Written for Unlimited Priorities and DCLnews Blog.
A librarian walked into a doctor’s office looked around and saw the steel cabinets overflowing with paper files taking up valuable office space and turned away with a knowing smile. Then the Librarian said to the doctor, ‘Don’t worry, this won’t hurt a bit.’
Today, all across the country, doctors, hospital administrators, and myriad other healthcare professionals are wrestling with the challenges of transitioning from their traditional record keeping of countless paper files in color tabbed folders to the emerging electronic health records (EHR) requirements. This takes me back to the days when libraries were beginning the uphill climb to adapt their reference tools and methods to online databases and online public access catalogs (OPAC).
Table of Contents
Looking Back at Changes for Libraries
In 1968, two key developments were underway that would later change the way libraries would function in the new information world. BRS, Bibliographic Retrieval Service, was underway as the Biomedical Communications Network (BCN) at SUNY Albany; and Systems Development Corporation (SDC) contracted with the United States Office of Education (USOE) for dissemination of educational information (ERIC). And the world is changing; by 1971, SDC created ORBIT and NLM installed it to support MEDLINE; ERIC is also offered publicly by SDC. The next year, Dialog becomes a commercial online service with NASA RECON, Nuclear Science Abstracts, and ERIC databases. i Unbeknown to librarians and their patrons the world over, these undertakings on opposite ends of the country would portend seminal changes to how information is provided and used going forward.
The Healthcare Community Begins Applying New Technology
In 2009, as part of what is known as the Stimulus Package (American Recovery and Reinvestment Act of 2009), the Federal Government included $19.2 billion to fund the conversion of medical records keeping from paper to electronic format to be interactive by 2015. ii While the technology of electronic health records (EHR) has been in practice for some years, for instance Kaiser Permanente in California began providing its patients’ electronic medical records some five years ago iii, most physicians and healthcare institutions have not embraced it. The major roadblock was the cost of making EHR a universally accepted reality. The Stimulus Package funding is intended to eliminate that barrier and pave the way for implementation of a national system for any and all healthcare providers receiving Medicare and/or Medicaid reimbursements to securely use and share health information. I will not entertain the political arguments for or against the utility of EHRs. The purpose of this piece is to present the similarities between the library/information field and the healthcare field in tackling the onset of technology to an established organization of information and tools.
So what are the commonalities between these two ventures? I find several—diversity of organization, patron/patient use, reformatting of existing formats, high cost of implementation, updating or new skillsets requirements, privacy concerns, and co-existence with existing methods. Let us explore each of these.
Diversity of Organization
The arrangement, pricing, and provision of information and information tools for healthcare providers are very similar to the challenges that confronted libraries—the issue of various organizational structures. Libraries are broadly grouped as public, academic, special and government types. But under these very broad umbrellas are many communities—public libraries that serve urban, suburban and rural communities; special libraries with diverse audiences such as medical, technical, scientific, and/or legal users; they might be in a corporation or be a standalone entity; their patrons may require special assistance, materials in languages other than English, provision of materials for remote use and several other profiles or combinations. The purpose of these organizations and the professionals that serve in them is the collection and provision of information to satisfy whatever the patron or users need. And their tools ideally should make it easy for them to meet these needs.
Likewise, a healthcare provider profile may be that of a single hospital or be part of a regional hospital network; it may be an ambulatory care center with no overnight patients or a long-term care facility; it may be mobile; it may be a teaching institution connected to a university with heavy research requirements; it may be a single doctor, a group practice specializing in a particular aspect of care or one that must prepare for an influx of new residents annually. Like libraries there are many profiles and characteristics that can exist. But the common link is the provision of healthcare to patients, whether in the office, in the hospital or clinic, on a schedule or in an emergency. And present in any scenario for the professionals in these facilities is the collection and dissemination of information to satisfy the need for timely and accurate patient care.
The Paradigm Shift
Both of these are long-standing services with tried and true systems in place as well as basic skills that have stood the test of time. And, like other long-standing services, at some point the basic assumptions are shaken up, and new methods and/or technologies impact the profession.
In the library world, the introduction of online databases was truly revolutionary. It changed how tools were organized, produced, disseminated, accessed, and used. Of course, the timeline changed again when the computer networks were linked around the globe and the Internet became a tool of communication and information sharing. The Internet has its origins in the 1960s as a United States military research tooliv—by the mid-1990’s, it became a commercial entity.
Healthcare has undergone its share of shakeups, too, particularly in the method of care and the growth of fields of specialization. Healthcare often requires a team to treat a patient where one general practitioner used to serve the purpose. The tools employed in healthcare have truly changed—no more leeching or bleeding of patients, no more exploratory surgeries. There are magnetic resonance imaging (MRI) technology, computed tomography (CT scans), dialysis treatment at home, and minimally invasive surgical procedures. Preventative care is highly recommended to provide a treatment at the earliest stages of serious illnesses with the goal of avoiding life-threatening effects.
Yet, with these cutting edge methods, most physicians and hospitals still utilize paper files and require their patients to complete paper forms. We go to our many physicians and complete similar forms providing the same information each time—name and address, vital statistics, spouse, insurance, health history, family health history, etc. Countless hours are spent collecting and filing this information. Healthcare facilities have valuable real estate taken up locally and in remote facilities just to store these paper documents. And then there is the staff time too. Filing, gathering when a patient comes in or is brought in, and goodness knows if the patient is unable to communicate—then valuable time is lost trying to guess what the patient’s history is, and whether special care is required, for example for allergic reactions.
One of the major concerns for the library profession was the new skills required when reference tools and sources were modified to fit the online and Internet environments. I will address the impact of the online tools because they were most disruptive at the time of their introduction. While the Internet offered its challenges, it seems that the providers of the information (publishers, music producers, studios, and authors) appear to be more severely impacted than the users.
The availability of reference tools online meant that the library profession had to adjust more quickly and radically than had previously been required. The predictable, timely arrangement and publication of known sources usually in book or serial format was suddenly uprooted. While early online search methods were clunky with the early technology of acoustic couplers and telephone lines, CRT terminals and the DOS operating system, they still provided more flexibility in providing more concise results than traditional print tools. Queries could be posted combining search terms—and, or, not—and searches could be saved and combined with new searches, then, the results could be printed and handed over to the requestor along with the cited materials usually photocopied from the identified sources.
These tools and database collections required new skills particularly in the area of search methodology. Vendors who wanted their products used had to provide training programs, printed documentation, and telephone help lines. User groups and networks sprang up all over the country and thousands of air miles were travelled to provide and take instruction. New occupations of search and topical specialists sprang up.
The healthcare profession is undergoing a similar transformation as their content technology tools are evolving. The U.S. Department of Health and Human Services (HHS) has created the Office of the National Coordinator for Health Information Technology (ONC) to coordinate the national efforts to implement health information technology (HIT) and the electronic exchange of information.v The mission of the ONC is promotion of the development of a nationwide HIT infrastructure that enables the electronic use and exchange of information; to provide leadership in the development and implementation of standards and the certification of HIT products; coordination of HIT policy; HIT strategic planning; and to establish the governance for the Nationwide Health Information Network.vi
Interestingly, libraries, by their nature, were eager to share their new methods and tools. In fact, new occupations began with librarians being employed by online database producers to research, develop, and design new tools, revamp existing products, and collect information from libraries about how they would like data provided to them.
The healthcare profession is doing this in a very concerted way, now, through the ONC. While the library profession had a structure in place to train in these new tools, the healthcare profession is in the position of having to build such a network. While physicians, nurses, and their support staff have been trained in using new computer-assisted tools, the people who input and manage patient information may not be as astute collectively. Of course, there are early adopters that will have their staff trained in whatever software and hardware is being introduced at their institution, but a formal program has not existed nationally for training in Health Information Technology—until now.
The ONC has initiated an ambitious program of workforce training to assure a solid foundation of personnel that can satisfy the future needs of the public health.vii This program is establishing a set of operations such as the State Health Information Exchange Cooperative Agreement Program to facilitate development of health information exchange capabilities between healthcare providers and hospitals; Health Information Technology Extension Program to provide technical assistance and best practices guidelines for healthcare providers.
In addition to these support programs are education and training tracts to assist preparation of a new workforce. Specifically the Community College Consortium to Educate Health Information Technology Professionals to quickly create HIT training and education programs at Community Colleges or to expand existing programs. The training time-frame for these non-degree programs is 6-months to meet the urgent need to provide a trained workforce. Grants are also being made available to develop Competency Examinations to certify those that complete non-degree programs. Likewise there is an Assistance Program for University-Based Training to prepare an adequate number of HIT professionals. Both of these programs are being supported by a set of Curriculum Development Centers providing grants to institutions of higher education in the development of HIT curriculum.
A critical issue that was much discussed when online database tools were developed was privacy. Patrons were accustomed to going to their library and for the most part locating materials they wanted personally, even if they interacted with staff to identify what they needed. Initially, with online databases this direct patron access did not exist. If you wanted a query conducted using an online database, it meant submitting requests—either verbally or often in writing—to information professionals who would process them. In certain settings, it was necessary for the professional to keep notes to properly charge the costs back to some cost-center or user. Naturally users, particularly in public libraries, were very concerned about their privacy. Who else would know what they were searching and why—and would the information be shared? These concerns did not lessen with Internet access in public places. What could be seen by children walking past a screen, what sites were being sought in academic libraries, and who would have access to that electronic trail continue to be discussed. Issues about surveillance, “Big Brother,” were discussed. Privacy policies were developed with the purpose of protecting the computer users, particularly in public spaces, and casual observers, e.g. children, when materials displayed may not have been appropriate.
And nowhere is privacy of greater concern than around the topic of patient information. The impact of insecure health information is fraught with issues such as exposure to employers, families, partners, and communities. The provision of the electronic transmission of health information by a healthcare provider, health plan, or clearinghouse is being guided by the HIPAA Privacy Ruleviii and enforced by the Office for Civil Rightsix. Additional steps are being developed to build upon requests for comment to implement the Health Information Technology for Economic and Clinical Health (HITECH) Act.
While HIT will assure the exchange of information for the clinical practitioner it will also provide access to information for patients. This is a major adjustment in the provision of healthcare in this country. Previously health information was consigned to be a physician’s or hospital’s domain. HIT will assure that patients have access to parts of their health history, too. This has been met with some resistance by the healthcare professionals, especially regarding notes and other observations made in the files for their eyes only.
The bottom line is that privacy in the healthcare arena is a serious factor and will require careful review.
The End User–To Be Continued
The library community was eventually faced with how to make its previously closely-held access tools and resources available to its patrons, even prior to the Internet. For centuries the librarian was the gate-keeper with special training in the resources available. Suddenly, with the advent of online databases, computer advances, and ultimately the World Wide Web, the barriers between the end user and the information were gone.
The healthcare profession is facing that dilemma with the advent of EHR. Patients will be able to access information previously kept from them.
More about this to come.
ii. Public Law 111-5 – American Recovery and Reinvestment Act of 2009. [PDF 1227 KB] Public and Private Laws. 111th Congress. H.R. 1. Tuesday, February 17, 2009.
iii. Huffington Post Investigative Fund, Fred Schulte, “Stimulus to Push Electronic Health Records Could Widen Digital Divide,” The Huffington Post. (accessed October 26, 2010)
iv. Wikipedia contributors, “Internet,” Wikipedia, The Free Encyclopedia, (accessed October 26, 2010).
v. U.S. Department of Health and Human Services, The Office of the National Coordinator for Health Information Technology. (accessed September 25, 2010).
vii. U.S. Department of Health and Human Services, The Office of the National Coordinator for Health Information Technology HITECH Programs. (accessed September 25, 2010).
viii. U.S Department of Health and Human Services, HSS Strengthens HIPAA Enforcement. HHS.gov News Release. (accessed October 15, 2010).
ix. U.S. Department of Health and Human Services, Health Information Privacy. HHS.gov.
About the Author
Debra Spruill is a consultant in the field of preservation with an emphasis on digital preservation. She was recently Director, OCLC Preservation Service Centers responsible for strategic, business development, operational, and contracting for its four Centers, including on-site locations. She was also responsible for client contracts. Most recently, Ms. Spruill was named to the Library of Congress ALTO XML Schema Editorial Board. Ms. Spruill is a member of the Unlimited Priorities team.