Health Information Technology : Quality Issues Author : Neha Salian Co-author : Malvika Hake Abstract Health IT is the technology that enables patients and providers to support better health and health care by providing targeted information meant to inform, educate or generally allow for improved decision making. With health care costs and quality assurance taking central roles in the health care arena, increasing attention is being directed towards the potential of health information technology (IT) to lower health care spending and to improve efficiency, quality and safety of medical care delivery.
One of the primary motivators for adopting many health IT applications is the belief that they improve the quality of patient care. Health IT holds enormous potential to propel the health care system to higher quality. Diffusion of IT in health care is generally low but surveys indicate that providers plan to increase their investments. Drivers of investment in IT include the promise of quality and efficiency gains. Barriers include the cost and complexity of IT implementation, which often necessitates significant work process and cultural changes.
This paper focuses on quality issues in health IT, including the types of quality problems information technology can be used to solve and implementation strategies to ensure that quality objectives are met. Keywords: Health Information Technology, diffusion of IT, quality issues, implementation strategies, quality objectives. INTRODUCTION Health Information Technology (HIT) provides framework to describe the comprehensive management of health information and its secure exchange between consumers, providers, government and quality entities, and insurers.
HIT in general is increasingly viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system. In general, the various IT applications fall into three categories viz. administrative and financial systems that facilitate billing, accounting, and other administrative tasks, clinical systems that facilitate or provide input into the care process and infrastructure that supports both the administrative and clinical applications.
Broad and consistent utilization of HIT will improve health care quality, prevent medical errors, reduce health care costs, increase administrative efficiencies, decrease paperwork and expand access to affordable care. Interoperable health IT will improve individual patient care, but it will also bring many public health benefits including early detection of infectious disease outbreaks around the country, improved tracking of chronic disease management and evaluation of health care based on value enabled by the collection of de-identified price and quality information that can be compared. Objectives
Quality issues in health IT, including the types of quality problems information technology can be used to solve and implementation strategies to ensure that quality objectives are met. Applications and Benefits Usefulness of implementing HIT must take into consideration several factors viz. the potential of this technology to improve health care quality, safety, and patient satisfaction and how this potential has been demonstrated. The cost-effectiveness of the technology the business case for adoption of the technology including the total costs of implementation (both financial and in terms of resources) and any cost savings that accrue.
Concerns exist that those who bear the greatest share of such costs are not able to recoup those costs. The ability to generalize the effects of an HIT intervention on costs and benefits in existing systems (using published experience with or research on these systems) to the technology’s use by other health care organizations. Type of IT Applications Hospitals Administrative and financial Billing General ledger Cost accounting systems Patient registration Personnel and payroll Clinical Computerized provider order entry for drugs, lab tests, procedures Electronic health record
Picture archiving and communication systems for film less imaging Results reporting of laboratory and other tests Clinical decision support systems Prescription drug fulfillment, error-alert, transcriptions Electronic monitoring of patients in intensive care units Infrastructure Desktop, laptop, cart-based, and tablet computers Servers and networks Wireless networks Voice recognition systems for transcription, physician orders, and medical records Bar-coding technology for drugs, medical devices, and inventory control Major Concerns
Diffusion of IT in health care is generally low (varying, however, with the application and setting) but surveys indicate that providers plan to increase their investments. Drivers of invest promise of quality and efficiency gains. Barriers include the cost and complexity of IT implementation. Diffusion of information technology in hospitals varies with the type of technology. It is greatest in administrative and financial applications such as patient registration, billing, and payroll. Clinical applications, such as computerized provider order entry for drugs or other items (e. g. lab work) and electronic health records, are less diffused. Infrastructure technologies build the base that other technologies work from, and include both widely diffused technologies, such as e-mail and telecommunications, and those that are less common, such as wireless connections and voice recognition. While many factors push hospitals to invest in IT, others pose barriers. Investment in IT is costly and must compete with other priorities, including investment in bricks and mortar, as well as in technologies with more direct application to clinical care and greater certainty for increased revenues, such as new imaging equipment.
Other significant barriers include vendors’ inability to deliver products effectively (14 percent), difficulty in providing quantifiable benefits or return on investment from IT (13 percent); and difficulty achieving end-user acceptance (11 percent), among others. Very few respondents (3 percent) considered lack of common data standards to be a significant barrier (HIMSS- Healthcare Information and Management Systems Society). American Health Association assessed hospitals’ use of six types of health IT—used to collect, store, retrieve, and transfer clinical information electronically.
Almost 90 percent of hospitals reported that their clinicians use at least one of the listed technologies. The number of hospitals using specific types of IT varied widely, with electronic lab results most common (88 percent of hospitals). Conversely, e-prescribing (also known as computerized physician order entry, or CPOE) was least common (21 percent). Hospitals with Clinicians Using Selected IT Capabilities Studies identified a large number of barriers to the implementation of HIT.
These barriers can be classified as situational barriers (including time and financial concerns), cognitive and/or physical barriers (including users’ physical disabilities and insufficient computer skills), liability barriers (including confidentiality concerns), and knowledge and attitudinal barriers. Cutting across all of these categories, however, may be the need for a major structural and ideological reorganization of clinical medicine as it is now practiced in the majority of settings to be able to integrate itself with and enjoy the benefits of HIT.
Quality and health information technology Quality in HIT refers to instant access to patient health data, clinical decision support at the point of care, transmission and receipt of lab requests and results, information aimed at avoiding medication errors and physician-performance measurement. One of the primary motivators for adopting many clinical healths IT applications is the belief that they improve the quality of patient care.
Yet, further research is needed to better document and understand the link between IT and quality, including the types of quality problems information technology can be used to solve and implementation strategies to ensure that quality objectives are met. The American College of Physicians believes that health information technology must be more widely utilized by physicians and their patients to encourage care that is based on clinically proven best practices. While electronic health records represent a major tool to help achieve quality and productivity improvement, only 17% of US physicians are using them on a regular basis.
The benefits of these technologies include instant access to patient health data, clinical decision support at the point of care, transmission and receipt of lab requests and results, information aimed at avoiding medication errors and physician-performance measurement. Health IT holds enormous potential to propel the health care system to higher quality. Specifically, IT may help close the quality gap, brought to national attention in 2001 by the Institute of Medicine in Crossing the Quality Chasm, by promoting care that is safe, effective, patient-centered, timely, efficient, and equitable.
Health care payers and providers alike are looking at IT not only to improve quality, but also to reduce costs, with efforts well under way to integrate it into the health care system. Has IT Improved Quality? More than 80 percent of the hospital executives interviewed reported that IT had been an important factor in improving quality in their hospitals, a notable degree of consensus given the range of IT functions covered by the survey. In hospitals that were using some type of IT, only 17 percent felt it had not been an important contributor to higher quality.
In terms of what was viewed as most helpful in enhancing quality, more timely clinical information, diagnosis, and treatment was the greatest benefit reported. Seventy-one percent of hospitals that responded to the question and used at least one of the IT functions in the survey cited this as the most important benefit to date. Many of these hospitals had implemented several IT functions; over half (55 to 63 percent) had implemented each type. Another important quality improvement was reduction of medical errors and improvement in patient safety.
Twenty-two percent of hospitals cited enhanced patient safety as the most important benefit they had observed to date. This category included effects related to error reduction, such as providing more accurate information, flagging abnormal lab results “so they no longer get lost in the shuffle,” and improving legibility of information. Hospitals reporting greater patient safety as the most important benefit had typically implemented fewer IT initiatives than hospitals citing more timely information as the most important benefit.
E-prescribing with decision support stood out as relatively common among hospitals that viewed better patient safety as the most important benefit of IT (36 percent). Only between 19 and 22 percent of these hospitals had implemented the other five types of IT. About 10 percent of hospitals felt that improved communication among the care team was the most important quality benefit of their IT initiatives. Although the survey asked about the most important quality benefit of IT, 11 percent cited greater efficiency in managing patients or more efficient decision processes as a benefit.
This finding supports the idea that many hospital executives view quality and efficiency as complementary and linked. The survey also explored whether hospitals with certain types of IT had reduced the amount of labor required to abstract chart data for quality measures submitted to CMS for Hospital Compare, a web-based tool for reporting quality information to the public. Four in 10 said that it had, with the majority (69 percent) saying that IT reduced the labor associated with chart abstraction by 20 to 80 percent. Most Important Quality Benefits from IT Cited by senior executives reporting an important quality benefit. Note: Eighty-three percent of hospitals with at least one type of IT in the survey reported an important quality benefit. This figure shows the percentage of that group citing each of the three most common quality benefits. How quality improvement is currently done? Quality improvement in healthcare today is going on at many levels, but is generally poorly coordinated. Organizations, practices, hospitals, and insurers all have programs intended to improve quality, but many of these programs overlap, and most are of marginal impact.
While the science of quality improvement has grown dramatically in recent years, many relatively ineffective approaches remain the workhorses of change, especially with regard to physician behavior. In particular, education continues to be a mainstay, and is often carried out through lectures and newsletters. While this kind of passive education clearly plays some role, studies repeatedly demonstrate that its effect is modest and wanes rapidly when discontinued. The other main strategies for changing physician behavior include feedback, financial incentives, rationing and penalties.
Feedback when given at all is typically aggregate and retrospective. Sometimes providers do get lists of patients who are out of compliance for a certain measure such as mammography, but these lists, while useful, are often inaccurate because they are based on claims data, and they cover only a tiny proportion of the issues that might be addressed. Financial incentives (e. g. capitation) and rationing (e. g. formularies) clearly work, but are resented by physicians, and can be hard to implement.
Penalties create even more resentment, and are generally counterproductive. A more effective approach to changing physician behavior appears to be provision of real-time education and feedback while providers are delivering care using clinical decision support. Such decision support improves decision-making and adherence to guidelines, and is generally well-accepted by providers. It is most effective if delivered in concert with other behavior changing approaches, including education and retrospective feedback.
Another highly effective approach for improving quality is to use industrial quality improvement techniques to address and retool specific processes, generally with multidisciplinary teams. Many of the processes within medicine were never consciously designed. Judicious introduction of IT into many of these processes may be helpful. How quality is currently measured? Today, most quality measurement within organizations is done using claims data, which lack clinical detail.
Cases are aggregated using diagnosis-related groups (DRGs) which are assigned post-hoc and may not accurately represent patients’ clinical presentations. The outcomes most frequently assessed are mortality, length of stay, and charges (though increasingly costs are being measured as well). For most conditions, mortality is sufficiently low to be meaningless, and even for conditions with higher mortality organizations often do not perform severity adjustment because of the difficulty of doing so, although increasingly good adjusters are becoming available.
Length of stay can be decreased with enough focus and effort, and it is useful for cost reduction efforts, but is hardly a comprehensive quality measure. The variables most amenable to change are process measures, and many have been associated with improved long-term outcomes. Examples include door-to-needle time in patients with suspected myocardial infarction, use of appropriate antibiotics in patients with community-acquired pneumonia, and use of beta-blockers in patients with cardiac ischemia.
However, such process measures are difficult or impossible to extract from claims data, and costly chart review is typically needed in today’s system. As a result, most organizations measure only a few of these at one time, because of the high cost of doing so. Moreover, for complications or adverse events, the standard is to rely on self-report by providers, which dramatically underestimates the frequency of these events.
Even among institutions which are leaders in quality measurement, the current state of the art is to compare crude outcomes by condition from claims data, typically using resources such as the University Hospital Consortium database which includes information like length of stay and morbidity and mortality data. Such comparisons can be useful and result in identification of problems that can be addressed in an organization (for example if high mortality is identified in patients with community-acquired pneumonia), but these comparisons often aggregate disparate groups of patients, involve long lag times and lack clinical detail.
In addition, the data may or may not be used by those actually delivering care. The recent interest in quality by payers and regulators has resulted in a multitude of requests for quality data, which is overwhelming the limited resources of quality managers in most organizations, especially as most call for process data which organizations do not have at hand. Typically, healthcare has devoted a tiny fraction of its overall revenues to quality measurement and management, so that it is not surprising that there is little reserve. The evidence on quality and IT
While increasing the use of IT in healthcare would result in benefits in several domains, the quality benefits will probably be some of the largest. In particular, this would improve the likelihood that processes will be successful, and would allow delivery of evidence-based decision support to providers, narrowing the gaps between evidence and practice. Many studies now show that computerization of reminders and prevention guidelines improves adherence. Reminders are especially important in the care of chronic conditions, which represent a large proportion of expenditures.
Management of these conditions requires tracking on the part of patients as well as excellent communication between providers and patients regarding tracking and deviations; this will be made dramatically easier with IT. It will also be possible to improve safety in a variety of ways by increasing the use of IT, including introducing checks for problems, highlighting and communicating information about key abnormalities to providers so they receive a rapid response, and facilitating communication between providers.
Communication between patients and providers is also vitally important for safety, especially outside the hospital. In one study of outpatient adverse drug events, a large proportion of events could have been prevented or ameliorated with better communication between patients and providers. Compared to direct improvement, quality measurement is even more profoundly affected when information is stored electronically in electronic medical records, which are vastly richer than claims databases.
It becomes possible to routinely find patients with certain conditions, to ask questions about their recent laboratory values, and even to go through their notes to look for certain issues, like new problems. Solutions Accelerate the Adoption of HIT Priority 1: Accelerate Adoption of Electronic Health records Encourage Use of Interoperable Electronic Medical Record Solutions, Require Minimal Level of Functional Requirements and CCHIT Certifications, Require Interconnectivity, Health Information Exchange as a Catalyst for Adoption and Centralized Help Desk Support.
Priority 2: Developing a Regional Information Technology Center Make available purchasing decision support, Develop waves of structured deployment, Provide training in the use of technology and Engage those who have already purchased systems. Priority 3: Encourage the Reimbursement System to Promote Use of Technology Priority 4: Encourage the Adoption of Telemedicine Technology Priority 5: Encourage e-Prescribing Priority 6: Encourage the use of Personal Health Records Health Information Exchange Priority 1: Encourage Clinical Messaging Priority 2: Coordinated Care
Priority 3: Improve Quality and Value:- Physician Analysis, Public Health, Personal Health Records, Research. Ensure Availability of a Broadband Infrastructure to Support Technology Use Priority 1: Complete a statewide Broadband Inventory. Priority 2: Establish a budget for the Tele-Health Alliance to Continue to Support Its Role. Priority 3: Align Reimbursement Model that Support a Local Business Case for Investments in Infrastructure. Priority 4: Work with the vendor community to encourage local investments. Create Usable and Accessible State-Wide Data
Priority 1: Leverage MITA to Establish State Data Infrastructure. Priority 2: Ensure Adoption of Standards to Guide HIT in the State. Priority 3: Establish Security Protocols for the Protection and Use of Data. Priority 4: Encourage Payers to Voluntarily Report Claims Data to a Centralized Warehouse Quarterly. Priority 5: Encourage Providers to Voluntarily Report Clinical Data Centrally on a Monthly basis. Priority 6: Provide Transparency in Line with the Patient Health Charter. Priority 7: Information will be used to drive improvement in key areas of need throughout the state. Develop the Work Force
Priority 1: Become a Regional Extension Center. Priority 2: Establish Centralized Help Desk Support. Priority 3: Recruit and retain Professionals with skills in HIT. Priority 4: Build a Pipeline of HIT Professionals, Collaborate with the professional Societies, Coordinate with State University System, and Community Colleges, Ensure Use of technology in medical education, Leverage State based Infrastructure to provide on-demand education and training, Encourage Hospitals and Health System s to Continue training opportunities. Ensure Financial Viability and Sustainability Conclusion
The vision for the health information system strategic plan is to ensure a coordinated information technology infrastructure and delivery system is established that allows patients, families, communities and the health care system to collaboratively partner to improve the health and well being of all. The Institute of Medicine (IOM) recognized these complexities in its Crossing the Quality Chasm report. “The challenge of applying information technology to health care should not be underestimated. Health care is undoubtedly one of the most, if not the most, complex sectors of the economy.
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