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 MonitoringThe 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 methods.
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 hand-held devices. Hence, 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 outcomes.
1. Department of Health and Human
Services, Centers for Disease Control and Prevention. ARRA-Health
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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 30, 2012.
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. http://healthit.hhs.gov/portal/server.pt/directory/july_29,_2010_mu_population_health/16965?DirMode=1. 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.
www.mass.gov/eohhs/gov/newsroom/press-releases/dph/dphs-infectious-disease-reporting-system-is-certified.html. 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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