June 2013

EHRs and Infection Control
By Mike Bassett
For The Record
Vol. 25 No. 9 P. 14

According to a recent study, the industry is failing to take advantage of HIT’s ability to help control the spread of disease.

A survey published in the Journal of the American Medical Informatics Association last year found that a large majority of respondents believe that EHRs (66%) and electronic health exchange (79%) will improve health care quality. Those numbers reflect the growing expectations that EHRs and the subsequent exchange of data through health information exchanges (HIEs) will enhance patient care and lower costs.

However, a recent study in the American Journal of Infection Control suggests that these informatics tools either are being underutilized by hospital infection control professionals or aren’t optimally designed to further the cause of better care.

While research has shown that electronic data exchange can increase the timeliness and completeness of infection reporting to local and national health authorities, it appears that many infection preventionists are unaware whether their hospitals participate in such projects, according to lead author Brian Dixon, MPA, PhD, an investigator at Regenstrief Institute and an assistant professor in the School of Informatics and Computing at Indiana University-Purdue University Indianapolis.

“From other survey work I’ve done and other work on HIE I’ve done, it’s pretty clear that while the ONC [the Office of the National Coordinator for Health Information Technology] is doing education about HIE and lots of institutions know about meaningful use, there is still a large segment of health care professionals who don’t know that much about HIE,” Dixon says. “They may know something about it in general, but they may not know a lot about it, and they may even have some misconceptions.”

The study, which was based on a survey of 44 infection preventionists from states with HIE networks, also found that while more than 70% of respondents have access to an EHR, fewer than 20% said they were involved in the system design, selection, and implementation. According to the authors, without that kind of involvement, these electronic information systems don’t include components that support the preventionists’ job activities.

“Typically, in informatics, our focus is on physicians, nurses, and other kinds of frontline clinicians who are interacting with patients and the EHR,” Dixon says. “So I wanted to see how infection preventionists perceived the value of HIE, but the more surprising outcomes [of the study] were related to how infection preventionists interface with their own EHRs. And it’s not even at the stage of pushing data outside of their own institution but within their own institutions—there seems to be little support there for leveraging the EHR to support their workflow and their needs.”

Survey responses suggested that infection preventionists have several issues with the way they can interact with EHRs. According to Dixon and colleagues, the most common problem involved support for decision-making tasks, with respondents asking for smarter EHR systems that “could interpret electronic laboratory and clinical reports, find the incidence of a notifiable condition, and place the information in a queue for review.”

Another issue involved concerns about ease of use, specifically infection preventionists’ ability to access information faster and more efficiently when they need to document a notifiable case. “Infection preventionists commented that they often need to ‘fish’ or ‘dig’ or search (in some cases ‘for hours’) within their current electronic systems to find the data and information they require,” Dixon and colleagues wrote. Other concerns were about interoperability and data completeness.

Charles Jaffe, MD, PhD, CEO of the standards development organization Health Level Seven International, says these concerns aren’t necessarily related. For example, he says, “If I were to manage a system that was incompatible with a hospital a block away, I could still have a decision-support system and superb workflow. And I could have superb interoperability between two departments and still have software that was poorly written so that the workflow wasn’t ideal for my needs.”

Jaffe adds that he doesn’t know how chief information officers and their committees go about selecting their EHRs, but “I’m guessing that infection control is not at the top of their list.”

Kathleen Roye-Horn, RN, CIC, an infection control director at Hunterdon Medical Center in Flemington, New Jersey, and vice chair of the Association for Professionals in Infection Control and Epidemiology’s Practice Guideline Committee, concurs that infection control does not appear to be a priority when it comes to EHR selection. For her, Dixon’s findings ring true. “Hospitals are moving as quickly as they can to become more electronically connected, but the primary focus of the development of these programs hasn’t been infection prevention or infection surveillance,” she notes, adding that she was involved in her organization’s EHR selection process, but discussions were more focused on how to make it user friendly for clinicians.

Impact on Public Health
Dixon says the study’s findings have several implications for public health. If infection preventionists aren’t familiar with or interacting with HIEs, then it will be more difficult for them to provide public health officials with the data they need to adequately monitor population health.

In his article, Dixon points out that electronic data exchange has been shown to improve infection control practice. He referred to a study in which researchers examined a large metropolitan area and detected 286 patients who generated more than 4,000 inpatient days in which the receiving hospital was unaware of a prior history of methicillin-resistant Staphylococcus aureus (MRSA). The researchers implemented a clinical reminder through an HIE to alert infection preventionists when patients with a history of MRSA were admitted to their facilities. In the first year of operation, the program delivered almost 2,700 admission alerts for patients with a history of MRSA, one-fifth of which was based on information that came from a different health care organization.

Roye-Horn is involved with a New Jersey program whose objective is to measure the potential value of electronic HIE for infection control purposes. About a dozen years ago, amid concerns about bioterrorism, the state implemented a system in which hospital emergency department records were mined for data on certain syndromes. The resulting information is downloaded into the information systems of local and state health departments.

Roye-Horn says the data are evaluated on a daily basis to determine whether any syndromes are prevalent and, if so, whether they require a response from public health officials. “It hasn’t shown anything since it’s been in use, except when the flu season starts,” she says. “It always shows that there’s a blip in that particular syndrome, so we know the system does work.”

Financial Factors
Stretched budgets have limited the resources set aside for public health, making electronic data exchange more of a necessity. “The days when epidemiologists in health departments can physically go out and collect information from hospitals and their communities are over,” Dixon says. “That’s tough to do considering budget cuts and all of the different things health departments have to focus on. So they need these electronic data feeds in order to effectively monitor populations.”

Dixon says the less-than-optimal interactions between infection preventionists and EHRs may have implications not only for public health but also with regard to growing concerns about providing more efficient, cost-effective health care. If infection preventionists are spending an inordinate amount of time performing manual tasks that could be automated, he says it’s a waste of health care resources.

For example, EHRs can increase efficiency and save money by providing decision support. Alerting infection preventionists when someone has a hospital-acquired infection or when a contracted disease needs to be investigated are two areas where EHRs can be leveraged to help infection preventionists perform their jobs more thoroughly. “If you can optimize the workflow of infection preventionists and get more value out of these EHRs—which are very costly—you can have a big impact on quality of care and the overall costs of health care,” Dixon says. “If we really want to drive down the spread of hospital-acquired infection, then we need to make sure that EHRs aren’t available just so they can let infection preventionists manually search through the records to find the proverbial needle in a haystack, but that they are set up to really alert and provide the information an infection preventionist needs at the right time.”

Solutions?
Lack of input from infection preventionists and design dilemmas often leave infection preventionists on the outside looking in when it comes to EHRs. “I am surprised to see so few infection preventionists have been involved in the choice of electronic record systems in their facilities,” Roye-Horn says. “But even if they had been, there aren’t too many available programs that have a very strong component for our use.”

There could be several reasons for EHRs’ minimal focus on infection control. Viet Nguyen, MD, chief medical information officer of Systems Made Simple, a provider of HIT systems and services, says there are time and labor costs associated with developing alerts and reports based on lab tests. He also notes that HIT systems originally were designed to deal with billing and reimbursement issues and still are evolving, giving some hope to infection preventionists who want a greater voice in design decisions. “As the health IT industry matures, we will identify ways for technology to measurably improve care,” he says.

Nguyen says there are several strategies for addressing the issues identified by Dixon and colleagues. For example, EHRs must be enabled to collect and report microbiology and other laboratory data in a standard format. “Dr Dixon’s institution, the Regenstrief Institute, is the home of the Logical Observation Identifiers Names and Codes [LOINC] terminology, a universal coding system for labs. By using LOINC along with SNOMED-CT [a clinical health care terminology], positive microbiology cultures could be automatically identified and reported by an EHR to the infection preventionists for further investigation,” he says. “Hospitals need to increase awareness of the preventionists as to the availability of this functionality in their EHR.”

Dixon says providers should examine their IT budgets and overall investment in HIT, and then define a strategy to support infection control. While acknowledging that EHR systems primarily are designed for frontline health care professionals such as physicians and nurses and for clinical documentation purposes and meeting meaningful use requirements, he says other health care interests also should be addressed.

“So we need to rethink our strategy to make sure that other services within hospitals or health networks are included in that overall strategy,” Dixon says. “To my knowledge there really aren’t any vendors that have [some kind of hospital-acquired infection solution] built into the main product, so there will need to be integration efforts and partnerships between providers and vendors.”

In addition, he says there must be more informatics research devoted to finding how EHRs can better handle infection data. Stronger algorithms to help detect when patients have hospital-acquired infections or to distinguish between community-based infections and hospital-acquired infections are among the possibilities for greater specificity.

“I think we also need some research in the area of better natural language processing techniques to identify things like catheter-associated urinary track infections,” Dixon says, adding that much of this information is documented in dense clinical or laboratory notes where infection preventionists ideally would like to see a simple quantitative result that confirms whether a patient has an infection.

“We know that health information exchange and well-designed electronic health records can help prevent the spread of infection among patients,” Dixon says. “And these findings underscore that HIE organizations, as well as the ONC, need to continue to provide more education about health information exchange and the benefits that health information exchange can provide to a whole range of health care professionals and not just frontline physicians.”

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.