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Using Health Information Technology to Improve Care: Evidence and Strategies

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Title: Using Health Information Technology to Improve Care: Evidence and Strategies


1
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
2
Overview
  • Need for Healthcare Change
  • Drivers of Change in VA
  • VA IT Infrastructure
  • Using HIT to Implement Evidence
  • Strategies

3
RAND StudyQuality 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.
4
Implementation of Research Findings Debunked
Assumption
Changes in Practice
----------------------------------17-18
Years----------------------------------
5
IOM, NAE and the IT Revolution
6
Veterans AdministrationOrganizational and IT
Infrastructure
7
VAs 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

8
VAs Health Information System is VistA
  • For FY2004
  • Cost per enrollee
  • - 78 / enrollee
  • Average cost per hospital (n158)
  • - 3.6 million

9
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

10
Articles About VAs Info Technology Quality Care
11
Using HIT to Implement Evidence
12
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.
2006144E-12-E-22.
13
Systematic Review Impact of HITon Quality,
Efficiency, and Costs of Medical Care
  • 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.
2006144E-12-E-22.
14
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.
2006144E-12-E-22.
15
Types of Clinical Decision Support Across VA
(n104)
Fung Doebbeling, Am J Manage Care 2004
16
Strategies
17
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, HSRD RRP
2006Walsh et al, HSRD 2006
18
Priorities and Strategies for the Implementation
of Integrated Informatics and Communications
Technology to Improve Evidence-based Practice
Doebbeling, Chou, Tierney JGIM 2006 S98-S105
19
(No Transcript)
20
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
21
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.
22
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
23
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
24
Informatics Technology For Clinical Guideline
Implementation Perceptions Of Multiple
Stakeholders
Facilitators of Computer Use
Administrators
Clinicians
Providers
Lyons, Tripp-Reimer, Doebbeling, JAMIA 2005
25
Providers' Assessment Regarding the Extent
Their Hospitals Provide ITfor Key Dimensions of
Practice
Doebbeling et al JAMIA (in review, 2006)
26
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
27
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., patients participation is
    increasingly necessary to achieve IT-facilitated,
    evidence-based, patient-centered care.

Doebbeling et al. JGIM 2006
28
(No Transcript)
29
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
30
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.

31
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.

32
Enterprise Wide Issues
  • gt50 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
33
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
34
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35
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
36
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
37
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
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