Using Health Information Technology to Improve Care: Evidence and Strategies

Brad Doebbeling, MD, MSc 

VA Health Services Research & Development Center of Excellence

for Implementing Evidence-based Practice,  Regenstrief Institute, Inc, Department of Medicine, IU School of Medicine, 

Indianapolis, IN

Overview

Need for Healthcare Change 

Drivers of Change in VA

VA IT Infrastructure

Using HIT to Implement Evidence

Strategies 

RAND Study:Quality of Health Care Often Not Optimal

We provide appropriate health care only about half the time!

E. McGlynn, S. Asch, J. Adams, et al.,

The Quality of Health Care Delivered to Adults in the United States, N Engl J Med, 2003.

Percentage of time

Alcohol dependence

Hip fracture

Peptic ulcer

Diabetes

Low back pain

Prenatal care

Breast cancer

Cataracts

11%

23%

33%

45%

69%

73%

76%

79%

Implementation of Research Findings: “Debunked Assumption”

Changes in Practice

|----------------------------------17-18 Years----------------------------------|

Question

Hypothesis

Study

Publications

IOM, NAE and the IT Revolution

          - To Err Is Human (2000) drew attention to the importance of health professionals’ using IT to develop safer systems
          - Crossing the Quality Chasm (2001) elaborated on importance of IT to all aspects of health care:  administrative and financial transactions, clinical decision making, consumer health, public health, professional education, and research
          - Improving the Quality of Long-Term Care (2001) noted the importance of automated information systems in improving care in nursing homes
          - Health Professions Education (2003) articulated “using informatics” as one of five core competencies all health professionals need (Who Will Keep the Public Healthy, which also was published in 2003, listed informatics as a core competency for public health professionals
          - Keeping Patients Safe (2004) reaffirmed the importance of nurses as knowledge workers creating learning organizations supported by IT

Veterans AdministrationOrganizational and IT Infrastructure

VA’s Health Information System is “VistA”

VA runs 128 VistA systems 

Down from 172 VistA systems 10 years ago

180,000 PCs and thin clients

“CPRS” is the integrated EHR application

Delivers a complete hospital information system

	- Electronic health record

	- Imaging

	- Bar-code medication administration

Hardware, software, maintenance, upgrades, staffing

VA’s Health Information System is “VistA”

For FY2004:

Cost per enrollee

	- $78 / enrollee

Average cost per hospital (n=158)

	- $3.6 million

Success In Supporting Care Delivery For Millions Of Veterans 

VistA is a success

Built by “fire” of VHA collaboration

Publicly owned by VA

Strong interest by public/private in using VistA

National software w/ local flexibility/innovation:

Innovation developed locally & enterprise wide

Standard packages distributed enterprise wide

Articles About VA’s Info Technology & Quality Care

“ . . .  Overall, VHA patients receive better care than patients in other settings” 

Using HIT to Implement Evidence

Systematic Review: Impact of HITon Quality, Efficiency, and Costs of Medical Care

Most of high-quality literature regarding multifunctional HIT systems comes from 4 benchmark research institutions.

Little evidence available on effect of multifunctional commercially developed systems.

Little evidence available on interoperability and consumer HIT.

Chaudhry et al, Ann Intern Med. 2006;144:E-12-E-22.

HIT shown to improve quality by:- increasing adherence to guidelines,- enhancing disease surveillance, - decreasing medication errors.

Much evidence on QI relates to 1° and 2° preventive care.

Chaudhry et al, Ann Intern Med. 2006;144:E-12-E-22.

Systematic Review: Impact of HITon Quality, Efficiency, and Costs of Medical Care

Major efficiency benefit has been decreased utilization of care.

Effect on time utilization mixed.

Empirically measured cost data are limited and inconclusive.

Chaudhry et al, Ann Intern Med. 2006;144:E-12-E-22.

Systematic Review: Impact of HITon Quality, Efficiency, and Costs of Medical Care

Types of Clinical Decision Support Across VA (n=104) 

Fung & Doebbeling, Am J Manage Care 2004

Strategies

Examples of IT Implementation Innovationat Indy VAMC

Human factors observation of CR use, work.

Patient Handoff Template incorporating Key CPRS data designed, implemented and in use by house-staff. 

Implemented pharmacy use comparisons, benchmarked, electronic review, pharmacy consultation, substitution, that saved $4.3 M last year.

Saleem, Patterson and Asch, JAMIA., 2005 and ongoingFlanagan & Doebbeling, HSR&D RRP 2006Walsh et al, HSR&D 2006

“Priorities and Strategies for the Implementation of Integrated Informatics and Communications Technology to Improve Evidence-based Practice”

Doebbeling, Chou, Tierney JGIM 2006: S98-S105

Issues in IT Implementation

Managing Informatics

Clinician/Provider Issues 

Patient Issues 

Researcher Issues 

Enterprise-wide Issues 

Organizational Issues 

Human Factors Issues 

Doebbeling et al.  JGIM 2006

GAO Consensus Goals for IT Implementation 

1) Establish IT architectures and standardize formats 

    for data exchange; 

2) implement EHR for information integration; 

3) improve electronic communications and  

    documentation; 

4) address issues related to security, especially with

    increasing use of wireless networks and devices.

GAO. Use of Information Technology for Selected Health Care Functions.  2003.

Managing Informatics 

Different health care organizations have unique IT demands and existing applications.

Linkages between clinical and administrative data enhance quality and efficiency of care provision process and facilitate use of data for quality improvement.

When inter-organizational exchange occurs, IT management will center on secure and affordable information exchange. 

Doebbeling et al.  JGIM 2006

Clinician/Provider Issues 

Use of IT systems in patient care depends upon IT availability & acceptance by providers.

Clinicians desire a system that allows safe and efficient review and action.

Most important IT clinical applications likely include CPOE, clinical information systems, CDS, & bar coded medication management.

Role of the computer vs. physician, data accuracy, and user interface issues must be solved to realize full potential.

Doebbeling et al.  JGIM 2006

Administrators

Clinicians

Providers

Facilitators of

Computer Use

Informatics Technology For Clinical Guideline Implementation: 

Perceptions Of Multiple Stakeholders 

Lyons, Tripp-Reimer, ...& Doebbeling, JAMIA 2005

Evaluation

Decision Support

Patient Records

Startup Efforts

Accessible

Education

Computer Literacy

Patient Scheduling

Automation

Web Access

Available

User Friendly

Standard Format

Documentation

Essential Data

Guideline Sharing

Adherence	    Attitudes

Custom Fit Data     Data Quality

Local Adaptation

Providers' Assessment Regarding the Extent Their Hospitals Provide ITfor Key Dimensions of Practice

Doebbeling et al JAMIA (in review, 2006)

Patient Issues 

Patient-centered care is increasingly seen as an important dimension.

IT provides opportunities to enhance patient-provider interactions and patients’ use of their own health data.

IT empowers patients in their exchange with providers and promotes the alignment of care between hospital/clinics and patients’ home.

IT use gives patients additional tools to manage their illness.

Doebbeling et al.  JGIM 2006

Patient Issues 

Patients’ role is more significant as IT development accelerates and access to information and interface capability increases.

Devices useful in enhancing individually tailored disease management.

With emerging tech., patient’s participation is increasingly necessary to achieve IT-facilitated, evidence-based, patient-centered care. 

Doebbeling et al.  JGIM 2006

Researcher Issues 

New methods needed to gauge success in implementing IT.

For successful investigation of issues related to implementing evidence, there are a number of important data, computer hardware and human resource needs.

Need for research in -Developing and validating a coherent theoretical framework of organizational and provider behavior; behavioral and institutional change.-Sound evaluation methods to demonstrate impact of CPOE and CDS within health care systems. 

Doebbeling et al.  JGIM 2006

Need for IT Implementation and Process Reengineering Research 

Interventions to improve clinical efficiency.

Intervene to eliminate wasted effort, 

Best implementation of CDS and incorporation into patient care.

Demands on time prioritized to give contextually appropriate CDS as needed.

Prioritize CRs - most clinically important, just in time, and with the greatest supporting evidence. 

Need for IT Implementation and Process Reengineering Research 

Interventions to improve clinical efficiency.

Intervene to eliminate wasted effort, incorporate IT and teamwork into workflow.

How to best implement CDS and incorporate it into the processes of patient care.

Enterprise Wide Issues 

>50% of health care executives identified the top IT priority as implementation.

Lack of financial support for widespread IT implementation considered a primary barrier.

Incentives misaligned.

Successful implementation requires leadership, long-term commitment to improving health care processes, and working to involve clinicians and sustain productivity.

Doebbeling et al.  JGIM 2006

Enterprise Wide Issues 

IT tools, such as internet-based or CDS, has the potential to facilitate networking and benchmarking among collaborating organizations.

Using IT for clinical documentation and order entry provides improvement opportunity to processes of care and capture QI efforts into data warehouses to support EBPs.

IT systems used to document and generate performance measures can ease accreditation processes.

Doebbeling et al.  JGIM 2006

Organizational Issues 

Success dependent upon organizational factors.

Requires significant resource investment.

Major organizational change effort:  Many levels of personnel and system interaction and management.

Active involvement of interdisciplinary groups of providers and users. 

Knowledge sharing mechanisms (e.g. e-mail networks) enables participation.

Create ad hoc communities of practice:  share information re: effectively use, share best practices.

Doebbeling et al.  JGIM 2006

Human Factors Issues 

Prior experience, different implementation approaches, and differential utility of structured data entry.

Computer literacy and openness to change. 

Observe user – IT interactions, particularly in development phase.

Assess time spent in documenting care. 

Product usability, process complexity and user-engagement methods influence uptake.

Audit tool to measure variation from the software's recommendation. 

Doebbeling et al.  JGIM 2006

Thank You!

VA Health Services Research & Development Center of Excellence

for Implementing Evidence-based Practice

1481 W. 10th Street, Indianapolis, IN 46202

(317) 554-1775