lives can be
used to support these initiatives. Technology now provides easy,
real-time access to high-quality data and decision supports. This
enhances the goal of linking patient care with the data and information
needed for quality outcomes. Patients, clinicians, and other
stakeholders, such as public health agencies, all have an equal
opportunity to share the same data in real time to ensure quality
1. Department of Health and Human
Services, Centers for Disease Control and Prevention. ARRA-Health
Information Technology and Public Health.
Accessed June 30, 2012.
2. Department of Health and Human
Services, Centers for Medicare and Medicaid Services. Medicare and
Medicaid Programs; Electronic Health Record Incentive Program. Federal Register,
vol. 75, no. 144, Wednesday, July 28, 2010, pp. 44314-44588.
www.gpo.gov/fdsys/pkg/FR-2010-07-28/pdf/2010-17207.pdf. Accessed June
3. Blumenthal D, Tavenner M. The “meaningful use” regulation for electronic health records. N Engl J Med. 2010;363:501-504.
4. Testimony by Guthrie Birkhead, deputy commissioner, New
York State Department of Health. Presented at: HIT Policy Committee
Meaningful Use Workgroup, Washington, DC; July 29, 2010.
Accessed June 30, 2012.
5. Executive Office of Health and Human
Services, Massachusetts Department of Public Health. Press release.
Massachusetts Department of Public Health’s infectious disease reporting
system certified by Obama administration. April 26, 2012.
Accessed June 30, 2012.
6. Nygård K, Werner-Johansen Ø, Rønsen S, et al. An
outbreak of legionnaires' disease caused by long-distance spread from an
industrial air scrubber in Sarpsborg, Norway. Clin Infect Dis. 2008;46:61-69.
7. Evans RS, Pestotnik SL, Classen DC, et al. A
computer-assisted management program for antibiotics and other
anti-infective agents. N Engl J Med. 1998;338:232-238.
8. Burdette SD. Electronic tools for infectious diseases and microbiology. Can J Infect Dis Med Microbiol. 2007;18:347-352.
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