Now is the time for ehealth

Information technology is increasingly prevalent in healthcare. Ignore it at your peril, say Matko Marlais and Josip Car

Ehealth is one of the most exciting developments in the history of medicine. Broadly, it is a synonym for the use of information-communication technology related to health or healthcare delivery-a discipline known as health informatics. Creating a service that integrates information technology (IT) in every aspect of health care delivery is globally seen as the key to improving and redesigning healthcare systems, by reducing errors, improving quality of care and patient safety, and increasing the efficiency of healthcare.

New modes of communication and improved access to information and care, "smart" monitoring, computer decision support, tracking of and rapid response to adverse events, or automation of processes are but a few advantages that information technology brings.

Governments throughout the developed world and in many developing countries are now making unprecedented investments in health information technology.^w1 In the United Kingdom, the new NHS Connecting for Health agency was created to implement the National Programme for IT.^w2 Although ehealth developments span a number of areas here we present some of the core applications that future doctors will use.

The electronic health record is a digitised version of a patient's individual medical documentation, usually accessed on a computer through a network. In several European countries, including the UK and Denmark, almost all primary care doctors use electronic health records. Canada's province Alberta is leading the country in giving every citizen an electronic health record by January 2008.^w3

The benefits of the electronic health record include clearer documentation and easier retrieval of information for clinical, audit, and research purposes. With increased standardisation and adoption, the electronic health record can facilitate exchange of information between healthcare providers.

Electronic health records have also roused some concerns principally related to privacy and confidentiality.^w4 Barriers to implementation of electronic health records, such as financial expenditures and technical support, have been encountered. This has resulted in most small medical practices in the US state of Massachusetts not yet having an electronic health record.^w5

"Computerised provider order entry" is a group of systems with the aim of digitising and standardising various aspects of patient care, including prescribing, ordering tests, and imaging. Electronic prescribing has been heralded as the technical solution that can reduce avoidable adverse drug events,^{w6 w7} although evidence of benefit in clinical practice is still inconsistent.

Such systems can incorporate support, which may appeal particularly to junior doctors. This provides alerts on various drug-drug interactions, or dosage guidance, for example. These systems aim to serve as additional safeguards, supporting prescribers by identifying potential errors and giving additional knowledge. They are not intended to replace clinical decision making but rather bridge the gaps in a clinician's knowledge or attention.

"Clinical decision support systems" are software applications that are designed to support clinicians' decision making that use clinical knowledge and patients' data to produce patient specific alerts, warnings, and suggestions or recommendations for care. These applications are often incorporated into computerised provider order entry systems, which replace a centre's paper based ordering system, or are incorporated with the electronic health record, but stand alone systems exist. Many different types of systems support clinical decision making, the most common being "expert systems." These use clinical knowledge, usually as a set of rules, about a specific task, and can determine logical conclusions for individual patients.^w8 Systems for computer assisted diagnosis have been used to interpret mammograms, and other systems that support clinical decision making have been used for management of long term disease-for example, diabetes.^w9

Although evidence shows the benefit of new ehealth applications, there are concerns over patient safety, with the emergence of a fascinating new phenomenon-e-iatrogenesis. E-iatrogenesis has been defined as "patient harm caused at least in part by the application of health information technology." An invalid or incomplete system can provide invalid conclusions, contributing to incorrect decision making and resulting in harm to patients.^w10 A recent study identified 22 situations in which computerised provider order entry has increased the probability of prescribing errors, many of these are caused by human error, such as problems with users logging in and out resulting in the wrong patient receiving the drug.^w11 In some situations, evidence shows increased mortality coincident with implementation of the system,^w12 further emphasising the need for proper evaluation of health information technology in each specific clinical setting.

With the expanding use of these and other ehealth innovations, there is considerable scope for improving health care. For a doctor in the year 1990, ignorance of ehealth was a handicap equivalent to not being able to drive a car. For a doctor in 2010, ignorance of ehealth will be a handicap equivalent to not being able to read.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

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