HIM 6509 UMGC Public Health & Consumer Informatics Discussion

Public Health Informatics and Consumer Informatics
Health Informatics Tool
a. Assignment Instructions:
Instructions
Course Outcome for Assignment:
•
Analyze and interpret processed health data and other evidence for the decisionmaking process in different healthcare settings.
Assignment Instructions:
You have been hired as a healthcare informatics specialist at a state health department that
focuses on four public healthcare goals – public health surveillance, immunization
information collection, public health reporting, and public health education.
Write a Briefing Report that addresses the following aspects:
1. Discuss four health informatics tools (Electronic Health Record -EHR, Health
Information Exchange – HIE, Web portals, eHealth, electronic media, mass media,
social media, communication technology, disease/immunization registries) used to
accomplish these goals. Select one tool for each goal and explain why you selected this
tool for this goal.
2. What challenges do you face in using the selected tools in accomplishing these public
health informatics goals and what state-level policies would you frame to overcome
them?
APA Requirements: Formatted in APA 7th Edition. Provide credible evidence, through the
use of in-text citations from your references, to support your conclusions/information.
b. Discussion: NOTE: This is due by Mon 12noon please
COVID-19 was a pandemic that took the entire world into its grip. Public education on the
preventive measures, principally wearing a mask in public and enclosed spaces, was greatly
emphasized before and after vaccination. How did consumer informatics play its role in
having this message across the public? What role does social media play in sharing COVID19 information with and among the public? In which ways do Patient Portals play a role in
creating healthcare awareness, increasing health literacy, and imparting health education?
What challenges were encountered by public health professionals in employing these tools?
Were the tools effective and efficient? Why? What could have been done to minimize the
negative effects?
Follow APA formatting, referencing credible evidence. Only one outside source is allowed.
Use the content of this class as the main source of evidence. This requires a min of 500 words.
Materials
•
Health Informatics: A Systems Perspective: Chapter 8 – E-Health and Consumer
Health Informatics, pgs. 167-181.
•
•
Mental Health Informatics: Chapter 1 – Informatics and Public Health, pgs. 4- 13.
Consumer Health Informatics: Past, Present, and Future of a Rapidly Evolving
Domain. Consumer Health Informatics: Past, Present, and Future of a Rapidly
Evolving Domain
Consumer Health Informatics Recent advances: Consumer health informatics
(nih.gov).
•
Other Resources
•
•
•
Public Health Informatics: Improving and Transforming Public Health in the
Information Age. 08Yasnoff67-75 (nwcphp.org).
Introduction to Public Health Informatics – PowerPoint PPT Presentation PPT –
Introduction to Public Health Informatics PowerPoint presentation | free to view – id:
4972b-ZDc1Z (powershow.com)
What is Consumer Health Informatics? What is Consumer Health Informatics?
(usfhealthonline.com)
Presentations
•
•
•
•
Consumer Health Informatics Consumer Health Informatics Lecture B lecture video Bing video
Introduction to Public Health Informatics Introduction to Public Health Informatics
– Bing video
Public Health Informatics Public Health 101 Series: Introduction to Public Health
Informatics (cdc.gov)
Introduction to Public Health informatics and their Applications Public Health
Informatics_FAnnor_8.25.15.pdf (georgia.gov).
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CHAPTER
E-HEALTH AND CONSUMER HEALTH
INFORMATICS
8
George Demiris and Blaine Reeder
Learning Objectives
After reading this chapter, you should be able to do the following:
• Identify and differentiate the different platforms that support e-health
applications.
• Explain consumer health informatics concepts and their role in the
design of e-health systems.
• Construct the essential elements of a health social network.
• Critically assess the implications and barriers of health social networks.
• Identify ethical and practical considerations pertaining to the use of
consumer-facing technologies.
Key Concepts
•
•
•
•
•
Personal health record
Social media
Health social network
Smart homes and Internet of Things
Patient empowerment
Introduction
E-health encompasses the use of telecommunications platforms, mobile (and
ubiquitous) hardware and software, and advanced information systems to support and facilitate healthcare delivery and education. E-health has triggered a
fundamental redesign of healthcare processes, integrating electronic communication at all levels and affecting all stakeholders. E-health also supports patient
E-health
Use of
telecommunication
platforms, mobile
and ubiquitous
hardware and
software, and
advanced
information
systems to support
and facilitate
healthcare delivery
and education
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Hea lt h I n fo r ma ti c s: A Sy ste ms Pe r s p e c tive
Consumer health
informatics
Area of health
systems
informatics that
focuses on the
implementation
and evaluation
of system design
to ensure that it
interacts directly
with the consumer,
with or without
the involvement
of healthcare
providers
engagement and even patient empowerment—the transition from a passive role
(where the patient is the recipient of care services) to an active role (where
the patient is involved in and perhaps even leads the decision-making process).
Feste and Anderson (1995) emphasize that the patient empowerment model
introduces “self-awareness, personal responsibility, informed choices and quality
of life.” Precision medicine—a new healthcare paradigm that uses vast amounts
of data from multiple data sources to identify and classify disease processes
(McGrath and Ghersi 2016)—is expected to create a new era of personalized
medicine in which individuals’ biological, physiological, behavioral, social, and
environmental parameters, as well as their values and preferences, will inform
tailored disease prevention and treatment. In this context, e-health can play a
significant role in collecting information about individual patients’ needs and
preferences and monitoring their physiological and behavioral parameters,
wherever they may be.
E-health bridges the clinical and nonclinical sectors and includes both
individual- and population health–oriented tools. It encompasses different
platforms, including telehealth applications that can span geographic distances
(e.g., videoconferencing), web portals and mobile apps, online support groups,
social media, wearable devices, and passive monitoring sensors. In addition,
e-health delivers healthcare information, diagnoses, treatment, and care in a
nonlinear manner where traditional hierarchies are obsolete and patients may
enter the system at an infinite number of points, each with his or her own
pattern and frequency of utilization. Healthcare lawyers are challenged “to
determine whether they are dealing with the sale of a product or the supply
of a service [and] whether to apply strict products liability or professional
negligence” (Terry 2000).
Advances in telecommunication technologies and data networks have
introduced innovative ways to enhance communication between health professionals and patients. The result has been a shift in focus for informatics
researchers and system designers, who had primarily aimed to design information technology (IT) applications that met the needs of healthcare providers
and institutions by using data models that included episodic patient encounters
as one group of healthcare-related transactions. The emerging model instead
centers on the life course of individual patients and aims to ensure continuity
of care and the inclusion of other stakeholders, such as family members, in the
decision-making process. New technologies and informatics approaches call for
the development of informatics tools that support patients and their families as
active consumers in the healthcare delivery system. This shift from institutioncentered to patient-centered information systems requires new approaches to
design and evaluation that examine and maximize the system’s effectiveness.
Consumer health informatics is the area of health systems informatics that focuses on the implementation and evaluation of system design to
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C h a p te r 8 : E – health and C onsum er H ealth Infor m atic s
ensure direct interaction with the consumer, with or without the involvement
of healthcare providers. It is a fast-growing subdomain of biomedical and
health systems informatics that emphasizes the potential of informatics tools
to engage and empower patients and equip them with the means to explore
choices (Demiris 2016). This domain also emphasizes the value of informatics
tools not only for those who become patients when they are diagnosed with
a condition and find themselves interacting with the health system but for all
health consumers who wish to engage in decision making about their wellbeing, disease prevention, and self-management. The applications and systems
described in this chapter all belong to the domain of consumer health informatics and aim to support individual patients’ healthcare needs and preferences as
well as those of their families.
Review of Patient-Centered Systems
Consumer health informatics applications reach out to patients in their homes
or in clinical settings. They help patients access and manage their own health
documentation or information; link them to friends, peers, and others; actively
engage them in health-related decision making; and provide them with tools
for managing their disease or maintaining wellness. This section reviews homebased e-health applications and social networks and discusses the barriers to,
and facilitators of, the successful adoption of patient-centered systems.
Home-Based E-health Applications
E-health applications offer a platform to support disease management for
patients diagnosed with chronic conditions and receiving care at home. These
applications address numerous diseases and conditions. The use of technologies
to facilitate symptom management for patients in the home has been explored
for many years, and the body of evidence has clearly evolved from a focus on
feasibility studies with small sample sizes in the early 1990s to today’s focus on
large, randomized clinical trials (RCTs), such as the IDEATEL study in New
York (Shea et al. 2009), the National Health Service–funded telemonitoring
study for chronic obstructive pulmonary disease in Scotland (Pinnock et al.
2013), and the Tele-ERA study in Minnesota (Takahashi et al. 2010), to name
just a few. Wootton (2012) synthesized the evidence pertaining to the use of
telehealth for chronic disease management by reviewing a total of 141 RCTs
on a variety of telehealth interventions delivered to 37,695 patients. Most of
these RCTs demonstrated positive effects for telehealth with no significant
differences between the various chronic diseases. A limited number of costeffectiveness studies were included in this body of literature. Although this
evidence base reinforces the value of telehealth in home-based disease and
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Smart home
Personal living
quarters with
an automated
network of devices
and systems that
operate together
by sharing data
Internet of Things
(IoT)
“Interconnection
via the Internet of
computing devices
[including smart
home devices]
embedded in
everyday objects,
enabling them to
send and receive
data” (Höller and
Höller 2014)
symptom management overall, the evidence is not solid for all chronic conditions or populations, and in some cases the evidence is contradictory as to
the effectiveness or performance of specific telehealth services compared with
traditional care (Wootton 2012).
Home-based monitoring can be classified as active monitoring (where a
patient or family member is asked to initiate the use of software or hardware,
often requiring user training) or passive monitoring (where technology embedded in the residential infrastructure enables the assessment of parameters without
anyone initiating or operating the system). When passive monitoring features
are integral components of the home, the setting is often referred to as a smart
home. Smart home projects that aimed to support the independence of older
adults or people with disabilities emerged initially as research demonstration
projects, but since they grew in number and in the type of technologies and
settings used, sensor-based solutions for home monitoring are now commercially available (Demiris and Thompson 2012; Reeder et al. 2013).
A more recent trend that is expected to disrupt traditional home-based
care is the Internet of Things (IoT), defined as “the interconnection via the
Internet of computing devices embedded in everyday objects, enabling them
to send and receive data (Höller and Höller 2014).” Commercially available
examples include home automation (e.g., the control of lighting and heating)
and the recording of movement through motion tracking. Users can control
such systems via a web interface or by voice interaction, which is made possible by the development of artificial intelligence (AI)–based voice assistant
smart speakers that may enhance the ease of use of IoT systems. IoT smart
home technologies have a unique opportunity to support home care patients
who wish to remain independent at home by identifying potential health patterns, detecting anomalous activities, and increasing quality of life. Research
has shown that many patient groups are motivated to receive data from smart
home technologies that provide insight into their health status and from sensor systems that have the potential to enhance their lives (Lee and Dey 2010).
Such technologies support the detection of health-related trends (e.g., decrease
in overall activity level, increase in sedentary behavior, reduced number of
visitors) that may require intervention, thereby helping patients maintain an
independent living style by connecting them with family members, support
systems, or other caregivers, and ultimately improving their quality of life.
Personal Health Records
E-health applications support not only the transmission of data from one’s
home to a clinical setting but also tools that allow patients to store and manage
their own health information as a personal health record (PHR). The National
Alliance for Health Information Technology (2008) defines a PHR as “an
individual’s electronic record of health-related information that conforms to
nationally recognized interoperability standards and that can be drawn from
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multiple sources while being managed, shared and controlled by the individual.”
The PHR is a tool to use in “sharing health information, increasing health
understanding and helping transform patients into better-educated consumers
of health care” (Kahn, Aulakh, and Bosworth 2009).
In recent years, several initiatives have explored the design and implementation of such PHR tools. The Veterans Health Administration launched
a PHR system called MyHealtheVet, which documents and manages appointments and medication requests (US Department of Veterans Affairs 2012). It
also assists veterans in selecting and accessing a variety of healthcare services.
Epic, the electronic medical record (EMR) software vendor, developed a PHR
application that is currently used by Kaiser Permanente, the Cambridge Health
Alliance, and other healthcare organizations. These PHR systems are widely
used by consumers because they offer important functionality that could lead
to improved health (Mechanic 2008). Between 2008 and 2013, the number of
PHR users in the United States increased by more than 23 million people to a
total of 31 million users, and models show that PHR adoption could reach rates
as high as 75 percent of the US patient population by 2020 (Ford, Hesse, and
Huerta 2016). Intervention studies have shown that PHRs have the potential
to increase patient activation (Solomon, Wagner, and Goes 2012), promote
health behaviors (Chrischilles et al. 2014), and improve the patient–clinician
relationship (Nagykaldi et al. 2012); larger RCTs, however, have not replicated
these gains (Wagner et al. 2012).
PHRs help patients manage their own health by enabling the sharing
of information such as health finances (e.g., bills, insurance claims), diagnoses
or conditions, allergies, immunizations, and medications (Hassol et al. 2004).
In these systems, the patient—not a healthcare facility or provider—owns and
manages the data. Traditional EMRs, in contrast, are owned by healthcare
organizations and maintained by clinicians and other staff.
The integration of EMR and PHR systems is a synergistic model, where
PHR data can augment EMR data and allow a collaborative continuum of care.
Several barriers present challenges to realizing this synergistic vision, however,
including legal and regulatory issues as well as sociotechnical concerns (e.g.,
clinicians’ lack of trust in data owned and generated by patients, acceptance
of the patient’s active role, and changes in clinical workflow).
Social Media and Consumer Health Informatics
Social media and social networking have seen widespread adoption in the past
decade. The sharing of personal details, including health information, has
increased since the advent of social media. Networking has been the subject of
social science research since the 1950s (Ackerson and Viswanath 2009; Berkman 1984; Berkman et al. 2000; Bott 1957; Burt and Schøtt 1985; Fowler
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Web 2.0
technology
Technology that
replaced the
traditional, static
World Wide Web
by enabling more
community-based
input, interaction,
content sharing,
and collaboration
and Christakis 2010; Heckathorn 1979; Israel 1982; Milardo 2000). Our
discussion in this section focuses on social networking made possible by social
media technologies that connect consumers and their health information.
Social media uses Web 2.0 technology and user-generated content
(UGC) to allow information, both health related and personal, to be communicated in new ways between individuals and groups (in contrast to the older
one-way flow of information in healthcare from care providers to patients). One
of the challenges in discussing social media is the lack of universally accepted
definitions for social media or Web 2.0, which creates confusion (Adams 2010;
Doherty 2008). Doherty (2008) notes that Web 2.0 “is essentially a set of
technologies and the range of affordances made possible by those technologies.” Kaplan and Haenlein (2010), meanwhile, define Web 2.0 as “a platform
whereby content and applications are no longer created and published by
individuals, but instead are continuously modified by all users in a participatory and collaborative fashion.” Kaplan and Haenlein (2010) define UGC as
content that is publicly available online, shows creative effort, and is created
outside of professional practices.
Social media uses Web 2.0 applications and UGC that allow multiway
communication, collaboration, and democratic content management (Orsini
2010). This technology also facilitates communication by breaking down
language barriers through natural language processing and machine translations (McNab 2009). Social media exchanges are instantaneous; conversations
rather than directives; active rather than passive; connective, linking people
with similar conditions and concerns; and representative of how lessons from
experiences can be shared. Health 2.0 is defined as “the affordances of Web
2.0 technologies for the healthcare community whilst recognizing that these
affordances are manifest in a variety of ways” (Doherty 2008).
As a means of sharing personal health information, social media is a
substantial tool. More than 50 percent of the world’s population were Internet users in 2017, and that number continues to grow (Internet World Stats
2018). The question now about using social media for healthcare purposes is
how control of personal health information will shift from government and
healthcare organizations to patients supported by private service providers
(Kidd 2008). A related question is what impact such a shift might have on
patient–provider relationships, quality of care, and efforts to equalize health
disparities (Bacigalupe 2011).
According to Boyd and Ellison (2007), social networking consists of
“web-based services that allow individuals to (1) construct a public or semipublic profile within a bounded system, (2) articulate a list of other users with
whom they share a connection, and (3) view and traverse their list of connections and those made by others within the system.” Other definitions and
characteristics of social networking include the following:
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C h a p te r 8 : E – health and C onsum er H ealth Infor m atic s
• “An online location where a user can create a profile and build a
personal network that connects him or her to other users” (Lenhart and
Pew Internet & American Life Project 2007).
• “Involves the explicit modeling of connections between people,
forming a complex network of relations, which in turn enables
and facilitates collaboration and collaborative filtering processes”
(Eysenbach 2008).
• Enables “users to connect by creating personal information profiles,
inviting friends and colleagues to have access to those profiles, and
sending e-mails and instant messages between each other. These
personal profiles can include any type of information, including photos,
video, audio files, and blogs” (Kaplan and Haenlein 2010).
• Makes “it possible for users to branch into different conversations and
create special relationships” (Landro 2006).
Health social networking supports the accessibility and exchange of
health information for consumers and is therefore considered a consumer health
informatics resource. With a health and wellness focus, a health social network
is powered by Health 2.0 applications. Swan (2009) defines a health social
network as “a website where consumers may be able to find health resources
at a number of different levels.” The types of interactions or communications
that a health social network supports are patient to patient, patient to provider,
and provider to provider (Doherty 2008). Patient-to-patient and patient-toprovider communications are most relevant to a discussion of consumer health
informatics.
Understanding the health implications of social networking entails learning who uses these sites. The wants and needs of patients and other customers
must be central to the design and features of a health social network. Civan
and colleagues (2006) conducted a group study of participants interested in
managing their personal health information and determined that a health social
network should deliver three goals: “monitoring and assessing health, making
health-related decisions, and planning preventive or treatment actions.” Meanwhile, Weiss and Lorenzi (2007) offer four considerations when designing and
rolling out a pilot health social network for patients with cancer: (1) It should
have a mechanism to inform patients whether information is actively sent or
passively posted, (2) it should have clearly delineated spaces to avoid unintentional personal disclosures, (3) it should offer a spell-check feature, and (4) it
should ensure that patients’ family members do not think site invitations are
spam. For patients with breast cancer, Skeels and colleagues (2010) argue that
a health social network’s features should support dissemination of caregiving
information and management of help requests and offers, and these features
should be implemented using the Facebook Connect platform.
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Hea lt h I n fo r ma ti c s: A Sy ste ms Pe r s p e c tive
According to Eysenbach (2007), people obtain health information in
three ways: (1) intermediation, where the person receives information from
a health expert or information gatekeeper; (2) disintermediation, where the
person eliminates the information gatekeeper; and (3) apomediation, where
the person receives guidance from network intermediaries. Use of a web portal
with content vetted by health experts, such as WebMD (www.webmd.com),
is an example of intermediation; use of a patient-initiated web search is an
example of disintermediation; and use of a health social network is an example
of apomediation (Eysenbach 2008).
The value of health social networking lies in its capability to connect a
person with others who have similar health conditions and with whom that
person can share information (Swan 2009). As Ancker and colleagues (2009)
note, people can obtain or share “advice, interpretation of medical language or
events, and personal experience. Such patient-generated information is likely
to be written in common terms, rather than in medical jargon, and it may
be easier to understand by those with lower health literacy or numeracy.” A
folksonomy (a combination of folk and taxonomy) is generated when people tag
digital information with their own keywords and classifications for later retrieval
or use; these tags are then found by other searchers (Dye 2006). On a health
social network, folksonomies provide insight about how patients use clinical
terminology and understand their conditions; for example, some patients discuss type 1 diabetes as a symptom and not a disease (Smith and Wicks 2008).
Online health communities connect citizens who are faced with challenges of symptom management, dealing with behavioral or lifestyle changes,
or in need of emotional support. Facebook, for example, has been found to be
a platform where individuals share health-related information, give advice and
opinions, and find value in others’ personal experiences (Thrul et al. 2017). In
many cases, “secret” Facebook groups—groups that are not searchable to outsiders and whose content is accessible only to members—have been created to
provide online communities where peers can find support for behavior changes
(e.g., dieting, smoking cessation), discuss symptom and disease management,
and access emotional distress resources.
The information on health social networks is crowd sourced, however,
and may therefore be unreliable or inaccurate. One study reports on the “very
low quality user-contributed health information on three different sites. Half
of all postings containing medical information were incomplete or contained
errors. Of these, over 80% were potentially clinically significant . . . [and thus
may] compromise patient safety as a distribution platform for persuasive, personally tailored, but harmful misinformation” (Tsai et al. 2007). Web 2.0
technology enables the creation of online health environments or communication channels for consumers, including those with alternative or nontraditional
health beliefs, to engage in group discussions with others who share and validate
their viewpoints, which may or may not be accurate (Wilson and Keelan 2009).
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175
Challenges in E-health Applications
Factors that are critical to the success and diffusion of e-health applications
include privacy/confidentiality and accessibility.
Privacy and Confidentiality
An important and ongoing issue in e-health and consumer health informatics
is the privacy and confidentiality of personal health information. Privacy is a
person’s right to be free from and to refuse interference, attention, observation,
and other types of invasion. In the context of healthcare, privacy is the assurance that (1) one’s health information is collected, accessed, used, retained,
and shared only when necessary and only to the extent necessary and (2) the
information is protected throughout its life cycle using fair privacy practices
and consistent with applicable laws and regulations as well as individual preferences. Confidentiality is the obligation of every HIPAA (Health Insurance
Portability and Accountability Act)–covered entity to enact and enforce policies
that protect patients’ privacy.
HIPAA addressed the need for comprehensive, national safeguards
from threats to privacy and confidentiality, mandating the implementation of
standards to keep personal health information safe, secure, and private (US
Department of Health and Human Services 2000). Compliance with these
standards greatly affected the design and functions of e-health applications.
Multimedia transactions (e.g., video and audio recording, transmission of still
images) not only must be able to conceal identifiable data but also must be
performed through a secure infrastructure or platform (e.g., mobile devices,
satellite, Internet). The widespread use of the Internet and Web 2.0 has heightened HIPAA compliance issues. For example, web-based applications for disease
management require organizations to consider issues of data ownership and
access, such as who owns the information stored on a vendor’s or third-party’s
server and who has the authority to use those data. Similarly, personal health
applications that empower patients to collect, store, and maintain their own
information must be examined, and their ownership, access and monitoring
rights, and potential confidentiality violations must be defined.
Privacy
In the healthcare
information
context, assurance
that one’s health
information
is collected,
accessed, used,
retained, and
shared only when
necessary and
only to the extent
necessary and that
the information
is protected
throughout its life
cycle using fair
privacy practices
consistent with
applicable laws
and regulations
and the
preferences of the
individual
Privacy and Social Media
High levels of personal health information disclosed or posted on health social
networks create risks for privacy abuses. Using Facebook as a framework, Grimmelmann (2009) conducted an in-depth analysis of the social and psychological
factors behind people’s use of social networks and their privacy expectations.
Grimmelmann asks, “What motivates Facebook users? Why do they underestimate the privacy risks? When their privacy is violated, what went wrong?” He
argues that failure of social network operators to ask similar questions of their
users will result in privacy policies that do not work (Grimmelmann 2009).
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Privacy issues related to health social networks include the following:
• Some people may not know the potential risks of giving up their
anonymity (thus undermining their privacy) when they participate in
social networking (Adams 2010).
• Personal information disclosed on social networks may “reinforce
existing stereotypes, making them more intractable” (Ellison, Lampe,
and Steinfield 2009).
• “Personal information may be misused by marketing agents or used
for nefarious purposes such as stalking, bullying, and identity theft”
(Ellison, Lampe, and Steinfield 2009).
• Personal information requests are more likely to be sent to “friends” via
a phishing scheme on social networks (Jagatic et al. 2007).
• Social network users must find a balance between the ease and
convenience of widely sharing their information with a network of
people and the need to protect their identity and associated information
by customizing their privacy settings, which limits the risk of privacy
invasion (Pratt et al. 2006).
According to a survey of 205 college students about privacy concerns
and risk-taking attitudes, “almost 10% of the participants provided their phone
number on their social network profile” (Fogel and Nehmad 2009). Most young
consumers on Facebook have taken steps to manage their privacy settings to
some degree, however (Boyd and Hargittai 2010). Regardless, providers and
parents should understand social networking to help mitigate the potential
risks and benefits for teenagers who use these sites (Moreno et al. 2009).
Allied health professionals, consumer groups, and communication professionals should push for policies that would display warnings about risk and privacy
before young consumers are permitted to create social network profiles (Fogel
and Nehmad 2009). Favoring the positive, Swan (2009) points out that “just
as patients are the only ones who can avoid HIPAA privacy regulations and
open source their own data to the benefit of the greater community, patients
can skirt the social taboos that other health care ecosystem members may
encounter regarding economic issues. . . . Providers would be forced to develop
consumer-presentable health service offerings and pricing.”
Accessibility
A significant number of consumers requiring home care services or managing multiple chronic conditions are older adults and, in many cases, may be
experiencing functional limitations because of their clinical condition or age.
Such limitations are the result of a decrease in cognitive, motor, or sensory
abilities associated with temporary or permanent injury or aging. The premise
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C h a p te r 8 : E – health and C onsum er H ealth Infor m atic s
of consumer health informatics applications is the empowerment of consumers
to play an active role in managing and making decisions about their personal
health information. In this context, consumers older than 50 years may be
at a disadvantage given that hardware and software designers often fail to
consider them as a potential user group. Addressing cognitive, functional, or
sensory limitations and recognizing consumers’ diverse levels of experience and
proficiency in using software and hardware are essential to designing systems
that maximize the positive elements of the user experience (i.e., increase the
system’s usability and accessibility to the largest possible number of consumers).
To achieve this goal, designers of e-health applications need to develop system
features that increase the functional accessibility of their products and subject
these features to rigorous usability testing with a wide range of consumers
who have various capabilities, interests, and motivations. Existing resources,
such as design recommendations developed for web systems for older adults
(Demiris, Finkelstein, and Speedie 2001), or considerations in implementing
telehealth systems to accommodate the functional, cognitive, and other needs
of consumers (Stronge, Rogers, and Fisk 2007), can guide designers of e-health
systems to maximize the accessibility of their products.
Another dimension of accessibility for e-health systems is the availability of the appropriate infrastructure for using these systems. Several e-health
applications, for example, require broadband Internet, which is not available
in every residence and geographic region. Other web-based programs require
peripheral devices, such as cameras or microphones, for synchronous communication; but it cannot be assumed that everyone has such peripheral equipment.
When planning a wide implementation effort, healthcare organizations and
their IT teams need to consider the technological restrictions faced by their
patient population and community at large, especially in rural areas, to avoid
excluding them and further increasing the digital divide.
Success Factors for E-health
Factors that determine the success and sustainability of e-health applications
include outcomes, processes, cost, and acceptance by patients, family members,
and providers.
Outcomes
If e-health applications are to be adopted as part of standard care, their outcomes
should be the same as or better than those achieved by traditional care. The
effect of e-health on clinical outcomes has been investigated to some extent,
but large RCTs are still needed to clearly demonstrate its impact (Johnston et
al. 2000). For example, when the effect of home-based e-health on medication
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Hea lt h I n fo r ma ti c s: A Sy ste ms Pe r s p e c tive
compliance and self-care ability was examined in a quasi-experimental study
with a control group (receiving traditional care) and an intervention group
(receiving traditional care plus access to a remote videoconference system),
the effect was found to be no different from that of traditional care (Jerant,
Azari, and Nesbitt 2001). However, a one-year RCT that involved congestive
heart failure patients equipped with a two-way videoconferencing device and
an integrated electronic stethoscope showed that e-health can reduce hospital
readmissions and emergency visits for this patient population.
It is generally assumed that most technologies used in telemedicine allow
early detection and intervention through more frequent and intensive physiological monitoring. In addition, they can monitor medication and treatment
compliance and promote patient education. The time has come to test this
hypothesis by measuring the technology in large RCTs rather than in smallscale feasibility studies.
Processes
In a face-to-face visit, the patient–provider communication does not include
addressing technical issues such as focusing the camera or adjusting the audio.
But these issues can be common in, or even dominate, a virtual visit. It is not
fully understood whether video-mediated or web-based communication alters
the relationship between clinicians and patients or how virtual encounters may
create barriers to care delivery processes. Use of technology during clinical
encounters may intimidate patients, limiting their participation in their care and
inhibiting their communication with providers, because face-to-face interactions are considered “more spontaneous and free-flowing” than technologyenabled contact (O’Conaill and Whittaker 1997). This diminished willingness
or ability to participate and engage is a serious threat to caregiving because
patients greatly value the opportunity to ask questions and voice concerns
when interacting with their clinicians (Ende et al. 1989; Street 1992). Active
patient participation contributes to greater satisfaction with care, adherence to
treatment, and improved health outcomes (Kaplan, Greenfield, and Ware 1989;
Lerman et al. 1990). Studying care delivery processes that use telemedicine is
therefore important.
One study reviewed 122 virtual visits and performed content analysis
to determine the themes of interaction during these visits (Demiris, Speedie,
and Finkelstein 2001a, 2001b). The research showed that visit time is spent
on the following categories of communication: assessing the patient’s medical
status, promoting medication and treatment compliance, addressing psychosocial issues, exchanging informal banter, educating the patient on health issues,
discussing administrative and technical issues, evaluating patient satisfaction, and
ensuring continued accessibility to the provider. Clearly, some of these topics do
not need to be covered during a virtual visit, but overall the discussions indicate
that e-health has the potential to enrich the care process. Further studies and
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C h a p te r 8 : E – health and C onsum er H ealth Infor m atic s
direct comparisons between face-to-face and virtual visits will provide insights
into the process of virtual patient–clinician encounters—for example, whether
e-health encourages or inhibits a patient telling his provider about his physical
discomfort, medical symptoms, and emotional state and, conversely, whether
it encourages or prevents a physician giving her patient treatment instructions
or expressing empathy (Bashshur 1995).
Cost
A comprehensive evaluation of e-health applications must include a cost analysis
to compare the inputs and outputs of e-health with those of traditional healthcare. Telemedicine evaluation methods have improved in recent years, but more
work needs to be done to ensure that the benefits and outcomes are balanced
with cost and other inputs (Bergmo 2010). Here, the inputs include medical
expertise, facilities, technology, service personnel, and client characteristics.
During a cost analysis, the effects of known quantities of traditional healthcare
(e.g., episodes of care, hospital stays) should be assessed. Cost savings from the
use of e-health can be realized if the following outcomes are demonstrated:
• Reduction of unnecessary visits to the emergency department
• Reduction of unnecessary or unscheduled visits to the physician’s office
• Early detection and intervention
• Patient education that leads to improvement of lifestyle choices and
medication adherence
• Prevention of repeat hospitalizations or overall decrease in
rehospitalization rates
• Reduction of indirect costs and burnout by easing the burden on
caregivers
The number of face-to-face consultations could, in some cases, be
reduced if some of the consultations are replaced by virtual or web-based
visits, which in turn eliminate travel time and travel costs. The use of portable
devices and e-health technologies allows the collection and interpretation of
vital signs data several times a day, rather than only at scheduled visits. This
permits early detection and intervention, which is especially important if signs
of deterioration are missed or problems are misidentified. In addition, telemedicine technologies enable family members and other caregivers to participate in
a collaborative care process, adding to the patient’s support network.
Acceptance by Patients and Family Members
One unique aspect of e-health is that the required technology is installed in
the patient’s home and operated by the patient or the patient’s surrogate. The
success of this form of healthcare delivery hinges on the patient’s and family’s
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Hea lt h I n fo r ma ti c s: A Sy ste ms Pe r s p e c tive
acceptance of its use. What influences this acceptance (and its diffusion) is the
understanding of the concept of e-health. Considering the patient’s possible
functional limitations and inexperience with the e-health technology, this initial
acceptance is essential.
Few survey instruments that have been tested for reliability and validity can measure patients’ perception of or satisfaction with e-health applications. One instrument that can is the Telemedicine Perception Questionnaire (TMPQ), which was developed by the University of Minnesota to assess
patients’ perceptions of the advantages and disadvantages of e-health. TMPQ
was tested extensively and was found to show high levels of internal consistency
and test-retest reliability. Its domains include the following (Demiris, Speedie,
and Finkelstein 2000):
• Perceived quality of and access to healthcare
• Time and money (e.g., time savings for the patient and nurse, reduced
costs for the patient and the healthcare agency)
• Components of the virtual visit (e.g., ease of equipment use, equal
acceptability of virtual and real visits, protection of privacy and
confidentiality, lack of physical contact, reduced sense of intimacy,
patient’s ability to explain her medical problems in a virtual
environment)
• General impression of home-based e-health and its role in the future
Acceptance by Providers
The success of e-health applications that involve healthcare providers (e.g.,
videoconferencing) obviously depends on the acceptance of both patients and
providers. Many e-health applications alter providers’ practice patterns and affect
their workflow. Thus, they have to accept this alternate mode of care delivery
and be comfortable using the required equipment to interact with their patients.
As is the case with all technological innovations, organizational commitment is essential to optimal use of telemedicine. This dependency can be
a challenge given that many complex, institution-centric information systems
do not support (at least not currently) the e-health infrastructure or endorse
a strategic agenda for e-health applications. Adoption of e-health implies a
restructuring of the institution and a redefinition of its services.
Conclusion
E-health and consumer health informatics have seen significant advances in
recent years. New technologies and pilot implementations in a variety of settings
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4
Introduction
Telecommunication also plays an increasingly important and prominent role within the
health care field, where the most remarkable opportunities, along with associated challenges and obstacles, have emerged in relation to telecommunication initiatives. For example, telecommunication or “telehealth” strategies continue to broaden access to health and
mental health care, health education, and health services delivery for at-risk populations
in America. The development of computer-based patient records, personal health information systems, and unified electronic claims systems utilize various electronic communication technologies to streamline and centralize databases (Levin & Hanson, 2011).
For the purposes of this text, health informatics will be viewed from both public health
and behavioral health perspectives. Behavioral health encompasses primarily the areas of
alcohol, drug abuse, and mental health services, all specialty areas within public health.
Nevertheless, throughout this text, the terms mental health and behavioral health will be
used interchangeably. In addition, this text will primarily cover the public sector (local,
state, and federal government agencies) and private sector practice, as well as the administrative, services delivery, and educational aspects of behavioral health informatics.
Telemedicine, Telehealth, and Health Informatics
Telemedicine “began” in the 1950s as physicians who were geographically remote from
their patients rendered treatment or provided consultations over the telephone and/or
through wire services. Today, although the principles are largely the same, the technology
and milieu of contemporary telemedicine are vastly different. In the age of high-speed
data lines, advanced data compression technologies, the privatization of federal technologies, and the computerization of patient medical records, clinical outcomes, and physician
practices, telemedicine promises to be the next milestone in health care advances.
Telehealth has been described as the use of communications and information technology to deliver a variety of health care services, information, and education to participants
who are not able to be at the same place to receive these services (Field, 2002). This helps
to improve access to health care and helps to overcome the geographic, transportation
infrastructure, and socioeconomic barriers to treatment in a timely fashion. Telehealth
may include clinical consultation, continuing professional education, health promotion,
and health and mental health care management and administration. Telehealth technologies initially included videoconferencing, telephones, computers, the Internet, e-mail, fax,
radio, and television. More recently, technologies are increasingly being introduced and
utilized in health care, through a variety of social media, including blogs, texting, Twitter,
wikis, digital portfolios, and portals. In addition, programs deliver health care using a combination of audio graphic, store-and-forward, and telemetry technologies (the automatic
transmission and measurement of data from remote sources by wire, radio, or wireless
technologies).
Health informatics covers a very wide range of applications for delivering services and
for applied services research, all dedicated to the improvement of patient care and public
health. Health informatics continues to incorporate rapidly changing information environments and continues to encounter emerging public health issues, some created by the
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Informatics and Public Health
5
advent of new technological opportunities, while others emerge through the application of
technology to complex public health problems. For example, applications range from electronic patient records to national health databases in the establishment of clinical guidelines and clinical (referral) pathways to care. The key component of health informatics is
the process of converting data to accessible and usable information that enables improvements in the quality, value, and effectiveness of health and mental health services.
Electronic information systems are revolutionizing health care practice, health research,
and health education. Efficient management of information improves patient satisfaction
and creates the development of new aspects of clinical practice, as well as creating new
opportunities for implementing health education initiatives. Many health care professionals realize that they are in need of additional skills and knowledge in finding and using
information, and in assessing health information systems.
The proliferation of interest in health informatics has centered on the technical and
sociological aspects of the medium. It is only recently, however, that legal and regulatory
issues have been discussed. In fact, the potential for mass availability of telemedicine and
telehealth information and services will likely depend upon how the legal and regulatory
issues are resolved. The rapid development and growth of health information and communication technologies provide a wealth of opportunities to create new approaches for the
delivery of health, mental health, and substance use services. Accordingly, mental health
informatics is the systematic application of health information and computer science and
technology to mental health practice and applied services research.
The remainder of this chapter will present some basic concepts in public health so that
readers will understand the public health approach to informatics. The next chapter will
address basic topics in mental health services delivery from a public health or population
perspective.
Public Health
introduction
Historically, in academic research and in the academy, it is common to examine problems
from a (single) discipline-specific perspective. The advantage of this discipline-specific perspective includes a comprehensive literature base with theoretical frameworks that help
guide future research and teaching in that discipline. The disadvantage of examining problems from a single perspective lies in the loss of potential contributions from other related
disciplines in examining issues or problems that might draw contributions from a multidisciplinary perspective.
Unlike academics, where knowledge-based areas are traditionally organized by
discipline-oriented departments, the field of health care has historically utilized a multidisciplinary team approach to services delivery, where improving health and clinical outcomes involves the utilization of evidence-based practices, with multidisciplinary health
care teams providing services to patients. This was particularly true with the advent of
prepaid health plans in early twentieth-century America.
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6
Introduction
The field of public health, by definition, utilizes a multidisciplinary approach to examining health and mental health problems in at-risk populations. It draws heavily from the
areas of biostatistics and epidemiology, environmental and occupational health, health
policy and management, and community and family health to address health issues and
problems from a population perspective.
While most definitions of public health include advancing a healthy lifestyle for communities through the promotion of health and the prevention of disease, one particular
definition of public health was suggested in the early twentieth century by Charles-Edward
Amory Winslow, a pioneer in public health practice in America:
[Public health is] the science and art of preventing disease, prolonging life, and promoting health and efficiency through organized community effort for the sanitation of the environment, the control of communicable infections, the organization
of medical and nursing services for the early diagnosis and prevention of disease, the
education of the individual in personal health and the development of the social
machinery to assure everyone a standard of living adequate for the maintenance or
improvement of health. (Winslow, 1920, pp. 6–7)
Toward the end of the twentieth century, the Institute of Medicine’s (IOM) Committee
for the Study of the Future of Public Health (IOM Committee) published The Future
of Public Health, which examined public health programs and the coordination of services across U.S. government agencies and within state and local health departments. The
Committee defined the substance of public health as “organized community efforts aimed
at the prevention of disease and promotion of health” (Institute of Medicine, 1988, p. 41)
and defined the mission of public health as “the fulfillment of society’s interest in assuring
conditions in which people can be healthy” (Institute of Medicine, 1988, p. 40).
The IOM Committee also identified three core functions of public health: (1) assessment; (2) policy development; and (3) assurance (of providing necessary public health
services in the community). Subsequently, the U.S Public Health Service convened the
Public Health Functions Steering Committee (1994), a national work group chaired by the
Surgeon General, which developed 10 essential public health services needed to carry out
the basic public health core functions in a community:
1. Monitor health status to identify community health problems;
2. Diagnose and investigate identified health problems and health hazards in the
community;
3. Inform, educate, and empower people about health issues;
4. Mobilize community partnerships to identify and solve health problems;
5. Develop policies and plans that support individual and community health
efforts;
6. Enforce laws and regulations that protect health and ensure safety;
7. Link people to needed personal health services and assure the provision of health
care;
8. Assure a competent public health and personal health care workforce;
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Informatics and Public Health
7
9. Assess effectiveness, accessibility, and quality of personal and population-based
health; and
10. Research for new insights and innovative solutions to health problems.
Thus, while there are a variety of definitions and functions of public health, common elements include a population-based, multidisciplinary approach that emphasizes health promotion and disease prevention, even at an international level (World Health Organization,
2012). Furthermore, a public health approach involves both formal activities undertaken
within government, combined with efforts by private and voluntary organizations and
individuals, working together to focus on maintaining the health of populations. This
public health framework of problem solving includes (1) problem identification (utilizing
epidemiologic surveillance); (2) identifying risks and protective factors; (3) development,
implementation, and evaluation of interventions; and (4) monitoring implementation in
relation to the impact on policy and cost-effectiveness. It also requires the determination
if a disease is preventable or not preventable, controllable or not controllable, as well as its
priority compared to other incidences of disease outbreak.
The remainder of this chapter will examine selected topics in public health. Where possible, the public health topics included below will contain a brief discussion of how that
area is related to the field of informatics.
epidemiology
Epidemiology, a fundamental science of public health, is the study of the factors that
determine the frequency and distribution of disease in (human) populations. In medicine,
physicians focus on individual patients; in public health, on the other hand, epidemiologists focus at a population level, that is, on a community or a specific population at risk
for selected diseases. Thus, in public health, the community replaces the individual patient
as the primary focus of concern (i.e., the “unit of analysis”). The objective is to evaluate
the health of a defined community, including those members who would benefit from, but
often do not seek, health care services. In epidemiology, disease does not occur in random
fashion and may have multiple causal factors. Factors whose presence is associated with an
increased likelihood that disease will develop at a later time are called risk factors.
Epidemiologic studies may be applied to all diseases, conditions, and health-related
events. Endemic occurrence is defined as the habitual presence of a disease or infectious
agent within a geographic area, or the usual prevalence of a given disease within such an
area. The term is used in contrast with epidemic, or the occurrence in a community (or
region) of a group of illnesses of similar nature, clearly in excess of normal expectancy. An
epidemic includes any kind of disease, exists whenever the number of cases exceeds what is
expected on the basis of past experience for a given population, has no specific geographic
limitations, and may encompass any time period.
Two common terms used in the measurement of disease frequency in epidemiologic
studies are incidence and prevalence. Incidence rates are designed to provide a measure of
the rate at which people without a disease develop the disease during a specified period
of time, that is, the number of new cases of a disease in a population during a specified
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8
Introduction
interval of time (e.g., the number of new cases of schizophrenia per 100,000 persons in
one year). The population in which the incidence is measured is restricted to those who
are susceptible to getting the disease during the observation time period. This restricted
population generally is called the at-risk population because they are at risk for contracting the disease. Incidence allows researchers to study the impact of harmful exposures or
preventive interventions on the occurrence of disease because it does not depend upon the
length of disease course or its fatality.
Prevalence rate measures the number of people in a population who have a disease (i.e.,
the existing cases) in the total population at a particular time (point prevalence), or during
a stated period of time (period prevalence). Thus, incidence reveals the rate at which new
illness occurs, whereas prevalence measures the “residual” of such illness, the amount existing at a given point in time in a community. Prevalence depends upon two factors: how
many people have become ill in the past, and the duration of their illnesses.
surveillance
Surveillance is the ongoing systematic collection, analysis, and interpretation of health
incidence data. Comprising population- and/or individual-based data, surveillance data
monitors the incidence of disease to establish patterns of progression. Surveillance helps
us to predict, observe, and minimize the harm caused by chronic and acute illnesses, such
as outbreaks, epidemics, and pandemics. It also increases our knowledge of the factors
that may contribute to the diagnosis and treatment of disorders. A key part of modern
disease surveillance is case reporting. Examples of mental health surveillance data are the
Centers for Disease Control and Prevention’s (CDC) Behavioral Risk Factor Surveillance
System (BRFSS) and the Substance Abuse and Mental Health Services Administration’s
(SAMHSA) National Survey on Drug Use and Health (NSDUH).
prevention
Primary, secondary, and tertiary prevention provide the foundation for the public health
model of prevention and form the underlying principles for avoiding and controlling public health problems. However, in the case of mental health, these concepts are more difficult to apply. The causes of many mental disorders are not fully understood, due to the
complexity of the etiology of mental disorders, the lack of knowledge on disease triggers,
and the lack of complete understanding of disease emergence, progression, and subsidence
from a physiological perspective. Hence, the avoidance of the occurrence of an illness,
which is true primary prevention, often eludes researchers and practitioners in the field
of mental health. Although great progress has been made in the genetics of diseases such
as early onset Alzheimer’s disease, we are still very distant from a basic knowledge of the
genetic predispositions of many mental disorders. Even though there has been a great deal
of “social engineering” attempted to prevent the occurrence of mental disorders, there is
little evidence that these efforts have been successful (Levin, Hanson, & Hennessy, 2004;
Levin, Hanson, Coe, & Kuppin, 2000).
Secondary prevention is the avoidance of disease recurrences or exacerbations post–
disease diagnosis. This has been a more achievable goal in mental health. With early
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Informatics and Public Health
9
identification and intervention, it is possible to stabilize many mood disorders, allowing
individuals to lead productive, relatively unimpaired lives (Levin, Hanson, & Hennessy,
2004). Early intervention in other diagnostic groups of mental disorders has varying
chances of success (Bird et al., 2010). However, considering the magnitude of the disabilities, particularly from a developmental perspective, such intervention is justifiable. To show
the efficacy of secondary prevention, high-quality program evaluation is critical.
Finally, tertiary prevention is the reduction of disability and the utilization of rehabilitation. A substantial portion of mental health services for individuals with serious mental
disorders is categorized as tertiary prevention. The mental health field can document considerable success through a number of program initiatives, including community support
programs, positive assertive community treatment, psychosocial rehabilitation, and systems
of integrated services delivery (U.S. Department of Health and Human Services, 1999).
When we examine the direct and indirect costs of the suffering and the care of individuals
with mental illnesses and their families, mental health professionals readily justify costs.
However, the funding of public mental health programs is a political process, and it is
critical to clearly demonstrate the cost-benefits of mental health treatment to the public, as
well as to state and federal lawmakers. Effective data collection and analyses, including cost,
efficacy, and outcomes, are key to defending these programs in terms of cost-effectiveness
and long-term successful outcomes for persons with serious mental illnesses.
evidence-based practice
Clinical guidelines are those guidelines developed to assist in “best practice” treatment
initiatives in order to be useful in diagnosis and treatment. These guidelines are often the
foundation of evidence-based practices (EBP). EBPs are those research practices that have
undergone and passed rigorous scientific and clinical practice review.
Evidence-based practice in behavioral health, for example, is an emerging field. There are
a number of organizations and agencies that are authoritative sources for clinical guidelines,
best practices, and EBP in the behavioral health field, including the National Registry of
Evidence-Based Programs and Practices (http://www.nrepp.samhsa.gov/), the Cochrane
Collaboration (http://www.cochrane.org/), and Blueprints for Violence Prevention:
Center for the Study and Prevention of Violence (http://www.colorado.edu/cspv/blueprints/index.html). Data from EBP provide new ways of thinking about services delivery
and what works best for whom, helping to reframe clinical treatment as well as services
delivery frameworks. This allows more systemic and innovative approaches to translating
research to clinical practice and clinical practice to research.
managed care
Managed care is an evolving array of health care review and service coordination mechanisms that ultimately attempts to control (i.e., reduce) health services utilization and costs,
to improve efficiency and services coordination, to increase access to preventive services,
and to improve the quality of health care (Frank & McGuire, 2004). Managed care organizations (MCOs) are constantly evolving entities of various organizational structures and
arrangements. A managed health care plan (MHCP) may be one or more products or
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10
Introduction
entities that integrate financing and management with the delivery of health care services
to an enrolled population. An MHCP may employ or contract with an organized provider
network that delivers services and that (as a network or individual provider) either shares
financial risk or incorporates various incentives to deliver high-quality and cost-effective
services. Most MHCPs use information systems capable of monitoring and evaluating
utilization and cost patterns of their enrolled population.
community mental health
The history of caring for individuals with mental illnesses is crucial in understanding the
development of public health services, particularly the role of deinstitutionalization, which
led to the development of the community mental health system in America (Deutsch,
1946; Regier et al., 1978; Drake et al., 2003). Table 1.1 briefly summarizes the prevailing
eras for how individuals with mental illnesses were treated in America.
Community mental health services are the treatment of persons with mental illnesses in
a community-based setting rather than in a hospital or psychiatric hospital environment.
table 1.1
Eras of Mental Health
Era
Age of Restraint
Time
1773–1836
Advocates
Moral Treatment
1836–1862
Pinel, Tuke,
Rush, Dix
Location
Home or
wilderness
Asylum
Theoretical framework
Containment
Humane, restorative
treatment
Custodial Care
1862–1900
Asylum
Personal and public
safety
Mental Hygiene
1900–1955 Beers, Meyer,
Mental hospital Prevention, early
Deutsch
or clinic
intervention,
promotion
Community
1955–1977 Felix, Anthony, Community
Deinstitutionalization,
Mental Health
Chamberlin,
mental health
community (re)
center
integration
Systems Delivery 1977–1981 Carter, Hatfield, Local
Social welfare concern
Lefley,
communities
Anthony,
(CASSP,
Deegan
PAMII)
Managed Care
1974–1990 Frank, McGuire, Local
Community support,
Pardes
communities
recovery
Behavioral Health 1990–
Rubinow,
Local
Decade of the brain,
Present
communities
disease management,
prevention
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Informatics and Public Health
11
Ten elements were determined to be essential to ensure successful outcomes for persons
with mental illnesses in the community. These included (1) a responsible case management
team; (2) residential care; (3) emergency care; (4) Medicare care; (5) halfway houses; (6)
supervised (supported) apartments; (7) outpatient therapy; (8) vocational training and
opportunities; (9) social and recreational opportunities; and (10) family and network
attention (Turner & Tenhoor, 1978).
Today, community mental health services provide a variety of mental health services,
from traditional mental health treatment programs to vocational programs and rehabilitation counseling. A variety of additional programs are provided, including supported
housing, employment, and education; partial hospitalization; local primary care medical
services; clubhouses and peer-run services; and self-help groups for mental health. The
significance of community mental health services is to provide the necessary services and
supports so that persons with mental illnesses can remain integrated in their local communities and can be productive as well as functioning members of society.
physical history
A physical history is the patient’s treatment history, defined as whether he or she had
ever received treatment prior to the current episode of care, and, if so, where. A history
often is in the form of an interview and may include physical examinations, basic patient
demographics, medications, allergies, and the presenting problem(s) or complaint(s) that
brought the patient to the practitioner. In addition, the practitioner usually takes a family history, developmental history (including stresses and transitions), and a social history (education, occupational history, religion, etc.), which also documents linguistic
and cultural issues that may be relevant in determining treatment. The service history is
an essential part of the evaluative process, not just of the patient’s current state but also
in determining effectiveness of treatment and short- and long-term patient outcomes.
Traditionally, this data may be kept in paper files, but increasingly these data are now part
of the electronic health record.
level of functioning
Severity and level of functioning measures an individual’s level of everyday functioning
and comparison with pre-morbid (before onset of diseases) functioning (Murray & Lopez,
1996). Relevant aspects of daily living include daily living skills, social and recreational
skills, financial skills, vocational skills, interpersonal skills, and parental skills. The point
of measuring level of functioning is to assess how much the illness has affected the person
and to use that information in designing appropriate levels of psychosocial treatment.
program evaluation
Effective program evaluation is a systematic way to improve and account for public health
services delivery and programmatic improvement. Program evaluation addresses how effectively decision making and administrative functions are performed, services are delivered,
and whether outcomes meet quality, patient, and service goals, as well as accountability
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Introduction
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12
guidelines. Quality assessment tools include system performance indicators, report cards,
and consumer outcome measures, all of which use guideline fidelity measures (standards).
They comprise domains that are issues, categories, or topics of interest. Indicators are
measurable activities, events, characteristics, or items that represent a domain. Measures
are the instruments used to assess, evaluate, and measure an indicator.
In public health evaluation, the following questions are asked:
What will be evaluated? (i.e., what is the program and in what context does it
exist?)
• What aspects of the program will be considered when judging program
performance?
• What standards (i.e., type or level of performance) must be reached for the program to be considered successful?
• What evidence will be used to indicate how the program has performed?
• What conclusions regarding program performance are justified by comparing the
available evidence to the selected standards?; and
• How will the lessons learned from the inquiry be used to improve public health
effectiveness? (Milstein & Wetterhall, 1999).
•
The data collected to effectively answer these questions come from a variety of sources
(including census data, surveillance data, and needs assessments) and from numerous data
sources at local, state, regional, and national levels. The synthesis of data and information
required to determine the effectiveness of programs, including patient outcomes, requires
an understanding of public health systems and informatics.
implications for mental health informatics
This chapter was designed to give readers a basic understanding of public health and how
the field views the world through an informatics perspective. For those with a basic understanding of public health, part of this chapter may seem like a review of basic principles.
However, for those who are looking at the dual areas of public health and informatics for
the first time, this overview is necessary.
The next chapter will briefly highlight some basic areas of mental health and mental
disorders, viewed from a public health perspective. This will be followed by an overview of
informatics in mental health services delivery.
References
Bird, V., Premkumar, P., Kendall, T., Whittington, C., Mitchell, J., & Kuipers, E. (2010).
Early intervention services, cognitive-behavioural therapy and family intervention in early
psychosis: Systematic review. British Journal of Psychiatry, 197(5), 350–356.
Field, M. (2002). Telemedicine: A guide to assessing telecommunications in health
care. Washington, DC: National Academy Press. Retrieved from www.nap.edu/
books/0309055318/html/index.html.
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