Health Information Technology and the National Quality Agenda. Daphne Ayn Bascom, MD PhD Chief Clinical Systems Officer Medical Operations

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1 Health Information Technology and the National Quality Agenda Daphne Ayn Bascom, MD PhD Chief Clinical Systems Officer Medical Operations

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4 Institute of Medicine Definition of Quality "The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."

5 Measures of Success? Outcomes - Functional - Quality of Life - Disease free Interval - Morbidity - Mortality Quality of Care - DVT prophylaxis - Medication administration - Perioperative complications

6 EMR ONC PHR MU ACO HIE

7 Drivers of Healthcare IT Adoption Rising Health Care Costs Declining Efficiency Clinical Leadership Industry Leadership Political Leadership Drivers of Health Information Technology Adoption

8 Goals of HIT Adoption Improved health outcomes Better integration and transfer of information across health care silos Decision support Cost efficiencies Improved patient provider provider satisfaction Ability to monitor health of the population

9 Health IT: The Challenges Provider Resistance Security and Privacy Safety Cost

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11 1 in 7 hospital admissions occurs because care providers do not have access to previous medical records 12% of physician orders are not executed as written 20% of laboratory tests are requested because previous studies are not accessible 1 in 6.5 hospitalizations complicated by drug error Cannot have integrated care without integrated information! Essential to patient centered care

12 Role of Healthcare IT in Driving Quality Ubiquitous availability of information to providers Improve collaboration between providers Reduce human error at the point of care through Clinical Decision Support Provide workflow automation and improvement Enable Computerized Provider Order Entry (CPOE) Enable the 5 Rights of Medication Administration

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14 How can an EHR make a difference? Structure Process Outcome Adoption Electronic Medical Record Record Implementation And And Adoption Effective Use Use Use Use key key EMR EMR features fully fully Smart Use Use Leverage EMR EMR decision support We are here Adapted from Role of the EHR in Healthcare Reform of Integrated Health Care Systems. Blackford Middleton, MD, MPH, MSc. Partners HealthCare System, Harvard Medical School. Meaningful Users of Information Technology

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16 CCHS HealthCare IT Strategic Objectives Access to all pertinent clinical information at the point of care Improve care giver decision making Reduce medical errors Standardization and variance reduction Ability to evaluate data on a patient and population basis for quality, research and outcomes initiatives

17 CCHS HIT Related Quality Initiatives Core Measures - Implementation of standard nursing documentation tools - Implementation of Standard Physician Documentation - Point of Care Decision Support - Near real time reporting tools - Core measures dashboard Improving Surgical Care - Standard documentation tools (Surgical Navigator) - Standard Day of Surgery Order set

18 CCHS HIT Related Quality Initiatives Medication Administration Workflows - Improved Medication Reconciliation Tools - System wide formulary - Standardized concentrations of key IV solutions Decision Support - Key medication related alerts - Standard order sets and alerts for high risk or quality related processes Heparin VTE Insulin

19 Potential Challenges with the Implementation of HIT Change is hard Does not eliminate all potential medication errors Human error still possible Lack of an interface with other information systems may impact clinical workflows Automating bad process simply makes errors happen more quickly

20 E Iatrogenesis Electronic iatrogenesis: The unintended consequences resulting from the implementation of health information technology

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22 Joint Commission Sentinel Event Alert No Examine workflow processes and procedures 2. Actively involve clinicians and staff 3. Assess your organization s technology needs beforehand 4. During the introduction of new technology, continuously monitor for problems 5. Establish a training program 6. Develop and communicate policies delineating staff authorized and responsible 7. Prior to taking a technology live, ensure that all standardized order sets and guidelines are developed, tested on paper, and approved by the Pharmacy and Therapeutics Committee (or institutional equivalent).

23 Joint Commission Sentinel Event Alert No Develop a graduated system of safety alerts in the new technology that helps clinicians determine urgency and relevancy. 9. Develop a system that mitigates potential harmful CPOE drug orders by requiring departmental or pharmacy review and sign off on orders that are created outside the usual parameters. 10. To improve safety, provide an environment that protects staff involved in data entry from undue distractions when using the technology. 11. After implementation, continually reassess and enhance safety effectiveness and error detection capability. 12. After implementation, continually monitor and report errors and near misses or close calls caused by technology through manual or automated surveillance technique. 13. Re evaluate the applicability of security and confidentiality protocols as more medical devices interface with the IT network.

24 EMR ONC PHR MU ACO HIE

25 National Health Care Transformation Plan Improving population health Improving the quality of care Improving the patient & provider experience of health care Improving objective and subjective outcomes Improving the value of money spent on health care

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27 25550 Federal Register/ Vol. 74, No. 101/ Thursday, May 28, 2009/ Notices

28 Meaningful Use of Health IT There are three stages of Meaningful Use: - Stage 1 (2011): Implement an Electronic Health Record to Capture and Share Data - Stage 2 (2013): Use Advanced Care Processes with Decision Support - Stage 3 (2015): Demonstrate Improved Outcomes Source : Ashish K. Jha, Catherine M. DesRoches, Peter D. Kralovec and Maulik S. Joshi, A Progress Report On Electronic Health Records In U.S. Hospitals. Health Affairs, October

29 Stage 1 Final Rule HITPC Proposed Stage 2 Improving Quality, Safety, Efficiency & Reducing Health Disparities EP: >30% of unique patients with at least one med order have at least one med order entered using CPOE Implement drug drug and drug allergy interaction checks (enabled functionality) EP: Generate and transmit permissible prescriptions electronically for >40% of prescriptions >50% of all unique patients have demographics recorded as structured data. (preferred language, gender race ethnicity, DOB, data and preliminary COD EH ONLY). Report CQM as per CMS attestation CPOE for 60% of Rx and lab ; radiology CPOE in use ( 1 order) (unless no radiology orders) Stage 1 Final Rule & HITPC Proposed Stage 2 Employ drug interaction (drug-drug, drug-allergy) checking; 50% of outpatient medication orders and 20% of hospital discharge medication orders transmitted as erx 80% of patients have demographics recorded and can use them to produce stratified quality reports using more granular demographic Report CQM electronically as per CMS Maintain an up to date problem list for >80% of all unique patients Maintain active med list for >80% of all unique patients Maintain problem list (80%) Maintain active med list (80%)

30 Stage 1 Final Rule HITPC Proposed Stage 2 Maintain active med allergy list for >80% of all unique patients Record and chart vital signs for >50% of all unique patients age 2 and over Maintain active med-allergy list (80%) 80% of patients have vital signs recorded during the reporting year 80% of patients have smoking status recorded Stage 1 Final Rule & HITPC Proposed Stage 2 Record smoking status for >50% of all unique patients 13 years or older Implement 1 clinical decision support rule relevant to specialty or high clinical priority along with ability to track compliance Menu: Implement drug formulary checks with access to at least one drug formulary Menu: Record AD for 50% of all unique patients 65 years and older Menu: Incorporate clinical lab tests results as structured data for more than 40% of all lab tests results ordered New Use CDS; HITSC: Suggest changing certification criteria definition as indicated on comment summary Implement drug formulary checks according to local needs For hospitals, 50% of patients >65 who have recorded the result of an advance directive discussion and the directive itself if it exists; for EPs 10% of patients seen during reporting period Incorporate lab results as structured data (40%) (move to core EHs: Hospital labs send structured electronic lab results to outpatient providers for 40% of labs sent electronically

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34 Quality Care and Healthcare Transformation Keys to Success Clinical and Executive Leadership Involve patients, physician and other care providers in the transformation Commitment to sustainability Health Information Technology Alignment of incentives Co ordination ordination of health and human resources Commitment to continuous quality improvement

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