Abstract
This case study aims to provide insight into establishing a health information curriculum that includes knowledge, skills, and abilities on digital competencies (DigCom) and provides instructional suggestions for developing a digital health pedagogy for instructors of the health information discipline. The context for incorporating digital health competencies into the health information curriculum recognizes the underlying challenges of health inequity, health literacy, and digital health literacy, along with the social determinants of health.
Keywords: digital health, health equity, digital literacy, social determinants of health, technology
Introduction
The scope of digital health in the United States and globally has grown exponentially, from computing platforms and software to mobile devices and mobile medical applications, digital therapeutics, telehealth, and other digital tools such as smartphones and wearable devices and sensors.1 Grand View Research, Inc., predicts the digital health market is expected to reach 1.5 trillion dollars by 2030.2 Digital health provides enormous opportunities in healthcare for both the provider and consumer of care. The adoption of digital health offers increased access to care, cost reduction, efficiencies, patient satisfaction, and quality care.3 Although it has been referred to as the digital transformation of healthcare, mHealth (mobile health) has been around for over 20 years and during the past decade, digital health has become the main topic of this transformation.4,5 However, the recent pandemic has rapidly advanced the use of digital tools, devices, and health technology in today’s mainstream healthcare. With digital tools and advanced health technology, digital health has been shown to improve patient outcomes for many, yet still there remain challenges. The demand for the use of digital health technology adds pressure on an already burdened healthcare workforce to increase its technical skills and capabilities.
In addition to the advancements in healthcare technology, educators are facing a generation of students who are digital natives, and who may find their expectations for the use of technology beyond what professors can provide.5 The need to include digital health competencies in health information (HI) profession educational programs lacks exploration. The program curriculum is a blueprint for student learning and experiences in the classroom. Currently, there is an absence of digital health competencies included as an intentional component of the curriculum. All health information programs vary in their curriculum construct and instructional design. Regardless of their content variations, programs must meet the American Health Information Management Association (AHIMA) Curricula Competencies© to be accredited by the Commission on Accreditation of Health Informatics and Information Management Education (CAHIIM).
The Digital Competence (DigCom 2.0) Framework developed by the European Commission Joint Research Centre describes 21 learning outcomes in 5 areas: 1) information and data literacy, including management of content (information and information literacy); 2) communication and collaboration, and participation in society (communication and collaboration); 3) digital content creation, including ethical principles (digital content creation); 4) safety (security); and 5) problem solving.6
This case study aimed to identify what digital health competencies and skills are currently needed, identify where they can be addressed in the AHIMA competencies and provide instructional suggestions for implementing a digital health pedagogy.
Methods
A review of the 2018 AHIMA Health Information Management Curricula Competencies© and incorporates digital health into the curriculum. The analysis of this case study forms the basis of incorporating digital health competencies into the following AHIMA 2018 Curriculum Competencies©, digital health data structure, and content.
From December 2022 to January 2023, three reviewers, experts in the content and familiar with AHIMA's Health Information Management (HIM) Baccalaureate Curriculum Competencies©, Curriculum Guidance, and the DigComp Conceptual Reference Model, conducted an evaluation. Their assessment centered on content applications of the AHIMA HIM Baccalaureate Curricula Competencies© and the integration of digital competencies within both the Curriculum Competencies and Curriculum Guidance.
Terminology Definitions
In this study, key terminologies are clearly defined and elaborated upon:
Computer Literacy: A foundational understanding of computer operations and interactions, emphasizing the essential skills needed to operate and troubleshoot a computer. While computer literacy does not equate to mastery over advanced software or programming, it prioritizes understanding the computer's core functions and components. This encompasses skills like starting the computer, interacting with its main features, and addressing common issues. Essentially, computer literacy sets the foundation for advanced technological exploration and expertise. 7
Digital Health: Digital health is the use of information and communication technologies in medicine and other health professions to manage illnesses and health risks and to promote wellness.8
Digital Literacy: Digital literacy is the ability to use information and communication technologies to find, evaluate, create, and communicate information, requiring both cognitive and technical skills.9
Health Equity: Health equity is the attainment of the highest level of health for all people. Achieving this means removing economic, social, and other barriers that might prevent individuals from accessing the care and resources they need.10
Health Literacy (Personal): Health literacy (personal) is the degree to which individuals can find, understand, and use information and services to inform health-related decisions and actions for themselves and others.11
Health Literacy (Organizational): Health literacy (organizational) is the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.11
Social Determinants of Health: Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.12
AHIMA Competencies
The 2018 Health Information Management (HIM) Curricula Competencies© consist of six common domains representing the academic framework for the areas of mastery vital for all health information professionals regardless of academic level. With the 2018 HIM Curricula Competencies©, previous subdomains were removed, and the competencies were revised in a broader context which allows for more flexibility permitting educators and academic programs to adjust to changes in educational demands. Specific curriculum competencies are addressed in the following six common domains.13
Domain I. Data Structure, Content, and Information Governance
Domain II. Information Protection: Access, Use, Disclosure, Privacy, and Security
Domain III. Informatics, Analytics, and Data Uses
Domain VI. Revenue Cycle Management
Domain V. Health Law and Compliance
Domain VI. Organizational Management and Leadership
The first three domains within the 2018 AHIMA Health Information Management Curricula Competencies© were explored for incorporation of digital (health) competencies into the curriculum.
Results
As a result of reviewing the literature on digital health competencies and the 2018 AHIMA Health Information Management Curricula Competencies©, curriculum design considerations were addressed. From this review, assessment examples for the competencies are provided, challenges and issues related to the domain content areas are discussed, and tips for curriculum design are included. The key content areas covered in this section include Domain I.: Data structure, content, and information governance; Domain II.: Information protection access, use, disclosure, privacy, and security; Domain III.: Informatics, analytics, and data use of the 2018 AHIMA Health Information Management Curricula Competencies©.
Health Information Curriculum Design
Digital health tools have the potential to transform healthcare, and so the healthcare industry is responding to the challenges associated with digital health. For example, chief information officers (CIOs) are looking to add strategies that support patient engagement. 14. Patients must engage and use the digital health tool to experience the benefits, yet patients may not have digital health literacy, health literacy, or access to technology to use digital health tools. Some states have issued public awareness campaigns for health and digital literacy and advances in developing intuitive technology to support digital health tools. For example, the healthcare industry has recognized that digital health tools are making significant care advancements, but patients must engage with the technology to take advantage of these advancements.
In 2019, Google managed 1 million health-related searches per day, accounting for 7% of Google searches or 70,000 per minute.15 People search for health information; however, health literacy remains a problem. The CDC prominently displays health literacy activities by state, with many states offering health literacy campaigns.16
There are many underlying challenges that the industry is addressing to transform healthcare with health technology. Still, the question remains unanswered: Can these digital health tools and digital competencies be effectively incorporated into the health information curriculum to support the transformation of healthcare? Is the absence of digital health competencies noted in the health information curriculum? Many medical schools have implemented digital health competencies into their educational programs17, are health information educators addressing digital health tools in their programs?
Domain I.: Digital Health Curriculum Consideration
Using the existing AHIMA competencies©, health information programs can easily incorporate digital health competencies into Domain I. For example, the study of data structure, content, and information governance provides foundational competencies needed for digital health. In addition, students learn about the stakeholders in the healthcare industry and the relationship between entities and stakeholders in the healthcare industry. Healthcare consumers are key stakeholders in healthcare and have a vested interest in using digital health tools. It is the consumers’ limitation in health literacy, and digital literacy that can be addressed in the HI curriculum. These gaps, as noted in the curriculum, limit the HIM professional’s advocacy work to support the consumer. Integrating both education and promotion of health literacy and digital literacy skills into the foundation of the HIM curriculum domain would help digital health competencies.
Secondly, Domain I supports the structure and capture of data. Understanding the life cycle of data from the generating, capturing, processing, storing, and using data are fundamental elements of data integrity. Health information professionals are data professionals who understand that the data cycle begins with the generation of data (structure) – knowing stakeholders’ needs, such as when to get the right data at the right time with integrity, is paramount to supporting health transformation.
Thirdly, Domain I supports healthcare external forces such as accreditation, regulation, and licensure. Curriculum considerations should include the following:
- What are the legal considerations for healthcare settings with the use of digital health technology?
- What are the legal concerns for digital health related to fraud and abuse, HIPAA, False Claims Act, and other laws?
- What about accrediting body requirements for digital health technology such as artificial intelligence (AI)?
- Are there biases and risks associated with the use of digital health technology?
- What impact does digital health technology have on health disparities?
To summarize Domain I, many curriculum considerations can be incorporated into this domain, such as the evaluation of policies and strategies to achieve data integrity; digital health and tools disruption in healthcare and the use of digital tools for data capture; foundational knowledge of digital health and health literacy. Finally, Domain I could easily capture the role of the external forces surrounding digital health tools.
Challenges
Although digital health tools are widely used among healthcare professionals, the HIM professional may encounter several challenges relating to data structure, content, and information governance. These challenges include the speed at which these tools are entering the market and the academic program’s ability to use these tools similarly to industry. The healthcare industry is faced with the challenge that digital tools are rapidly entering the market, and not all health professionals are prepared to use digital health tools.18,19 The lack of preparedness and confidence with the digital tools among healthcare providers has a downstream effect on those individuals, such as the health information professionals implementing the tools. Many health information professionals work closely with the providers on implementing and integrating digital tools within a healthcare system. Therefore, the health information professional should be prepared to work with providers and patients with digital health competencies, such as include digital literacy, eHealth literacy, psychological and emotional acceptance of digital health, and digital technology.20
Design Tips
Domain I.: Data Structure, Content, and Information Governance is a broad category that incorporates such content as healthcare stakeholders, external and internal forces, strategies for policies, governance and organizational, and health record requirements, and types of data structures, among other content. Missing from Domain 1 is the focus on engaging stakeholders in the use, education, and training of digital health tools. An increase in the use of digital tools beyond the electronic health record and the collection and use of data beyond the traditional healthcare settings could be incorporated into Domain I. The health data ecosystem in healthcare should contain not only electronic health records but all devices generating data from digital tools. Didactic coursework, laboratory exercises, and capstone projects (digital health projects) could be built into the curriculum. 21 This coursework should consist of the health data ecosystem with personal health, genetic data, devices generating data, and the electronic health record.
Domain II.: Information protection access, use, disclosure, privacy, and security competency
Historically, the health information management professional’s role in privacy and security of health information was documented in the AHIMA Code of Ethics as “protecting information; promoting confidentiality and teaching others of the importance of this principle; preserving and securing health information”.22 Although privacy and security have evolved today, it remains a prominent focus for the health information professional. As a result, privacy and security are embedded into the health information management curriculum through Domain II.
Privacy and security concerns should prompt academic programs to consider the technological aspects of digital health—for example, the use of privacy-enhancing technologies or privacy-preserving technologies. Privacy and security strategies for digital health can encompass digital literacy, similar to Domain I, because a lack of digital literacy compounds one’s understanding of privacy and security, along with concerns for vulnerable populations needs.
The DigCom 2.0 digital health model identifies safety as an important digital health competency. Safety is a broad category that encompasses protecting an individual’s health data by understanding the digital environment.23 Students need to develop the knowledge, skills, and attitudes to safeguard the devices that house the data. Domain II could explicitly include the knowledge, skills, and abilities for privacy and security by addressing the digital environment as they relate to safety.
Challenges
Privacy and security remain a challenge for digital health technologies. The use of digital health tools has increased data and compounded the concern for privacy among individuals and healthcare providers. Privacy challenges include the following but are not limited to those: individuals are unaware of how their data is used, the length of time data is retained (immortality of data), and the value of data.24 Keeping in mind the persistence of privacy and security in healthcare data, education is needed on the evolving trends as digital health tools continue to disrupt healthcare.
The curriculum should be updated with the latest methods of deidentification and reidentification — the anonymization of health data using data masking techniques can be incorporated into the curriculum. In addition, the health information management curriculum should include global policy and regulation as digital health expands globally. The pace and adoption of privacy regulations are accelerating.25 As the aforementioned curriculum updates are needed, the focus is on digital tools that capture the collection of data and how that data is used. For example, students should be exposed to sound management practices that provide the foundation for data-sharing practices and policies.
Design Tips
Many design tips can be used, including many assessments such as case studies, risk assessments, policy writing, and projects. For example, projects may include the student selecting a digital application whereby the student can recommend privacy strategies used or used for the desired application. Then, the student can evaluate the application for strategy and create a privacy awareness infographic handout explaining the privacy strategies. For example, infographics may include the following: Is the privacy policy accessible to the public? Or is the privacy policy written in plain language? Does it inform the patient about the technology?
Finally, curriculum consideration for Domain II can include identifying the legal, ethical, and regulatory considerations for digital health. For example, is there a need to address privacy regulations such as GDRP or state privacy regulations? How does privacy policy impact digital health? Students can compare US state laws for privacy and security. Do any of these laws address digital health apps? For example, does HIPAA need to be updated to reflect digital health? Students should also be introduced to the FTC’s and FDA’s roles in digital health apps and devices.
Domain III.: Informatics, analytics, and data use
Health informatics involves the interaction between humans and information through information processing and digital health technologies. There is ample opportunity to examine health informatics concepts and evaluate data, information, and digital content as part of incorporating digital competencies such as solving technical problems or suggesting technological solutions. Data analytics in healthcare is widespread and serves multiple purposes. Data analysts serve the purposes of administrative (used in operations management), financial, and clinical (accelerates research in prevention and disease and population management). The use of data analytics from research studies to create dashboards and reports can be utilized to examine healthcare findings with data visualization techniques. The effective use of data and the displays are crucial to healthcare and strong consideration for a digital health curriculum. Digital competencies include effective presentations, interactive videos, QR code and infographics.
Challenges
As digital health tools are introduced and huge amounts of data become readily available, data analytics and data use become challenging. In addition, the understanding of bias in data is a concern and should be addressed with the creation of digital content. Consideration of the ethical implications of algorithms is essential, along with the concern and knowledge for health equity and vulnerable populations.
Design Tips
Design tips for curriculum considerations include applying a fundamental understanding of the ethical and legal issues related to accessing and using information technologies, accounting for the social determinants of health, and incorporating analytic tools, data visualization techniques, and research methodologies. Assessment that creates questions and methods to collect data for social determinants of health in electronic health records and other digital health tools can be developed. Data analytic assignments offer students the opportunity to develop skills filtering and analyzing data and creating useful information. Students should be introduced to data analytic tools and open-sourced data lakes to practice and hone their analytic skills. It is also important that students develop data visualization and presentation skills through explanations of how data was used and most importantly the outcomes of the analysis keeping with the digital competencies of digital communication and collaboration, developing digital content and digital problem solving. 26
Discussion/Conclusion
As evident from this case study, there are various ways an educator can introduce digital health into their curriculum. Whether one is developing an entire course on digital health or simply providing a lecture and assignment within a module of a course, it is important that students are made aware of the need to continue learning about digital health and health technology advances and their impact on the management of health information. Students should also be aware of digital health disparities and the importance of equity in healthcare with the use of digital health tools and health technology. Consider including social determinants of health and discuss their effects on health equity, the lack of digital literacy, and health disparities relating to digital health tools and health technology. Digital health is expanding and will continue to serve a valuable role in the future of healthcare. Therefore, it is incumbent upon educators to ensure their students receive an education that makes them more marketable in the workforce and seen as highly valued employees by including digital competencies (DigCom) within their health information curriculum.
References
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Author Biographies
Cathy A. Flite PhD, RHIA, FAHIMA, (cflite@temple.edu) is an associate professor in the Department of Health Services Administration & Policy at Temple University in Philadelphia, Pennsylvania.
Shannon H. Houser, PhD, MPH, RHIA, FAHIMA, (shouser@uab.edu) is a professor in the Department of Health Services Administration at the University of Alabama at Birmingham in Birmingham, Alabama.
Susan L. Foster, EdD, MBA, RHIA, CHPS, CHC, CHPC, CIPP/US, CC, FAHIMA, (susan.foster@fsw.edu) is a program director and associate professor in the School of Health Professions, at Florida SouthWestern State College in Fort Myers, Florida.