1. 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

2. Overview  Need for Healthcare Change  Drivers of Change in VA  VA IT Infrastructure  Using HIT to Implement Evidence  Strategies

3. RAND Study: Quality of Health Care Often Not Optimal  We provide appropriate health care only about half the time! Percentage of time Alcohol dependence Hip fracture Peptic ulcer Diabetes Low back pain Prenatal care Breast cancer Cataracts 11% 23% 33% 45% 69% 73% 76% 79% 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.

4. Implementation of Research Findings: “Debunked Assumption” Changes in Practice |----------------------------------17-18 Years----------------------------------| Question Hypothesis Study Publications

5. IOM, NAE and the IT Revolution

6. Veterans Administration Organizational and IT Infrastructure

7. 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

8. VA’s Health Information System is “VistA”  For FY2004:  Cost per enrollee - $78 / enrollee  Average cost per hospital (n=158) - $3.6 million

9. 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

10. Articles About VA’s Info Technology & Quality Care “... Overall, VHA patients receive better care than patients in other settings”

11. Using HIT to Implement Evidence

12. Systematic Review: Impact of HIT on 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.

13.  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. Systematic Review: Impact of HIT on Quality, Efficiency, and Costs of Medical Care

14.   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. Systematic Review: Impact of HIT on Quality, Efficiency, and Costs of Medical Care

15. Types of Clinical Decision Support Across VA (n=104) Fung & Doebbeling, Am J Manage Care 2004

16. Strategies

17. Examples of IT Implementation Innovation at 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. Flanagan & Doebbeling, HSR&D RRP 2006 Saleem, Patterson and Asch, JAMIA., 2005 and ongoing Flanagan & Doebbeling, HSR&D RRP 2006 Walsh et al, HSR&D 2006

18. “Priorities and Strategies for the Implementation of Integrated Informatics and Communications Technology to Improve Evidence- based Practice” Doebbeling, Chou, Tierney JGIM 2006: S98-S105

20. 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

21. GAO Consensus Goals for IT Implementation 1) Establish IT architectures and standardize formats for data exchange; for data exchange; 2) implement EHR for information integration; 3) improve electronic communications and documentation; documentation; 4) address issues related to security, especially with increasing use of wireless networks and devices. increasing use of wireless networks and devices. GAO. Use of Information Technology for Selected Health Care Functions. 2003.

22. 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

23. 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

24. Administrators Evaluation Decision Support Patient Records Startup Efforts Accessible Education Computer Literacy Patient Scheduling Automation Web Access Available User Friendly Standard Format Documentation Essential Data Guideline Sharing Adherence Attitudes Custom Fit Data Data Quality Local Adaptation CliniciansProviders Facilitators of Computer Use Informatics Technology For Clinical Guideline Implementation: Perceptions Of Multiple Stakeholders Lyons, Tripp-Reimer, …& Doebbeling, JAMIA 2005

25. Providers' Assessment Regarding the Extent Their Hospitals Provide IT for Key Dimensions of Practice Doebbeling et al JAMIA (in review, 2006)

26. 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

27. 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

29. 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

30. 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.

31. 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.

32. 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

33. 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

35. 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

36. 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

37. Thank You! VA Health Services Research & Development Center of Excellence for Implementing Evidence-based Practice 1481 W. 10 th Street, Indianapolis, IN 46202 (317) 554-1775