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The Reason We’re All Here …

Introduction

We began our week with an overview of variation in healthcare and its key role in quality and patient safety. We also discussed measurement, data and the use of statistical tools.

This session will focus on the role of Information Technology as well as the use of leadership tools to create organizational alignment around key goals.

Week Two – What is Next?

Got a Wicked Problem?

This is a reminder to view the bonus video this week!

This is a fun way to explore how to look at our work as a process!

HCA 622 Week Two Roadmap

√ Please read Chapters in the required text prior to our class

√ In order to get the most out of the course, pace yourself by completing something everyday

√ Catch up as needed over the weekend

√ All graded assignments must be turned in no later than Sunday at midnight PT each week

HCA: 622 Quality Appraisal and Evaluation– WEEK TWO ROADMAP
	Monday	Tuesday	Wednesday	Thursday	Friday	Sat/Sun
Themes	Variation for Medical Practice, Data Collection, Statistical Tools	IT, Dashboards and Scorecard: Tools for Creating Alignment, Quality Infrastructure (Optional)
Readings	Read Chapters 3, 5, 6, 13, 10, (15 – Optional) in required text
Film Festivals
Discussion Questions		Complete DQ3		Complete DQ4
Reflection Journal			Reflection Journal Entry #1		Reflection Journal Entry #2
Assessments						Complete Quiz #2
Case Studies					Week Two Paper Due
Course project

Chapter 13: Information Technology:
Implications for Healthcare Quality
Chapter Outline

Healthcare IT Infrastructure and Information Systems
Electronic Health Record (EHR) Systems
Privacy and Security
HITECH Act and Health Reform
EHRs and Quality Reporting
Telemedicine and Mobile Health
Health IT for Consumers
Keys to Successful Implementation and Lessons Learned

As part of our review, we will look at the history of Information Technology (IT) in healthcare, the infrastructure, the key role of electronic health records (EHR), the most important legislation that is setting the foundation for the future use of IT, and a review of the some of the applications for the future.

Introduction

“The Institute of Medicine (IOM) report - Patient Safety:

Achieving a New Standard for Care (2003b) asserted that, to achieve the six aims of healthcare improvement set forth in Crossing the Quality Chasm (IOM 2001), “a new health care delivery system is needed—a system that both prevents errors and learns from them when they occur. This requires, first, a commitment by all stakeholders to a culture of safety, and, second, improved information systems” (IOM 2003b, 45).

One of the key recommendations that came out of the IOM in the Crossing the Quality Chasm report was that first, a commitment to improving patient safety must be in place and second, improved information systems.

Once again, we see the seminal reports from the IOM setting the stage for the future of health care.

Long History of Adoption of HIS and Technology

Development of HIS actively pursued since 1960s
Early beginnings
Early healthcare computing used large, water-cooled mainframes
Focused on finance and accounting applications
1970s
Advent of air-cooled minicomputers
Early hospital information systems were charge capture systems to feed financial systems

The beginning of what we know today as Information Technology (IT) in health care, really began in the 1960s led by the administrative and financial needs for data, primarily for billing purposes.

Long History of Adoption of HIS and Technology

1980s
Era of the mini-computers
Automation became more affordable
Software vendors emerged – by specialty!
Niche ancillary clinical systems emerged
Laboratory, radiology, pharmacy
“Best of breed” systems
Healthcare organizations began to integrate in-house developed systems with vendor-supplied
Early clinical information systems developed by VA, a few other pioneer organizations

This focus continued on with modifications for the advent of “mini” computers and advancing uses for technology solutions.

Starting in the 1980s, technology grew in specialty areas in health care such as Lab and Radiology and there was early work done by the VA system to begin to develop clinical information support systems.

Long History of Adoption of HIS and Technology

1990s
Number and types of healthcare organizations implementing HIS expanded
Advent of www. – the Internet
Federal government enacted Health Insurance Portability and Accountability Act (HIPAA)
To protect security and privacy of citizens’ data
Sweeping effects

By the 1990s, especially with the advent of the Internet, there were numerous vendors and different uses of advancing technologies emerging in healthcare.

Because of the exponential growth in the use of technology, we saw the beginnings of the support from a legislative standpoint with the passing of the HIPPA legislation to address the security and privacy of patient information.

Long History of Adoption of HIS and Technology

2000s
IOM reports
Healthcare organizations building comprehensive HIS architectures with intent of improving quality and efficiency of care
Regulatory emphasis on HIS: ARRA and HITECH
2010s
Pursuing Meaningful Use
Agenda: improve efficiency and quality of health care

Following the IOM reports in the early 2000s, there was wide-spread emergence of clinical applications driven by legislation to encourage implementation of EHRs with the focus on improving the quality and patient safety of care, access to care and the reduction of cost.

In 2010, with the introduction of the Meaningful Use mandates, technology really stepped to the forefront of moving the quality and patient safety agenda forward.

Challenges in Adoption of HIS and Technology in Health Care

Contrast stark between promise and reality of HIS create barriers to adoption
Difficult to change how patients are cared for
EHR benefits often ambiguous
Mismatch between concept of computers making work easier and actual activities of those who end up doing that work
Physicians complaint: EHRs hamper productivity
High up-front capital costs to implement
Instability amongst vendor companies

As with any long-standing model, the use of technology, specifically the implementation of EHRs faced challenges. These challenges included:

A multitude of vendors with different products and approaches to the EHR process;
The high cost of implementation both in terms of infrastructure as well as training and implementation;
A lack of enthusiasm on the part of providers to change their workflows and complaints about how implementation changed their key processes of care and documentation habits.

Healthcare IT Infrastructure and Information Systems

Infrastructure – Very Expensive!!
Technical infrastructure: computers and cables
Internet: regional high-speed networks
Recently, technology has been outsourced to specialized firms that manage equipment in their own facilities.
“Cloud computing”
Information Systems
Financial/administrative
Clinical/patient management
Data analytics

Electronic Health Record Systems

Primary uses of EHRs
Patient care delivery
Patient care management
Patient care support processes
Financial and administrative purposes
Patient self-management
Secondary uses of EHRs
Education
Regulation
Public health and homeland security*
Policy support

The implementation and use of EHRs had both very practical uses as well as the opportunity to improve care and safety.

Primary uses include the easy access to patient data and patient care management, patient care support processes and financial uses, and the opportunity for patients to have easy access to their own care information.

In addition, there was a key focus for the widespread uses of EHRs including their use for education, regulation, public health and homeland security and public policy and research.

Electronic Health Record Systems

Institute of Medicine: Eight core functions of EHRs (Improving Quality/Patient Safety)

Health information and data storage

Result management

Order management

Decision support

Electronic communication and connectivity

Patient support

Administrative processes and reporting

Reporting and population health

Vendor evaluation/IT Planning*

Patient Safety – ie. drug interactions

The IOM laid out eight key functions for EHRs to enhance care and safety to include: data storage, decision-support - including order management, enhanced communication across care settings, patient support, patient safety enhancement and administrative and billing functions.

Electronic Health Record Systems

This graphic demonstrates how we collect data from our key patient care processes, and then utilize it to study how we can produce better outcomes and for our ongoing evaluation of quality and safety.

This is a closed-loop that is focused on using the data for ongoing improvement or care, desicion-making and safety.

Information Technology Applications for Improved Quality

Requirements and Architecture Framework for Clinical Information Technology

According the Institute of Medicine (IOM), electronic records should support the following high-level functions:

Physician access to patient information, such as diagnoses, allergies, lab results, and medications

Access to new and past test results among providers in multiple care settings

Computer order entry

Electronic records support high-level functions that allow for physician access to all key patient information, past and present, computerized order entry, secure communications and enhanced admirative functions and patient access

Information Technology Applications for Improved Quality

Requirements and Architecture Framework for Clinical Information Technology (cont.)

Computerized decision-support systems to prevent drug interactions and improve compliance with best practices

Secure electronic communication among providers and patients

Patient access to health records, disease management tools, and health information resources

Computerized administration processes, such as scheduling systems

Standards-based electronic data storage and reporting for patient safety and disease surveillance efforts

. One of the core applications to improve quality and safety includes access to evidence-based best practices for decision-making and support of patient safety.

Information Technology Applications for Improved Quality

This graphic depicts the use of a “data warehouse”.

A data warehouse if a virtual warehouse where data can be stored and accessed to promote use across several settings of care.

Key Functions:
Order Management and Clinical Decision Support

Order management has tremendous potential benefits
Computerized provider order entry (CPOE)
Clinical decision support (CDS)
Medication management
Barcode medication administration
Medication reconciliation

Connectivity: Health Information Exchange
and Patient Support

Health information exchange (HIE)
Several models:
Point to point
Hub and spoke
Central repository
Integrated health exchange
HIE is often used to connect disparate EHR systems within large integrated delivery systems.
Accountable care organizations will establish a “private” HIE to facilitate the coordination of care for their shared patient population.
I.e. Kaiser!

A key feature for the enhancement of care through the use of an EHR is access to care information across all care settings regardless of distance or time of day.

This “interoperability” allows physicians to access a patient’s information, for example, if a patient is on vacation in Florida and has an accident – the ED physician can access the patients information to better plan for care in consideration of the patients pre-exiting conditions, medication usage and other key information.

This type access can enhance immediate care with the best information.

Connectivity

“The good news and the bad news!”
“Interoperability!”

Personal Health Records and Patient EHR Portals

Personal health records (PHRs) extend the reach of EHRs to consumers of healthcare.
Patients are able to access their clinical information, browse relevant educational content, schedule an appointment with their physician, receive reminders for preventive and other health maintenance services, request prescription refills, and securely exchange messages with members of the care team.

This also allows for the patient to have access to their care information in order to create a “care partnership” between the patient and their physician.

Privacy and Security

Health Insurance Portability and Accountability Act (HIPAA)
HIPAA Privacy Rule: Regulates the use and disclosure of protected health information (PHI)
HIPAA Security Rule: Deals specifically with PHI stored in an electronic medium
Requires three classes of safeguards: administrative, physical, and technical

Beginning in 1996, with the passage of the Health Insurance Portability and Accountability Act (HIPAA), the federal government introduced a series of key bills that laid the groundwork for the widespread, imperative use of EHRs.

HITECH Act and Health Reform

“Decade of Health Information Technology”
A period of unprecedented federal support for the adoption of information technology in the clinical domain
2004: Establishment of the Office of the National Coordinator for Health Information Technology (ONC)
2009: HITECH Act and EHR incentive program
HITECH established a formal incentive program for the adoption of EHRs.

In 2009, the HITECH Act and EHR incentive program was initiated with quality reporting as a core dimension of the bill.

An ideal model representing “interoperability”.

EHRs and Quality Reporting

Before EHRs, extraction of data required for producing quality reports relied on manual chart abstraction and use of claims.
HITECH Act established quality reporting as a core dimension of the EHR incentive program.
Meaningful use framework

Table 7.1: Summary of Meaningful Use Criteria Stages 1, 2, and 3

Reproduced from healthit.gov. (n.d.). EHR incentives and certification:

How to attain Meaningful Use. http://www.healthit.gov/ providers

-professionals/how-attain-meaningful-use

Through the Meaningful Use framework, the bill incentived hospitals and physician practices to implement EHRs; required the use of core data definitions for all of the EHRs no matter who the vendor was; and created the framework for the “meaningful use” of the data collected to enable advanced clinical processes such as e-prescribing and connectivity across multiple care settings.

It also established criteria for the use of the collected data from the EHRs for use for evaluating care, outcomes, cost and other key criteria for use in benchmarking organizations, and creating a “pay-for-performance model” based on the quality and safety of the care provided.

Stats! – Then!

“Despite the recommendations in the IOM reports and general advocacy for EHRs among quality and patient safety experts, adoption of EHRs was superficial at the turn of the twenty-first century:
(2006) Studies found that approximately 23.9 percent of physicians used EHRs in the ambulatory setting;
5 percent of hospitals used CPOE;
(2009) Adoption of EHRs by hospitals and determined that fewer than 2 percent of acute care hospitals had a comprehensive EHR system;
between 8 and 12 percent had a “basic” EHR system.

The implementation and use of EHRs was slow to start, but bolstered by incentives, is now in widespread use across all settings of care.

STATS - Now!!!!

https://dashboard.healthit.gov/quickstats/quickstats.php

EHRs and Quality Reporting

HITECH Act established quality reporting as a core dimension of the EHR incentive program.
Meaningful use framework
Standardized definitions and systems – INTEROPERABILITY!

Telemedicine and Mobile Health

Health information technology plays an important role in the expansion of care delivery.
Telemedicine – the application of telecommunications technology to provide clinical services at a distance
Two types of interactions:
Asynchronous: information transmitted or exchanged is not real time (e.g., teleradiology, clinical communications similar to e-mail)
Synchronous: information is transmitted or exchanged in real time (e.g., telephonic consultations, remote patient monitoring)

The potential use of IT in health care is being created before our eyes – with telemedicine and mobile health, patients’ easy access to their care information and support services, as well as the opportunities for new applications to make care safer.

Telemedicine and Mobile Health

Mobile health – health information technology applications residing on mobile devices, such as cell phones and tablets

Health IT for Consumers

Personal health records
Patient EHR portals
Health-related informational websites
Peer-health websites
Healthcare-related apps
Social media

A continual focus on supporting consumer use of IT in health care is of vital importance moving forward.

Information Technology Applications for Improved Quality

Computerized decision-support systems to prevent drug interactions and improve compliance with best practices

Secure electronic communication among providers and patients

Patient access to health records, disease management tools, and health information resources

Computerized administration processes, such as scheduling systems

Standards-based electronic data storage and reporting for patient safety and disease surveillance efforts*

This slide addresses additional important application of technology for quality and safety.

Information Technology Applications for Improved Quality

Workflow Automation Technology Applied to Clinical Processes

Improvements in processes of care

Improvements in change management

The People-Process-
Technology Paradigm

“Hand and Glove”

You Can Not Fix

a Process

with Technology!

An important reminder – we must evaluate our key processes before we automate them.

Automating a broken process only exacerbates any risk issues in the process.

Technology must be a configuration of people, processes and technology to be successful!

Information Technology Applications for Improved Quality

Other Clinical Information Technology Components

Telemedicine

Rules servers

Clinical vocabulary servers

Patient surveys

Evaluation of systems

“Making It Easy to Do the Right Thing, Hard to Do the Wrong Thing!”

A reminder that technology, when well thought out, can enhance all we do in patient safety to “make it easy to do the right thing and hard to do the wrong thing”!

Keys to Successful Implementation and
Lessons Learned

Organizational and cultural considerations
Readiness for change*
Attentiveness to organizational structure
Project leadership based on partnership between clinical and technology stakeholders
Formal integration of clinicians into the information services organization
*Project Management!

As future health care leaders, some of the key success factors for this broadened use of technology include:

creating an organization whose culture is open to changes;
working to assure that clinicians are a part of the planning and implementation process; and
assuring that resources can anticipate and support new and emerging technologies.

Quality and Safety Leadership (Everyone!)

All leaders and those involved in patient safety play key roles in design and implementation of HIS
Definition of quality metrics, data elements to populate those measures
And to build these data elements into clinical workflow
Ensure quality and performance measures woven into fabric of workflows and systems

Get

Involved!!!!

In addition to these factors, for those leaders who are not an active part of the IT processes in your organizations – find a way to be a part of planning for new technology or providing information about key care processes – these opportunities will enhance your leadership roles in the future.

Conclusion

Healthcare Reform and the Era of Accountability
Care delivery models will undergo a radical makeover as payment shifts from fee-for-service reimbursement to value-based care.
This transition will require greater transparency in terms of public reporting of performance data and continued expansion of the library of quality measures.
Health systems and providers that invest in health IT and are able to satisfy the meaningful use criteria will be better able to cope with the challenges of accountable care.

What is certain, in this time of tremendous change and growth in healthcare is that technology will play a primary role in improving quality and patient safety in the future.

Conclusion

Healthcare Quality and IT
There are parallel trajectories of the modern healthcare quality and health IT movements.
Both movements can trace their origins to landmark IOM reports that called for unprecedented public and private attention to systematic gaps in the US healthcare system.
Both have benefited from federal support in the form of funding for research and incentive programs.
But even more remarkable than the parallels between quality and technology is their convergence. As the IOM reports have predicted, the needed transformation of healthcare delivery will come about as a result of the combined and cooperative efforts of clinicians, healthcare quality professionals, and IT workers.

Consistent with the Healthcare Analytics Adoption Model - …”the model is designed to ensure that organizations establish a foundational understanding of analytic technology and organizational use of analytics in step-wise fashion before attempting the more complicated topics of the upper levels.

THE JOURNEY TO PROACTIVE DECISION MAKING

Growing our

Data Analytic Foundation

“The Healthcare Analytics Adoption Model:

A Framework and Roadmap”, Sanders, Dale,

Senior Vice President; Burton, David A., MD,

Executive Chairman; Protti, Denis, SC.D,

Health Catalyst, 2013

This article looks at the progression from data to information and beyond. It is a great read!

Contact your Professor for Questions!

Chapter 10: Dashboards and Scorecards:
Tools for Creating Alignment
Chapter Outline

Background and Terminology
Scope and Use of Dashboards and Scorecards in Healthcare
Commonly Used Quality-Measurement Sets
Applications of Scorecards and Dashboards
Clinical and Operational Issues
Creating Alignment
Keys to Successful Implementation and Lessons Learned

Once we have the data that we need to evaluate and improve care, what are some of the best practices for the sharing of that information, by leaders, in health care organizations?

We will explore some key tools that can be used for these purposes, and some of the keys to successful use and planning for measurement and sharing of key organizational data.

Introduction

Measurement is a critical leadership function.
Most healthcare organizations use measurement tools to track their performance in dimensions beyond mere financial results.
Those dimensions commonly include clinical quality, patient satisfaction, patient safety, employee satisfaction, and organizational culture.
As a means of organizing and using measurement to drive change, dashboards and scorecards are useful tools.
When used properly, they can contribute to better alignment of effort, accelerated rates of improvement, and focused execution of organizational strategies.

Measurement is a critical leadership function. Leaders use many approaches for tracking and reporting their performance data.

Some of the “best practice” tools are the use of dashboards and score cards.

Dashboards and Scorecards

Dashboard: Like the indicator panel on an automobile or airplane that provides key performance metrics such as speed and fuel level while the vehicle is in motion, an organizational dashboard is a tool that monitors and reports the ongoing, real-time performance of the critical processes that lead to organizational success.
Scorecard: Like a school report card or golf scorecard, organizational scorecards are used to record and report prior period or past performance rather than real-time performance.
Outcomes vs. processes

A dashboard is a tool, sometimes likened to a car’s dashboard, that supplies real time, ongoing information on key performance indicators.

A scorecard on the other hand could be compared to a report card – it looks retrospectively at data over time to evaluate performance.

Key Points!

In the business world, dashboards are tools that report on the ongoing performance of the critical processes that lead to organizational success rather than on the success itself.
Leading indicators – The behaviors that get us to these outcomes! Hand washing!
Lagging indicators – (Outcomes!) Patient Satisfaction, Employee Satisfaction, Readmissions, Length of Stay, Market Share, Infection Rates.
We are seeing this play out in real life!

With the use of these tools, it is important to present data that represents both leading indicators – the behaviors that get us to key outcomes – such as “hand-washing”.

We also need to present lagging indicators – the outcomes that we are loo