PITAC BFG CC NOV 2003

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The Role of Health Information Technology in
Improving Health Care Quality and Patient Safety
Carolyn M. Clancy, MD Director 2004 HIMSS
Annual Conference February 24, 2004
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We have wonderful technology, but some grocery
stores have better technology than our hospitals
and clinics.
Secretary Tommy Thompson Chicago Medical School
Commencement June 7, 2002
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Overview

• Patient safety and quality of care
• Role of HIT in quality improvement
• Opportunities and challenges

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RAND Study Quality of Health Care Often Not
Optimal
Medical errors corrode quality of healthcare
system
Medical Care Often Not Optimal Failure to Treat
Patients Fully Spans Range of What Is Expected of
Physicians and Nurses
Study U.S. Doctors are not following the
guidelines for ordinary illnesses
The American healthcare system, often touted as a
cutting-edge leader in the world, suddenly finds
itself mired in serious questions about the
ability of its hospitals and doctors to
deliver quality care to millions.
.
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New York Times, December 18, 2002
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Patient Safety Achieving A New Standard For Care

• Americans should be able to count on receiving
  health care that is safe..This requires, first,
  a commitment by all stakeholders to a culture of
  safety, and, second, improved information
  systems.
• Institute of Medicine, 2003

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RAND Study Quality of Health Care Often Not
Optimal

• Doctors provide appropriate health care only
  about half the time

Percentage of 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
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NHQR Missed Opportunities

• Only 20.9 of patients with diabetes receive all
  recommended tests
• 90 of adults are screened for high blood
  pressure but only 25 are controlled
• Nearly 1/3 of adults and children with asthma do
  NOT receive effective Rx
• Almost 20 of persons with a usual source of care
  report that they are not asked about medications
  to prevent interactions

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Percent of Americans Saying I Have A Chronic
Condition

Chronic Illness and Caregiving Survey, Harris
2000
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Improving Quality and Safety
We need to make the right thing the easy
thing Mark Chassin, MD October 12, 2000
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Overview

• Patient safety and quality of care
• Role of HIT in quality improvement
• Opportunities and challenges

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How can we use Health Information Technology
(HIT) to improve care?

• Tools to improve health care
• Electronic health records (EHR), e-prescribing,
  decision support, CPOE
• Share needed information
• Connectivity and interoperability
• Organizational and financial systems
• Bed flow, test result management

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IT Can Improve Quality

• Timeliness mothers receiving computer-generated
  reminders had 25 higher on-time immunization
  rate for their infants (Alemi)
• Efficiency 9 of redundant lab tests at a
  hospital could be reduced using a computerized
  system (Bates)
• Equity if available, access to internet-based
  health information could help to reduce
  disparities and access to needed health services

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Potential of IT for Enhancing Quality

• IT can enhance the precision and decrease the
  cost of measurement i.e., getting to the
  right measures
• IT can also enhance translation of strategies to
  improve quality (e.g., decision support)
• IT can greatly enhance the timeliness of data
  collection

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Potential is what you have when you havent done
it yet Darrel Royall University
of Texas Football coach
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IT Impact on Quality and Safety

• Outpatient Advanced CPOE and EMR
• Avoid 2.1 million adverse drug events per year
  (national adoption)
• Inpatient CPOE and EMR
• Decrease serious medication errors by 55
• Healthcare information exchange and
  interoperability between settings
• Improve physician decision-making at the
  point-of-care through complete information access

Source CITL
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Safety

• Computerized order entry systems can reduce
  medication errors
• Improve drug prescribing
• Improve drug dosing
• Drug-drug interactions
• Drug allergies
• Bates et al. JAMA. 1998 Bates et al. J Am Med
  Inform Assoc. 1999 Teich et al. Arch Intern
  Med. 2000 IOM Report. 1999 Leapfrog Group.
  2000.

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IT Patient Safety Practices by Strength of
Evidence

• High evidence
• Use of computer monitoring for potential ADEs
• Information transfer between inpatient and
  outpatient pharmacy
• Medium evidence
• use of CPOE with decision support
• Lower evidence
• use of automated medication dispensing

Making Health Care Safer A Critical Analysis of
Patient Safety Practices, AHRQ, July 2002
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Knowledge Gaps

• Research limited to a small number of sites
• Inpatient setting
• Limited data on important outcomes
• Adoption and implementation
• Incentives
• Barriers
• Workflow
• Efficiency and effectiveness
• Resources
• New technology and applications

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Costs

• Electronic medical records with decision support
  can reduce costs
• Reduce medical errors and adverse events
• Recommend equally effective but less costly
  alternative interventions
• Reduce the use of inappropriate tests
• Reduce the ordering of redundant tests
• Teich et al. Arch Intern Med. 2000 Bates
  et al. JAMA. 1997 Evans, et al. Ann
  Pharmacother 1999. Glaser et al. Proc Healthcare
  Information and Management Systems Society Annual
  Conf. 1996

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Effectiveness

• Computerized reminders can improve effectiveness
  and quality of care
• Preventive services
• Use of appropriate medications
• Use of antibiotics
• Prevention of venous thromboembolism
• Use of other interventions
• Shea et al. J Am Med Inform Assoc. 1996 Hunt et
  al. JAMA. 1998
• Evans et al. N Engl J Med. 1998 Durieux et al.
  JAMA. 2000
• Teich et al. Arch Intern Med. 2000

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Patient-Centered Care

• Information technology can support
• Communication
• Clinical knowledge
• Online support groups
• Decreased hospitalizations and shorter lengths of
  stay
• Improve health care outcomes
• Improved quality of life
• Gustafson et al. Am J Prev Med. 1999

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Building the Evidence Base for HIT

• Electronic Health Records
• Shared Online Health Records for Patient Safety
  and Care
• Clinical Decision Support
• Automated Lab Test Follow-up to Reduce Medical
  Errors
• Electronic Prescribing
• Error rates and prescribing practices in
  pediatric clinics
• Use of hand-held devices
• Acceptance, benefits, and barriers in the use of
  hand-held decision support systems in ambulatory
  settings
• Consumer use of the Internet
• Parent-Initiated Prevention Program

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AHRQ Case Study Computerized ICU System and
Nursing Care

• Computerized medical information management
  system in hospital intensive care units (ICU)
  significantly reduced time ICU nurses spent on
  documentation

?
Nurses were able
to complete more tasks without
interruption
52 minutes saved in an 8-hour shift
D. Wong, Y. Gallegos, M. Weinger, et al., Changes
in intensive care unit nurse task activity after
installation of a third-generation intensive care
unit information system, Critical Care Medicine,
2003
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Ambulatory CPOE

• The Center for Information Technology Leadership
  estimates that implementing advanced ambulatory
  CPOE systems would
• Eliminate over 2 million ADEs/year
• Avoid nearly 1.3 million physician visits,
  190,000 admissions, and over 130,000
  life-threatening adverse drug events/year.
• Nationwide adoption of advanced CPOE systems in
  the outpatient setting save 44 billion/year (60
  medications, 24 radiology, 11 labs, and 5
  ADEs.

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National Cost Saving projections from Ambulatory
CPOE 44 billion
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IT and Research

• Identify and prioritize critical questions e.g.,
  clinical variations as a reflection of inadequate
  knowledge
• Accelerate collection of relevant data
• Facilitate consistent measurement of key outcomes
• Enhance participation of communities and
  stakeholders
• Reinvent dissemination and translation

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Overview

• Patient safety and quality of care
• Role of HIT in quality improvement
• Opportunities and challenges

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How has practice changed?
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The CPR Adoption GapThe United States Versus
Others
Primary Care Physician Office CPR Use by
Country, 2002
Source "European Physicians Especially in
Sweden, Netherlands, and Denmark, Lead U.S. in
Use of Electronic Medical Records." Harris
Interactive Health Care News 2(16).
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The Costs/Value of IT

• Significant capital investment for the purchase
  and installation
• Limited data on return of investment for IT -- is
  there a business case for quality?
• The "opportunity cost" of physician time and use
  of IT have not been determined.
• Economic impact uncertain -- hard to track all
  costs and savings following IT adoption (diffuse
  and indirect)

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Information Management Problems

• Physician and Nursing Inefficiencies
• Physician time spent on paperwork 38
• Paper forms to fill in gt 20,000/yr/MD
• Cost of transcription gt 10,000/yr/MD
• Nurse time spent on paperwork 50
• Clinic Workflow Problems
• Charts missing 30 of encounters
• Tests duplicated 11 because results lost
• Cost to find and file a chart 5-25
• Medical Management Problems
• Errors illegible prescriptions, miscommunication
  with patients, incomplete data for consultants

MedicaLogic, 2001, White Paper Establishing a
Business Case for EMR www.medicalogic.com
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Challenges to HIT Diffusion

• Absence of clear ROI.
• High costs and significant capital investment for
  the purchase and installation
• The opportunity costs of physician time has not
  been assessed
• Limited data on return of investment for HIT --
  is there a business case for quality?
• Preliminary estimates promising
• Does it get us to the map of incentives that we
  need?
• New AHRQ evidence report under development

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Current and Future Initiatives

• Increased emphasis on
• Integration of diffusion strategies and
  classical research
• Exploring and overcoming the barriers to HIT
  adoption
• Understanding the value of HIT
• Defining not only the business case but the
  safety and quality case for HIT

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Medicare Prescription Drug, Improvement, and
Modernization Act of 2003

• Health IT Provisions
• Electronic Prescription Program
• Grants to Physicians ePrescribing systems
• Telemedicine Demonstrations Projects
• Medicare Care Management Performance
  Demonstration
• Council for Technology and Innovation
• Commission on Systemic Interoperability

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FY 04 HIT Investment

• 60M initiative
• 26M to implement proven technologies in small
  and rural communities where HIT penetration has
  been low
• 24M targeted for developing, implementing, and
  evaluating the use of new and innovative
  technologies to improve patient safety and
  quality of care in diverse health care settings.
  
• 10M targeted for clinical data standards and
  interoperability

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AHRQs HIT Portfolio

• Research portfolio related to the development,
  evaluation, and diffusion of HIT in clinical
  settings
• Emphasis on the role of HIT in patient safety
• Clinical Informatics to Promote Patient Safety
  (CLIPS)
• HIT grants/contracts
• FY01 18.4M
• FY02 21.8M
• FY03 11.6M
• FY04 60M

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FY04 Transforming Healthcare Quality through HIT

• Current and Planned AHRQ initiatives
• 3 Grant Solicitations
• Health IT Resource Center
• Indian Health Service EHR Collaboration
• CMS AHRQ Collaboration

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Transforming Healthcare through HIT (THQIT)

• Grant Solicitations
• Determining the Value of HIT 10M
• assess the value derived from the adoption,
  diffusion, and utilization of HIT
• THQIT Planning 7M
• assist healthcare systems and their partners in
  planning for activities that will lead to
  successful HIT implementation
• THQIT Implementation 24M
• support organizational and community-wide
  implementation and diffusion of HIT
• http//www.ahrq.gov/fund/grantix.htm

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HIT Community Partnerships

• Definition of partnerships Collaborative
  working relationship between three or more
  organizations through a written agreement.
  Agreements must include the following elements
• Substantial and meaningful contributions of
  personnel, expertise, money, equipment,
  facilities or other resources to and from each
  partner.
• Sharing of clinical and research data across
  sites.

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Public-Private PartnershipsNew HIT Leap

• Ambulatory Safety/Quality Task Force
• Agency for Healthcare Research and Quality (AHRQ)
• Centers for Medicare and Medicaid Services (CMS)
• Leapfrog Group
• Goal
• To promote the adoption of a set of information
  technology-based systems for physician offices
  which have the potential to immediately improve
  safety and quality of care and which catalyze
  progress toward more robust electronic systems of
  clinical decision support and data exchange

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Physician Office Decision Support (PODS)

• Leap to Catalyze Adoption of Clinical Information
  Systems in Physician Offices
• Summary Statement of Leap Better, safer care for
  patients through electronic prescribing, lab
  results management, and care reminders

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Secretary ThompsonMarch 21, 2003

• In the modern era, every century has had its
• major advance that has brought medical
• science another giant step forward. . What will
  
• the major advance of the 21st century be?
• I am convinced that the medical revolution
• of our childrens lifetimes will be the
• application of information technology to
• health care.

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• For additional questions, please contact
• Dr. Carolyn Clancy
• cclancy_at_ahrq.gov