Practitioners profit from insights into the importance of technologies and systems and their application. Alles zeigen. Infrastructure Seiten Integration Services Seiten Knowledge Services Seiten Branching logic based on results can be used to verify that each step in the treatment is accomplished. The system described would not only reduce errors, such as missed handoffs and unnecessary waiting times, it would also interact with enterprise systems for supply-chain management and capacity planning.
Another key component of the health information infrastructure, digital sources of evidence—including bibliographic references, evidence-based clinical guidelines, and comparative databases—is essential for evidence-based practice. Currently, most digital sources of evidence are stand-alone systems that are not integrated into clinical information systems. The challenge for practitioners is to use these sources of evidence in combination with their experience and expertise to make clinical decisions Bakken, However, as the medical-evidence base continues to expand exponentially and more and more clinicians accept the validity of best-demonstrated practices for diagnosis and treatment, there is mounting interest in integrating rapidly expanding digital sources of evidence including genomic and phenotypic [clinical] data into decision-support tools that can be fully integrated into care processes.
At the same time, fueled by the rapidly expanding medical-evidence base, there is a growing awareness among care professionals of the need for customization of best demonstrated practice rules for almost all patients. Another emerging area is translational medicine, the use of the results of the genome project to predict and customize treatment. The standardization of health care data, the development of digital sources of medical evidence and knowledge, and the creation of EHRs will all facilitate the use of decision-support tools, which are key components of clinical information systems.
Decision-support tools that are fully integrated into the care process will enable both care providers and patients to access medical knowledge relevant to the patient's care. They may, for example, identify negative interactions between a drug the patient is already taking and an additional drug that might be prescribed. A necessary platform for decision-support tools is the clinical-data repository, a database that collects and stores patient care information from diverse sources.
Clinical-event monitors, which work with clinical-data repositories in support of real-time delivery of care, are usually triggered by clinical events e. The event monitor combines clinical rules, the triggering event, and information present in the repository to generate alerts, reminders, and other messages important to the delivery of care. For more than 20 years, departmental systems e. But there is no health care process-management system in which all information concerning a patient's history is gathered in one place in standardized text where the appropriateness and strategy of orders for patient care can be checked.
Equally important, a health care process-management system would ensure that the result of each step in treatment was entered into the record and communicated to all relevant parties. The collection of data, the consideration of the decision support offered, followed by the ordering and carrying out of the diagnostic and or treatment plan is an iterative process.
The Impact of the Internet of Things to Value Added in Knowledge‐Intensive Organizations
As results are entered, the next steps in the care process are instituted. This area of research, which combines expertise in cognitive and software engineering, behavioral science and cooperative work, and computer and cognitive sciences, focuses on the development of techniques and concepts that facilitate interactions between people and computers Winograd and Woods, ; Woods, Health care computer systems have been administrator-centered or billing-centered systems rather than provider-centered or patient-centered systems.
However, software and telecommunications capabilities are being expanded, although slowly, to achieve continuity of care without losing sight of economic and other pressures Box Designing Computer Systems for Health Care. Software-intensive systems are the norm for all modern high-performance systems. But simply extending the reach of computer technology will not guarantee high performance in a complex setting like health care.
Areas for research include hardware interfaces, as well as sociological and psychological aspects of the use of computerized systems by physicians and other health care workers. Because software-intensive systems perform valuable functions, the consequences of failure are generally serious. For example, developers may assemble modules, each apparently dependable, but, when they are integrated, problems and weaknesses emerge.
Usability failures are also an issue. In some cases, the initial software-intensive system may be dependable, but changes in use over time may lead to changes in the software that lead, in turn, to unnoticed side effects that can introduce weaknesses in the system.
Another type of failure can occur when cost overruns in the development process prevent the project from ever reaching the commercialization stage.
In some instances, noncritical software that interacts directly or indirectly with critical functions introduces failures and weaknesses NRC, ; Rae et al. As these and other forms of software-system failure show, investments in clinical information systems must be complemented by investments in research on software dependability. Opportunities for improvement and research include: better human-computer system interfaces; software to improve the interoperability of systems from various vendors; systems and accompanying business models for spreading costs among multiple users; and software dependability in the context of health care delivery.
The delivery of quality care, especially in a highly fragmented delivery system, requires that both clinicians and patients have access to complete patient information and decision-support tools and that communications among clinicians and between clinicians and patients are effective.
[PDF] Modeling Knowledge Work for the Design of Knowledge Infrastructures - Semantic Scholar
The Internet and the World Wide Web have provided patients with unprecedented access to health information and made possible more continuous, asynchronous communication between patients and their care providers. Meeting the current and emerging communications needs of health care will require a combination of wireless and fixed-line networks. Because of financial constraints, creating different systems for different settings will not be feasible, however.
Vendors of hardware and software components of the system will need system transparency, which can only be achieved once standards have been adopted. The challenge will be to generate a robust, but flexible system that can be duplicated in many different circumstances without requiring major modifications; the system must be based on technology that can be rapidly diffused and at low cost. Five technical factors are important in planning for the implementation of communication networks: 1 bandwidth requirements and availability; 2 latency in transmission throughout the network; 3 continuous availability of the network; 4 confidentiality and security of data; and 5 ubiquity of access to the network NRC, Enabling patients to communicate effectively with health care providers without face-to-face meetings will require many improvements in electronic communications.
The Internet and World Wide Web provide a framework for communication links, and a few large provider organizations have demonstrated the potential of these technologies. But making them accessible to large populations in a health care community will require experimentation and research Perlin et al. Other issues that must be addressed include ensuring the confidentiality and security of transmissions and health care data. In the preceding discussion of major components of the NHII, a number of technical impediments to implementation of these systems were identified e.
Educational barriers are discussed in Chapter 5. At the present time, several factors severely undercut the returns health care providers might expect to capture on their investments. This lack of connectivity, in turn, has severely limited improvements in efficiency and quality. Another major barrier is the prevailing reimbursement arrangement for health care services, which does not reimburse care providers differentially on the basis of quality of care. Contrast this with incentives for provider organizations to invest in new diagnostic equipment, such as MRI machines, which begin to generate revenue as soon as they are up and running.
Nevertheless, the barriers persist.
The committee believes that as conceptual and material progress is made in measuring quality and productivity in health care, significant returns on investment at all levels of the health care system will be demonstrated NRC, ; Triplett, , In addition, many clinicians have a very limited understanding of the potential uses, impacts, and benefits of advanced information systems for the production and delivery of care. Thus, the benefits of change are not immediately visible, but the costs are.
Not surprisingly, then, there has been significant resistance to innovation and changes in work processes and the division of labor among health care professionals.
Table of Contents
The cultural and organizational factors that have contributed to a rigid division of labor in many areas of health care often impede the introduction and exploitation of tools, technologies, and other innovations that could improve quality and productivity in health care see Bohmer, this volume; Christenson et al. Finding A critical step toward realizing the National Health Information Infrastructure will be the development and widespread adoption of network standards for health care data and software.
Research must focus on standards-related issues concerning the integrity of data, controlled access to data, data security, and the integration of large-scale wireless communications. There is also a pressing need for low-cost tools for standardizing new and legacy digital data without disrupting clinical work flows. Progress in systems interoperability and data standards is likely to improve remote access to self-care educational tools, patient health records, and health care provider and insurer services scheduling, billing, etc.
Cross-sector learning and research on information and communications standards among federal agencies, health care insurers, and health care providers represents a potentially vast source of knowledge and advancement. The Internet and World Wide Web provide a framework for communication links, but making them accessible to large populations in a health care community to promote communication between patients and health care providers will require experimentation and research, particularly to ensure the confidentiality and security of transmissions of health care data.
However, many barriers will have to be overcome before it can be implemented. Recommendation The committee endorses the recommendations made by the Institute of Medicine Committee on Data Standards for Patient Safety, which called for continued development of health care data standards and a significant increase in the technical and material support provided by the federal government for public-private partnerships in this area. The committee endorses the recommendations of the President's Information Technology Advisory Council that call for: 1 application of lessons learned from advances in other fields e.
The committee applauds the U. Department of Health and Human Services year plan for the creation of the National Health Information Infrastructure and the high priority given to the creation of standards for the complex network necessary for communications among highly dispersed providers and patients. Special attention should be given to issues related to large-scale integration. Funding for research in all of these areas will be critical to moving forward.
These initiatives include efforts to reimburse providers for care episodes or other bundling techniques e. The emerging technologies in wireless communications and microelectronic systems described in this section have the potential to advance the patient-centeredness and quality performance of the health care delivery system and to change the structure of care delivery in the process.
Microelectronics promises to be a powerful tool for meeting quality and productivity challenges in health care delivery, provided that resources can be marshaled in a rational way. The microelectronics revolution began in the s with the advent of integrated circuits and has since revolutionized data processing, communications, and control.
The number of transistors that can be integrated on a silicon chip the size of a finger-nail has increased from about 2, on the first micro-processor to about ,, today; the speed of these chips has increased more than a thousand-fold. At the same time, the number of bits of memory on a chip has increased by a factor of more than a million, and costs have decreased just as precipitously. Low-cost disk storage is now approaching a density of more than 40 gigabytes per square inch. In short, the processing and storage of data, the creation of information and knowledge based on those data, and the efficacy of decisions have improved exponentially.
In the coming decades, as the number of nurses and physicians decreases, monitoring and diagnostics will have to improve dramatically. Efforts to develop sensors using integrated circuit technology has resulted in microelectro-mechanical systems, which can be combined with microelectronics and wireless interfaces to create wireless integrated microsystems WIMS for use in health care delivery.
In the near future, WIMS will be merged with sensors with embedded microcomputers and minute wireless transceivers a cubic centimeter in size or smaller that operate at power levels of less than 1 milliwatt, consistent with long-term operation fueled by batteries maintained by energy scavenged from the environment Wise, , These new devices could potentially provide continuous monitoring of critical functions, thereby turning every hospital room into an intensive care facility.
WIMS devices small enough to be worn comfortably and unobtrusively could communicate with a bedside receiver that communicates, in turn, with monitoring stations and a larger health care facility. The system just described would go a long way toward meeting the objective of the Leapfrog Group of having an ICU physician present in every hospital at all times Leapfrog Group, WIMS systems are still scarce, and their performance is limited, but they are emerging. Blood oximeters, heart rate monitors, and temperature sensors could all be components of WIMS; swallowable capsules for viewing the digestive tract are already in use Fireman, ; Pelletier, ; Pennazio et al.
Wearable devices that monitor blood pressure hypertension , breathing patterns sleep apnea , and other variables will certainly be available in the near future see Budinger in this volume. The major challenges to their use are interfaces with the body itself. Swallowable capsules for all kinds of internal viewing and measurements could significantly improve diagnoses of a variety of conditions and thus could improve the quality of health care. DNA analysis chips will bring advances in genetics into the hospital, and even the local doctor's office Burns et al. However, the impact of these developments on costs will be indirect.
In addition, privacy issues must be addressed before they can be widely used.
Enterprise Knowledge Infrastructures
WIMS for health care are expected to be technically feasible in the coming decade, but to reduce costs, they must be part of a complete system. Bedside receivers and wearable monitors might be technical triumphs, but they could also lead to economic disaster for the company that produces them unless they fit into a larger system. A similar situation has existed for at least 20 years in the process-control industry.
Although prototypes of sophisticated sensors have been produced, they are still not widely used because controllers that can exploit their features have not yet been developed.
In the transportation industry, the entire control system of the automobile engine had to be redesigned to take advantage of microprocessors and electronic sensing. Comparable redesigning of the health care system will be necessary at every level to take advantage of WIMS.
The application of WIMS technologies in the hospital promises to significantly improve the quality and patient-centeredness of inpatient and ambulatory care. The potential impact of WIMS on home care and the quality of life for senior citizens and chronically ill patients is even greater Whitten et al. Moving WIMS technology into the home is being seriously considered by makers of home communications equipment. With properly integrated home-based WIMS systems, patients could be monitored on a continuous basis and care professionals alerted automatically when events merit attention.
Continuous or at least more frequent home monitoring of the health status of elderly and chronic care patients could notify clinicians of the need for timely therapeutic interventions that could avoid hospitalizations and shorten hospital stays, thus reducing the costs associated with the care of the patient over time see Budinger in this volume. Moreover, home-based WIMS could facilitate safe home environments and the activities of daily living that are so important for the health of the elderly and chronically ill.
The main technical problems in the development of WIMS are largely related to reliable interfaces between sensors and the body and ensuring that sensors are capable of differentiating between instrumentation artifacts and physiological events. WIMS may also have therapeutic uses. The development of wireless implantable microsystems has been the subject of research for 40 years or more, but, to date, few devices have been developed besides pacemakers. Pacemakers have become increasingly sophisticated electronically, but their interfaces with the body are primarily via electrodes.
Nevertheless, they have set the stage for the emergence of new devices in the coming decade. For example, cardiovascular catheters have been used for diagnosing cardiac conditions for many years, and pressure sensors small enough to be mounted directly on catheters have existed for some time Chau and Wise, ; Ji et al. In fact, catheter-based electronics for improving diagnostic capabilities are long overdue. Another example is stents, which are widely used for treating coronary occlusions and now have chemical coatings to prevent re-stenosis.
In the near future, stents may also be used as platforms for instrumentation, such as wireless sensors for monitoring blood pressure or blood flow that could be activated by a radio frequency wand positioned over the chest. Significant challenges remain involving range, accuracy, and size, but such systems may be feasible soon Collins, ; DeHennis and Wise, ; Stangel et al. Wireless sensors could also be used in intracranial, intraocular glaucoma , and intra-arterial applications. Miniature biocompatible packages that can exist for many decades in the body are also being developed for long-term use in chronic conditions Ziaie et al.
WIMS could also have a dramatic impact on the treatment of conditions involving the central nervous system. More than 90, cochlear implants are in use worldwide today, enabling many profoundly deaf and severely hearing-impaired individuals to function normally in a hearing world House and Berliner, ; Spelman, Even though their performance is still limited and there is some opposition to them in the deaf community, these devices may render most kinds of deafness treatable disorders in the next two decades. In the United States alone, more than 2 million people are profoundly deaf, and 20 million are severely hearing impaired.
There is considerable interest in treating other neurological disorders using WIMS. Visual prostheses have recently received considerable attention but are still at a very early stage of development Lui, The same is true of prostheses for severe epilepsy and paralysis. For example, an implanted electrode array might detect the onset of an epileptic seizure and provide local electrical stimulation or drug delivery to prevent the spread of the seizure.
Functional neuromuscular stimulation FNS is being used to help quadriplegics stand and even walk, and the use of dense electrode arrays to capture control signals directly from the motor cortex has recently enabled primates to control robotic arms Chapin et al. Combining FNS with cortical control could lead to at least limited closed-loop activation of paralyzed limbs Wise et al. And the use of deep brain stimulation in the subthalamic nucleus to eliminate the manifestations of Parkinson's disease has yielded impressive results and is now approved for human use Limousin et al.
Although all of these devices are still at a relatively early stage of development Table , some are gaining acceptance now, and many could be in wide use in the next 20 years, which could substantially impact the quality of health care and the costs of rehabilitation. Microsystems implemented as wearable and implantable devices connected to clinical information systems through wireless communications could provide diagnostic data and deliver therapeutic agents for the treatment of a variety of chronic conditions. In fact, WIMS could potentially restructure care delivery in the hospital.
There is no question that microdevices can and will significantly improve the daily lives of many people. The barriers to the realization of this vision are significant, however. For patients to take on greater control and responsibility for their own care, they will have to be educated or able to educate themselves. In addition, patients must continue to have access to trusted sources of advice and counsel.
Changes in the division of labor between patients and care teams implicit in the self-care model will also have a profound impact on the roles, work processes, and division of labor among members of the patient's care team. Resistance to change, especially if roles, authority, and jobs are threatened, may arise among care professionals and organizations that deliver services both within and outside of hospital setting e.
Current reimbursement systems may also present barriers if care providers are not reimbursed for e-visits, patient modules, remote care services, and so on. The implications of the self-care model for the health care industry are profoundly disruptive. The move toward self-care could be considered threatening to businesses e. The current complex mix of professional licensing, regulation, liability law, and other constructs established to ensure the health care safety and reliability also pose barriers. The current hierarchical culture and rigid division of labor in the health care profession could make the reallocation of responsibilities and changes in the roles of care team members extremely contentious.
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