Implementing EHRs to Improve Healthcare Quality

Quality is a vital component
to healthcare, and effective use
of Health IT can vastly improve quality
and outcomes. However, the effective use
of Health IT depends on many things, including process
and workflow change. So, I’m a family physician,
that is my background. Before I came to AHRQ,
I was in Pennsylvania delivering babies, admitting
patients to the hospital, seeing folks in my clinic. And I came to appreciate
and understand that in order to be able to deliver
really great healthcare, you read really good
information. And in order to get
really good information, you need good information tools
and systems. So, AHRQ is the Agency for
Healthcare Research and Quality. It’s an operating division
of Health and Human Services, and AHRQ’s mission
is to improve the quality of healthcare
for all Americans. And the way we do that
is by developing the best evidence about
what improves quality, pullin’ that information
together in synthesis and making it available
to everybody. And creating tools for folks
to be able to use to help improve
your quality. Your average provider may
know us best through the National Guidelines Clearing
House, or That’s what I used
all the time when I was in practice, but there’s
a lot of other great resources available
at the agency. The Institute of Medicine
has a great definition of healthcare quality, which
breaks into six components. It says that quality healthcare
is safe, timely, effective, efficient, equitable,
and patient-centered. And those are the dimensions
that we frequently use to define high-quality
healthcare. Increasingly, payment
is not gonna be based on how many office visits
you can squeeze into the day and how quickly you can get
patients in and out. It’s not gonna be based on
how many operations a hospital can do,
regardless of the necessity or quality of those operations
or safety of their operations. Increasingly, healthcare
is gonna be paid for so that we get
the outcomes we want. There’s gonna be value,
not just volume. So, providers, there’s
gonna be transparency, if I wanna see a doctor, well,
they’re doing knee operations, what are the complication rate
for that, doctor, for their knee oper–
knee surgeries? If I want to see a primary care
doctor for my diabetes, of all patients
with this doctor with diabetes, how many of them have their
blood sugar or their lipids or their blood pressure
well-controlled? How do they do on flu shots
for their patients? How did their patients
like the experience of care? Not just, you know,
a popularity contest, but what was
the experience of care when I went into this
hospital? As we have implemented
meaningful use in our practice, we’ve more surrounded it
as a quality issue than a electronic
health record issue. Yes, we are using
the electronic health record with some hard stops,
some steps that you can’t go to the next step
without completing, to meet some quality issues that are also
meaningful use issues. In other words, I can’t
discharge a patient without measuring
their core measures. And in doing so, I meet
a meaningful use criteria, but I also meet some quality
indicators that help us. So we as a system have not
really pushed out meaningful use
to our physicians. We’ve more pushed out
we’re meeting these quality indicators
such as our diabetics, are they getting
their hemoglobin A1Cs? Are our, uh, cardiac patients
getting a aspirin? It’s sort of in the system,
and yes, it is the electronic record
that’s cueing you, you need to do this,
but it’s really a quality indicator
that we’re trying to meet. There’s lots of different ways
to measure quality in healthcare. A lot of people care
about outcomes. We all care
about outcomes because that’s what really
matters to us. Do we live longer,
do we suffer less, do we get good value
for our money? The problem
with healthcare outcomes as a measure of quality
is that’s it’s hard to draw that direct line
between “I did this and then that happened,”
lots of things affect the outcomes
in healthcare. So, a next step up that you can
take is say, “Did the right thing happen at the right time
in the right way?” And that’s called
a process measure. So, you know, we measured,
“Did Dr. White get the right lab test for a patient with
this condition in a timely way?” It’s not that ultimate
end goal, the outcomes, which again,
we all care about. But it helps us understand
the delivery of care, and it helps us understand
what the right thing is and when the right thing is. There’s been a lot
of discussion about using data from electronic
health records and other Health IT sources
to measure quality. We think it’s a really important
source of data, because it’s really the data about the actual
care–delivery that happened. Right now, a lot of quality
measurement that happens is based on billing data,
so it’s based on a code that a biller has–
has sent in. Um, which is a great
first approximation, but all those of us who provide
care know it’s not necessarily what actually happened
in the delivery of care. What you’ve got to consider
when you’re looking at information from electronic
medical records to measure quality, is that
it’s not being captured for the purpose of measuring
quality, it’s being captured for the purpose
of delivering care. Okay, so the kind
of information that’s captured may not be exactly
what you need when you’re trying to say,
“Out of this population of patients who should’ve
gotten this service, okay, how many of ’em
got that wa–that service and by the way, how many
of ’em weren’t supposed to get that service ’cause it
wasn’t appropriate for them?” So, uh, use of data from
electronic health records for the purposes
of quality measurement is not perfect right now. It’s an evolving science. It’s an evolving art. But we’re getting bet at it–
better at it over time, we continue to pay a lot
of careful attention to it and develop
good science about it. You can’t just digitize
a paper-based process. Then you’re not getting any
efficiency out of the electronic health record,
and I think that’s where a lot of the growing pains
are felt now, is if people just assume
that they’re gonna take the same paper-based
process they had and then duplicate that
electronically. That’s not gonna be
the most efficient way to do it, so it’s an opportunity
to re-think the workflows, find efficiencies in that
practice and help every member of the team–
that’s a really important word. Medicine’s a team sport
and every member of the team does their part, and they’re
gonna do it differently. The dance is gonna be different
when you have an electronic health record
that can really help manage that process and have
every member of the team, the front office person,
the medical assistant, the nurse, the physician,
and the patient do their part in a way
that gets someone through the process
as quickly, as efficiently, and with as much quality
as possible. If you don’t consider workflow
it might also become a safety issue. Making sure
that people have the information they need,
when they need it, not only can improve safety,
but if people don’t have the information they need
when they need it or in a way that
makes sense to them, you might be making it
really hard for them to do their job and you might
be causing, uh, challenges for the care
delivery. AHRQ has some great tools
for people who are implementing and adopting and trying
to meaningfully use Health IT. On the issue of workflow
in particular, we have a workflow toolkit,
specifically addressed for providers who are
trying to adopt. It’s created by industrial
engineers, so it’s people who know what they’re
talking about. And it’s a really great
resource. What we found is in getting
everyone to a common goal of success in an EMR
implementation, is listening, giving them an opportunity
to speak their mind, looking at their workflow,
going to their clinic. Seeing how they actually
take care of real patients. This makes a big difference. We have found primarily
that work flow practice sessions were some
of the biggest winners as far as getting clinics ready
for implementations. You can’t do it
all yourself. There has to be, as I mentioned,
a team approach, a clinical informatics group, and the big implementation
is critical. And our group
is spectacular. They work, seems like
28 hours a day, and they have been really
the reason that we’ve been successful thus far,
because they spent hundreds of hours of time
with the users, with the nurses,
with the providers. They wished they could’ve spent
more with some providers that were
in denial a little bit, but that team approach,
with a clinical team combined with an IT team,
as well, really is the–is the bridge
that makes this work. Our workflow sessions involve
sometimes, real patients. Maybe the last patient
of the day, who is agreeable to allowing the physician,
the nurse, to sit down at the computer,
see what the workflow from the time the patient
checks in, getting them in the system,
taking their vital signs, submitting them
electronically, bringing them back
to the room, opening up the electronic chart
in the computer for the doctor to see, and seeing really
how we would do a note, how we would do an order,
how we would send their medications
to the pharmacy. And that–it–to physicians
and providers that had not ever worked
in the system, they just don’t know
how that looks. They don’t know
what they don’t know. They’ve been used to pulling out
a prescription pad, hand-writing prescriptions,
hand-writing orders, they’re put in
by someone else. And so, those workflow sessions
are, uh, extremely helpful. I think optimization is about
how you, um, optimize the care environment,
so, um, and information management
is important to that so how do you manage
the care delivery processes in a more effective,
efficient, and safe way that drives quality? And so, driving all of that
process change, so bringing information
more proactic– proactively to the providers,
things like that, so how do you get information
instead of it being more of a– of a, “I gotta go pull things
and go search for things.” We know what the nurse needs
or the pharmacist needs or the doctor, uh,
of this type needs and that we get them the information
to ’em proactively. If there’s information there
that they don’t even know is important,
that we would tell ’em or we message ’em,
we alert ’em. And so, it’s really about
process change and efficiency and standardization of process
and getting the processes worked out but our processes
are so information-dependent, to optimize ’em is really–
it becomes an information management
optimization kind of function. Introduction of IT
into a practice is a big deal because, again, along this
premise that IT is a tool that’s a means to an end, okay,
you’ve gotta use the tool right. So, really before
you just–you say, “I’m just gonna implement IT,
I’m gonna adopt IT, I’m gonna buy a new EHR.” You really start–oughta start
by thinking about, “How do I run my practice? Okay, and how do I deliver care
to my patients? And where do I need information
and when do I need it, and how do I like to get access
to it, by the way, in a way that’s easier
for me than having to flip through a chart
or whatever,” okay? Then, once you understand
that reasonably well, and most providers do, they do
it on a day in, day out basis, okay, then–then you can
start saying, “How do I adopt those
information tools in a way that makes it better for me,
that makes it better for my patients, that makes it better
for my office manager, that makes it better for, you know,
the family members of patients to be able to participate
and help support their care?” When you talk about small
providers adopting, it’s hard. It’s very challenging:
you’re a small office, you really focus on delivering
care for your patients, you got a lot of responsibilities
on your shoulders. So it’s hard to think about
adopting Health IT. My message back to those folks
is, “I get it. I agree, it’s hard. It’s really important. It’s really important to be able
to have these tools at your disposal to deliver
great care to your patients. So, I know it’s hard,
but I know you can do it. I have great faith in you.” Healthcare Quality
has many dimensions, as the definition from the Institute of Medicine
illustrates. EHRs can improve quality,
but this improvement may not happen
automatically. EHRs can improve quality
by making the information accessible, and by providing
reminders to clinicians for such things as proper
medication use or ordering
preventive screening tests. The data in the EHR
can be used to document both the process of care, that is, those things
that a healthcare provider does, and the outcomes, that is,
what happens to the patient. Many processes
that were developed when we had paper charts
will not work as well when we implement electronic
health records. We need to re-think
and re-design our processes. These changes require
involvement of the whole team. Not just the clinicians, but office staff,
and even patients. Although it is a challenge
to redesign work processes, the rewards are that we can
finally begin to deliver healthcare that meets
the IOM’s high standards for quality, efficiency,
and safety. Captioned by
Video Caption Corporation

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