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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,

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using health information technology to improve care evidence and strategies
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

overview
Overview
  • Need for Healthcare Change
  • Drivers of Change in VA
  • VA IT Infrastructure
  • Using HIT to Implement Evidence
  • Strategies
rand study quality of health care often not optimal

Alcohol dependence

11%

23%

Hip fracture

Peptic ulcer

33%

Diabetes

45%

Low back pain

69%

Prenatal care

73%

Breast cancer

76%

Cataracts

79%

Percentage of time

RAND Study:Quality 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.

implementation of research findings debunked assumption

Question

Hypothesis

Study

Publications

Implementation of Research Findings: “Debunked Assumption”

Changes in Practice

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

va s health information system is vista
VA’s 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
va s health information system is vista1
VA’s Health Information System is “VistA”
  • For FY2004:
  • Cost per enrollee

- $78 / enrollee

  • Average cost per hospital (n=158)

- $3.6 million

success in supporting care delivery for millions of veterans
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
systematic review impact of hit on quality efficiency and costs of medical care
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. 2006;144:E-12-E-22.

slide13

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. 2006;144:E-12-E-22.

slide14

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. 2006;144:E-12-E-22.

slide15

Types of Clinical Decision Support Across VA (n=104)

Fung & Doebbeling, Am J Manage Care 2004

examples of it implementation innovation at indy vamc
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, HSR&D RRP 2006Walsh et al, HSR&D 2006

slide18

“Priorities and Strategies for the Implementation of Integrated Informatics and Communications Technology to Improve Evidence-based Practice”

Doebbeling, Chou, Tierney JGIM 2006: S98-S105

issues in it implementation
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

gao consensus goals for it implementation
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.

managing informatics
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

clinician provider issues
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

slide24

Informatics Technology For Clinical Guideline Implementation:

Perceptions Of Multiple Stakeholders

Guideline Sharing

Adherence Attitudes

Custom Fit Data Data Quality

Local Adaptation

Available

User Friendly

Standard Format

Documentation

Essential Data

Automation

Web Access

Evaluation

Decision Support

Patient Records

Startup Efforts

Accessible

Education

Computer Literacy

Patient Scheduling

Facilitators of

Computer Use

Administrators

Clinicians

Providers

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

providers assessment regarding the extent their hospitals provide it for key dimensions of practice
Providers' Assessment Regarding the Extent Their Hospitals Provide ITfor Key Dimensions of Practice

Doebbeling et al JAMIA (in review, 2006)

patient issues
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

patient issues1
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., patient’s participation is increasingly necessary to achieve IT-facilitated, evidence-based, patient-centered care.

Doebbeling et al. JGIM 2006

researcher issues
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

need for it implementation and process reengineering research
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.
need for it implementation and process reengineering research1
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.
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.

Doebbeling et al. JGIM 2006

enterprise wide issues1
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

organizational issues
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

human factors issues
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

thank you
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