Using Health Information Technology to Improve Care: Evidence and Strategies Brad Doebbeling, MD,...

Using Health Information Using Health Information Technology to Improve Care: Technology to Improve Care:

Evidence and StrategiesEvidence and Strategies

Brad Doebbeling, MD, MSc Brad Doebbeling, MD, MSc

VA Health Services Research & Development Center of ExcellenceVA Health Services Research & Development Center of Excellencefor Implementing Evidence-based Practice, for Implementing Evidence-based Practice,

Regenstrief Institute, Inc, Regenstrief Institute, Inc, Department of Medicine, IU School of Medicine, Department of Medicine, IU School of Medicine,

Indianapolis, INIndianapolis, IN

Overview

Need for Healthcare Change Need for Healthcare Change

Drivers of Change in VADrivers of Change in VA

VA IT InfrastructureVA IT Infrastructure

Using HIT to Implement EvidenceUsing HIT to Implement Evidence

Strategies Strategies

RAND Study:RAND Study:Quality of Health Care Often Not OptimalQuality of Health Care Often Not Optimal

We provide appropriate health care only We provide appropriate health care only about half the time!about half the time!

Percentage of timePercentage of time

Alcohol dependenceAlcohol dependenceHip fractureHip fracturePeptic ulcerPeptic ulcer

DiabetesDiabetesLow back painLow back painPrenatal carePrenatal careBreast cancerBreast cancer

CataractsCataracts

11%11%23%23%

33%33%45%45%

69%69%73%73%76%76%79%79%

E. McGlynn, S. Asch, J. Adams, et al.,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.The Quality of Health Care Delivered to Adults in the United States, N Engl J Med, 2003.

Implementation of Research Findings: Implementation of Research Findings: “Debunked Assumption”“Debunked Assumption”

Changes in PracticeChanges in Practice

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

QuestionQuestion

HypothesisHypothesis

StudyStudy

PublicationsPublications

IOM, NAE and the IT RevolutionIOM, NAE and the IT Revolution

Veterans AdministrationVeterans AdministrationOrganizational and IT Organizational and IT

InfrastructureInfrastructure

VA’s Health Information System is VA’s Health Information System is “VistA”“VistA”

VA runs 128 VistA systems VA runs 128 VistA systems Down from 172 VistA systems 10 years agoDown from 172 VistA systems 10 years ago 180,000 PCs and thin clients180,000 PCs and thin clients ““CPRS” is the integrated EHR applicationCPRS” is the integrated EHR application Delivers a complete hospital information systemDelivers a complete hospital information system

- Electronic health record- Electronic health record- Imaging- Imaging- Bar-code medication administration- Bar-code medication administration

Hardware, software, maintenance, upgrades, staffingHardware, software, maintenance, upgrades, staffing

VA’s Health Information System is VA’s Health Information System is “VistA”“VistA”

For FY2004For FY2004:: Cost per enrolleeCost per enrollee

- $78 / enrollee- $78 / enrollee Average cost per hospital (n=158)Average cost per hospital (n=158)

- $3.6 million- $3.6 million

Success In Supporting Care Delivery For Success In Supporting Care Delivery For Millions Of VeteransMillions Of Veterans

VistA is a successVistA is a success Built by “fire” of VHA collaborationBuilt by “fire” of VHA collaboration Publicly owned by VAPublicly owned by VA Strong interest by public/private in using VistAStrong interest by public/private in using VistA

National software w/ local flexibility/innovationNational software w/ local flexibility/innovation:: Innovation developed locally & enterprise wideInnovation developed locally & enterprise wide Standard packages distributed enterprise wideStandard packages distributed enterprise wide

Articles About VA’s Info Technology & Articles About VA’s Info Technology & Quality CareQuality Care

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

Using HIT to Implement EvidenceUsing HIT to Implement Evidence

Systematic Review: Impact of HITSystematic Review: Impact of HITon Quality, Efficiency, and Costs of on Quality, Efficiency, and Costs of

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

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


Systematic Review: Impact of HITSystematic Review: Impact of HITon Quality, Efficiency, and Costs of on Quality, Efficiency, and Costs of

Medical CareMedical Care

Major efficiency benefit has been decreased utilization of care.

Effect on time utilization mixed.

Empirically measured cost data are limited and inconclusive.


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 Innovation

at 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.Saleem, Patterson and Asch, JAMIA., 2005 and ongoingFlanagan & Doebbeling, HSR&D RRP 2006Flanagan & Doebbeling, HSR&D RRP 2006

Walsh et al, HSR&D 2006

““Priorities and Strategies for the Priorities and Strategies for the Implementation of Integrated Implementation of Integrated

Informatics and Communications Informatics and Communications Technology to Improve Evidence-Technology to Improve Evidence-

based Practicebased Practice””

Doebbeling, Chou, Tierney JGIM 2006: S98-S105

Issues in IT ImplementationIssues in IT Implementation

Managing InformaticsManaging Informatics Clinician/Provider Issues Clinician/Provider Issues Patient Issues Patient Issues Researcher Issues Researcher Issues Enterprise-wide Issues Enterprise-wide Issues Organizational Issues Organizational Issues Human Factors IssuesHuman Factors Issues

Doebbeling et al. JGIM 2006

GAO Consensus Goals for IT GAO Consensus Goals for IT Implementation Implementation

1)1) Establish IT architectures and standardize formats Establish IT architectures and standardize formats for data exchange; for data exchange;

2)2) implement EHR for information integration; implement EHR for information integration;

3)3) improve electronic communications and improve electronic communications and documentation; documentation;

4)4) address issues related to security, especially with address issues related to security, especially with increasing use of wireless networks and devices.increasing use of wireless networks and devices.

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

Managing Informatics Managing Informatics

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

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

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


Clinician/Provider Issues Clinician/Provider Issues

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

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

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

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


Administrators

EvaluationDecision SupportPatient RecordsStartup Efforts

Accessible

EducationComputer Literacy Patient Scheduling

AutomationWeb Access

AvailableUser Friendly

Standard FormatDocumentationEssential Data

Guideline SharingAdherence Attitudes

Custom Fit Data Data QualityLocal Adaptation

Clinicians Providers

Facilitators ofComputer Use

Informatics Technology For Clinical Informatics Technology For Clinical Guideline Implementation: Guideline Implementation:

Perceptions Of Multiple Stakeholders Perceptions Of Multiple Stakeholders

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

Providers' Assessment Regarding the Providers' Assessment Regarding the Extent Their Hospitals Provide ITExtent Their Hospitals Provide IT

for Key Dimensions of Practicefor Key Dimensions of Practice

0.46

0.22

0.99

0.84

0.98

0

0.41

0.15

0.98

0.73

0.9

0.29

0.97

0.79

0.86

0.5

0.59

0.95

0.62

0.95

0.070.04

0.47

0.04

0

0.2

0.4

0.6

0.8

1

1.2

Access toLiterature/Evidence

Based Medicine WhileDelivering Care

Computer AssistedDecision Support

Systems

Computerized PatientClinical Data

Automation ofDecisions to Reduce

Errors

ElectronicCommunication

between Providers

ElectronicCommunication

between Providers andPatients

Perc

ent o

f Hos

pita

ls w

ith A

vera

ge R

espo

nse

of G

reat

or V

ery

Gre

at (>

3.5

)

Overall

Physician

PA/NP

Nurse

Doebbeling et al JAMIA (in review, 2006)

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

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

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

IT use gives patients additional tools to manage their illness.IT use gives patients additional tools to manage their illness.


Patient Issues Patient Issues

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

Devices useful in enhancing individually tailored Devices useful in enhancing individually tailored disease management.disease management.

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


Researcher Issues Researcher Issues New methods needed to gauge success in implementing IT.New methods needed to gauge success in implementing IT.

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

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


Need for IT Implementation and Need for IT Implementation and Process Reengineering ResearchProcess Reengineering Research

Interventions to improve clinical efficiency.Interventions to improve clinical efficiency.

Intervene to eliminate wasted effort, Intervene to eliminate wasted effort,

Best implementation of CDS and incorporation Best implementation of CDS and incorporation into patient care.into patient care.

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

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

Need for IT Implementation and Need for IT Implementation and Process Reengineering ResearchProcess Reengineering Research

Interventions to improve clinical efficiency.Interventions to improve clinical efficiency.

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

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

Enterprise Wide Issues 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.


Enterprise Wide Issues Enterprise Wide Issues

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

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

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


WishardHealth Service

ClarianHealth Partners

CommunityHospitals Indnpls

St. FrancisHospitals

St. VincentHealth Service

RoudebushVAMC

Security

Global PatientIndex

Global ProviderIndex

Data Dictionary

Indianapolis Network for Patient Care

Security

IndianaMedicaid

Marion CountyHealth Department

RxHub Lab Corp Indiana StateCancer Registry

VeteransInformationSystem andTechnologyArchitecture

(VISTA)

IRB- ApprovedResearch

CredentialedProviders

Sec

uri

ty

CredentialedProviders

State MedicareData

Figure 1

Organizational IssuesOrganizational Issues

Success dependent upon organizational factors.Success dependent upon organizational factors. Requires significant resource investment.Requires significant resource investment. Major organizational change effort: Many levels of personnel and system Major organizational change effort: Many levels of personnel and system

interaction and management.interaction and management. Active involvement of interdisciplinary groups of providers and users. Active involvement of interdisciplinary groups of providers and users. Knowledge sharing mechanisms (e.g. e-mail networks) enables participation.Knowledge sharing mechanisms (e.g. e-mail networks) enables participation. Create Create ad hocad hoc communities of practice: share information re: effectively communities of practice: share information re: effectively

use, share best practices.use, share best practices.


Human Factors IssuesHuman Factors Issues Prior experience, different implementation approaches, and Prior experience, different implementation approaches, and

differential utility of structured data entry.differential utility of structured data entry. Computer literacy and openness to change. Computer literacy and openness to change. Observe user – IT interactions, particularly in development phase.Observe user – IT interactions, particularly in development phase. Assess time spent in documenting care. Assess time spent in documenting care.

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

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


Thank You!Thank You!

VA Health Services Research & Development Center of ExcellenceVA Health Services Research & Development Center of Excellencefor Implementing Evidence-based Practicefor Implementing Evidence-based Practice1481 W. 101481 W. 10thth Street, Indianapolis, IN 46202 Street, Indianapolis, IN 46202

(317) 554-1775(317) 554-1775

Using Health Information Technology to Improve Care: Evidence and Strategies Brad Doebbeling, MD,...

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