Title: Using Health Information Technology to Improve Care: Evidence and Strategies
1Using 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
2Overview
- Need for Healthcare Change
- Drivers of Change in VA
- VA IT Infrastructure
- Using HIT to Implement Evidence
- Strategies
3RAND 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.
4Implementation of Research Findings Debunked
Assumption
Changes in Practice
----------------------------------17-18
Years----------------------------------
5IOM, NAE and the IT Revolution
6Veterans AdministrationOrganizational and IT
Infrastructure
7VAs 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
8VAs Health Information System is VistA
- For FY2004
- Cost per enrollee
- - 78 / enrollee
- Average cost per hospital (n158)
- - 3.6 million
9Success 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
10Articles About VAs Info Technology Quality Care
11Using HIT to Implement Evidence
12Systematic 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.
13Systematic 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.
14Systematic 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.
15Types of Clinical Decision Support Across VA
(n104)
Fung Doebbeling, Am J Manage Care 2004
16Strategies
17Examples 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
18Priorities and Strategies for the Implementation
of Integrated Informatics and Communications
Technology to Improve Evidence-based Practice
Doebbeling, Chou, Tierney JGIM 2006 S98-S105
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20Issues 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
21GAO 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.
22Managing 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
23Clinician/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
24Informatics Technology For Clinical Guideline
Implementation Perceptions Of Multiple
Stakeholders
Facilitators of Computer Use
Administrators
Clinicians
Providers
Lyons, Tripp-Reimer, Doebbeling, JAMIA 2005
25Providers' Assessment Regarding the Extent
Their Hospitals Provide ITfor Key Dimensions of
Practice
Doebbeling et al JAMIA (in review, 2006)
26Patient 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
27Patient 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
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29Researcher 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
30Need 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.
31Need 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.
32Enterprise 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
33Enterprise 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
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35Organizational 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
36Human 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
37Thank You!
VA Health Services Research Development Center
of Excellence for Implementing Evidence-based
Practice 1481 W. 10th Street, Indianapolis, IN
46202 (317) 554-1775