Improving Quality and Safety Through Health Information Technology

1. Improving Quality and Safety Through Health Information Technology Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality NCHICA Conference September 11, 2005

2. We’re building the field, and they are coming…

3. …but what will be the rules of the game?

4. How will Health IT improve the quality of patient care and enhance safety? We need to deliver answers…now.

5. Overview • AHRQ mission and organizational focus • Health information technology initiatives • Health IT and the future of health care

6. AHRQ’s mission Improve the quality, safety, efficiency and effectiveness of health care for all Americans

7. HHS organizational focus NIH Biomedical research to prevent, diagnose and treat diseases

8. HHS organizational focus NIH Biomedical research to prevent, diagnose and treat diseases CDC Population health and the role of community-based interventions to improve health

9. HHS organizational focus NIH Biomedical research to prevent, diagnose and treat diseases CDC Population health and the role of community-based interventions to improve health AHRQ Long-term and system-wide improvement of health care quality and effectiveness

10. A system-wide focus • Identify ways to improve patient safety and quality of health care systems • Assess the effectiveness of health care services • Advance the appropriate use of Health IT • Understand system issues: organizational design, management, workflow, and incentives on efficiency and effectiveness • Develop data on the health care system for monitoring and decision-making

11. Strategic redirection • Accelerate the pace of innovation • Ensure value through more informed choice • Assess innovation faster • Implement effective innovations sooner

12. National priorities for Health IT • Interoperable systems • Electronic health records (EHRs) for most Americans by 2014 • E-prescriptions • Electronic reporting of adverse reactions to medications

13. How AHRQ is helping • We fund grants and contracts to promoteHealth IT investment, especially in rural and underserved areas • We evaluate what works best, where barriers exist, and how Health IT can be successfully implemented • We offer technical assistance through the AHRQ Resource Center for Health Information Technology to help clinicians make the leap from pencils to PDAs

14. Health IT: A means to an end AHRQ’s Role: Prove Health IT works in real-life clinical settings • How does Health IT drive safety and quality improvement? • How can we ensure that doing the right thing is the easy thing to do? • How can we use the power of Health IT to provide better quality measures faster?

15. The promise of Health IT • Enable information exchange and interoperability between healthcare settings • Enhance the precision and decrease the cost of measurement • Improve translation of strategies to improve quality (e.g., decision support) • Improve timeliness of quality data collection – link to incentives

16. HIT, quality and safety • Outpatient Advanced CPOE and EMR Avoid 2.1 million adverse drug events • Inpatient CPOE and EMR Decrease serious medication errors by 55% • Healthcare information exchange and interoperability between settings • Improve decision-making at the point-of- care through complete information access Source: CITL

17. Bridging the Quality Chasm Where Where we we are want to be Health IT Innovation Diffusion Adoption

18. Overview • AHRQ mission and organizational focus • Health information technology initiatives • Health IT and the future of health care

19. Building HIT evidence base • Electronic Health Records • Clinical Decision Support • Electronic Prescribing • Use of hand-held devices • Consumer-directed IT

20. Planning 1 yr Implementation 3 yr Demonstrating Value 3 yr AHRQ Resource Center for Health Information Technology AHRQ Health IT Portfolio State and Regional Demonstrations 5 yr

21. FY04: Health IT initiatives • Transforming Healthcare Quality through Information Technology: 3 RFAs • AHRQ Resource Center for Health IT • State demonstrations on interoperability • Indian Health Service EHR Collaboration • CMS–AHRQ demonstration collaboration • Development of clinical data standards

22. Transforming Healthcare Quality through Health IT (THQIT) FY04 Grant Solicitations Determine the value of Health IT • Assess the value derived from the adoption, diffusion, and utilization of HIT THQIT planning • Assist healthcare systems and their partners in planning for activities that lead to successful Health IT implementation THQIT implementation • Support organizational and community-wide implementation and diffusion of Health IT

23. Health IT grants Promote access to Health IT • $139 million investment over 5 years • Over100grants to communities, hospitals, providers, and health care systems to help in all phases of the development and use of Health IT • The grants spread across 40 states • Special focus on small and rural hospitals and communities

24. Value grants • Epic EHR installation at Kaiser • CDSS in nursing homes on medication ordering • State-wide rollout of e-prescribing • EHR and/or web-based patient program for diabetics • Human factor analyses and CPOE implementation • Tele-ICU monitoring on outcomes and costs • Health information exchange in ambulatory care

25. Planning grants • Area-wide EHR in remote Alaska • Regional planning for Health IT in Michigan’s upper peninsula • Electronic sharing of behavioral health information in Nebraska • Unified EHR for hospitals, private providers, and hospice in rural New York • Community-driven effort to bring community health centers and hospitals together to share data in Hawaii

26. Implementation grants • Community-wide EHR to improve asthma care for inner-city children in Connecticut • Emergency department EHR across Louisiana’s critical access hospitals • Electronic radiology initiative across three hospitals in rural Maine • CPOE in an inner-city, minority community in Ohio • Patient-centered medication information system to improve health of chronically ill elders in rural Oregon

27. AHRQ Health IT research in NC (Total funding over 3 years: $3.0 million) PROJECT: Automated Adverse Drug Events Detection and Intervention PI: Peter Kilbridge, Duke University PROJECT: Showing Health Information Value in a Community Network PI: David Lobach, Duke University

28. AHRQ Research Study: CPOE • Major Finding:While computerized physician order entry (CPOE) is expected to significantly reduce medication errors, systems must be implemented thoughtfully to avoid facilitating certain types of errors • Study looked at clinicians’ experience in using one CPOE system at a major urban teaching hospital • Implementation problems can be minimized through testing before products are marketed and through adaptation to meet the needs of individual clinical settings R. Koppel, J. Metlay, A. Cohen, et al., Role of computerized physician order entry systems in facilitating medication errors,Journal of the American Medical Association, March 9, 2005

29. Interoperability demos • 5-year state-based contracts: • Help states develop secure networks • Ensure privacy of health information • Make individual health information more available to health care providers. • FY04: 5 states awarded $1M/year • Colorado • Indiana • Rhode Island • Tennessee • Utah

30. IHS-EHR deployment/support • AHRQ and IHS funding evaluation • Currently in active deployment phase • National and regional support supplied by the IHS through federal employees and contracted support • Ongoing enhancements, with focus on OB, pediatrics, as well as integrated case management • Pilot site: Cherokee Hospital

31. AHRQ Resource Center for Health Information Technology • Repository and portal of best health IT practices from real clinical settings and day to day experience • Real world laboratory now provides technical support for health IT grantees • Access will be expanded to HHS supported public health clinics, state agencies and to the public

32. Work in progress • Randomized trials of e-prescribing to reduce errors • With substantial hand-holding, 46% of physicians will use • Functionality challenges – both the applications and their use • Multiple reporting demonstrations for patient safety • Multiple studies to improve care using one or more HIT applications as an intervention

33. Health IT and research • Identify and prioritize critical questions: e.g., clinical variations as a reflection of inadequate knowledge • Accelerate collection of relevant data • Facilitate consistent measurement of key outcomes • Enhance participation of communities and stakeholders • “Reinvent” dissemination and translation

34. Health IT and patient safety Key challenges • Tap and collect ongoing resources • Convince providers to buy in • Understand existing workflow • Understand HIT impact on workflow • Data standards/integration • Get vendors to make needed changes

35. Insights from HIT grantees • Pay attention to human factors • Involve users from the beginning • Usability testing • Get a broad base of support • Senior leadership • Clinical champions • Expect system modifications • Mid-course corrections/improvements

36. Insights from HIT grantees • Communicate with front-line staff • Set reasonable expectations/promote successes • Look for unanticipated consequences and new errors caused by the technology • Automation can identify existing bad practices • HIT can standardize and structure data to improve measurement and benchmarking • Haven’t learned it all yet– need more support for evaluation and implementation studies!

37. HIT Privacy Study State Level Variations • Purpose: • Better understand the privacy and security barriers to the exchange of personal health information within and across states. • $11.5 million contract with up to 40 subcontractors (states). • One of four studies to better inform the Secretary, AHIC and other stakeholders on significant HIT issues.

38. American Health Information Community • Advisory Committee • Inform and recommend to the Secretary specific actions to achieve a common interoperability framework for health information technology and • serve as a forum for participation from a broad range of stakeholders to provide input on achieving interoperability. • Up to 17 voting members

39. S 1418 – Wired for Health Care Quality Act • Establishes Office of the National Coordinator of Health IT within HHS • Secretary is to establish and chair American Health Information Collaborative • Provides for standards development and technology certification, using private entities • Three grant programs for planning and acquisition ($125M FY06, $155M FY07) • New demonstration grant program for health professional training • Requires formal process for developing and updating care quality measurement systems • AHRQ is to develop a Health IT Resource Center

40. AHRQ-Specific Provisions • Directs AHRQ to develop a Center for Best Practices to provide technical assistance and develop best practices to support and accelerate health IT adoption • “appropriate” amounts authorized • Secretaries of HHS, VA, and DoD, along with representatives of other federal agencies, are required jointly to develop or adopt a quality measurement system. Must • Be evidence-based, reliable and valid • Include clinical process and outcomes, patient experience, efficiency, and equity • Include overuse and underuse

41. Overview • AHRQ mission and organizational focus • Health information technology initiatives • Health IT and the future of health care

42. Medicare Modernization Act Health IT Provisions • Electronic Prescription Program • Grants to Physicians – ePrescribing systems • Telemedicine Demonstrations Projects • Medicare Care Management Performance Demonstration • Council for Technology and Innovation • Commission on Systemic Interoperability

43. Medicare and EHR • Free VistaOffice EHR software distribution from CMS (9/05) • Significant cost-saving incentive, especially for small groups • Will accelerate adoption of EHR in small practice settings • Example of pivotal role of CMS in Health IT adoption and transformation

44. Health IT opportunities Reengineer processes to improve patient safety • As we migrate to a health IT infrastructure, put effective processes in place as the same time • Augment health IT applications for error reduction, CPOE and other decision support tools • Build in the necessary disciplines and team approaches

45. Health IT opportunities Remove barriers • Build interoperable systems • Standardize medical nomenclature • Examine privacy issues • Prepare the health care sector and clinicians to use full potential of health IT • Learn and share best practices through the AHRQ Resource Center for Health IT and other channels

46. Health IT opportunities Develop/disseminate evidence • Assess effectiveness of different treatment options for high-priority conditions (MMA) • Use health IT channels to deliver important information faster and more effectively, especially in patient safety • Identify new research needed

47. AHRQ Research Study: Risks Associated With Erythromycin Combined With CYP3A Inhibitors • Major Finding: Concurrent use of erythromycin and strong inhibitors of CYP3A should be avoided • Patients who took erythromycin with VYP3A drug enzymes (certain calcium-channel blockers and anti-fungal drugs, and some anti-depressants), had a 5x greater risk of sudden death from cardiac causes W. Ray, K. Murray, S. Meredith, et al., Oral Erythromycin and the Risk of Sudden Death from Cardiac Causes, New England Journal of Medicine, September 9, 2004

48. Future program emphasis • Regional health information exchange • Technical support to states and regions • Focus on privacy and security • Product testing • Electronic reporting of performance measures and adverse events • Synergize ongoing and future initiatives • ePrescribing (grants to physicians, MMA eRx programs) • Chronic Disease Programs • Create avenues enhancing technical and resource support (CHCs)

49. The keys to HIT Teamwork > Tools > Timing > Connection

50. Your questions?