SPECIAL FEATURE Improving U.S.

Healthcare Symposium
Feature Editors: Drs. John R. Feussner,
Eugene Oddone & Eugene Rich

The Promise of Information and

Communication Technology in
Healthcare: Extracting Value From
the Chaos
Burke W. Mamlin, MD and William M. Tierney, MD

ABSTRACT

Healthcare is an information business with expanding use of information and communication technologies (ICTs). Current ICT
tools are immature, but a brighter future looms. We examine 7 areas of ICT in healthcare: electronic health records (EHRs),
health information exchange (HIE), patient portals, telemedicine, social media, mobile devices and wearable sensors and
monitors, and privacy and security. In each of these areas, we examine the current status and future promise, highlighting
how each might reach its promise.
Steps to better EHRs include a universal programming interface, universal patient identifiers, improved documenta-
tion and improved data analysis. HIEs require federal subsidies for sustainability and support from EHR vendors,
targeting seamless sharing of EHR data. Patient portals must bring patients into the EHR with better design and
training, greater provider engagement and leveraging HIEs. Telemedicine needs sustainable payment models, clear
rules of engagement, quality measures and monitoring. Social media needs consensus on rules of engagement for
providers, better data mining tools and approaches to counter disinformation. Mobile and wearable devices benefit from
a universal programming interface, improved infrastructure, more rigorous research and integration with EHRs and HIEs.
Laws for privacy and security need updating to match current technologies, and data stewards should share
information on breaches and standardize best practices.
ICT tools are evolving quickly in healthcare and require a rational and well-funded national agenda for development,
use and assessment.
Key Indexing Terms: Health information technologies; Electronic medical records; Telemedicine; Information management.
[Am J Med Sci 2016;351(1):59–68.]

INTRODUCTION amount of information recorded but decrease its

readability.4

H
ealthcare is mainly an information business. The
quality, efficiency and outcomes of care depend
on effectively capturing and managing patient
information. There is no healthcare without management,
and there is no management without information. The use
of information and communication technologies (ICTs) is
expanding dramatically in healthcare: more than three-
quarters of U.S. hospitals and half of outpatient practices
have installed electronic health records (EHRs).1 Almost
all practice venues have high-speed Internet connections,
and most clinicians use electronic media for professional
and personal communications.2,3 Yet, chaos reigns:
 The many different EHR systems serving U.S. health-
care have limited ability to share information.
 There are no secure connections between EHRs, no
national identifiers to link patients' data and few
existing standards for formatting, summarizing or
displaying patient information.
 Mandates for billing, quality improvement and other
initiatives have expanded documentation requirements
whereas funding constraints have reduced clinician
time. Consequently, clinicians use shortcuts (eg, tem-
plates and copy-and-paste) that often increase the
 The amount of available information is constantly
increasing; the tools to safely digest, summarize and
empower the provider have not kept up.
Despite the chaos, a brighter future looms as new,
exciting ICT solutions are being applied to healthcare in:
 evolving EHRs,
 health information exchange (HIE),
 patient portals and personal health records (PHR),
 telemedicine,
 social media,
 mobile devices and wearable sensors or monitors,
 privacy and security.
We discuss each area's current status, promises for
tomorrow and how to realize those promises (Table).
ELECTRONIC HEALTH RECORDS
Current Status
EHR systems are longitudinal repositories of patients'
health information. Nearly every U.S. physician has

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES  Copyright © 2016 Southern Society for Clinical Investigation. 59
Published by Elsevier Inc. All rights reserved.
VOLUME 351 NUMBER 1 January 2016  www.amjmedsci.com  www.ssciweb.org
Mamlin and Tierney

TABLE. Future uses of information and communication technologies and how to achieve them

Technology Promise Getting there

Electronic health (1) User interactions will improve with less variability between (1) Create a universal application programming
records (EHRs) EHRs, improving provider experience interface (API)
(2) Standards will enhance data sharing (2) Demand and commit to creating and using a universal
(3) Documentation will be easy and less time-consuming patient identifier
(4) Instead of being an electronic version of the paper patient (3) Improve role-specific clinical documentation
record, the EHR will become an active participant in care (4) Grow and evolve the field of clinical database
(5) EHR data will be routinely used for practice management, epidemiology
public health and research

Health information (1) The number of sustainable HIEs will grow (1) Establish federal subsidies for HIEs to help them
exchange (HIE) (2) Regardless of source, all patients' data will be available in all of become sustainable
their care encounters (2) Require EHR vendors to support export of patient data
both into HIEs and import of data from HIEs
(3) Focus HIEs on enhancing existing EHRs rather than
becoming yet another EHR

Patient portals and (1) Patients will be able to easily access their data across health (1) Design better patient portals and PHR platforms
personal health systems and apps (2) Consider and incorporate patients as integral users into
records (PHRs) (2) Access to their data will help patients be active participants in PHR and EHR designs
their care (3) Develop training programs to enhance patient health
(3) Patients will contribute data to their PHRs and EHRs and EHR literacy
(4) Establish provider payment models that support their
using patient portals in delivering care and managing
patients' health
(5) Leverage HIEs to facilitate PHRs without becoming yet
another PHR

Telemedicine (1) Telemedicine systems will be widely used to connect
patients to providers
(2) Most routine care will be conducted via telemedicine
Social media (1) Social media will be widely used to disseminate health
information and enhance communication between healthcare
providers and consumers
(2) Social media will increase peer-to-peer support among
patients
(3) Social media will provide data for public health surveillance
(1) Establish realistic and sustainable payment models for
telemedicine
(2) Develop more user-friendly interfaces between
providers and patients
(3) Agree upon clear rules of engagement for telemedicine
and educate providers about them
(4) Establish telemedicine quality measures and monitoring
(1) Expand our understanding of social media beyond
Facebook and Twitter
(2) Establish reliable and valid approaches to mining health
information from social media
(3) Learn how to effectively leverage social media to
disseminate appropriate health information and counter
existing disinformation

Mobile devices and (1) The number and variety of mobile apps and sensing devices (1) Develop a universal platform or API that would
wearable sensors for capturing health data will rapidly increase encourage rapid development of apps for capturing
and monitors (2) Data from mobile apps and sensors will be incorporated into data into mobile devices
PHRs, EHRs and HIEs and become increasingly used in (2) Enhance our communication infrastructure to allow
patient care widely available, fast connectivity
(3) Fund research that assesses the value of mobile apps
to enhance health and healthcare
(4) Continually improve human-computer interfaces and
interactions for consumer-facing solutions
(5) Contribute data from mobile apps to the
medical record
(6) Discover how wearable sensor and monitoring data
should be presented to providers

Privacy and security (1) Standards and tools will ensure that data are safe and (1) Update law to match current methods for recording
breaches are rare. and transmitting data.
(2) Security and privacy standards will adapt over time. (2) Standardize and share best practices for security and
(3) Patients will have granular control over privacy. privacy.
(3) Increase public awareness and transparency of uses of
deidentified data.
(4) Routinely budget and plan for regular security
enhancements.

60 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES

VOLUME 351 NUMBER 1 January 2016

personal experience with EHRs, whose use has
expanded rapidly over the past decade under the
Affordable Care and the Health Information Technology
for Economic and Clinical Health Acts.1 Enacted in 2009,
these acts direct the government to spend $25.9 billion
to promote and expand the adoption of health informa-
tion technology. Yet, although most providers are now
using EHRs, most are unsatisfied or frustrated.5
Hospitals obtain EHRs from a small number of large
vendors, whereas outpatient practices have purchased
EHRs from a larger number of smaller vendors.1 Each
EHR has a unique user interface and approach for
representing and storing clinical information with little
sharing of data between them. Standards to enhance
data sharing are appearing, with minimal information
sharing between health systems, outpatient practices
and other venues. Barriers to such data sharing are
mainly logistical and organizational, not technical. U.S.
Senator Lamar Alexander (R-TN) recently asserted the
“failed promise” of the nearly $30 billion EHR program,
which can jeopardize the president's precision medicine
initiative unless physicians can use systems that share
data.6
Under the Health Information Technology for Eco-
nomic and Clinical Health, EHRs must meet meaningful
use criteria, documenting that can improve quality,
reducing disparities, engaging patients, improving care
coordination and maintaining data privacy and security.
In recent years, meeting meaningful use criteria has
dominated vendor development, crowding out innova-
tive responses to clinicians' needs. Consequently, EHRs
do not improve healthcare quality, efficiency, safety or
outcomes of care as expected. They remain clumsy
electronic versions of paper charts, not realizing digital
media's advantages and serving health systems better
than clinicians or patients. For example, documentation
tools focus more on administrative and medicolegal
needs than on patient care,7 increasing the amount of
documentation while diminishing its clinical usefulness.
The Promise
Improving practices and standards for user interac-
tions enhances providers' EHR experiences. Competi-
tion reduces the number of EHR systems that have less
variability between EHRs, especially in core features. As
healthcare apps and sharable programming platforms
increase, features applicable across EHRs increase,
further improving providers' options and experiences.8,9
Widely adopted standards facilitate the use and
sharing of data. Imagine healthcare providers opening
patient's EHR and seeing data from their hospital, all
other health systems and providers their patients have
visited, presented as a seamless comprehensive chart.
Documentation could be simple, easy and accurate with
providers spending more time delivering care. Docu-
menting for administrative and medicolegal purposes
would disappear as those data are captured
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES  Copyright © 2016 Southern Society for Clinical Investigation.
Published by Elsevier Inc. All rights reserved.
VOLUME 351 NUMBER 1 January 2016  www.amjmedsci.com  www.ssciweb.org
The Promise of Health Information Technology
automatically. For example, no documentation would
be needed for reviewing systems or examining a
shoulder because these data would be captured auto-
matically during the physician-patient interaction. This
technology exists; it is not being used.
Eventually, traditional EHRs would disappear—inter-
active, anticipatory EHRs would become active partic-
ipants in care and not barriers between providers and
patients. EHRs would understand providers' actions with
patients, providing and presenting easily consumable
information (eg, summarizing past history and future
risks). These EHRs would aid healthcare management
(eg, identifying quality gaps), enhancing public health
(eg, identifying unmet needs) and understanding pop-
ulation health and healthcare needs (eg, filling knowl-
edge gaps and quantifying benefits and harms).
Getting There
A universal application programming interface (API)
could control communication between EHRs and apps,
with libraries of apps and routines using common pro-
gramming languages, so developers of certified EHRs
and apps can use the API without digesting voluminous,
complicated specifications. The Fast Healthcare Intero-
perability Resources of Health Level 7 messaging stand-
ard seems promising.10 Merging data between EHRs and
apps requires a universal patient identifier or at least an
agreed-upon minimum set of unique identifying data.
Patients must believe that it is critical to health and well-
being and would not be misused.
Healthcare providers populate visit records with their
unique observations, interpretations, decisions and
plans; physicians would not do all of this. Accomplishing
this efficiently requires automated recording of metadata
(data describing and storing information about other
data). For example, automated analysis of audio or video
encounter recordings could document tasks performed
and instructions given; vital signs could be automatically
captured using low-energy and low-cost identification
and tracking technologies to automatically capture data
into patients' EHRs. Recording of information for prac-
tice management and billing should be handled by less-
expensive, better-trained dedicated specialists, not
physicians.
The epidemiologic tools for effective use of EHRs are
either primitive or nonexistent but could be enhanced by
using a common analytic data model, for example, the
Observational Medical Outcomes Partnership model,
into which data from any EHR can be translated.11 We
need standard definitions for conditions and outcomes,
cognizant of messy EHR data and balancing sensitivity
and specificity. For example, multiple different published
definitions of “diabetes mellitus” vary in their use of
diagnoses and test results, and pharmacy data yield
different patients with different outcomes.12 Robust
methods for minimizing and managing bias and con-
founders must be developed.13 Narrative descriptions of
61
Mamlin and Tierney
clinical encounters would always be necessary, resulting
in erroneous or inconsistent EHR data. Methods to
identify and sequester or ignore bad data are needed
to provide better separation of signal from noise.
We also need to establish accepted, efficient, inexpen-
sive methods to reliably deidentify patient data for
analysis.
HEALTH INFORMATION EXCHANGE
Current Status
HIEs share healthcare information within or between
healthcare organizations mostly as state or regional
hubs that bridge offices, clinics and hospital systems.
Few of the dozens of U.S. HIEs are financially stable,
solvent and sustainable with no long-term governmental
commitment or support; although, the National Coordi-
nator for Health Information Technology is strongly
committed to data sharing standards.14-16 Standards
for storing, sharing and managing data across EHRs are
lacking, although demonstrable progress is finally occur-
ring after decades of stagnation.17 Competition between
healthcare providers inhibits data sharing, although new
funding models such as accountable care organizations
are increasing and provide strong incentives for coop-
eration and sharing data.18 Even when data are shared,
HIEs typically create new consolidated EHRs independ-
ent from healthcare providers' EHRs. This forces pro-
viders to look in 2 places for patient health information:
their own local patient record and the HIE. Requiring this
extra step lessens the viewing of HIEs and thus their
effects on healthcare.19
Emerging regional and statewide HIEs are not being
fully leveraged to support data analysis to enhance care
management, public health or research generating new
knowledge.19 Ironically, those who stand to benefit the
most from burgeoning HIEs—patients—have little access
to or control over them, nor do they know when or how
their data are being used or shared.20
The Promise
Unless or until there is a common platform that
connects all EHRs and users to securely and rapidly
share data “in the cloud,” HIEs would be needed. We
expect the number of successful HIEs to grow as
sustainability models proliferate owing to wide recogni-
tion of the power of healthcare data by providers and
patients and support from federal and local initiatives
designed to require, promote and reward seamless
sharing of data across systems.15 Patients' health-
related data would be available whenever and wherever
they seek care. Health systems and providers value
cooperating on patient safety and healthcare quality while
competing on service.21 Accepted standards incorporate
EHR data seamlessly into HIEs and vice versa, giving
providers a single platform, connection and password to
access their patients' data. This network of HIEs and EHRs
62
and health-related apps would be the “central nervous
system for health,” a seamless shared health record.
In addition to supporting healthcare delivery, HIEs
would support data analyses to identify opportunities to
enhance patient care, public health and research. Pro-
viders and patients would be able to monitor and control
their data's use across institutions.
Getting There
Sustaining HIEs requires some support from federal
or state governments—no generalizable, successful
business model has emerged that relies solely on
support from healthcare providers or patients. HIEs are
“commons” of healthcare and require broad societal
support. Federal support comes with mandates for
interoperability conditioned on adhering to accepted
standards for data coding and interoperability, reliable
and universal patient identification and rules of data
governance, access and use.22
EHR vendors and the growing number of healthcare
mobile apps should be able and are required to routinely
send data to HIEs and receive data from them. Providers
and patients should demand this open, effective
exchange of data so all of a patient's clinical information
is available wherever and whenever it is needed. HIEs
should work closely with EHR vendors to empower
patients to monitor, control access to and even contrib-
ute to their HIE data.
PATIENT PORTALS AND PERSONAL HEALTH
RECORDS
Current Status
Patient portals and PHRs are required for health
systems to meet current meaningful use criteria. Yet,
despite a rapid increase in the number of PHRs, most
patients do not use them,23 especially minorities and
patients with few medical problems.24 PHRs can be
standalone, tethered to EHRs or integrated into EHRs.25
In most cases, PHRs are siloed within a single health
system, so many patients have separate PHRs for each
health system they encounter. Fortunately, efforts like
Blue Button have simplified patients' downloading of
records from various EHRs.26
Many PHRs' patient interfaces fail to follow best
practices.27 Most existing patient portals do share many
common features, for example, access to progress
notes and educational materials, medication renewals,
appointment requests, patient reminders and patients'
ability to enter data.24
Large national PHRs such as Google Health or
Microsoft's HealthVault have been discontinued or have
not caught on. They are little used by providers, and
many patients are concerned about secondary data
uses.28-30 Finally, despite evidence that PHRs are improv-
ing chronic disease management, their effects on health
outcomes remain largely unknown.24
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
VOLUME 351 NUMBER 1 January 2016

The Promise
Patients have open, user-friendly access to their
data across health systems and health apps. Through
PHRs, patients understand their health risks better and
have effective tools for lowering risks, managing their
conditions and adhering to treatments, ultimately leading
to better health outcomes. Patient portals would be
integrated into EHRs or HIEs or both, rather than being
standalone or tethered systems, and patients would join
the healthcare team, all viewing the same patient data to
provide patients with seamless views of their health data
regardless of the source. Over time, as systems evolve
to support both providers and patients better in patient-
centered care, PHR and EHR distinctions would blur as
patients become active members of their healthcare
teams.
Getting There
Patient portals and PHR platforms need to improve
their usability prospectively to identify practices and
approaches that work best, although they may vary by
patient age, culture, literacy, etc. Such research findings
should be shared and incorporated by all PHR vendors
and include enhancements that target minorities and
patients with educational and communication disabil-
ities. Large EHR vendors that currently manage most
PHRs need to view patients as members of the health-
care team and involve them in PHR design. Providers
have historically been reticent to share records with
patients; however, there is growing evidence that shar-
ing records with patients, including clinical notes, has
more benefits than harms.26,31 Creating useable patient
portals is not enough. Consumers, including those with
disabilities and low literacy, must be educated on how to
understand and interact with their PHRs and use their
personal health data to improve their health.
To coordinate and improve the interaction between
providers and patients, new payment models must
incentivize patients and providers to use PHRs. Integrat-
ing PHRs within the EHR helps make these interactions
more intuitive and should improve workflow. Moreover,
HIEs should also support patient portals and help
patients navigate between healthcare systems without
becoming yet another PHR. EHRs and HIEs must sup-
port patient-contributed data, data from patients' apps,
including wearable activity sensors and other technology,
and patient-driven additions and corrections to their
health records. Rather than becoming another patient
portal, HIEs should link healthcare services to allow
patients to access and control their complete online
record whether by using computers or smartphone apps.
TELEMEDICINE
Current Status
Telemedicine—using information technology to deliver
heath care services at a distance—is already in wide
use. Hundreds of millions of virtual visits are taking place
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES  Copyright © 2016 Southern Society for Clinical Investigation.
Published by Elsevier Inc. All rights reserved.
VOLUME 351 NUMBER 1 January 2016  www.amjmedsci.com  www.ssciweb.org
The Promise of Health Information Technology
annually, and nearly half of employer plans allow tele-
medicine consultations to their workers.32 Telemedicine
historically focused mostly in narrow content areas such
as reading radiographs and retinal photographs, mon-
itoring critical care patients, managing diabetes mellitus
and monitoring care in emergency departments and at
home.33,34 Most U.S. healthcare venues and patients'
homes have broadband, making telemedicine far more
feasible than a decade ago.2 Billing for telemedicine is
evolving, becoming less of a barrier.35 Telemedicine
vendors are experimenting with subscription versus
pay per use models, some targeting employers and
insurers and others selling directly to consumers.
Although some specific telemedicine interventions have
lowered costs, the effectiveness and cost-effectiveness
of telemedicine compared to face-to-face medicine are
unknown.33
Telemedicine affects the provider-patient relation-
ship, both positively and negatively.36 Telemedicine can
be more convenient for patients and allow providers to
reach many more patients, but these interactions are
often not as robust as face-to-face interactions.37
The use of teleconsultation (video advice and, some-
times, care from previously unknown providers) is
expanding rapidly, though State licensing of providers
limits their geographic spread.32 Their primary focus has
been urgent primary care (general medicine, dermatol-
ogy and behavioral health) with concerns that telecon-
sultation may add to, rather than replace, standard care
and thus increase healthcare costs, communication
errors and safety issues.32 Virtual visits may also result
in more prescriptions than do face-to-face visits and
may reduce care coordination.32 Lowering barriers to
teleconsultation, however, might increase the delivery of
healthcare to people with limited access to providers.
The Promise
Telemedicine changes the practice of medicine,
facilitating disconnected care for patients without a need
to visit providers, reserving the time and expense of
face-to-face care for when it is truly needed. In fact,
telemedicine would become the de facto standard
expected by patients for routine care, supporting care
over wide geographic areas when resources are scarce
or travel is difficult and allowing more convenient,
asynchronous care for nonurgent issues such as blood
pressure checks and follow-up of milder acute events.
Teleconsultation would be safe and secure, improve
patient outcomes and contribute data to patients' EHRs.
Recent and ongoing advances in virtual reality would
make telemedicine cheaper, simplify development of
new apps and usher in a new wave of exciting tele-
medicine opportunities.38
Getting There
Realistic and sustainable payment models for tele-
medicine are in evolution but must be accelerated and
63
Mamlin and Tierney
studied. Ongoing experimentation with payment models
should be accompanied with rigorous research to iden-
tify the most efficient, effective and cost-effective pay-
ment models in each context. Ultimately, we need to
understand which approaches in which context are cost-
effective and lead to improved outcomes.
Techniques and best practices for engaging and
informing users should be shared and widely adopted.
Usability research focusing not only on user experience
but also on cost and outcomes should drive system
design. Capabilities for measuring vital signs and point-
of-care tests should be incorporated into increasingly
sophisticated telemedicine applications. To facilitate
communication and coordination of care between pro-
viders, information generated during telemedicine “vis-
its” should be seamlessly incorporated into patients'
EMRs and local HIEs.
In April 2014, the Federation of State Medical Boards
released a model for the appropriate use of telemedi-
cine, addressing licensing, physician-patient relation-
ships, consent, evaluation and treatment, continuity,
referral to emergency services, medical records, privacy
and disclosures.39 We should agree on such a model
and then strive to educate providers engaging in tele-
medicine. The federal government should facilitate sim-
plifying and aligning these rules across state lines to
reach consensus, reduce confusion and minimize errors.
With the explosion in numbers of mobile devices and
health-related apps, there is no doubt that telemedicine
will grow over time. To ensure that we are improving
care and not simply increasing the use of healthcare
services without improving outcomes, we must invest in
meaningful evaluations of the technology and the care it
supports.
SOCIAL MEDIA
Current Status
People are already using Facebook, Twitter, reddit,
YouTube and other social media sites to document and
discuss their health and healthcare issues and seek
healthcare information.40 Healthcare specific social
media sites are emerging for the general public (eg,
PatientsLikeMe) and by advocacy groups for patients
with specific conditions (both common and rare con-
ditions). The literature has many examples of how social
media might be used to disseminate health information
and improve care.41 Most prior studies focused on
implementation or observation, and rigorous evaluations
are lacking;41 for example, mining Facebook and Twitter
posts and Google searches for disease surveillance
such as increasing influenza incidence; yet, social media
content remains a mostly untapped resource.42
Providers are using social media to advance their
craft, and social media is demonstrating the ability to
affect changes in healthcare at unprecedented scale.43
For example, Dr. Aaron Carroll hosts a YouTube channel
called Healthcare Triage that has more than 130,000
64
subscribers and nearly 7 million views. Dr. Joel Topf
(@kidney_boy) has nearly 5,000 followers on Twitter and
hosts a twitter-based nephrology journal club twice a
month called #NephJC. When Johns Hopkins turned to
Facebook to solicit organ donations, it boosted organ
donation registrations 21 folds in a single day.44
The Promise
The medical establishment would find effective ways
to not only disseminate and target health information
through an ever-widening array of social media but also
engage with consumers through social media. Social
media helps bring healthcare providers and consumers
closer together and become an effective platform for
health promotion and disease prevention. There would
be more peer-to-peer social support for patients, espe-
cially those with rare conditions. Patient engagement in
research would increase, especially among those with
rare conditions. Information from social media would
empower and enhance public health surveillance activ-
ities by state and county health departments and
increase the speed and accuracy in monitoring and
detecting health trends.
Getting There
We need to expand our understanding and use of
social media. In addition to Facebook and Twitter,
consumers are using YouTube, reddit, Instagram, Link-
edIn, Pinterest and other programs to discover and
discuss health-related issues. This landscape is likely
to continue to grow over time; each platform presents
unique opportunities for enhancing patient care and
health.
We need to expand our understanding of the ethical
and privacy aspects of using social media in health-
care.45 Part of this includes evolving and adapting our
understanding of how physicians can appropriately
engage patients through social media.43,46 We need to
provide patients with an ever-increasing range of options
that enhance their personal comfort in the security and
usability of their information in social media. Their
comfort would vary depending on age and the type of
health information, so targeted approaches would be
the key.
Researchers and care providers must gain a deeper
understanding of the data being placed in social media.
We need to learn what types of questions we can ask
and develop guidelines and tools for reliably finding the
answers. To assure sustainability, patients, providers,
and social media companies must engage in a dialogue
on the appropriate secondary uses of health information
placed in social media.
Consumers have embraced social media. A small
number of providers have found ways to engage other
providers and patients through social media. We need to
learn from these pioneers and find ways to replicate their
success to enhance public health communication,
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
VOLUME 351 NUMBER 1 January 2016

engaging county, state and federal public health agen-
cies where appropriate. We need to learn how to
effectively disseminate appropriate health information
and also counter disinformation generated through a
democratized Internet.
MOBILE DEVICES AND WEARABLE SENSORS
AND MONITORS
Current Status
Mobile health and wearable sensors are the fastest
moving areas in informatics. We are currently in a mobile
health revolution: mobile devices (smartphones, tablets
and global positioning system devices) have been
adopted globally and are increasingly being applied to
healthcare.47,48 We already have evidence that mobile
devices can improve healthcare. For example, mobile
phone programs can enhance medication adher-
ence.49,50 Myriads of health-related apps (eg, fitness
programs using cellular positioning programs and activ-
ity logs) are available, and their adoption and use are
rapidly increasing. Mobile devices are rapidly replacing
desktop and laptop computers as portals for healthcare
providers to record and view patient data.51
As the use of mobile devices and apps is rapidly
expanding, we are in the early stages of the use of
wearable sensors and monitors (eg, Fitbit and Jawbone).
This has resulted in a myriad of data but relatively little
useful information so far. What information is being
generated is generally not provided to or used by health
systems and providers. But it could be that activity
monitors could identify elderly patients who have fallen
or become incapacitated or nonmobile for whatever
reason. Adherence to exercise prescriptions among
diabetics could be assessed. Sleep patterns and
arrhythmias could be monitored. The possibilities are
huge and largely untapped.
Mobile technologies have the potential to reshape
health information capture in the coming decades. To
put things in perspective, a recent report found that
more than half of diabetic millennials would trust a
mobile health app over a health professional for
advice.52
The Promise
The number of apps and devices for sensing and
monitoring generic measures (eg, steps walked and
calories burned) and condition-specific measures (mobi-
lity among elders, blood sugar in diabetics, vital signs
among heart failure patients, etc) continues to grow
exponentially. Information gleaned from mobile devices,
sensing devices and other apps would be linked to
patients' EHRs and HIEs and may become the most
common means by which patients inform the healthcare
system. Prescriptions for healthcare activities, and auto-
matically documenting adherence, would be incorpo-
rated into everyday healthcare plans.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES  Copyright © 2016 Southern Society for Clinical Investigation.
Published by Elsevier Inc. All rights reserved.
VOLUME 351 NUMBER 1 January 2016  www.amjmedsci.com  www.ssciweb.org
The Promise of Health Information Technology
Wearable sensors and monitors continue to grow in
capabilities as they shrink in size, eventually finding their
way into our very clothing.53 The ubiquity of the “Internet
of things” presents endless opportunities for innovation
and intervention as the amount of data relevant to
healthcare explodes.
Getting There
We need to develop a universal platform or API to
encourage rapid development of apps for capturing data
into mobile devices. APIs like Apple Health Kit and
Google Fit, middleware services like Validic that connect
to dozens of different wearable sensors and present
their data in a uniform format for developers and stand-
ards like the Observational Medical Outcomes Partner-
ship's common data model and the Fast Healthcare
Interoperability Resources are moving us in the right
direction by encouraging adoption of normalized models
and web services. Supporting efforts that drive us
toward a convergent model and API simplifies the job
for developers.
Fast Internet connectivity needs to become widely
available. Telecommunication networks are improving
and expanding yearly, but reliable, affordable and broad-
band connectivity remains elusive for many poor and
rural communities.54
Despite the explosive production of health-related
mobile apps, most of the research has been focused on
how they are implemented and used. We need more
rigorous evaluations of the effects, outcomes, costs and
generalizability of mobile health solutions.
Human-computer interfaces and interactions for
consumer-facing solutions must continue to rapidly
improve and evolve. Healthcare apps should adhere to
the well-documented style guides developed by com-
panies leading in the mobile space (Apple and Google).
Human-computer interface engineers should expand on
existing best practices in the mobile space to describe
and demonstrate relevant healthcare specific interac-
tions and workflows.
Except for apps built specifically to integrate with
EHRs, most mobile apps create new silos of data. We
need to treat mobile apps that collect personal, medi-
cally relevant data as extensions of the medical record.
Just like the EHR, mobile apps should interact with the
HIE. Mobile apps should be able to both extract data
from EHRs or HIEs (eg, an app for improving diabetes
mellitus management should have access to treatments
and test results) and contribute any new data to the
patient's record so it can be made seamlessly available
within other systems touched by patients.
Medical education has not kept up with the revolu-
tion in information technology inside and outside the
health sector. As the number of sensors and monitors
increases, so would the amount and variety of data. To
make the most of these data, we need innovative ways
to display these data to providers who must be both
65
Mamlin and Tierney
literate in the technologies and understand how to
employ them and their data in everyday patient care.
Mobile app data displays in the form of graphs, sum-
mary reports, aggregate statistics, trends, etc should be
a uniform weapon in every clinician's armamentarium.
PRIVACY AND SECURITY
Current Status
Security breaches have become all too common-
place and health information is being increasingly tar-
geted.55,56 Since 2009, more than 1,100 breaches of
health data have exposed data of more than 120 million
people.57 For example, in February 2015, hackers stole
more than 37.5 million records from Anthem, Inc, con-
taining personally identifiable data.58
The Health Insurance Portability and Accountability
Act of 1996 and its subsequent amendments provided
vague statistical thresholds for deidentification, a “safe
harbor” provision of removing 18 data elements, and a
“limited data set” for specific uses.59 Additional guid-
ance in 2012 provided some clarification but has been
criticized for leaving too much to user judgment and was
still based on the outdated law.60,61 Most laws and
regulations do not cover security issues surrounding
deidentified data.59
The amount of health information is rapidly growing
in detail and diversity and is increasingly collected
outside traditional medical records, for example, within
mobile devices, wearable sensors and home wireless
networks. Mobile health apps are covered by a patch-
work of policies.62,63 Beyond the basic ubiquitous
Internet security infrastructure such as transport layer
security, each healthcare organization faces its own
siloed efforts to secure data.
Although healthcare organizations are beginning to
shift from reactive to more holistic approaches toward
security, there are still many challenges, and many
organizations still consider security to be a technical
issue separate from providing care.64 There are constant
struggles between security and usability.65 As a result,
security measures that can decrease the threat of
hackers, such as multifactor authentication, are not
commonly used.66 The atmosphere is often one of fear
of litigation and penalties with little reward for getting
security right.
Use of the cloud is increasing, where data may be
stored in different countries beyond local control or
oversight.67 Similarly, there is limited oversight of tele-
health applications and concerns about privacy and
security of patient information placed on social
media.46,68 Despite the explosion of health data and
their uses, patients want more control over access to
their health data.69,70
The Promise
Standardized approaches and tools for security
would ensure that data are safe, access is secured
66
and breaches are rare. There would be an objective
process for vetting security and standards for automated
deidentification. Healthcare organizations would collab-
orate, learning from their security failures and celebrating
successes as they address both technical and non-
technical aspects of security.
The increasing amount of health data in the cloud and
used for telehealth would be better protected by stand-
ards for security that adapt to changing privacy expect-
ations over time. Advances in secure infrastructure across
domains would also benefit the healthcare domain,
making it easier to secure health information while
providing patients with granular control over privacy.
Getting There
We need to update laws to match current methods
for recording and transmitting data. As we do, we need
to realign security priorities with patient priorities and
establish a process to regularly update policies to adjust
to patients' individual and changing privacy expectations.
Although media attention and bad press will con-
tinue to be a deterrent, we can no longer afford to vilify
organizations that are victims of breaches. Instead, we
need to standardize and share best practices, make
security practices more transparent, insist on learning
from our failures and find better ways to incentivize best
practices.
There must be increased public awareness and
transparency surrounding the use of deidentified data.59
Companies should be able to get certified in providing
deidentification as a service. Finally, healthcare organ-
izations should avail themselves of existing advances in
security—for example, implement multifactor authenti-
cation—and routinely budget for security enhancements
so security is a fundamental component of healthcare
and new advancements are adopted quickly.
POLICY IMPLICATIONS AND CONCLUSIONS
All of the 7 types of health information technology
discussed earlier are still in early stages of development
and use in healthcare. Now is the time for a rational and
well-funded national agenda for ICT development in
healthcare. The National Coordinator for Health Informa-
tion Technology is in a position to lead this effort.
Funding for research and development should be tied
to EHR implementation and come from both federal
sources (for general infrastructure such as enhanced
wireless communications, the universal platform or API
and objective research showing what works and what
benefits can be expected) and the private sector for
EHRs, HIEs, PHRs and other large-scale software sys-
tems along with apps. Only then can healthcare, an
information business, maximize the benefits realizable
by leveraging existing and rapidly developing ICT. Only
then can we extract value from the chaos.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
VOLUME 351 NUMBER 1 January 2016

REFERENCES
1. The ONC Health IT Dashboard. 2015. Available at: http://dashboard.
healthit.gov/index.php. Cited June 20, 2015.
2. Healthcare Broadband in America. 2010. Available at: http://download.
broadband.gov/plan/fcc-omnibus-broadband-initiative-%28obi%29-work
ing-reports-series-technical-paper-health-care-broadband-in-america.pdf.
3. Physician Adoption and Predictions of Mobile in 2015. www.medda
tagroup.com. 2015. Available at: http://www.meddatagroup.com/wp-con
tent/uploads/Physician-use-of-mobile-2015-2.pdf. Cited June 26, 2015.
4. Hirschtick RE. A piece of my mind. Copy-and-paste. J Am Med Assoc
2006;295(20):2335–6.
5. Friedberg MW, Chen PG, Van Busum KR, et al. Factors affecting
physician professional satisfaction and their implications for patient care.
Health Systems and Health Policy. RAND Corporation; 2013.
6. Alexander: Failing Electronic Health Records Program May Stand in Way
of Precision Medicine. help.senate.gov. 2015. Available at: http://www.
help.senate.gov/chair/newsroom/press/alexander-failing-electronic-heal
th-records-program-may-stand-in-way-of-precision-medicine. Cited May 5,
2015.
7. Payne TH, Corley S, Cullen TA, et al. Report of the AMIA EHR 2020
Task Force on the Status and Future Direction of EHRs. J Am Med Inform
Assoc 2015;22(5):1102–10.
8. Newman J. Epic Systems to open its own app exchange. Wisconsin
State J. 2015. Available at: http://host.madison.com/business/epic-sys
tems-to-open-its-own-app-exchange/article_fc7e8b94-b1ec-59f4-9065-
1e6143fe351c.html. Cited June 25, 2015.
9. A Robust Health Data Infrastructure. healthit.gov. 2014. Available at:
http://healthit.gov/sites/default/files/ptp13-700hhs_white.pdf. Cited June
25, 2015.
10. HL7 FHIRs. hl7.org. 2015. Available from: http://www.hl7.org/fhir/. Cited
June 25, 2015.
11. Overhage JM, Ryan PB, Reich CG, et al. Validation of a common data
model for active safety surveillance research. J Am Med Inform Assoc
2012;19(1):54–60.
12. Richesson RL, Rusincovitch SA, Wixted D, et al. A comparison of
phenotype definitions for diabetes mellitus. J Am Med Inform Assoc
2013;20(e2):e319–26.
13. Bosco JL, Silliman RA, Thwin SS, et al. A most stubborn bias: no
adjustment method fully resolves confounding by indication in observa-
tional studies. J Clin Epidemiol 2010;63(1):64–74.
14. Vest JR, Campion TR, Kaushal R, et al. Challenges, alternatives, and
paths to sustainability for health information exchange efforts. J Med Syst
2013;37(6):9987–8.
15. DeSalvo KB. Health Information Technology: Where We Need To Go. 2015.
Available at: http://www.healthit.gov/buzz-blog/from-the-onc-desk/incentivizin
g-interoperability-standards-data-security-privacy/. Cited June 25, 2015.
16. Adler-Milstein J, Bates DW, Jha AK. Operational health information
exchanges show substantial growth, but long-term funding remains a
concern. Health Aff 2013;32(8):1486–92.
17. Richesson RL, Chute CG. Health information technology data standards
get down to business: maturation within domains and the emergence of
interoperability. J Am Med Inform Assoc 2015;22(3):492–4.
18. Tu T, David I, Lawrence I, et al. Origins and Future of Accountable Care
Organizations. brookings.edu 2015. Available at: http://www.brookings.
edu/research/papers/2015/05/12-origins-and-future-of-accountable-car
e-aco. Cited June 25, 2015.
19. Rahurkar S, Vest JR, Menachemi N. Despite the spread of health
information exchange, there is little evidence of its impact on cost, use,
and quality of care. Health Aff 2015;34(3):477–83.
20. Meslin EM, Alpert SA, Carroll AE, et al. Giving patients granular control
of personal health information: using an ethics points to consider to inform
informatics system designers. Int J Med Inform 2013;82(12):1136–43.
21. McDonald CJ, Overhage JM, Barnes M, et al. The Indiana network for
patient care: a working local health information infrastructure. An example
of a working infrastructure collaboration that links data from five health
systems and hundreds of millions of entries. Health Aff 2005;24(5):
1214–20.
22. Connecting Health and Care for the Nation. healthit.gov. 2015.
Available at: http://www.healthit.gov/sites/default/files/nationwide-intero
perability-roadmap-draft-version-1.0.pdf. Cited May 28, 2015.
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES  Copyright © 2016 Southern Society for Clinical Investigation.
Published by Elsevier Inc. All rights reserved.
VOLUME 351 NUMBER 1 January 2016  www.amjmedsci.com  www.ssciweb.org
The Promise of Health Information Technology
23. Irizarry T, DeVito Dabbs A, Curran CR. Patient portals and patient
engagement: a state of the science review. J Med Internet Res 2015;
17(6):e148.
24. Goldzweig CL, Orshansky G, Paige NM, et al. Electronic patient
portals: evidence on health outcomes, satisfaction, efficiency, and atti-
tudes: a systematic review. Ann Intern Med 2013;159(10):677–87.
25. Studeny J, Coustasse A. Personal health records: is rapid adoption
hindering interoperability? Perspect Health Inf Manag 2014;11(Summer):1e.
26. Blue Button. 2015. Available at: http://en.wikipedia.org/wiki/Blue%20Button.
Cited June 21, 2015.
27. Cruz Zapata B, Hernández Niñirola A, Idri A, et al. Mobile PHRs
compliance with Android and iOS usability guidelines. J Med Syst 2014;
38(8):1–16.
28. Google Health. 2012. Available at: http://en.wikipedia.org/wiki/Google%
20Health. Cited June 26, 2015.
29. Microsoft HealthVault. 2012. Available at: http://en.wikipedia.org/wiki/
Microsoft%20HealthVault. Cited June 26, 2015.
30. Angst W. Privacy safeguards in PHR adoption. Health Manag Technol
2008;29(4): 40,39.
31. Walker J, Meltsner M, Delbanco T. U.S. experience with doctors and
patients sharing clinical notes. Br Med J 2015;350:g7785.
32. Tahir D. Telehealth services surging despite questions about value. Mod
Healthc 2015;45(8):18–20.
33. Ward MM, Jaana M, Natafgi N. Systematic review of tele-
medicine applications in emergency rooms. Int J Med Inform 2015;84(9):
601–16.
34. Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a
systematic review of reviews. Int J Med Inform 2010;79(11):736–71.
35. Weinstein RS, Lopez AM, Joseph BA, et al. Telemedicine, telehealth,
and mobile health applications that work: opportunities and barriers. Am J
Med 2014;127(3):183–7.
36. Blake JH, Schwemmer MK, Sade RM. The patient-surgeon relation-
ship in the cyber era: communication and information. Thorac Surg Clin
2012;22(4):531–8.
37. Sabesan S, Allen D, Caldwell P, et al. Practical aspects of telehealth:
doctor-patient relationship and communication. Intern Med J 2014;44(1):
101–3.
38. Beyond Games, Oculus Virtual Reality Headset Finds Medical
Uses. 2015. Available at: http://www.reuters.com/article/2015/06/11/
us-oculus-medicine-idUSKBN0OR02620150611. Cited June 10, 2015.
39. Model Policy fro the Appropriate Use of Telemedicine Technolo-
gies in the Practice of Medicine. fsmb.org. 2014. Available at: http://
www.fsmb.org/Media/Default/PDF/FSMB/Advocacy/FSMB_Telemedicine_
Policy.pdf. Cited June 20, 2015.
40. Burke-Garcia A, Scally G. Trending now: future directions in
digital media for the public health sector. J Public Health 2014;36(4):
527–34.
41. Capurro D, Cole K, Echavarría MI, et al. The use of social networking
sites for public health practice and research: a systematic review. J Med
Internet Res 2014;16(3):e79.
42. Schmidt CW. Trending now: using social media to predict and track
disease outbreaks. Environ Health Perspect 2012;120(1):A30–3.
43. Perna G. Trend: social media. The surface is being scratched. Providers
are using social media to engage patients, collaborate with each other.
Healthc Inform 2014;31(2):24–5.
44. The Facebook Effect: Social Media Dramatically Boosts Organ
Donor Registration. hopkinsmedicine.org. 2013. Available at: http://
www.hopkinsmedicine.org/news/media/releases/the_facebook_effect_so
cial_media_dramatically_boosts_organ_donor_registration. Cited June 21,
2015.
45. Denecke K. Ethical aspects of using medical social media in healthcare
applications. Stud Health Technol Inform 2014;198:55–62.
46. Model Policy Guidelines for the Appropriate Use of Social Networking in
Medical Practice. library.fsmb.org. 2012. Available at: http://library.fsmb.
org/pdf/pub-social-media-guidelines.pdf. Cited June 21, 2015.
47. Ainsworth B, Cahalin L, Buman M, et al. The current state of physical
activity assessment tools. Prog Cardiovasc Dis 2015;57(4):387–95.
48. Wools-Kaloustian KK, Sidle JE, Selke HM, et al. A model for
extending antiretroviral care beyond the rural health centre. J Int AIDS
Soc 2009;12(1):22.
67
Mamlin and Tierney
49. Dayer L, Heldenbrand S, Anderson P, et al. Smartphone medication
adherence apps: potential benefits to patients and providers. J Am Pharm
Assoc 2013;53(2):172–81.
50. Pop-Eleches C, Thirumurthy H, Habyarimana JP, et al. Mobile phone
technologies improve adherence to antiretroviral treatment in a resource-
limited setting: a randomized controlled trial of text message reminders.
AIDS 2011;25(6):825–34.
51. Sclafani J, Tirrell TF, Franko OI. Mobile tablet use among academic
physicians and trainees. J Med Syst 2013;37(1):9903–6.
52. Telcare Diabetes Awareness Index Reveals National Knowledge
Gap for the Common and Deadly Disease. 2015. Available at: http://
www.marketwired.com/press-release/telcare-diabetes-awareness-index-
reveals-national-knowledge-gap-common-deadly-2028304.htm. Cited June 20,
2015.
53. Zeng W, Shu L, Li Q, et al. Fiber‐based wearable electronics: a review of
materials, fabrication, devices, and applications. Adv Mater 2014;26(31):
5310–36.
54. Bureau UC. Nearly 8 in 10 Americans Have Access to High-Speed
Internet. 2014. Available at: http://www.census.gov/newsroom/press-re
leases/2014/cb14-202.html. Cited June 1, 2015.
55. Liu V, Musen MA, Chou T. Data breaches of protected health
information in the United States. J Am Med Assoc 2015;313(14):1471–3.
56. Cascardo D. HIPAA investigation risks are increasing: make sure you
avoid the wall of shame. J Med Pract Manage 2014;30(2):119–23.
57. Peterson A. 2015 is Already the Year of the Health-Care Attack—And It's
Only Going to Get Worse. 2015. Available at: https://www.washington
post.com/news/the-switch/wp/2015/03/20/2015-is-already-the-year-of-
the-health-care-hack-and-its-only-going-to-get-worse/. Cited August 9, 2015.
58. Riley C. Insurance giant Anthem Hit by Massive Data Breach. Available at:
http://money.cnn.com/2015/02/04/technology/anthem-insurance-hack-
data-security/. 2015.
59. McGraw D. Building public trust in uses of Health Insurance Portability
and Accountability Act de-identified data. J Am Med Inform Assoc
2013;20(1):29–34.
60. Guidance Regarding Methods for De-identification of Protected
Health Information in Accordance with the Health Insurance
Portability and Accountability Act (HIPAA) Privacy Rule. 2012.
Available at: http://www.hhs.gov/ocr/privacy/hipaa/understanding/covere
dentities/De-identification/hhs_deid_guidance.pdf. Cited August 5, 2015.
68
61. Blumenthal D, McGraw D. Keeping personal health information safe:
the importance of good data hygiene. J Am Med Assoc 2015;313(14):
1424.
62. Yang YT, Silverman RD. Mobile health applications: the patchwork of
legal and liability issues suggests strategies to improve oversight. Health
Aff 2014;33(2):222–7.
63. Cortez NG, Cohen IG, Kesselheim AS. FDA regulation of mobile health
technologies. N Engl J Med 2014;371(4):372–9.
64. Kwon J, Johnson ME. Security practices and regulatory compliance in
the healthcare industry. J Am Med Inform Assoc 2013;20(1):44–51.
65. Cresswell KM, Bates DW, Williams R, et al. Evaluation of
medium-term consequences of implementing commercial computerized
physician order entry and clinical decision support prescribing systems in
two early adopter hospitals. J Am Med Inform Assoc 2014;21(e2):
e194–202.
66. 3 Keys to Improving Privacy & Security Protections for Electronic
Health Information Exchange. 2015. Available at: http://hitconsultant.
net/2015/08/05/protections-for-electronic-health-information-exchanges/.
Cited August 5, 2015.
67. Malin BA, Emam KE, O'Keefe CM. Biomedical data privacy: problems,
perspectives, and recent advances. J Am Med Inform Assoc 2013;20(1):
2–6.
68. Hall JL, McGraw D. For telehealth to succeed, privacy and security risks
must be identified and addressed. Health Aff 2014;33(2):216–21.
69. Caine K, Hanania R. Patients want granular privacy control over health
information in electronic medical records. J Am Med Inform Assoc
2013;20(1):7–15.
70. Kim KK, Joseph JG, Ohno-Machado L. Comparison of consumers'
views on electronic data sharing for healthcare and research. J Am Med
Inform Assoc 2015;22(4):821–30.
From the Regenstrief Institute, Inc. (BWM, WMT), Indiana University
School of Medicine, Indianapolis, Indiana
Submitted June 29, 2015; accepted September 8, 2015.
The authors have no financial or other conflicts of interest to disclose.
Correspondence: William M. Tierney, MD, Regenstrief Institute, Inc.,
1101 West Tenth Street, Indianapolis, IN 46202 (E-mail: wtierney@
regenstrief.org).
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES
VOLUME 351 NUMBER 1 January 2016