Real-World DecisionsHRM350 Version 21University of Phoe.docx

Real-World Decisions
HRM/350 Version 2
1
University of Phoenix Material
Real-World Decisions
Read the following scenarios, which represent real-world
decisions, and respond to each in 150 to 200 words.
Scenario One
You are the director of production at a multinational company.
Your position is in Tokyo, Japan. Recently, this division
experienced production quota problems. You determine that you
must identify a team leader who will lead the work team to
tackle the problem. You identify several possible team leaders,
including Joan, a manager who is an expatriate US citizen and
has recently arrived in your company’s Japanese office. You are
also aware of Bob, a European national who has worked at the
facility for about a year. His experience includes reengineering
production processes at one of the company’s production
facilities in Europe. The final candidate is Noriko, a Japanese
national who has been at the facility for several years.
Questions
The team you assemble is composed of American expatriates
and Japanese nationals. Compare the three candidates for the
position. Based on cultural norms and traditions, what cultural
factors and management styles may benefit or present obstacles
for others on the team? Explain.

Response
Scenario Two
You have been assigned to an overseas position with your
company. The local government of the host country offers gifts
periodically to senior management as a way of thanking them
for opening a facility and employing locals. These gifts include
cash or merchandise into the thousands of dollars. Typically, to
refuse a gift is considered an insult. Your country’s policy is to
prohibit employees from accepting anything from clients and
customers of more than $50. Your employer values its
relationship with the host country and government officials, and
it intends to continue operating in the venue.
Questions
How would you address a situation where you are presented
with a gift of more than $50? Explain your rationale. How could
your actions affect your company? How could your decision
affect your working relationship with your company’s and the
host country’s officials?
Response
Scenario Three
Christine, the leading expert in information technology (IT)
organizational design, works for a large consulting firm and has
been asked to work on a temporary assignment in Saudi Arabia.
One of her firm’s biggest revenue-generating customers is
embarking on an initiative to redesign the IT structure to
improve efficiency and effectiveness, and to align the business
unit’s output with the organization’s strategic objectives. The
customer has read research reports and articles Christine has
published, and the chief executive officer has asked Christine to
handle this project. She is excited about the professional
challenge of the assignment, but she is unsure of adopting

customs and practices in a Muslim country.
Questions
Discuss the ethical considerations for Christine and her
company. What implications must Christine consider when
making her decision? Why? How might Christine’s role as a
female expatriate affect her employer’s response if she passes
on the assignment?
Response

Insights to a Changing World (Volume 2014 Issue 1)
Franklin Publishing Company www.franklinpublishing.net
Does CPOE Increase Patient Safety By Reducing Medical
Errors?
Krista Charles
Lewis College of Business
Marshall University Graduate College
100 Angus E. Peyton Drive
South Charleston, WV 25303
Kent Willis
Alberto Coustasse, DrPH, MD, MBA
Associate Professor

(304) 746-1968
(304) 746-2063 FAX
[email protected]
81
http://www.franklinpublishing.net/
mailto:[email protected]
DOES CPOE INCREASE PATIENT SAFETY BY REDUCING
MEDICAL ERRORS?
ABSTRACT
Computerized Physician Order Entry (CPOE) is a system that
allows physicians to electronically
order patient services. The services that can be ordered, but are
not limited to include:

prescriptions, labs, x-rays, and referrals. Adopting CPOE will
eliminate the use of paper orders
with illegible hand writing. The purpose of this research project
was to examine the cause of
medical errors and to determine if adopting a CPOE system
would be an effective solution to this
problem. The findings of this study suggest that CPOE can
reduce medical errors and adverse
drug events significantly. The Adoption and implementation of
CPOE has been growing in
recent years pushed by financial incentives and potential
penalties of the HITECH Act of 2009.
Some major barriers of adoption and implementation of a CPOE
system has been the high cost
associated with it and older physicians being trapped in old
ways of practicing medicine.
Key words: CPOE, Meaningful Use, HITECH act, Medical
errors, Adverse Drug Events, quality,
patient safety
INTRODUCTION
The Health Information and Technology for Economic and

Clinical Health (HITECH) provision
of the American Recovery and Reinvestment Act of 2009 was
put into place hoping health
information technology would improve patient care, decrease
medical errors, decrease costs, and
advance the health of the population (Bloomrosen et. al., 2011).
Medicare and Medicaid
providers could be eligible to receive incentives once the
standards have been met using a
certified Electronic Health Record (EHR) for Meaningful Use
(MU), (Blumenthal, 2010). The
earlier the adoption the more incentives a medical clinic could
make using an EHR. Medicare
will pay $44,000 and Medicaid will pay $63,750 for the
adoption and implementation of an EHR
after demonstrating Meaningful Use (CMS, 2013). To make sure
a facility is going to receive
incentives 14 core objectives and 5 menu objectives needed to
be met to demonstrate Meaningful
Use (Jha, DesRoches, Kralovec, & Joshi, 2010). If medical
clinics take advantage of the
82

http://content.healthaffairs.org/search?author1=Ashish+K.+Jha
&sortspec=date&submit=Submit
incentives and demonstrate MU the money that is received can
help cover a huge amount of the
cost.
Meaningful Use has been divided into three stages.
Computerized Physician Order Entry
(CPOE) use is involved in the all three stages. In the first stage
CPOE needs to be used with at
least 30% of patients who are eligible. This means that
providers need to use CPOE to order
medication for at least 30% of the patients. The next two stages
would increase that percentage
close to 80% of patients. CPOE use is stressed in stage one as
the thought of preventable medical
errors starts at the moment a provider hand writes a prescription
(Jones, Heaton, Freidberg, &
Schneider, 2011). With the mandate that medical facilities
operate using a CPOE is underway,
by the end of 2011 57% of physicians/doctors have already
reported having an EHR system

(Hsiao, Decker, Hing & Sisk, 2011).
In the United States (U.S) every year approximately 200,000
people die due to
preventable medical errors (Andel, Davidow, Hollander, &
Moreno, 2012). The physician when
ordering services and prescriptions for patients initially starts
most medical errors. Physicians
that write out prescriptions using a paper pad often do not have
legible handwriting and are not
able to be read by a number of important individuals who
process the prescription and prepare it
for the patient. Adverse Drug Events (ADEs) are another cause
of 770,000 patient injuries and or
deaths a year (AHRQ, 2013). If a patient is given a drug that
was not prescribed by the
pharmacist who was not able to read the physicians hand
writing, those patients are at risk for
ADEs. The results from ADEs are patients experiencing
negative reactions to drugs which can
result in extended hospital stays, increased medical costs,
permanent disability, and possibly
death (Du, Goldsmith, Aikin, Encinosa, and Nardinelli, 2012).
A solution to fix the increasing

number of medical errors and ADEs is for hospitals to adopt a
CPOE system. According to
Jones, Heaton, Freidberg, & Schneider (2011), using a CPOE
system will enhance patient safety
and decrease preventable medical errors.
CPOE is a software system that can be utilized in hospitals and
can remove physician
hand written order legibility, remove abbreviations, and
increase order speed by having
physicians electronically order services and prescriptions
(Cucina, 2013). CPOE systems coexist
with Clinical Decision Support Systems (CDSSs) which offer
additional functions for a
providers use. Some functions of CDSSs include drug
interaction checks, drug allergy checks,
and prompts for the provider about when to order a service for a
patient (Kaushal & Bates,
83

2013). Some CDSS’s have been enabled with many different
alerts for the physician to check on
a patient’s health. When there are so many different alerts
popping up physicians can ignore
them, which can be a problem especially if the alert was about a
life-threatening drug that was
prescribed, this is known as alert fatigue. Providing a tailored
system to an individual facility for
the type of patients the facility provides care for or a certain
age group could help minimize the
excess alerts and limit the number of alerts the physicians may
receive (Kesselheim, Cresswell,
Phansalkar, Bates, & Sheikh, 2011).
With the adoption of a CPOE system, the increased number of
preventable medical errors
can decrease considerably. Unfortunately, less than 10% of
hospitals have adopted a CPOE
system (Altuwaijri, Bahanshal, & Almehaid, 2011). Some
barriers for implementing CPOE have
been the significant cost to hospitals and small practices that
cannot afford an EHR system and
the concerns that CPOE could reduce medical errors and ADEs.
At Brigham and Women’s

Hospital, $11.8 million dollars was spent to cover the cost of
adoption and implementation of a
CPOE system. This is a large cost for any facility yet the CPOE
system saved the hospital over
$28 million dollars (Kaushal et. al., 2006). The size of a health
care facility is not the only factor
to consider when looking at the adoption rate. Geographic areas,
private or public regulation,
teaching hospitals, are all factors to consider with adoption
rates. Hospitals that have a higher
bed capacity are more likely than smaller hospitals to adopt,
this is due to the insufficient funds
smaller hospitals have (Furukawa, Raghu, Spaulding, & Vinze,
2006). In an effort to help with
the costs of the CPOE system implementation, incentives have
been given out by the
Government to facilities that adopt an EHR (GEC, 2009). On
the other hand facilities that do not
comply with MU and adopt a CPOE system will receive
penalties by the Government which will
result in lower reimbursements (Harrison & Lyerla, 2012).
Starting in 2015, one percent
penalties will go into effect by the Recovery Act (DHHS, 2011).
The percentage will then

increase in 2016 and in 2017 where it will stay at a five percent
penalty (GEC, 2009).
The purpose of this research project was to examine the cause
of medical errors and to
determine if adopting a CPOE system would be an effective
solution to this problem.
84
METHODOLOGY
The methodology for this study was a literature and case studies
review. The electronic databases
of Academic Search Premier, ProQuest, Science Direct,
PubMed, EBSCOhost and Google
Scholar, were searched for the terms ‘CPOE’, OR
‘Computerized Physician Order Entry’, OR
‘Meaningful Use’, OR, ‘Electronic Prescribing’ AND ‘Medical
Errors’ OR ‘ADEs’, OR

‘Adoption’, OR ‘Implementation’. Reputable websites from the
AHRQ, Health Affairs, and
CMS were also used. Additionally, citations and abstracts
identified by the search were assessed
in order to identify relevant articles.
Attempting to stay current in research, only articles published
from 2002-2013 were
included in the review process. The search was limited to
sources attainable as full texts, and
those written in the English language. Original articles and
research studies including primary
and secondary data were included. The methodology and results
of the identified texts were
analyzed and key papers were identified and included within the
research query. Thirty
references were used for this study, nine of which were utilized
in the results. In addition, a semi-
structured interview with the Chief Information Officer (CIO)
or as referred in the rest of the
text, as Expert of CPOE systems in a hospital setting was added
to the data collected (Appendix
A). This Expert will be referred to as Expert in CPOE Systems
within this study. The interview

was recorded, and only relevant and pertinent answers were
used to support the information
found in the literature review.
The use of the conceptual framework by Queenan et. al. in the
current study is
appropriate as the focus is on prevention, failure detection, and
appraisal of CPOE systems.
Figure 1 depicts three uses for CPOE. CPOE is used for
prevention by having alerts in the event
of a medication interaction that could harm the patient. With the
difficulty of providers ordering
tests not knowing the patient just received the same test
recently, CPOE can check a patients past
history of tests given. Next is the use for failure detection, since
CPOE is electronic, there exists
a capability to track documentation of patients charts and prior
test results. Lastly, is the use for
appraisal; CPOE can check for dosing recommendations,
preventive care eligibility and can
check to see if a test ordered would give them positive results
(Queenen et. al., 2011).
85

Figure 1
Source: Queenan et. al. (2011)
Figure 1. Prevention–Appraisal–Failure Conceptual Framework
Model in the Context of CPOE
Use.
RESULTS
Benefits of CPOE Adoption
Adopting and implementing a CPOE system has a number of
benefits. Most importantly
are the benefits the patient will gain from going to a facility
that has made the transition from
paper to electronic charts.
A medical group experienced a 70% reduction in medical errors
when electronic prescribing was

implemented Devine et. al. (2010). Within the same study, many
benefits were noted for an
independent medical group. Some of the benefits included were
a decrease in patient paper
charts, improvements in accessible patient information,
additional coordination of care, reduction
in prescription ordering by the physician, and by having total
support by the organization helped
the process of implementing the new system.
86
The Expert in CPOE Systems mentioned that one of the biggest
benefits to adoption at
the hospital he is employed with was the turnaround time.
Providers are able to utilize
electronically order entry of a service for the patient, thus
resulting in faster patient care. An
additional benefit the hospital experienced is instant access to
patient’s previous medical history.

CPOE Use for Prevention
CPOE systems can be tailored to individual healthcare
facilities. Once an organization
identifies its main problem, whether it is with a certain age
group of patients or increased
medical errors during a certain procedure, the facility can adopt
a system within CPOE to help
decrease the errors. In 2004, a study was performed on a
Massachusetts medical center that was
experiencing problems with potentially inappropriate
medication with older patients.
Programmers were able to develop a program within CPOE that
would alert physicians once a
patient’s medication order would be placed (Mattison, Afonso,
Ngo, & Mukamal, 2010). The
same authors explain that the study was performed and tracked
before and after the new system
was embedded into their CPOE system. The researchers
demonstrated the alert system prevented
numerous potentially inappropriate medication orders to their
older patients. In addition, the use
for CPOE to prevent medical errors was found to be successful
at that medical facility in
Massachusetts (Mattison, Afonso, Ngo, & Mukamal, 2010).

CPOE Use for Appraisal
A CPOE system has many capabilities for providers. The
initial stage of a medication
error begins when a provider prescribes the patient medication
(Riedmann et al., 2011).
Implementing a CPOE system can help clinicians and physicians
have a check and balance
system. Doolan & Bates (2002) reported; CPOE coupled with a
CDSS can check for all drug
interactions and for the recommended doses for patients with
limited organ function. The authors
stated, the technology can reduce medical errors and ensure
appropriate tests are ordered while
alerting the provider when a duplicate test has been ordered.
Further, it was reported, CPOE can
allow users to utilize drug references and provide specific drug
recommendations for a patient.
87

CPOE Use for Failure Detection
In 2004, eight billion dollars was estimated to be wasted on
duplicate tests for a patient
(Jha, Chan, Ridgway, Franz, & Bates, 2009). Often time’s
patients who go to the doctor
excessively might not remember what tests were performed
from one doctor’s visit to the next.
One of many perks to implementing a CPOE system is the
rewards it can offer for the patient and
hospital by reducing the extra healthcare costs. Using a CPOE
system, the ordering physician has
instant access to a patients’ electronic health record, including
testing and the results of those
tests (Callen, Westbrook, & Braithwaite, 2006).
Within a CPOE system interruptive or non-interruptive “pop
ups” can be installed to
decrease unnecessary testing. The same authors stated that “pop
ups” can allow a physician to
know when a test has been selected and if that patient has

previously had the test performed or
not. The interruptive “pop ups” can halt the physician from
going any further in the ordering
process, and the non-interruptive “pop ups” inform the
physician but does not interfere with
ordering tests (Baron & Dighe, 2011).
Barriers of CPOE Adoption
Barriers to implement CPOE systems begin with cost. CPOE
systems are costly and the
cost threatens small clinics while sufficient funds to adopt are
not available. Another barrier to
implementation is the limited function of a basic CPOE system.
If the standard CPOE system is
adopted and does not have any added features, for example, for
increased medical error
reduction, then this can become another barrier for the facility.
With additional features of an
integrated system, medical errors can be reduced more
effectively.
According to the Expert in CPOE Systems another barrier to
the implementation of a
CPOE system is the hesitation by physicians to adopt because

all they have known their entire
medical career is how to use paper charts which has worked for
so many decades, why would
they want to learn a whole new way of charting electronically
now. One concern physicians do
have is on patient satisfaction. If the doctor goes into a patient
room then they think that patients
will not be satisfied by the loss of eye contact, decreased
opportunity for psychosocial
communication, and less sensitivity to the patient from missed
nonverbal cues. This was
88
measured by rating patient satisfaction before and after the
implementation of a CPOE. The
overall results illustrate there was no significant decrease in
patient satisfaction (Irani,
Middleton, Marfatia, Omana, & D’Amico, 2009).
One of the purposes of going electronic was the ability of

providers to have easy access
to a patient’s medical record; also the speedy access of records
was a benefit. Physicians have
the ability to be at home or another office and have access to a
patient’s past visit with for
example, a specialist. Unfortunately, some systems have a lack
of interoperability with other
systems hindering the physician ability to access to a patient’s
medical record (Yaffee, 2011). If
a physician cannot access needed information it defeats the
purpose of having the system.
A few studies have shown that implementing a CPOE system
can do more harm than
good. It is important for all health care personnel to have in
depth knowledge of what a CPOE
system can offer. A way to get that knowledge is researching
and reading studies on the subject.
If there are not many studies on the topic then those individuals
will not have all the knowledge
required to make an educated decision about adopting a CPOE
system.
. If CPOE is going to be effective then other systems need to be
integrated into it. As reported
earlier one of those systems could be the CDSS’s. Additionally,

pharmacy and EHR systems can
impact medical error reduction (Aartz & Koppel, 2009). While
there are few barriers to adopt
and implement CPOE none of the ones reported are significant
enough to change the facilities
decision about implementing such a system.
DISCUSSION
The purpose of this research was to examine implementing a
CPOE system in medical facilities
to reduce the number of medical errors and ADEs. The results
of the literature and case studies
review and the interview with an Expert in CPOE Systems have
demonstrated, implementing a
CPOE has positive effects on the number of preventable medical
errors. This literature review
supports the adoption and implementation of CPOE in most
healthcare facilities.
While preventable medical errors and ADEs continue to
increase, it is important for
healthcare facilities to implement a CPOE system for the
clinical staff and providers to utilize. A

CPOE system with CDSS capability can be used to diminish
individual facilities’ preventable
89
medical error rates and this is proven by this literature review.
CPOE is seen as a significant
technology to enhance patient safety (Aarts & Koppel, 2009).
CPOE has been around since the
1970s, yet only recently has it become more popular and found
to be very effective in healthcare
facilities. With the recent mandate of EHR and all the
incentives and penalizations a facility can
receive CPOE is gaining popularity every day while as facilities
try to demonstrate MU.
This literature review was limited due to the restrictions in the
search strategy used, such
as the number of databases accessed, and publication and
researcher bias may have affected the
availability and quality of the research identified during the
examination. Future research should

address the cost effectiveness, Return over the Investment
(ROI) and effectiveness of CPOE
systems. The adoption and implementation process can take a
very long time. Extensive studies
need to be done to make sure the most effective system for the
individual organization is
adopted. Training needs to be available for all authorized
personnel using the system, as well as,
technical support needs to be accessible at all hours of the day
(Crosson et. al., 2011). Hospitals
are open twenty-four hours a day and seven days a week and
hospital employees need to be able
to contact technical support in the event of a system error or
malfunction. Once all employees are
trained and ready for the change from paper to electronic forms
of charting the transition process
should run a lot smoother.
CONCLUSION
CPOE has been demonstrated to have a vast ability to improve
the overall healthcare system in
the U.S. This literature review has indicated that adoption of
CPOE in hospitals and medical

clinics have significantly decreased medical errors and ADEs
among the population.
90
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entry warning system. Archives of Internal Medicine, 170(15),
1331-1336.
Queenan, C.C., Angst, C. M., and Devaraj, S. (2011). Doctors’
orders–If they’re electronic, do
they improve patient satisfaction? A complements/substitutes
perspective. Journal of Operations
Management, 29(7-8), 639-649.
Riedmann, D., Jung, M., Hackl, W. O., Stuhlinger, W., Van Der
Sijs, H. and Ammenwerth, E.

(2011). Development of a context model to prioritize drug
safety alerts in CPOE systems.
Medical Informatics and Decison Making, 11(35).
Yaffee, A. (2011). Financing the Pulp to Digital Phenomenon.
Journal of Health & Biomedical
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94
http://www.ahrq.gov/clinic/ptsafety/chap6.htm
APPENDIX A
Questions asked in semi-structured interview of an Expert of
CPOE systems on April 25, 2013
• How is CPOE related to EHR and EMR?
• Has CPOE reduced medical errors at CHH? How?
• How much did the CPOE system cost here? Ball park figure?

• What have been the barriers to adoption so far?
• What has been the main challenge to adoption?
• What has been the biggest benefit to CPOE adoption?
• When did you adopt CPOE, how long did it take to train
physicians?
95
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property of Franklin Publishing
Company and its content may not be copied or emailed to
multiple sites or posted to a listserv
without the copyright holder's express written permission.
However, users may print,
download, or email articles for individual use.
Use of Electronic Technologies to Promote Community and
Personal
Health for Individuals Unconnected to Health Care Systems
Ensuring health care ser-

vices for populations outside
the mainstream health care
system is challenging for all
providers. But developing
the health care infrastructure
to better serve such uncon-
nected individuals is critical
to their health care status, to
third-party payers, to overall
cost savings in public health,
and to reducing health dis-
parities.
Our increasingly sophisti-
cated electronic technolo-
gies offer promising ways to
more effectively engage this
difficult to reach group and
increase its access to health

care resources. This process
requires developing not only
newer technologies but also
collaboration between com-
munity leaders and health
care providers to bring un-
connected individuals into
formal health care systems.
We present three strate-
gies to reach vulnerable
groups, outline benefits and
challenges, and provide
examples of successful
programs. (Am J Public
Health. 2011;101:1163–1167.
d o i : 1 0. 21 0 5/ A J P H . 2 0 10 .
30 0 00 3 )
John F. Crilly, PhD, MPH, MSW, Robert H. Keefe, ACSW,

PhD, and Fred Volpe, MPA
DURING THE PAST DECADE,
the United States has experien-
ced a rapid growth of electronic
health information technology in
hospital and health care provider
systems to enhance access and
quality for service recipients. State
health departments have devel-
oped health information ex-
changes across large health care
networks, insurance providers,
and independent physician prac-
tices, and the use of electronic
health records has greatly accel-
erated.1 These initiatives evince
progress toward achieving a fully
connected national health care
system by 2014.2
Nevertheless, cities and
counties struggle to understand
the health care needs of individ-
uals who do not or cannot easily
access formal health care net-
works but use expensive services
for emergency and routine care.
Health information technology is
currently designed to benefit pri-
marily populations already con-
nected to such systems. As systems
increase their use of health data to
influence treatment and policy,
developing strategies to include

individuals who are largely out-
side health care networks is criti-
cal.
The US health care system has
been criticized for low-quality care
that produces multiple medical
errors3,4 and high-cost services
that limit access to care,5 perpetu-
ating health disparities. Primary
care focused on preventing illness
and death is associated with more
equitable distribution of health
and better outcomes than is spe-
cialty care6---8; countries directing
resources to primary care and
enhancing population health have
lower costs and superior out-
comes.9 Although the United
States has the world’s most ex-
pensive health care system, other
countries regularly surpass the
United States on most health in-
dicators, including quality, access,
efficiency, equity, and healthy
lives.10 Capturing data on individ-
uals unconnected to health care
systems can improve health care
access and outcomes while reduc-
ing costs––important public health
goals.
The federal government allows
states and local communities to
develop their own health care in-

frastructures. By making changes
at the local level, communities can
become more effective in using
existing services to capture health
care data for hard to reach pop-
ulations. We have examined sev-
eral strategies for using existing
electronic technologies to better
connect such individuals to some
aspect of their local health care
system.
THE PROBLEM OF HEALTH
CARE ACCESS AND
POSSIBLE RESPONSES
Converging social problems
(e.g., geographic isolation, limited
education, poor health, poverty,
and the marginalization of vul-
nerable groups including people of
color and the rural poor) inhibit
certain individuals’ access to
health care services.5 People who
have the poorest health tend to
receive the least health care, and
those with limited health options
because of inadequate insurance
or unavailable providers often use
high-cost services, such as urgent
care and emergency rooms, which
may not be appropriate to their
needs. This problem is significant:
nearly 75 million adults––42% of
the population younger than 65

years––had either no or inade-
quate insurance in 2007.11 Lack of
consistent, documented contact
impedes the accumulation of
meaningful health data for health
care planning and intervention
development. Uninsured or un-
derinsured groups are at risk for
remaining isolated despite health
care reform.
Although few health care ser-
vice data may be collected from
these groups, there are other ways
to track service use. Data from
contacts with other community-
based, nonhealth services can be
employed to target specific com-
munity health needs. For example,
some groups without regular
health care may have contact with
departments of social services,
criminal justice, specialty courts
(e.g., drug, mental health, veterans,
and family), or schools. Data
extracted from these systems, us-
ing secure data transfer protocols
already developed by health in-
formation exchanges, could help
address and evaluate the health
and service needs of these groups.
These data can then be used to
develop and strategically imple-
ment novel health-promotion and
grassroots interventions.

Similar approaches have been
applied to track or monitor clinical
intervention outcomes,12,13 clinical
trials,14 adherence to specific
COMMENTARY
July 2011, Vol 101, No. 7 | American Journal of Public Health
Crilly et al. | Peer Reviewed | Commentary | 1163
interventions,15,16 and infections.17
Broader cross-systems data-use
collaborations between commu-
nity and health care providers to
increase care among uncon-
nected groups have also been
successful.18---21 Clinical trials of
cross-program multidisciplinary
interventions have reduced such
health-related stressors as high
blood pressure and cardiac
problems among poor families,22,23
disseminated HIV prevention
programs in African American
communities,24 delivered inner-
city tuberculosis prevention
efforts,25 and decreased negative
birth outcomes among low-
income African Americans.26
Initiatives derived from these
concepts are already under way in

some communities. The Partnership
for Results in Auburn, New York
(http://www.partnershipforresults.
org), developed a cross-systems data
access and sharing collaboration
around children at risk for school
violence. San Francisco Children’s
System of Care (http://nccc.
georgetown.edu/documents/
ppsanfran.pdf) developed and
expanded their collaboration to
collect individual-level data on
youth across a series of systems,
including schools and probation,
to target and evaluate novel in-
terventions.
Access to health-related infor-
mation and health promotion has
expanded with the growth of the
Internet,27,28 particularly in the
mental health field, which is rap-
idly developing online versions of
actual treatment.29 No-cost per-
sonal health records are available
online, allowing individuals to
bank and control their own health
data. Broadband Internet access
and mobile wireless are available
in all urban and most nonurban
areas, offering new opportunities
to reach individuals outside health
care networks.
TECHNOLOGY TO REDUCE
BARRIERS TO HEALTH

CARE
Developing cohesive, commu-
nity-based strategies for using
health information technology and
electronic communication tech-
nologies optimally is critical to
dismantle barriers to health care
and health information.4 To help
communities reduce such impedi-
ments, we propose several strate-
gies.
Communities: Collaborations
for Health-Focused Use of
Community-Based Data
Individual-level data exist in
public and private agencies and
institutions (e.g., social services,
criminal justice, colleges, and trade
schools). These data are confiden-
tial and protected and typically
include personal identifiers and
service use history. Because of
their size and scope, these systems
have a similar database infra-
structure and often contain data
on the same individual. Collective
data from these systems could
help drive new forms of commu-
nity-wide health promotion and
service delivery. To build such
systems, three tasks are essential.

Task 1: Engaging the community.
It is essential to understand a
community’s political geography
and to identify entities that will
form the infrastructure to facilitate
and coordinate the use of data
from extant systems for that com-
munity to use. Choosing key
leaders from potential participat-
ing agencies that will form the
collaborative should be according
to their willingness, influence, and
ability to collaborate and properly
use centralized data. The collabo-
rative can then team with broader
health-focused organizations, such
as local health departments in
urban areas and offices of rural
health in state health departments,
to build the initial support base
and vision.
Task 2: Developing a plan. Once
formed, members of a collabora-
tive must develop an action plan.
A critical component is an assess-
ment of the content of all partici-
pating data systems. The plan may
involve building a comprehensive
data dictionary of potential data
fields applicable to health-related
risk. A feasible system must be
relatively simple, low cost, risk
controlled, time efficient, and

beneficial for participating
agencies. A key collaborator in this
task is a regional health informa-
tion exchange, which can assist in
providing a secure information
exchange environment. Particu-
larly important are the consent
and data security processes30 and
the development of effective data
use agreements that limit liability
regarding the unintended use of
data.31
Task 3: Forming a collaborative.
Building a collaborative to drive
this process and use the data re-
quires input from various experts,
including researchers, program
developers, and trainers, who can
introduce fresh ideas regarding
program development, care deliv-
ery, and outcomes tracking and
measurement. Indicators of the
success of the initiatives may in-
clude fewer missed days of work
or school, decreased emergency
room visits, and better communi-
cation among multiple health care
systems. Ideally, the collabora-
tive’s leadership should be based
at local public health departments
because of their community-wide
scope.
Veterans returning from over-
seas could serve as a test case for

how such a system might work.
Despite available care, many vet-
erans do not connect with the
Veterans Affairs health care
system and struggle for long pe-
riods with adjustment problems
affecting their physical and mental
health. Identifying points of entry
into community systems such as
schools or social services may help
these systems better meet the
needs of veterans with high-risk
burdens but only minimal in-
volvement with health or mental
health services. The Veterans Af-
fairs health care system has al-
ready obtained much information
that may be used to improve
returning veterans’ quality of
care.32,33
Health Care Systems:
Reaching Out Through
Electronic Means
Although the Internet can serve
as a conduit for reaching geo-
graphically and socially isolated
individuals, understanding its cur-
rent usability and limits is neces-
sary for effective planning. Inter-
net access occurs through (faster)
broadband or (slower) dial-up

depending on geography.34 Some
areas have no access at all; some
households choose not to use the
Internet (Table 1).
The Internet is the primary way
most users (67%) obtain health
care information,36 but only 63%
of US households have an Internet
connection. Urban areas have
greater broadband access than do
nonurban areas, which typically
have more dial-up connections.
Whites use computers to connect
to the Internet more often than do
African Americans (59% and
45%, respectively), but more Af-
rican Americans (48%) use mobile
wireless devices than does the
general population (32%).28
Wireless handheld devices are
better options for contact in rural
areas because signal delivery is
more flexible, although gaps per-
sist as the result of terrain or
geography. Consequently, reaching
COMMENTARY
1164 | Commentary | Peer Reviewed | Crilly et al. American
Journal of Public Health | July 2011, Vol 101, No. 7
individuals electronically may re-

quire a multifaceted approach.
Health-related Web sites pro-
vide information on specific med-
ical diagnoses (e.g., diabetes), gen-
eral medical guidance (e.g., http://
www.WebMD.com), access to
medical literature (e.g., http://
www.PubMed.com), and treat-
ment options for mental health
conditions.29 Sites such as http://
www.patientslikeme.com allow
individuals to report their symp-
toms and evaluations of medica-
tions or treatments.37 Message
dissemination technology can now
rapidly access targeted groups in
communities for specific safety or
health purposes.38 Twitter tech-
nology is increasingly used in pri-
vate industry39 and is gaining ac-
ceptance in medical settings.40
Effective use of these technolo-
gies by health care systems can
increase their range to reach un-
connected individuals. Handheld
devices can receive brief an-
nouncements, appointment re-
minders, or health tips. Wellness
webs (composed of individuals
with similar health-related needs
who are connected electronically
to enhance their ability to work
together and better meet their
health goals) targeting individuals

to receive messages according to
need or interest can be built
through collaborations among
community agencies, insurance
companies, and providers. These
technologies may also facilitate
connection with African Ameri-
cans and Hispanics. Technology
alone cannot alleviate disparities
in health care access, but a na-
tional study finds that although
people with higher incomes use
the Internet more for their health
records, people with lower in-
comes and people without college
degrees are likely to benefit more
from having their health informa-
tion online.36 Connection fosters
more regular, better coordinated
care, with improved outcomes.
Individuals: Building and
Maintaining Personal Health
Records
Many health care systems and
insurance companies offer public
health records (PHRs) to help pa-
tients coordinate their care and
keep in touch with their providers.
PHRs allow patients to view parts
of their own health record (e.g., lab
results, medication history), input

data (e.g., weight, blood pressure),
and schedule appointments. In-
surance companies are the pri-
mary providers of PHRs (51%),
followed by health care providers
(26%), but other health-related
organizations offer PHRs to mem-
bers (e.g., the American Heart
Association).36
Recently, both Google (Google
Health) and Microsoft (HealthVault)
introduced publicly available,
Internet-based PHRs at no cost.
Although these providers pledge
that PHR data will be secure and
not exploited for advertising or
other commercial purposes, users’
trust must be developed. Only
25% of potential users report
a willingness to use a PHR from
a private corporation.36 Despite
these concerns, PHR options have
considerable value. PHRs contain
functions that can import data
over the Internet directly from
specific health devices (e.g., blood
pressure monitors, weight scales,
blood glucose tests) plugged into
computers or handheld devices.
Both Google and Microsoft prod-
ucts allow individuals to designate
specific entities for data sharing.
With this feature alone, commu-
nities can implement and monitor

targeted health-promotion pro-
jects and measure progress and
outcomes from self-reported data
through a central location that
links participants. As individuals
join health care systems, become
insured, or relocate, they can ex-
port and import data to electronic
health records and back into PHRs
no matter where they receive care.
MOVING FORWARD
Although they do pose some
risks, using electronic technologies
to improve conventional health
services offers opportunities to
reduce health disparities. It is in-
structive to examine successful
community programs and imper-
ative to continue assessing how
best to harness these technologies
to advance public health goals
without compromising privacy
or security. Researchers should
conduct rigorous reviews of the
literature to identify promising
programs and recommend appro-
priate policies and safeguards.
Developing new avenues of
communication with various
health care systems has already
helped unconnected individuals
access health care in some regions.

Through strategic collaborations
using established technologies, or-
ganizations such as participants in
the Substance Abuse and Mental
Health Services Administration’s
Drug Free Communities program
have been successful, including
incorporating accountability mea-
sures. One program in Florida
(http://www.onevoiceforvolusia.
org/data.htm) has included in its
mission promoting cross-system
data-gathering capabilities to ad-
dress high-risk groups. Inclusive
consensus building and commu-
nity action planning approaches
have produced successful systems-
level interventions in several US
cities and counties,41---43 enabling
vulnerable groups to take charge
of their health information.44 Such
initiatives not only create alterna-
tive access but also have important
policy implications aligned with
Healthy People 2020 objectives.45
TABLE 1—US Internet Connection Types and Use by Region:
October 2007
South (n = 43 370) Midwest (n = 26 714) West (n = 26 203)
Northeast (n = 21 553)
Urban
(n = 32 510), No. (%)

Nonurban
(n = 10 861), No. (%)
Urban
(n = 20 461), No. (%)
Nonurban
(n = 6253), No. (%)
Urban
(n = 23 322), No. (%)
Nonurban
(n = 2882), No. (%)
Metro
(n = 18 154), No. (%)
Nonurban
(n = 3399), No. (%)
Dial-up 2872 (8.8) 1976 (18.2) 1752 (8.6) 1374 (22.0) 2093
(9.0) 531 (18.4) 1345 (7.4) 632 (18.6)
Broadband 16 772 (51.6) 3682 (33.9) 10 689 (52.2) 2379 (38.0)
13 227 (56.7) 1376 (47.7) 10 088 (55.6) 1635 (48.1)
No use 9704 (29.9) 4073 (37.5) 5693 (27.8) 1776 (28.4) 5883
(25.2) 724 (25.1) 5421 (29.9) 859 (25.3)

Overall use 19 740 (60.7) 5677 (52.3) 12 494 (61.1) 3764 (60.2)
15 390 (66.0) 1918 (66.6) 11 450 (63.1) 2287 (67.3)
Source. Data from the US Census Bureau, Current Population
Survey, Internet Supplement, October 2007.35
COMMENTARY
For example, health policy deci-
sions are generally derived from
medical data from health care
systems and insurance compa-
nies.46 Using these data as the
primary source can invite the ap-
pearance of full knowledge when
the data actually represent only
individuals connected to the sys-
tem; excluding the unconnected
generates an incomplete picture
that can perpetuate disparities in
access and outcomes.
The new federal health reform
legislation is already promoting
creative changes by increasing
funds for community health
centers to boost the number of
treated patients.47 Under this
legislation, millions of Americans
will gain access to care previously

unavailable to them. There is an
urgent need to effectively handle
this expected rapid growth. Shift-
ing greater focus, responsibility,
and control to the local commu-
nity constitutes one encouraging
approach. For example, collabo-
ration to better distribute care
may prompt more efficacious
distribution of health care fund-
ing. At the time of this study,
health care dollars flowed directly
to formal providers as reim-
bursement for services rendered.
The distribution of funds depends
entirely on the delivery structure
of those entities, not the broader
needs of the community. Without
appropriate strategies and infra-
structure, communities will have
little power to create meaningful,
effective partnerships with health
care systems to assist their mem-
bers in need.
Obviously, the challenges, limi-
tations, and risks of using these
technologies must be understood
and continuously evaluated. New
applications for health-related
purposes raise many security and
privacy concerns that require the
attention of consumer health
advocates and health policy ana-
lysts. Although the Internet re-

mains the largest venue for access-
ing health-related information and
health-monitoring tools, it is neither
ubiquitous nor a panacea.
Electronic technologies must
be more broadly and effectively
implemented to realize their po-
tential to improve health out-
comes for vulnerable populations,
lower costs, and reduce health
disparities. To advance this
promising application, we need to
devote more attention to devel-
oping creative approaches to help
people access appropriate re-
sources, devising better safe-
guards, measuring effects and
evaluating programs, and sharing
information about programs that
are working. But by exploring
how to use technology to reach
unconnected individuals, com-
munity systems and health care
providers can begin to address
the problem––and enhance the
coordination of health care for
millions of Americans. j
About the Authors
At the time of this study, John F. Crilly
was with the Department of Psychiatry,
University of Rochester Medical Center,
Rochester, NY, and the US Department of
Veterans Affairs, Canandaigua, NY. Robert
H. Keefe is with the School of Social

Work, State University of New York,
Buffalo. Fred Volpe is with the Drug Free
Communities Program, Substance
Abuse and Mental Health Services
Administration, Leesburg, VA.
Correspondence should be sent to Robert
H. Keefe, PhD, ACSW, Associate Professor,
School of Social Work, 685 Baldy Hall,
University at Buffalo, State University of New
York, Buffalo, NY 14260-1050 (e-mail:
[email protected]). Reprints can be
ordered at http://www.ajph.org by clicking
the ‘‘Reprints/Eprints’’ link.
This commentary was accepted August
11, 2010.
Contributors
J. F. Crilly conceptualized the article and
led the writing of the initial draft. R. H.
Keefe edited the initial draft, aided in
writing, and led the revisions. F. Volpe
outlined the strategies and provided
examples of programs that have shown
some success.
Acknowledgments
The authors acknowledge Diana J. Biro,
PhD, for her assistance editing the article.
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Ann Intern Med. 2004;141(12):938---
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33. Evans DC, Nichol WP, Perlin JB.
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cessed June 11, 2010.
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04/consumers-and-health-information-
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37. Frost JH, Massagli MP. Social uses
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3454651.html?mod = WSJ_hpp_sections_
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COMMENTARY
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“Competencies for Nurse Informaticists”
Program Transcript
[MUSIC PLAYING]
PATRICIA BUTTON: You know, in terms of the competencies
of nurse
informaticians, there's really been a lot of really excellent work
done in the past 5
to 10 years, both from the ANA, the American Nurses
Association, and the
TIGER Initiative. And really outlining what are the key
competencies. And I think
just an overarching statement about the competencies of
informaticians is-- being
an informatician is not knowing how to use PowerPoint.
I mean, it's not being computer literate. That certainly is part of
it. Much more
important is really having an appreciation of the management of
data,
information, knowledge, from all the different perspectives of

how those provide
value in the delivery of care.
I would really encourage you to look at the competencies that
the ANA and
TIGER have sort of keyed in on. And I think what it will really
do is help you
understand that yes, you need to be computer literate. You need
to know how to
use a whole variety of applications.
But it's really in the name of understanding what infrastructure
is available
technically to support the use of these systems in a very
productive and impactful
way. And in order to do that, there is a whole other layer of
competencies in
terms of defining use cases, understanding requirements,
definitions,
understanding how to structure content to make it quote,
"computable," ie, that it
can be used in a computer system and support the collection of
data. So I mean,
there really are layers or categories of competencies, again, that
both ANA and
TIGER have done a fantastic job of outlining.
The skills that serve me very well in this role are understanding
what is
technically necessary to actually embed content in the software
workflow in a
way that that will be available sort of at the right time in the
clinical process to
really impact what clinicians are doing. There's that piece of it.
There's very much
understanding, and this really is an informatics competency,

what is evidence-
based content.
It's not what five people sit around a table and say, oh, I think
we should do it this
way. I think we should do it that way. It's really understanding
the role of research
in looking at the relationship between interventions or orders
and patient and
family outcomes.
ROY SIMPSON: Let's review competencies. First of all, we
must remember that
competencies are defined professionally by a professional
organization. And a
© 2012 Laureate Education, Inc. 1

professional organization takes in information from other
organizations in order to
apply certification to those competencies.
So when we look at the American Nurses Association
competencies for staff
nurse or nurse informatician, we begin to see, if we choose it as
a specialty, that
it has key characteristics associated with it, for instance, in
understanding of
databases, how databases are structured, do you understand the
scope of
practice, what are the characteristics of the scope of practice for
a nurse
informatician. Ethics is clearly a component of a nurse
informatician certification.
So we begin to look at those competencies to be established.
When we look at an organization like TIGER, TIGER is not an
organization. It is a
501(c) foundation. And it supports the dissemination of
information to get out to
professional organizations some of the components that need to
be in the
standard. So we look to our professional organizations to
establish our
competency, but we look to multiple organizations to feed into
the profession to
help us establish our competencies.

One of the things that I think sometimes we get confused in
competencies and
informaticians is that we lose sight of the fact that you need to
have nurse
competencies, that you need to understand nursing data. You
can chart all day
sometimes and never put in any information that's about nursing
and the patient's
well being to be able to impact with nursing care. So we need to
be aware that
nursing data, on a lot of competency evaluations, that's where
most people will
fall behind because they see themselves more in a project
implementer, that they
know project planning, which is not centric to a nurse
informatician.
It's not core to their unique knowledge. It's part of their
knowledge, but it's not
core to their individual knowledge. We shouldn't get confused
that someone who
does project management or rolls out an implementation
program is a nurse
informatician. That to be a nurse informatician, you're
competent in the nursing
knowledge that's needed to be assigned to that profession and
that scope of
practice.
What competencies do, I believe, are key in being a vice
president of nursing for
a large HIT vendor or a software developer, ie, which is Cerner
Corporation. I
think there are a couple. Number one is to know what is and
what is not nursing.
And I think many times there is a lot of gray areas about what is

and what is not
nursing.
The second thing is to understand the competencies associated
with the
profession. What does the profession expect for this type of
practice? I think
those are key. I think there are nontangible components.
One of them is how to work in a matrix structure. I think a lot
of times, so many
people are used to line operations. I have 127 people reporting
to me. I have 260

people. And in a matrix structure, you're not about how many
people report to
you, but how many people can you work with to get across a
certain concept or a
certain type of driver that needs to happen within the
organization for culture.
Those are really key components.
I think the other thing is that you have to be above reproach. I
think that is a key
component for anyone in executive leadership. You have to be a
part of the
discipline, and you have to be knowledgeable of the discipline.
And keeping up with the discipline means you go to school
forever. And it's
important to understand life-long learning, especially as an
informatician.
Because we know the data's going to change. We know the
professions are
going to change. So we need to be aware of that.
Another key component of competency, besides just knowing
the scope of
practice and licensure requirements and copyrights and
infringements and
trademarks and all of those things, is to understand that you're
always
representing your corporation. No matter where you are, 24
hours a day, seven
days a week. When you're out and about, you have no other
choice but to be on
good behavior.

And it's important because I think a lot of people think that you
can just separate
your job from your personal life and all the other things and
with technology, it's
kind of voided. I mean, people have Facebooks. When we
interview people
today, we go and check their Facebook. We pull their credit
ratings. There's a
whole different host of things today that technology has done
that bring your
personal life into you as a person when you're hired in a
corporation. And I think
that's really key as a competency is to be mindful of what your
impression is
upon those that you work with.
And I think the other thing that is really key is to understand
the roles that people
have in your organization. That they may not be reporting to
you, but you have a
responsibility in the corporation to make sure that the work is
being done.
However you decide to get it done, you have to make sure it
gets done. And I
think that's a real group process skill. And I think that's
different than initial hire.
And of course, you have to know your products. You have to
your products
backwards and forwards. You have to know what they're going
to do, where
they're going to go.
And I think one of the other key components is vision. You
have to have a vision

for where you're going to take whatever you're doing and drive.
You can't have
change without a vision.
Use of Electronic Technologies to Promote Community and
Personal
Health for Individuals Unconnected to Health Care Systems
Ensuring health care ser-
vices for populations outside
the mainstream health care
system is challenging for all
providers. But developing
the health care infrastructure
to better serve such uncon-
nected individuals is critical
to their health care status, to
third-party payers, to overall
cost savings in public health,
and to reducing health dis-

parities.
Our increasingly sophisti-
cated electronic technolo-
gies offer promising ways to
more effectively engage this
difficult to reach group and
increase its access to health
care resources. This process
requires developing not only
newer technologies but also
collaboration between com-
munity leaders and health
care providers to bring un-
connected individuals into
formal health care systems.
We present three strate-
gies to reach vulnerable
groups, outline benefits and

challenges, and provide
examples of successful
programs. (Am J Public
Health. 2011;101:1163–1167.
d o i : 1 0. 21 0 5/ A J P H . 2 0 10 .
30 0 00 3 )
John F. Crilly, PhD, MPH, MSW, Robert H. Keefe, ACSW,
PhD, and Fred Volpe, MPA
DURING THE PAST DECADE,
the United States has experien-
ced a rapid growth of electronic
health information technology in
hospital and health care provider
systems to enhance access and
quality for service recipients. State
health departments have devel-
oped health information ex-
changes across large health care
networks, insurance providers,
and independent physician prac-
tices, and the use of electronic
health records has greatly accel-
erated.1 These initiatives evince
progress toward achieving a fully
connected national health care
system by 2014.2

Nevertheless, cities and
counties struggle to understand
the health care needs of individ-
uals who do not or cannot easily
access formal health care net-
works but use expensive services
for emergency and routine care.
Health information technology is
currently designed to benefit pri-
marily populations already con-
nected to such systems. As systems
increase their use of health data to
influence treatment and policy,
developing strategies to include
individuals who are largely out-
side health care networks is criti-
cal.
The US health care system has
been criticized for low-quality care
that produces multiple medical
errors3,4 and high-cost services
that limit access to care,5 perpetu-
ating health disparities. Primary
care focused on preventing illness
and death is associated with more
equitable distribution of health
and better outcomes than is spe-
cialty care6---8; countries directing
resources to primary care and
enhancing population health have
lower costs and superior out-
comes.9 Although the United
States has the world’s most ex-
pensive health care system, other

countries regularly surpass the
United States on most health in-
dicators, including quality, access,
efficiency, equity, and healthy
lives.10 Capturing data on individ-
uals unconnected to health care
systems can improve health care
access and outcomes while reduc-
ing costs––important public health
goals.
The federal government allows
states and local communities to
develop their own health care in-
frastructures. By making changes
at the local level, communities can
become more effective in using
existing services to capture health
care data for hard to reach pop-
ulations. We have examined sev-
eral strategies for using existing
electronic technologies to better
connect such individuals to some
aspect of their local health care
system.
THE PROBLEM OF HEALTH
CARE ACCESS AND
POSSIBLE RESPONSES
Converging social problems
(e.g., geographic isolation, limited
education, poor health, poverty,
and the marginalization of vul-
nerable groups including people of
color and the rural poor) inhibit

certain individuals’ access to
health care services.5 People who
have the poorest health tend to
receive the least health care, and
those with limited health options
because of inadequate insurance
or unavailable providers often use
high-cost services, such as urgent
care and emergency rooms, which
may not be appropriate to their
needs. This problem is significant:
nearly 75 million adults––42% of
the population younger than 65
years––had either no or inade-
quate insurance in 2007.11 Lack of
consistent, documented contact
impedes the accumulation of
meaningful health data for health
care planning and intervention
development. Uninsured or un-
derinsured groups are at risk for
remaining isolated despite health
care reform.
Although few health care ser-
vice data may be collected from
these groups, there are other ways
to track service use. Data from
contacts with other community-
based, nonhealth services can be
employed to target specific com-
munity health needs. For example,
some groups without regular
health care may have contact with
departments of social services,

criminal justice, specialty courts
(e.g., drug, mental health, veterans,
and family), or schools. Data
extracted from these systems, us-
ing secure data transfer protocols
already developed by health in-
formation exchanges, could help
address and evaluate the health
and service needs of these groups.
These data can then be used to
develop and strategically imple-
ment novel health-promotion and
grassroots interventions.
Similar approaches have been
applied to track or monitor clinical
intervention outcomes,12,13 clinical
trials,14 adherence to specific
COMMENTARY
interventions,15,16 and infections.17
Broader cross-systems data-use
collaborations between commu-
nity and health care providers to
increase care among uncon-
nected groups have also been
successful.18---21 Clinical trials of
cross-program multidisciplinary
interventions have reduced such

health-related stressors as high
blood pressure and cardiac
problems among poor families,22,23
disseminated HIV prevention
programs in African American
communities,24 delivered inner-
city tuberculosis prevention
efforts,25 and decreased negative
birth outcomes among low-
income African Americans.26
Initiatives derived from these
concepts are already under way in
some communities. The Partnership
for Results in Auburn, New York
(http://www.partnershipforresults.
org), developed a cross-systems data
access and sharing collaboration
around children at risk for school
violence. San Francisco Children’s
System of Care (http://nccc.
georgetown.edu/documents/
ppsanfran.pdf) developed and
expanded their collaboration to
collect individual-level data on
youth across a series of systems,
including schools and probation,
to target and evaluate novel in-
terventions.
Access to health-related infor-
mation and health promotion has
expanded with the growth of the
Internet,27,28 particularly in the
mental health field, which is rap-

idly developing online versions of
actual treatment.29 No-cost per-
sonal health records are available
online, allowing individuals to
bank and control their own health
data. Broadband Internet access
and mobile wireless are available
in all urban and most nonurban
areas, offering new opportunities
to reach individuals outside health
care networks.
TECHNOLOGY TO REDUCE
BARRIERS TO HEALTH
CARE
Developing cohesive, commu-
nity-based strategies for using
health information technology and
electronic communication tech-
nologies optimally is critical to
dismantle barriers to health care
and health information.4 To help
communities reduce such impedi-
ments, we propose several strate-
gies.
Communities: Collaborations
for Health-Focused Use of
Community-Based Data
Individual-level data exist in
public and private agencies and
institutions (e.g., social services,

criminal justice, colleges, and trade
schools). These data are confiden-
tial and protected and typically
include personal identifiers and
service use history. Because of
their size and scope, these systems
have a similar database infra-
structure and often contain data
on the same individual. Collective
data from these systems could
help drive new forms of commu-
nity-wide health promotion and
service delivery. To build such
systems, three tasks are essential.
Task 1: Engaging the community.
It is essential to understand a
community’s political geography
and to identify entities that will
form the infrastructure to facilitate
and coordinate the use of data
from extant systems for that com-
munity to use. Choosing key
leaders from potential participat-
ing agencies that will form the
collaborative should be according
to their willingness, influence, and
ability to collaborate and properly
use centralized data. The collabo-
rative can then team with broader
health-focused organizations, such
as local health departments in
urban areas and offices of rural
health in state health departments,
to build the initial support base

and vision.
Task 2: Developing a plan. Once
formed, members of a collabora-
tive must develop an action plan.
A critical component is an assess-
ment of the content of all partici-
pating data systems. The plan may
involve building a comprehensive
data dictionary of potential data
fields applicable to health-related
risk. A feasible system must be
relatively simple, low cost, risk
controlled, time efficient, and
beneficial for participating
agencies. A key collaborator in this
task is a regional health informa-
tion exchange, which can assist in
providing a secure information
exchange environment. Particu-
larly important are the consent
and data security processes30 and
the development of effective data
use agreements that limit liability
regarding the unintended use of
data.31
Task 3: Forming a collaborative.
Building a collaborative to drive
this process and use the data re-
quires input from various experts,
including researchers, program
developers, and trainers, who can
introduce fresh ideas regarding
program development, care deliv-
ery, and outcomes tracking and

measurement. Indicators of the
success of the initiatives may in-
clude fewer missed days of work
or school, decreased emergency
room visits, and better communi-
cation among multiple health care
systems. Ideally, the collabora-
tive’s leadership should be based
at local public health departments
because of their community-wide
scope.
Veterans returning from over-
seas could serve as a test case for
how such a system might work.
Despite available care, many vet-
erans do not connect with the
Veterans Affairs health care
system and struggle for long pe-
riods with adjustment problems
affecting their physical and mental
health. Identifying points of entry
into community systems such as
schools or social services may help
these systems better meet the
needs of veterans with high-risk
burdens but only minimal in-
volvement with health or mental
health services. The Veterans Af-
fairs health care system has al-
ready obtained much information
that may be used to improve
returning veterans’ quality of
care.32,33

Health Care Systems:
Reaching Out Through
Electronic Means
Although the Internet can serve
as a conduit for reaching geo-
graphically and socially isolated
individuals, understanding its cur-
rent usability and limits is neces-
sary for effective planning. Inter-
net access occurs through (faster)
broadband or (slower) dial-up
depending on geography.34 Some
areas have no access at all; some
households choose not to use the
Internet (Table 1).
The Internet is the primary way
most users (67%) obtain health
care information,36 but only 63%
of US households have an Internet
connection. Urban areas have
greater broadband access than do
nonurban areas, which typically
have more dial-up connections.
Whites use computers to connect
to the Internet more often than do
African Americans (59% and
45%, respectively), but more Af-
rican Americans (48%) use mobile
wireless devices than does the
general population (32%).28
Wireless handheld devices are

better options for contact in rural
areas because signal delivery is
more flexible, although gaps per-
sist as the result of terrain or
geography. Consequently, reaching
COMMENTARY
individuals electronically may re-
quire a multifaceted approach.
Health-related Web sites pro-
vide information on specific med-
ical diagnoses (e.g., diabetes), gen-
eral medical guidance (e.g., http://
www.WebMD.com), access to
medical literature (e.g., http://
www.PubMed.com), and treat-
ment options for mental health
conditions.29 Sites such as http://
www.patientslikeme.com allow
individuals to report their symp-
toms and evaluations of medica-
tions or treatments.37 Message
dissemination technology can now
rapidly access targeted groups in
communities for specific safety or
health purposes.38 Twitter tech-
nology is increasingly used in pri-
vate industry39 and is gaining ac-
ceptance in medical settings.40

Effective use of these technolo-
gies by health care systems can
increase their range to reach un-
connected individuals. Handheld
devices can receive brief an-
nouncements, appointment re-
minders, or health tips. Wellness
webs (composed of individuals
with similar health-related needs
who are connected electronically
to enhance their ability to work
together and better meet their
health goals) targeting individuals
to receive messages according to
need or interest can be built
through collaborations among
community agencies, insurance
companies, and providers. These
technologies may also facilitate
connection with African Ameri-
cans and Hispanics. Technology
alone cannot alleviate disparities
in health care access, but a na-
tional study finds that although
people with higher incomes use
the Internet more for their health
records, people with lower in-
comes and people without college
degrees are likely to benefit more
from having their health informa-
tion online.36 Connection fosters
more regular, better coordinated
care, with improved outcomes.

Individuals: Building and
Maintaining Personal Health
Records
Many health care systems and
insurance companies offer public
health records (PHRs) to help pa-
tients coordinate their care and
keep in touch with their providers.
PHRs allow patients to view parts
of their own health record (e.g., lab
results, medication history), input
data (e.g., weight, blood pressure),
and schedule appointments. In-
surance companies are the pri-
mary providers of PHRs (51%),
followed by health care providers
(26%), but other health-related
organizations offer PHRs to mem-
bers (e.g., the American Heart
Association).36
Recently, both Google (Google
Health) and Microsoft (HealthVault)
introduced publicly available,
Internet-based PHRs at no cost.
Although these providers pledge
that PHR data will be secure and
not exploited for advertising or
other commercial purposes, users’
trust must be developed. Only
25% of potential users report
a willingness to use a PHR from

a private corporation.36 Despite
these concerns, PHR options have
considerable value. PHRs contain
functions that can import data
over the Internet directly from
specific health devices (e.g., blood
pressure monitors, weight scales,
blood glucose tests) plugged into
computers or handheld devices.
Both Google and Microsoft prod-
ucts allow individuals to designate
specific entities for data sharing.
With this feature alone, commu-
nities can implement and monitor
targeted health-promotion pro-
jects and measure progress and
outcomes from self-reported data
through a central location that
links participants. As individuals
join health care systems, become
insured, or relocate, they can ex-
port and import data to electronic
health records and back into PHRs
no matter where they receive care.
MOVING FORWARD
Although they do pose some
risks, using electronic technologies
to improve conventional health
services offers opportunities to
reduce health disparities. It is in-
structive to examine successful
community programs and imper-
ative to continue assessing how

best to harness these technologies
to advance public health goals
without compromising privacy
or security. Researchers should
conduct rigorous reviews of the
literature to identify promising
programs and recommend appro-
priate policies and safeguards.
Developing new avenues of
communication with various
health care systems has already
helped unconnected individuals
access health care in some regions.
Through strategic collaborations
using established technologies, or-
ganizations such as participants in
the Substance Abuse and Mental
Health Services Administration’s
Drug Free Communities program
have been successful, including
incorporating accountability mea-
sures. One program in Florida
(http://www.onevoiceforvolusia.
org/data.htm) has included in its
mission promoting cross-system
data-gathering capabilities to ad-
dress high-risk groups. Inclusive
consensus building and commu-
nity action planning approaches
have produced successful systems-
level interventions in several US
cities and counties,41---43 enabling
vulnerable groups to take charge
of their health information.44 Such
initiatives not only create alterna-

tive access but also have important
policy implications aligned with
Healthy People 2020 objectives.45
TABLE 1—US Internet Connection Types and Use by Region:
October 2007
South (n = 43 370) Midwest (n = 26 714) West (n = 26 203)
Northeast (n = 21 553)
Urban
(n = 32 510), No. (%)
Nonurban
(n = 10 861), No. (%)
Urban
(n = 20 461), No. (%)
Nonurban
(n = 6253), No. (%)
Urban
(n = 23 322), No. (%)
Nonurban
(n = 2882), No. (%)
Metro

(n = 18 154), No. (%)
Nonurban
(n = 3399), No. (%)
Dial-up 2872 (8.8) 1976 (18.2) 1752 (8.6) 1374 (22.0) 2093
(9.0) 531 (18.4) 1345 (7.4) 632 (18.6)
Broadband 16 772 (51.6) 3682 (33.9) 10 689 (52.2) 2379 (38.0)
13 227 (56.7) 1376 (47.7) 10 088 (55.6) 1635 (48.1)
No use 9704 (29.9) 4073 (37.5) 5693 (27.8) 1776 (28.4) 5883
(25.2) 724 (25.1) 5421 (29.9) 859 (25.3)
Overall use 19 740 (60.7) 5677 (52.3) 12 494 (61.1) 3764 (60.2)
15 390 (66.0) 1918 (66.6) 11 450 (63.1) 2287 (67.3)
Source. Data from the US Census Bureau, Current Population
Survey, Internet Supplement, October 2007.35
COMMENTARY
For example, health policy deci-
sions are generally derived from
medical data from health care
systems and insurance compa-
nies.46 Using these data as the
primary source can invite the ap-
pearance of full knowledge when
the data actually represent only

individuals connected to the sys-
tem; excluding the unconnected
generates an incomplete picture
that can perpetuate disparities in
access and outcomes.
The new federal health reform
legislation is already promoting
creative changes by increasing
funds for community health
centers to boost the number of
treated patients.47 Under this
legislation, millions of Americans
will gain access to care previously
unavailable to them. There is an
urgent need to effectively handle
this expected rapid growth. Shift-
ing greater focus, responsibility,
and control to the local commu-
nity constitutes one encouraging
approach. For example, collabo-
ration to better distribute care
may prompt more efficacious
distribution of health care fund-
ing. At the time of this study,
health care dollars flowed directly
to formal providers as reim-
bursement for services rendered.
The distribution of funds depends
entirely on the delivery structure
of those entities, not the broader
needs of the community. Without
appropriate strategies and infra-
structure, communities will have
little power to create meaningful,
effective partnerships with health

care systems to assist their mem-
bers in need.
Obviously, the challenges, limi-
tations, and risks of using these
technologies must be understood
and continuously evaluated. New
applications for health-related
purposes raise many security and
privacy concerns that require the
attention of consumer health
advocates and health policy ana-
lysts. Although the Internet re-
mains the largest venue for access-
ing health-related information and
health-monitoring tools, it is neither
ubiquitous nor a panacea.
Electronic technologies must
be more broadly and effectively
implemented to realize their po-
tential to improve health out-
comes for vulnerable populations,
lower costs, and reduce health
disparities. To advance this
promising application, we need to
devote more attention to devel-
oping creative approaches to help
people access appropriate re-
sources, devising better safe-
guards, measuring effects and
evaluating programs, and sharing
information about programs that
are working. But by exploring
how to use technology to reach

unconnected individuals, com-
munity systems and health care
providers can begin to address
the problem––and enhance the
coordination of health care for
millions of Americans. j
About the Authors
At the time of this study, John F. Crilly
was with the Department of Psychiatry,
University of Rochester Medical Center,
Rochester, NY, and the US Department of
Veterans Affairs, Canandaigua, NY. Robert
H. Keefe is with the School of Social
Work, State University of New York,
Buffalo. Fred Volpe is with the Drug Free
Communities Program, Substance
Abuse and Mental Health Services
Administration, Leesburg, VA.
Correspondence should be sent to Robert
H. Keefe, PhD, ACSW, Associate Professor,
School of Social Work, 685 Baldy Hall,
University at Buffalo, State University of New
York, Buffalo, NY 14260-1050 (e-mail:
[email protected]). Reprints can be
ordered at http://www.ajph.org by clicking
the ‘‘Reprints/Eprints’’ link.
This commentary was accepted August
11, 2010.
Contributors
J. F. Crilly conceptualized the article and
led the writing of the initial draft. R. H.
Keefe edited the initial draft, aided in

writing, and led the revisions. F. Volpe
outlined the strategies and provided
examples of programs that have shown
some success.
Acknowledgments
The authors acknowledge Diana J. Biro,
PhD, for her assistance editing the article.
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