This issue of JAMIA reports on a collection of informatics research and applications developed and implemented worldwide. I highlight below some of the latest findings in our field and discuss how they are interconnected.
The increasing adoption of electronic health records (EHR) and secondary use of clinical data for research have fueled research in privacy technology. In this issue, Malin (page 3) uses simple techniques to show that the same level of privacy preservation attained with the ‘safe harbor’ rule from the US government can be achieved, even if select portions of the data that are not supposed to be disclosed under the safe harbor rule (eg, the ages of individuals above 89 years old) are made available. The article is important because it illustrates the rationale behind the safe harbor rule but proposes technological alternatives that may influence how new policies and regulations are formulated. More research in this burgeoning field is sorely needed to enable effective use of clinical data for research without compromising individual privacy.
A secondary finding, related to privacy, in a study from Atkinson (page 24) shows that patients are reluctant to enter their personal information in a web application that helps locate appropriate clinical trials. The main focus of the study is the evaluation of user perceptions of a web-based system. The authors systematically study patient perceptions of two web-based systems and show that a counterbalanced design (ie, a design in which the order of presentation of two different systems are alternated) is important to avoid overestimation of preference toward the system that is presented last. On a related topic, Or (page 51) utilizes a model based on technology acceptance theory to determine the factors that influence the use of a home-care web-based self-management tool by patients with chronic cardiac disease. For this population, the main factors were the perceived usefulness and ease of use, social influence (‘peer pressure’), and the patients' healthcare knowledge.
Clinician perceptions are important for acceptance of new clinical systems. Hincapie (page 60) describes how physicians in limited focus groups perceived a particular health information exchange (HIE) system. Physicians thought that HIE could improve care, but that it would not have much impact if data were not comprehensive, as was the case in their setting. This might explain why limited scope HIE initiatives have failed. Additionally, opponents of electronic health systems have raised concerns about the potential for EHRs to increase the length of visits and to decrease the clinician's face time with the patients and/or their families. Fiks (page 38) shows that pediatricians spend a large proportion of visit time interacting with the families while using the computer. They also show that, after adjusting for visit characteristics such as number and types of diagnoses, computer use is not associated with increased time per visit; nor is it associated with decreased face time.
On the other hand, advocates for electronic health systems often assume that these systems improve efficiency and accuracy. Blaya (page 11) reports on negative results of a cluster randomized controlled trial that implemented an electronic communication system for laboratory results. Although the turnaround time to receive tuberculosis culture and drug-sensitivity results was significantly reduced for regional health centers, indicating that the system was effective at that level, the system did not benefit the end users directly, as it did not cover the ‘last mile’ of communication between the regional centers and local point-of-care users. Lessons learnt from this study should inform those who are designing new interventions, especially in situations where resources are very limited as in many global health informatics projects.
On the topic of clinical documentation, Collins (page 45) reports that critical goals and actions discussed in ICU rounds are not adequately documented in clinical notes authored by attending physicians, nurses, respiratory therapists, and residents. The results indicate an urgent need to define a common information source for the care plan that is consistent across team members, since its absence may compromise patient safety. Clinical documentation is fraught with difficulties. For example, the use of certain abbreviations in clinical documents is unsafe. Myers (page 17) reports on the teaching effects of a system that required users to remove inappropriate abbreviations when writing clinical notes in an EHR system. Fewer inappropriate abbreviations in subsequent handwritten notes were written by subjects in this ‘hard stop’ group, but not for the group in which the corrections were done automatically by the EHR system. Further work is certainly needed to clarify whether this observation can generalize to other situations. Also related to patient safety, the article by Saverno (page 32) describes the heterogeneous implementation of decision-support tools to detect drug–drug interactions in different pharmacies. Results are concerning: the median sensitivity across 64 pharmacies in Arizona for some important drug interactions was only 0.85, ranging from 0.23 to 1. Interestingly, the variability was not related to the type of system being used (different vendors were represented) or to the type of pharmacy (such as hospital- or community-based), but rather related to the particular configuration at the site. More research on this topic is certainly warranted to understand how best to implement decision-support tools for pharmacists.
Readers will find in this issue and in the JAMIA online archives a wealth of information that can be applicable to their professional activities. In addition to these Research and Application articles, this issue contains peer-reviewed Case Reports, a Brief Communication Correspondence, and Perspectives on important topics such as ethics and EHR vendors, unintended consequences of Health Information Technology (HIT) interoperability, and lessons learnt from the decade long HIT experience in the UK. Reviews that systematically synthesize important topics and primers on biomedical and health informatics research areas not previously highly represented in JAMIA (algorithms and methods, translational bioinformatics, clinical research and public health informatics) will be featured in future issues.
JAMIA welcomes submissions in all article categories, as well as feedback from readers and authors. I hope this synopsis helps readers navigate and enjoy the journal.