Running head: MEDICAL INFORMATICS REPORT 1 Medical Informatics Report Cynthia Brown April 10, 2012
MEDICAL INFORMATICS REPORT 2 AbstractThis report discusses Health Information Technology (HIT), specifically medical informatics andthe challenges and benefits of its use at Nazarene Community Health Clinic (NCHC). The reporttouches on the fact that the underutilization of HIT in the health care industry has played asignificant role in the poor quality of health care delivery. In this report, medical informatics isdefined as how certain components of medical informatics can assist the NCHC in providing andsustaining quality health care. The analysis, interpretation, and management of data are essentialcomponents in improving the health care delivery system. The importance of the medicalinformatics program’s alignment with NCHCs core objectives is discussed along with using asystems development cycle (SDLC) to ensure successful implementation of the program. Theimplementation process is outlined capturing the role of key senior managers in ensuring asmooth transition from our current infrastructure to one of a technology driven qualitymanagement infrastructure. Cross-functional teams and an organizational culture of teamwork isnecessary to successfully make the transition is also be discussed. The perceived challengesalong with the benefits of implementing a medical informatics program are argued. Three legal,ethical, and regulatory safeguards are suggested to improve the patient safety and the quality ofcare at NCHC. Keywords: medical informatics, health information technology, electronic health record,health information exchange, personal health record, systems development life cycle
MEDICAL INFORMATICS REPORT 3 Medical Informatics Report Information Technology (IT) and management have been directly linked to quality inother industries. The Health Care Industry however has failed to see the correlation betweenquality and IT for many years. The Health Care Industry has been known to be one of the lowestinvestors in IT at an annual percentage rate of 3.5; while similar industries invest at a 9 to 10percent rate (Gupta, Harrington, Pexton & Trusko, 2007). This lack of attention to IT has beenstated as one of the major reasons health care has the poorest quality of any other industry in theworld (Gupta et al., 2007). Recently, the rate of IT investment among health care organizations has risen to 4.5(Gupta et al., 2007). The Federal government along with many of today’s health care providersis in agreement that medical informatics will play an essential role in improving the quality andsafety of our fragmented health care delivery system. This strong conviction has been shown inNazarene Community Health Clinic (NCHC) receiving a Federal grant to develop and put intoaction an organization-wide medical informatics program. This report will cover key topicsconcerning a medical informatics program at NCHC along with the barriers of implementationand the role medical informatics will play in improving quality at NCHC. Legal, regulatory, andethical topics will be covered that will promote patient safety as well as quality. TopicsThe Role of Medical Informatics in Quality Improvement and Two-Three AnticipatedBenefits of Health Information Technology for the NCHC The overall strategic plan of NCHC for the 21st century is to provide health care that issafe, efficient, cost-effective, and of the highest quality. To remain in alignment with thisstrategic plan, it is imperative that NCHC take the opportunity afforded by the Federal grant to
MEDICAL INFORMATICS REPORT 4improve its health information infrastructure through the use of medical informatics. A medicalinformatics programs allows the clinic to improve clinical efficiency, accuracy, and reliabilitythrough the effective use of medical data (Shi & Singh, 2010). Clinical efficiency, accuracy, andreliability are all contributing factors to improved, quality health care and a medical informaticsprogram will assist NCHC in these areas. Medical informatics’ role in achieving quality health care can be attributed to its purposeof examining the structure, the acquisition, and the use of health care information at NCHC(Varkey, 2010). Some very distinct areas medical informatics can be used to improve health carequality and quality measurements are (Varkey, 2010): 1) In increased access to pertinentmedical information; 2) In real time evidence and decision support systems used at the time ofcare; 3) In improved synchronization of information among health care providers and betweenpatients and health care providers; 4) In augmented ability to collect and report information onperformance; 5) In promoted practice of evidence-based medicine through access of theelectronic health record (EHR) and electronic medical literature; and 6) In aided decision-makingthrough the use of “alert systems”. Health Information Technology (HIT) is an integral part of the overall health caredelivery system and can be described in a wide range of technologies for transmitting andmanaging health information for use by consumers, providers, payers, insurers, and otherinterested in health care (Blumenthal and Glaser, 2007). One of the benefits of HIT for theNCHC can be seen in the use of the EHR. The EHR can electronically collect and store dataabout patients, supply that information to providers upon request, permit providers to directlyenter orders into the computer, provide health care professionals with advice in making decisionsabout the patient’s care (e.g., alerts, reminders, clinical decision support) (Blumenthal and
MEDICAL INFORMATICS REPORT 5Glaser, 2007). The EHR can also allow health information exchange (HIE) across organizationalboundaries; allow prior authorizations along with benefits/insurance verification in more thanhalf the time; and finally allow for uniform public and private health reporting (Bradley, Burns &Weiner, 2012). The ability to share information across organizational boundaries in itself greatlyincreases the perception of higher quality in health care delivery; because it supports continuityof care among providers. A second benefit of Health Information Technology at NCHC focuses on the patient’sparticipation and managing of their own health care through the access of their personal healthrecord (PHR). A PHR although electronic and accessed via the Internet is quite different fromthe EHR. It is usually managed and controlled by the patient. The patient is able to access theirPHR to include both health and wellness information pertaining to their diet, medications,exercise and daily routines, and future appointments (Bradley et al., 2012). Some organizationsare combining PHR data with EHR data to have a complete representation of the patient’s healthinformation (Halamka, Mandl & Tang, 2008). The patient can perceive a sense of partnershipwith the provider through the use of the PHR; which in turns heightens the patient’s perceptionof quality health care. The PHR is also a useful tool to promote the patient’s management ofchronic illnesses such as diabetes, hypertension, and chronic renal failure.Two-Three Organizational Factors Essential to Successful Implementation of a MedicalInformatics Program The first and foremost organizational factor essential to successful implementation of aMedical Informatics Program at NCHC is that of strategic alignment. It is imperative that theprogram is parallel to NCHC’s organizational strategies. For instance, one of the strategies ofNCHC is to improve organizational performances. The EHR component of the Medical
MEDICAL INFORMATICS REPORT 6Informatics Program can improve adherence to evidence-based practice guidelines, enhancesurveillance and monitoring, and decrease medical errors each of which are related to theorganization’s strategy to improve performance (Bradley et al., 2012). Long and short termgoals/objectives must be identified in relation to the Medical Informatics Program. The second factor essential to successful implementation of a Medical Informaticsprogram at NCHC is in choosing a customized systems development life cycle (SDLC)methodology (Bradley et al., 2012). SDLC is a methodology which can be used to select,acquire, implement, and maintain NCHCs health information system (Bradley et al., 2012). TheSDLC includes the following (Bradley et al., 2012): 1) Defining (planning), 2) Construction(analysis, design, and testing), 3) Implementation, and 4) Maintenance phases. Using acustomized SDLC methodology helps to improve the chances that NCHC selects the correctapplication or system for its particular needs and increases the probability of successfulimplementation.T he Role of the Senior Management Team and One-Two Functional Benefits theProgram’s Implementation will provide for each Team Member Category The role of the senior management team comprised of chief executive officer, chiefinformation officer, chief financial officer, chief nursing officer, and the chief of the medicalstaff should be that of assisting in the implementation of the medical informatics program atNCHC (Bradley et al., 2012). Each of the roles of the senior management team is outlinedbelow. Chief Executive Officer. The Chief Executive Officer’s (CEO) role in implementing theMedical Informatics Program is that of transformational leader. The CEO is the visionary andcommunicator of the organization’s core values and how they relate to the organization’s goal of
MEDICAL INFORMATICS REPORT 7transitioning from its current information system to a medical informatics system. The CEOshould take the following steps to ensure acceptance of the strategic plan to incorporate medicalinformatics into the practices at NCHC (Hofmann & Nelson, 2007): 1) Point out inefficientbusiness and work practices. 2) Ensure that NCHC’s mission, vision, and value statements arefully understood by all staff, and that decisions and actions made are consistent with thesestatements. 3) Involve physician, board, management, and staff in significant change efforts. 4)Assess all positive and negative effects on the organization, staff, patient, community, and otherkey stakeholders. Chief Information Officer. The role of the Chief information Officer (CIO) is to ensurethat the information systems plans are aligned with the overall strategic plan of the organizationof upgrading to a medical informatics system. The CIO should make recommendations aboutthe implementation approach and the types of applications needed for the project (Bradley et al.,2012). The CIO defines the as-is system; provides end-user feedback on screen designs orprototypes of the new system, coordinates training, and monitors system testing (Bradley et al.,2012). Chief Financial Officer. The Chief Financial Officer’s (CFO) role is that of managingthe financial aspect of developing a medical informatics program. The CFO is responsible forprogram proposal and the feasibility analysis (Bradley et al., 2012). The CFO also provides thefunds for the program, develops the budget, and oversees the program to ensure the benefits arerealized (Bradley et al., 2012). Chief Nursing Officer and Chief of the Medical Staff. The main role of these twoindividuals would be that of advocating health information technology for the organization, aswell as, further communication of the vision and its benefits within the organization; making
MEDICAL INFORMATICS REPORT 8sure adequate training is provided; and making sure incentives for adopting and using the newsystem are provided (Bradley et al., 2012). These two roles can also encourage input from theirrespective staff allowing them to voice their concerns and later disseminating them to the seniormanagement team. The program’s implementation is expected to benefit each team member category byimproving “the efficiency, cost-effectiveness, quality, and safety of medical care delivery bymaking best practices guidelines and evidence databases immediately available to clinicians, andby making computerized patient records available throughout NCHCs health care network”(AHRQ, n.d., page 10). For example, reduction in patient errors, redundant tests ordering; andefficient job performance can be realized as a result of using decision support systems,computerized alerts, computerized performance measurements, and electronic orders; therebygenerating cost-savings that can be passed along throughout the entire organization. Cost-savings can be transformed into dollars for additional staff, professional training, newequipment, and future expansion all of which benefit each team member category.One-Two Perceived Organizational Challenges Regarding such an Implementation andOne-Two Recommendations to Manage those Challenges Albeit there are many benefits to the implementation of a medical informatics system forNCHC; there are also challenges regarding such an implementation that must be consideredbefore moving forward. One is that of cost. The costs for developing, implementing,maintaining, and supporting the program can be substantial. The resources needed bothfinancially and in human resources to sustain the system must be analyzed carefully. Theorganization may find it difficult to come up with the capital necessary to invest in a medicalinformatics program, especially since the break-even points range from 3-13 years (AHRQ, n.d.).
MEDICAL INFORMATICS REPORT 9 A solution to this concern is for there to be a total evaluation of the organization’s annualreports which will provide an overview of the company’s financial position. Along with thefinancial evaluation the costs of the project must be evaluated to see if the tangible benefits (i.e.,improved quality, lower costs in providing services, increased patient load, pay for performanceincentives, return on investments) and intangible benefits (i.e., patient/employee satisfaction,better market positioning, community image, provider relations) are worth the costs. Otherintangible benefits that should be considered are higher productivity, improved documentationquality, and guideline compliance management. Another way to control the costs ofimplementing the program is to the research programs of similar providers so as to afford costlymistakes. It is prudent to learn from others mistakes. NCHC can also look into making costsharing alliances with local hospitals where their patients are typically referred or seen foradditional services or treatment. Finally, NCHC can take advantage of the American Recoveryand Reinvestment Act (ARRA) of 2009. Subtitles A and B of Title IV in Division B of ARRAauthorize incentive payments for eligible Medicare and Medicaid providers’, such as NCHC, forthe adoption and meaningful use of certified EHR technology (CMS, 2012). A second barrier to the medical informatics program’s implementation is people and taskoriented resistances to change from the current information system to a medical informaticssystem. The probability of resistance to change is high and should be faced head on; therefore itis the responsibility of the transformational leader to eliminate the resistance. The resistance canbe due to several reasons (Gavin & Quick, 2000): 1) threat to one’s self-interest; 2) lack ofconviction that change is necessary; 3) fear of being manipulated; 4) threat to personal values; 5)lack of confidence that change will succeed; 5) distrust of leadership; and 6) uncertainty. There
MEDICAL INFORMATICS REPORT 10are two types of change resistance, namely people-oriented and task-oriented. A new medicalinformatics program will evoke both. To eliminate and/or reduce resistance to people-oriented change, leaders should (Mourier& Smith, 2001): 1) Show relentless support and unquestionable commitment to the changeprocess. 2) Communicate the need and urgency for change to everyone. 3) Maintain ongoingcommunication about the progress of change. 4) Avoid micromanaging and empower people toimplement change. Ensure change efforts are adequately staffed and funded. 5) Anticipate andprepare people for the necessary adjustments that change will trigger, such as career counselingand/or training. To eliminate and/or reduce resistance to task-oriented change, leaders should (Kanter,2000): 1) Assemble a coalition of supporters inside and outside the organization. 2) Alignorganizational structure with a new strategy for consistency. 3) Transfer the implementationprocess to a working team. 4) Recruit and fill key positions with competent and committedsupporters. 5) Know when and how to use ad hoc committees or task forces to shapeimplementation activities. 6) Recognize and reward the contributions of others to the changeprocess.The Role of Cross-functional Teams and the Type of Organization Culture that willsupport a Successful Informatics Program Implementation The role of a cross-functional team in implementing the medical informatics program isthat of understanding the goals and objectives of developing the program. Cross-functionalteams should make the objective of the teams clear to all members as well as their part in helpingthe organization meet its objective. Cross-functional teams ensure that everyone buys in to theobjective. It also relies upon the expertise and skill set of a group of people rather than
MEDICAL INFORMATICS REPORT 11individuals. Cross-functional teams must understand its interrelationship and interconnectivityassociation with other members and other cross-functional teams. Each member of theorganization must work cooperatively and interpersonally as a team. Cross-functional teams must also have an organizational culture that values andemphasizes teamwork and participation (Bonache & Zarraga, 2003). Senior management mustencourage the concept of a team culture and be aware how a team culture is consistent with andconducive to the organization’s overall objective of creating a medical informatics program(Bradley et al., 2012). This can be accomplished by doing the following (Moorhead & Griffin,1998): 1) Believe employees want to be held accountable for their jobs. 2) Exhibit the teamphilosophy. 3) Have resourcefulness and power to overcome obstacles as they presentthemselves. The complexity of the task calls for team interaction and team cohesiveness among itsmembers. The diagram below illustrates the interaction between the senior management teammembers as a continuous flow in implementing the medical informatics program. CFO Medical Informatics Program P CNO CEO CMO CIO
MEDICAL INFORMATICS REPORT 12Three Legal, Regulatory, and/or Ethical Safeguards that NCHC should have in Place toAssure Quality and Patient Safety One of the goals seen throughout the existence of NCHC is that of providing a quality,safe patient encounter. One of the ways in which NCHC will safeguard quality, safe health careis to motivate our physicians and local hospitals to collaborate in areas of patient care (Bradley etal., 2012). The Medicare Payment Advisory Commission discussed how the lack of integrationbetween hospitals and clinical physicians converts into a health care system that is more apt tohave errors, inefficiency, and poor quality (Bradley et al., 2012). NCHC will develop policiesand procedures for ensuring continuity of care across its clinical settings by passing alongmedical information to local hospitals regarding patients seen in the clinic. This can beaccomplished through the use of an EHR that is accessible and linked to area hospitals so that inthe event of emergency treatments, referrals, and surgical interventions the patient does not losethe efficacy of the treatment. NCHC can also benefit financially from this safeguard in thatcertain policy initiatives have been implemented which provide financial incentives and otherincentives designed to encourage hospitals and physicians to work more collaboratively toenhance patient care (Bradley et al., 2012). Another way in which NCHC can have safeguards in place that promote quality, safehealth care is to strengthen its peer review processes. The Health Care Quality Improvement Act(HCQIA) of 1986 reflects on issues of poor peer review processes and the identification ofphysicians who are deemed incompetent or who are involved in unprofessional, unethicalbehavior (Bradley et al., 2012). This safeguard is aimed at improving both the safety of thepatient through error reduction and the quality of the health care being delivered. The HCQIAlimits the immunity of physicians who are involved in the peer review process, greatly
MEDICAL INFORMATICS REPORT 13diminishing the risk of lawsuits from physicians who face dismissal or loss of privileges(Bradley et al., 2012). HCQIA provides legal exception of the clinic if the peer review actionswere taken (Bradley et al., 2012): 1) in the reasonable belief that the action taken was done so toimprove the quality of health care; 2) after a reasonable attempt to get the facts of the matter; 3)after sufficient notice and hearing procedures were made known to the physician; and 4) in thereasonable assumption that the action was deemed necessary by the facts and after meeting thecriterion of (3) above. The third safeguard NCHC can put in place to ensure safe, quality health care is toappoint a Regulatory Compliance Officer (RGO). NCHCs noncompliance to legal, regulatory,and ethical standards can lead to serious consequences resulting in fines, loss of accreditation,and loss of licensure. The role of the RCO consists of the following (Bradley et al., 2012): 1)Educating staff on regulatory compliance protocols through training programs. 2) Monitoringcompliance. 3) Implementing enforcement policies; responding to compliance violations; andseeking out opportunities to prevent future violations. 4) Acting as liaisons between NCHC andappropriate regulatory agencies. 5) Collaborating with Risk Management, Internal Audit,Employee Services, and Human Resources. 6) Conducting internal audits in search of violations. In conclusion, the transition of NCHC from our current information systems to a medicalinformatics system can only solidify our goals of safe, effective, efficient, affordable health care.The medical informatics system will assist the clinic in developing and monitoring performancemeasurements which will increase productivity and streamline clinical processes. The EHR andthe PHR will benefit the patient and the clinic in working together to achieve continuous, qualitycare. The alignment of the medical informatics system with the organizational goals/objectivesis imperative to its success. A customized SDLC will assist NCHC in selecting, acquiring,
MEDICAL INFORMATICS REPORT 14implementing, and maintaining the medical informatics system. The implementation of thesystem will require the collaborative efforts of the senior management team comprised of theCEO, CIO, CFO, CNO, and the CMO. Although there will be challenges the clinic must workthrough to have successful implementation, the benefits of the system are felt to outweigh thechallenges. A cross-functional team approach is necessary to pull off the development,implementation, and maintenance phases of the project. An organizational culture of teamworkmust be evident and emphasized throughout the process of change. Lastly, the legal, regulatory,and ethical standards mentioned in this report should help to assure quality, safe health care.
MEDICAL INFORMATICS REPORT 15 ReferencesAgency for Healthcare Research and Quality (AHRQ). (n.d.). Costs and benefits of health information technology. Retrieved from http://www.ahrq.gov/data/informatics/informatria.pdf.Blumenthal, D. & Glaser, J.P. (2007). Information technology comes to medicine. New England Journal of Medicine, 356(24), 2527-2534. Retrieved from http://search.proquest.com.Bonache, J. & Zarraga, C. (2003). Assessing the team environment for knowledge sharing: An empirical analysis. International Journal of Human Resource Management, 14(7), 1227- 1246. Retrieved from http://search.proquest.com.Bradley, E.H., Burn, L.R. & Weiner, B.J. (2012). Health care management: Organization, design & behavior (6th ed.). Clifton Park, NY: Delmar Cengage Learning.Centers for Medicare and Medicaid Services (CMS). (2012). Health information extension program. Retrieved from http://cms.gov/EHRIncentivePrograms/.Gavin, J.H. & Quick, J.C. (2000). The next frontier: Edgar Schein on organizational therapy. Academy of Management Education, 14(1). Retrieved from http://search.proquest.com.Gupto, P., Harrington, H.J., Pexton, C. & Trusko, B.E. (2007) Improving health care quality and cost with six sigma. Upper Saddle River, N.J.: Pearson Education, Inc.Halamka, J.D., Mandl, K.D., & Tang, P.C. (2008). Early experiences with personal health records. Journal of the American Medical Informatics Association, 15(1), 1-7. Retrieved from http://search.proquest.com.Hofmann, P.B. & Nelson, W.A. (2001). Managing ethically: An executive’s guide. Chicago, IL: Health Administration Press.
MEDICAL INFORMATICS REPORT 16 ReferencesKanter, R.M. (2000). The enduring skills of change leaders. Ivey Business Journal, 64(5), 31-36. Retrieved from http://search.proquest.com.Moorhead, G. & Griffin, R.W. (1998). Organizational behavior: Managing people and organizations. Boston, MA: Houghton Mifflin.Mourier, P. & Smith, M. (2001). Conquering organizational change: How to succeed where most companies fail. Atlanta, GA: CEP Press.Shi, L. & Singh, D.A. (2010). Essentials of the U.S. health care system (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers.Varkey, P. (2010). Medical quality management: Theory and practice. Sudbury, MA: Jones and Bartlett Publishers.