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HIT's Impact on Quality and Safety
- 1. Quality Improvement Introduction to Quality Improvement and Health Information Technology Lecture d This material (Comp 12 Unit 1) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/
- 2. Introduction to Quality Improvement and Health Information Technology Learning Objective — Lecture d • Analyze the ways that HIT can either help or hinder quality and patient safety. 2
- 3. Enhancing Equity with HIT Data capture • Can monitor by population characteristics. • Can uncover health care disparities. Tailor to patient needs • Can enable competency- based patient education. • Can tailor information to educational background and development status. Multi-modal functionality • Can provide various ways for patients to get health information. • Can decrease health care disparity. Decision support • Can provide drug cost information. • Can assist providers in selecting alternatives for low-income patients. 3
- 4. Equity: Case Review Event: • One of the greatest challenges to chronic care management in a public housing community is keeping patients engaged in their care. • They are often lost to follow-up care when they do not return for medical visits or refill their prescriptions. • This is especially problematic for vulnerable patients with diabetes. 4
- 5. What They Did: Self-Management Counseling System change: • Community volunteers were provided online training on self-management counseling for patients with diabetes. • They created a diabetes registry in the electronic health record to identify and recall patients due for routine diabetes care. • Just prior to the scheduled visit, the community volunteer reminds the patient of the visit and asks him to arrive early for self-management teaching. 5
- 6. HIT and Optimizing Equity • There are few stroke specialists in rural areas, so people at risk for stroke in these areas have unequal access to quality care. • Physicians in Arizona set up a hub-and- spoke service using telemedicine (audio- video) to decrease health disparities. (hub=urban stroke center; spoke=outlying rural hospitals) 6
- 7. Systematic Reviews of Health IT’s Impact on Quality and Safety Source: Banger, A., & Graber, M. (2015 February). Recent evidence that health IT improves patient safety (Issue Brief). Retrieved March 28, 2016, from the U.S. Department of Health and Human Services, Office of the National Coordinator Web site: https://www.healthit.gov/sites/default/files/brief_1_final_feb11t.pdf 7
- 8. Workarounds • Defined – Alternative processes that help workers avoid demands placed on them that they perceive to be unrealistic or harmful. – Unanticipated behaviors directly or indirectly caused by the EHR when the system impedes one’s work. • Examples – Nurses taking verbal orders rather than prescribers entering the order into CPOE due to workflow timing of event. – Significant events located in multiple locations in the EHR due to lack of standardization of data entry screens. 8
- 9. Artifacts • Defined – Manmade tools that aid or enhance the worker’s thinking abilities. – Developed to meet the demands of an activity. • Examples – Bedside references. – Patient locator boards. – Report sheets. – Documenting on paper then transcribing into electronic record. 9
- 10. HIT and Workarounds — 1 • Dr. Foxwood creates a new order each time he wants to re-order a medication. • The nurse enters a verbal order to discontinue the previous medication order, so that the medication will be removed from the electronic medication record. • Dr. Foxwood fails to co-sign the discontinuation order because he sees this as an administrative task. 10
- 11. HIT and Workarounds — 2 • When a barcoding medication system interfered with their workflow, nurses devised workarounds, such as removing the armband from the patient and attaching it to the bed because the barcode reader failed to interpret bar codes when the bracelet curved tightly around a small arm. Image courtesy U.S. Navy, Photo by Petty Officer 1st Class Brian A. Goyak. 11
- 12. HIT and Workarounds — 3 • Investigators found increased mortality among children admitted to Children’s Hospital in Pittsburgh after CPOE implementation. • Three reasons were cited for this unexpected outcome: 1. CPOE changed the workflow. 2. Order entry required as many as 10 clicks and took as long as two minutes. 3. When the team changed its workflow to accommodate CPOE, face- to-face contact among team members diminished. 12
- 13. HIT Safety Tools Source: https://www.healthit.gov/safer/ 13
- 14. Introduction to Quality Improvement and Health Information Technology Summary — Lecture d • Well-crafted HIT solutions can: – Improve safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness of care. – Work to accomplish the best care for the whole population at the lowest cost. • Unintended consequences of HIT: – Can lower quality and result in unsafe care. – Can be minimized through best practices and avoidance of workarounds. – Need to be studied further. 14
- 15. Introduction to Quality Improvement and Health Information Technology References — Lecture d — 1 References Banger, A., & Graber, M. (2015 February). Recent evidence that health IT improves patient safety (Issue Brief). Retrieved March 28, 2016, from the U.S. Department of Health and Human Services, Office of the National Coordinator Web site: https://www.healthit.gov/sites/default/files/brief_1_final_feb11t.pdf Doyle, M. (2005). Impact of the Bar Code Medication Administration (BCMA) system on medication administration errors. Unpublished doctoral dissertation, University of Arizona, Tucson, in Nursing Informatics and the Foundation of Knowledge. Sudbury, MA: Jones and Bartlett Publishers. Han, Y.Y., Carcillo, J.A., Venkataraman, S.T., et al. (2005). Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics. 116;1506 – 1512. Images Slide 7: Systematic reviews of health IT’s impact on quality and safety. Banger, A., & Graber, M. (2015 February). Recent evidence that health IT improves patient safety (Issue Brief). Retrieved March 28, 2016, from the U.S. Department of Health and Human Services, Office of the National Coordinator Web site: https://www.healthit.gov/sites/default/files/brief_1_final_feb11t.pdf 15
- 16. Introduction to Quality Improvement and Health Information Technology References — Lecture d — 2 Images Slide 11: Patient armbands. Department of Defense. Retrieved March 24, 2016, from: http://archive.defense.gov/dodcmsshare/homepagephoto/2011-05/hires_110502-N- QD416-033d.jpg Slide 13: SAFER guides. U.S. Department of Health and Human Services, Office of the National Coordinator. Retrieved March 24, 2016, from: https://www.healthit.gov/safer/ 16
- 17. Quality Improvement Introduction to Quality Improvement and Health Information Technology Lecture d This material (Comp 12 Unit 1) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC000013. This material was updated in 2016 by Johns Hopkins University under Award Number 90WT0005. 17
Editor's Notes
- Welcome to Quality Improvement: Introduction to Quality Improvement and Health Information Technology. This is Lecture d.
- The Objective for Introduction to Quality Improvement and Health Information Technology is to: Analyze the ways that HIT can either help or hinder quality and patient safety.
- HIT can enhance equity of health care and services. Data capture can allow for monitoring by population characteristics to uncover health care disparities. The multi-modal functionality of systems can allow for various ways for patients to get health information to decrease health care disparities. Competency-based patient education can tailor information to the patient’s educational background and developmental status. Decision support can offer drug cost information to assist providers in selecting alternatives for low-income patients.
- Over the past two to three decades, there has been a remarkable increase in the aging and diversity of our population. Many people in the U.S. come from Latin America, Eastern Europe, Southeast Asia, and Africa; these people make up one-third of the U.S. population. This proportion is expected to increase to half by 2050. Health care disparity, or unequal access to quality care, is a major concern. For example, particularly in low-income public housing developments, the effort to both engage and retain that engagement is a huge challenge. Chronic care management is difficult when so many are lost to follow-up (meaning that they do not return for follow-up care or regular checkups) or when they do not either fill their prescriptions – or – do not take their medications. This is especially problematic for vulnerable patients with diabetes. Often times, the decision comes down to, “do I pay for my prescriptions or do I buy food? I cannot afford to do both.” Consider how you would address this issue.
- As a result of this event, community volunteers were provided online training on self-management counseling for patients with diabetes. They created a diabetes registry in the electronic health record to identify and recall patients due for routine diabetes care. Just prior to the scheduled visit, the community volunteer reminds the patient of the visit and asks him to arrive early for self-management teaching.
- There are few stroke specialists in rural areas, so people at risk for stroke in these areas have unequal access to quality care. Physicians in Arizona set up a ‘hub’ (urban stroke center) and ‘spoke’ (outlying rural hospitals) service using telemedicine (audio-video) to decrease health disparities. There is actually a growing demand for the use of non-physician providers to supplement care in areas where there is no doctor as well. Nurse practitioners, physician assistants, and other types of care providers are being successfully used to provide a bridge for those on the far side of the care divide.
- In a February 2015 Issue Brief prepared for DHHS Office of the National Coordinator (ONC), key takeaway points included the following: “Health information technology (health IT) has been adopted widely in U.S. health care systems with expectations of lowering cost and improved quality and patient safety. While we see many examples, as discussed already, has this concept been studied in more systematic fashion? Four separate but linked systematic reviews examining this concern have been published over the last decade. These analyses have revealed the following: “Health IT is working. With each review, the evidence base is expanding, with articles that describe net benefit in a wide range of settings and applications. “The number of health care organizations perceived as leaders in advancing health IT is growing. “Research should now turn to understanding the relatively small but important number of unintended consequences that detract from the overall impact of this new technology and the variability in the success of health IT implementations, especially in areas that impact patient safety.”
- Workarounds are alternative processes that help workers avoid demands placed on them that they perceive to be unrealistic or harmful. These unanticipated behaviors can be directly or indirectly caused by the EHR when the system impedes the provider’s work. For example, a nurse may take a verbal order rather than the prescriber entering the order into CPOE due to workflow timing of the event, such as the surgeon being scrubbed on a case in the OR. Another example is the case where significant events are located in multiple locations in the electronic record due to lack of standardization of data-entry screens.
- Artifacts are man-made tools that help the worker to think. They are developed to meet the demands of a particular activity. Examples include: Keeping references at the bedside so that the nurse can refer to them during the course of care Patient locator boards that list names of patients and room assignments so that unit personnel can track where patients are housed Report sheets that list important patient information for hand-off purposes Even documenting on paper then transcribing into the electronic record is an aid for the provider to remember data that he or she wants to enter into the electronic record at a later time.
- So let’s talk about workarounds. You will find that health care providers are expert at creating workarounds when technology does not fit into their clinical workflow. Here’s an example. Dr. Foxwood creates a new order each time he wants to re-order a medication. The nurse enters a verbal order to discontinue the previous medication order, so that the previous medication will be removed from the electronic medical record. Dr. Foxwood fails to co-sign the discontinuation order because he sees this as an administrative task. Other examples include: Drug orders written in a free-text message screen, causing delay or omission of medications because they are not seen by the pharmacist. Data entered into multiple information systems due to lack of interfaces, resulting in transcription error. Entering admission and discharges into the system in order to create lab test requisitions. Frequent reviews of the electronic health record every 15 minutes to detect new orders. Can you think of workarounds that you have seen in your current job? Why were these created?
- This and the following two slides talk about workarounds caused by poor HIT design. Doyle reported that when a barcoding medication system interfered with their workflow, nurses devised workarounds, such as removing the armband from the patient and attaching it to the bed because the barcode reader failed to interpret barcodes when the bracelet curved tightly around a small arm.
- Han and colleagues reported increased deaths in children admitted to Children’s Hospital in Pittsburgh after CPOE implementation. Three reasons were cited for this unexpected outcome. First, CPOE changed the workflow in the emergency room. Before CPOE, orders were written for critical and time-sensitive treatment based on radio communication with the incoming transport team before the child arrived. After CPOE implementation, orders could not be written until the patient arrived and was registered in the system (a policy that was later changed). Second, entering an order required as many as ten clicks and took as long as two minutes; moreover, computer screens sometimes froze or response time was slow. Finally, when the team changed its workflow to accommodate CPOE, face-to-face contact among team members diminished. Despite the problems with study methods identified by some of the informatics community, there certainly were serious human-technology-interface problems.
- The ONC has compiled a set of resources to help organizations with EHR safety. Together, these resources are called the Safety Assurance Factors for EHR Resilience — or the SAFER Guides. The guides have been collected into three groups: Foundational, Infrastructure, and Clinical Process Guides. They are meant to be used by organizations as a means of self-assessment in regard to the recommended practices for EHR safety. Interactive PDF versions of the guides are available for download at the HealthIT.gov website.
- This concludes Quality Improvement: Introduction to Quality Improvement and Health Information Technology. In summary, when well designed and used as intended, HIT can improve all of the aims of quality and can work to accomplish the best care for the whole population at the lowest cost. When designed poorly and subject to workarounds, HIT can result in unintended adverse consequences. HIT best practices similar to the ONC SAFER guidelines can minimize these risks. HIT safety issues should be studied and improved upon further.
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