1. Introduction to Quality Improvement and Health Information Technology
Welcome to Quality Improvement: Introduction to Quality Improvement and Health Information Technology. This is Lecture c.
Lecture c
This material (Comp12_Unit1c) was developed by Johns Hopkins University, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number IU24OC

2. Quality Improvement Introduction to QI and HIT
Introduction to Quality Improvement and Health Information Technology Learning Objective─Lecture c
Analyze the ways that HIT can either help or hinder quality improvement.
The Objective for Introduction to Quality Improvement and Health Information Technology is to:
Analyze the ways that HIT can either help or hinder quality improvement.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

3. What Is Health Care Quality? Improvement?
So what needs improvement in our healthcare system? In 2001, the US Institute of Medicine (also referred to as the IOM) produced a report that called for a marked redesign of the American healthcare system. In this report, the IOM called for transformational change that will help to close the quality gap. In addition, the IOM provided far-reaching principles that provide directions for those who purchase healthcare, those who provide healthcare, those who regulate healthcare and those involved with policy-making for healthcare.
This report identified six aims of quality improvement. These aims state that healthcare should be:
Safe,
Effective,
Patient-centered,
Timely,
Efficient,
And equitable.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

4. Health Information Technology (HIT)
Has the potential to:
improve health care quality
prevent medical errors
increase health care efficiency & reduce unnecessary costs
increase administrative efficiencies
decrease paperwork
expand access to affordable care
improve population health
Most of our interest in increasing the use of Health Information Technology is its potential to improve the quality of healthcare as we know it, to increase our ability to achieve the six aims of quality improvement. Not only does Health IT have the potential to improve quality and prevent medical errors, but it also has the ability to increase efficiencies of all kinds, reduce cost, and decrease paperwork. HIT also has the potential to expand access to affordable care and improve population health.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

5. Quality Improvement Introduction to QI and HIT
Safety: Case Review
Event: Mr. Smith was prescribed a blood thinner to be taken once a day. He received his daily dose of the drug and was then transferred to another unit. In the receiving unit, the blood thinner order was rewritten and POE interpreted this as a new order and scheduled a dose to start that same day. This resulted in Mr. Smith receiving two doses of the drug during the same day.
Mr. Smith was prescribed a blood thinner to be taken once a day. He received his daily dose of the drug and was then transferred to another unit. In the receiving unit, the blood thinner order was rewritten and POE interpreted this as a new order and scheduled a dose to start that same day. This resulted in Mr. Smith receiving two doses of the drug during the same day.
Considering this case, how would you address this issue?
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

6. Role of HIT in Improvement Efforts Patient Safety
CPOE
Computerized provider order entry
Can reduce errors in drug prescribing and dosing
Medical Device Interface
Automated vital sign capture
Can reduce errors in transcription
Knowledge Links
Reference information links
Can reduce errors due to lack of knowledge
Monitoring
Quality metric reporting
Can identify opportunities for improvement
e-MAR
Computerized medication administration record
Can reduce errors in drug administration
e-Allergy List
Computerized allergy list
Can reduce errors in preventable adverse drug events
Reminders
Prompts and flags
Can reduce errors in omission
Structured Notes
Standardized observations
Can reduce errors related to failure to detect subtle changes in status
Safety is defined as freedom from the occurrence or risk of injury, danger, or loss. When applying the term to patients, we are speaking of protecting our patients from unintentional harm from the care that is intended to help them. HIT has the potential to protect patients from unintentional harm. Computerized Provider Order Entry (CPOE) can reduce errors in drug prescribing and dosing by triggering alerts when doses exceed acceptable limits, for example. Medical device interfaces allow for automated capture of vital signs, such as heart rate and blood pressure. This reduces the possibility of error on the part of the human who collects this information by eliminating the transcription step. The electronic medication administration record can reduce errors in drug administration by displaying a record of drugs that have already been administered, and those that are scheduled to be administered.
An electronic allergy list can reduce errors by preventing adverse drug events caused by administering drugs the patient is allergic to.
Knowledge links can reduce errors by providing links to reference materials when there is a lack of knowledge on the part of the prescriber or the patient. Quality metric reporting can identify opportunities for improvement. Reminder prompts and flags can reduce errors in omission by reminding providers of interventions that are scheduled, and structured notes use standardized observations that can reduce errors related to failure to detect subtle changes in status.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

7. Quality Improvement Introduction to QI and HIT
What They Did
System change: A medical logic module (MLM) was created that provides the following functionality: When selected drugs are ordered at a frequency of every 24 hours or longer, the prescriber is automatically presented with the last administration time if the drug had been ordered previously.
In response to this event, a decision rule, or medical logic module (MLM), was created that provides the following functionality: When selected drugs are ordered at a frequency of every 24 hours or longer, the prescriber is automatically presented with the last administration time if the drug had been ordered previously.
In this example, the way in which the CPOE was configured was not helpful to prescribers who were trying to order drugs taken once per day. In fact, a patient’s safety was compromised in that he received duplicate medication therapy. This appears to have been, in part, due to the way in which the system interpreted an order. A careful review of reported events such as the event depicted here often results in recommendations for change to the way the IT system is configured. For this reason, it is helpful to appoint an IT professional to sit on incident review committees.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

8. HIT & Optimizing Patient Safety
Early detection and effective treatment are the cornerstones of treatment for pneumonia. Adults aged 65 and older should receive the influenza and pneumococcal immunization to prevent pneumonia and its complications.
Early detection and effective treatment are the cornerstones of treatment for pneumonia. Adults aged 65 and older should receive the influenza and pneumococcal immunization to prevent pneumonia and its complications.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

9. Enhancing Clinical Effectiveness with HIT
Knowledge access
Patient-friendly websites
Can provide medical information and access to support groups
Tailor to Patient Needs
Clinical decision support
Can tailor information according to patient characteristics and condition
Patient portal
Patient access and manage own health record
Can enable self-management
Disease management
Customized health education and disease management messaging
Can enable self- management
Clinical effectiveness can be enhanced by HIT by providing knowledge links to clinical practice guidelines in order to increase use of best practices; quality measure reporting to identify gaps in practice; reminders in the form of practice alerts and flags; and structured notes to guide providers through standardized observations to enhance assessment and diagnosis.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

10. Effectiveness: Case Review
Event: A standard protocol (document specifying best practices for care) and electronic prescriber order sets are used for all adult patients receiving intravenous blood thinners. There are new changes to the protocol due to a switch to new laboratory tests for monitoring drug activity.
There are a number of best practices that are written in the form of protocols or practice guidelines. Protocols provide guidance for care surrounding particular clinical conditions to increase the effectiveness of care. Think about a scenario in which a standard protocol (document specifying best practices for care) and electronic prescriber order sets are used for all adult patients receiving intravenous blood thinners.
Considering this case, how would you address this issue?
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

11. Quality Improvement Introduction to QI and HIT
What They Did
System Change: The current protocol and electronic order sets were revised to include orders for the new laboratory tests. The new order sets include changes to the therapeutic goals of nurse-managed therapy.
There are new changes to the protocol due to a switch to new laboratory tests for monitoring drug activity. The team responded to this event by revising the current protocol and electronic-order sets to include orders for the new laboratory tests. The new order sets included changes to the therapeutic goals of nurse-managed therapy.
In this scenario, modifications made to changes in the protocol required changes in the electronic order sets that had been in use in the facility. Keeping up with care standards requires up-to-date order sets and electronic clinical documents. Here it is helpful to have HIT professionals involved in protocol-development work.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

12. HIT & Optimizing Effectiveness
Telemedicine is the use of telecommunication technology to provide, enhance, or expedite health care services. This technology is typically used to increase access to clinical expertise to improve the effectiveness of care.
Telemedicine is the use of telecommunication technology to provide, enhance, or expedite healthcare services. This technology is typically used to increase access to clinical expertise to improve the effectiveness of care.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

13. Enhancing Patient Centeredness with HIT
Knowledge access
Patient-friendly websites
Can provide medical information and access to support groups
Tailor to Patient Needs
Clinical decision support
Can tailor information according to patient characteristics and condition
Patient portal
Patient access and manage own health record
Can enable self-management
Disease management
Customized health education and disease management messaging
Can enable self- management
Patient-centered care is supported by HIT as well. Patient-friendly websites provide medical information and access to support groups; patient portals allow patients to access and manage their own health records; clinical decision support can tailor information according to patient characteristics; and customized health education and disease management messaging can enable patient self-management.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

14. Patient-Centeredness: Case Review
Event: Mr. Jackson took his mother to a pre-operative evaluation center in preparation for her impending surgery. He was asked to help her complete an information form that included her home medications. Mr. Jackson’s sister manages these medications and he had forgotten to bring the list. He was unable to contact her on her cell phone and became increasingly frustrated since, after all, his mother’s doctors should know what medicines she is taking!
Mr. Jackson took his mother to a pre-operative evaluation center in preparation for her impending surgery. He was asked to help her complete an information form that included her home medications. Mr. Jackson’s sister manages these medications and he had forgotten to bring the list. He was unable to contact her on her cell phone and became increasingly frustrated since, after all, his mother’s doctors should know what medicines she is taking! In response to this event, the ambulatory care center implemented a web-based patient portal that would allow patients or caregivers to enter much of the history information in advance, from home. Patient satisfaction scores improved with this active role in their care.
Consider how you would address this issue.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

15. Quality Improvement Introduction to QI and HIT
What They Did
System Change: The ambulatory care center implemented a web-based patient portal that would allow patients or caregivers to enter much of the history information in advance, from home. Satisfaction scores for patients improved with this active role in their care.
Effective patient-provider communication, where the patient and family perceive themselves as participants in the patient’s care, is essential for quality health care. The scenario depicted in the previous slide highlights a frequent situation encountered surrounding the issue of home medications. Collecting an accurate and current home medication list at each patient encounter is a national patient safety goal. HIT can help to engage the patient and family in the patient’s care to ensure that this goal is met.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

16. HIT & Optimizing Patient Centeredness
A medical office practice is considering the use of a web-based secure messaging system to improve patient-provider communication and enhance patient satisfaction.
A medical office practice is considering the use of a web-based secure messaging system to improve patient-provider communication and enhance patient satisfaction.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

17. Enhancing Timeliness with HIT
Telemedicine
Internet-based access
Can provide immediate access to medical information
Time-sensitive Prompts
Timed draw alerts
Can remind nurses when to draw blood based on a medication intervention
Clinicians Reminders
Task list schedules
Can remind nurses when treatments are due
Patient Reminders
Appointment scheduling
Can remind patients when they need to return for follow-up visits
HIT can support timely care. Telemedicine provides immediate access to medical information through the internet. Task list schedules can remind nurses when treatments are due. Time-sensitive prompts, such as timed draw alerts, can remind nurses when a procedure is due; and patient reminders can let patients know when they need to return for follow-up visits or tests.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

18. Timeliness: Case Review
Event: Medication patches are small, flesh-colored, and are usually placed in discreet locations, e.g. the upper shoulder area or on the back of the upper arm. Some patches are appropriately left on for 2-3 days or longer. It is difficult to track the placement and removal of these patches over time, leading to errors in which medication patches were not removed and the patient received too much medicine.
Timeliness is a quality aim that is especially amenable to HIT solutions. In this scenario, the importance of timely placement and removal of medication patches lends itself well to an HIT solution. Medication patches are small, flesh-colored, and are usually placed in discreet locations, for example, the upper shoulder area or on the back of the upper arm. Some patches are appropriately left on for 2-3 days or longer. It is difficult to track the placement and removal of these patches over time, leading to errors in which medication patches were not removed and the patient received too much medicine.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

19. Quality Improvement Introduction to QI and HIT
What They Did
System Change: A change was made to the electronic medication record (eMAR). After the nurse documents the application of the patch in the eMAR, a follow-up task to remove the patch at the ordered date and time is automatically generated. If the follow-up task is still active during a transfer in care, the receiving nurse will see this task on the eMAR.
In response to this event, a change was made to the Electronic Medication Record (eMAR). After the nurse documents the application of the patch in the eMAR, a follow-up task to remove the patch at the ordered date and time is automatically generated. If the follow-up task is still active during a transfer in care, the receiving nurse will see this task on the eMAR.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

20. HIT & Optimizing Timeliness
A healthcare system saw increases in adverse events in its home care company due to inadequate transfer of clinical information at hospital discharge. An electronic hospital discharge summary with auto-faxing was developed to increase availability of discharge information at the time of follow-up care.
Patient-satisfaction surveys reveal that timeliness of care is a powerful indicator of healthcare quality from the patient’s perspective. Patients and families value their time as much as do health care professionals. HIT can help by ensuring timely access to information. Think about the following case: A health care system saw increases in adverse events in their home care company due to inadequate transfer of clinical information at hospital discharge. An electronic hospital discharge summary with auto-faxing was developed to increase availability of discharge information at the time of follow- up care.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

21. Enhancing Efficiency with HIT
Wireless mobile technology
Vital Sign Capture
Can eliminate need to write or type vital signs
System integration
Pull forward historical information
Can reduce data collection time
Character expansion
Ability to translate a few characters into phrases, sentences or paragraphs
Can decrease typing time
Clinical decision support
Prompt for duplicate labs
Can reduce redundant laboratory testing
HIT can enhance efficiency in many ways. Wireless mobile technology allows for vital sign capture and can eliminate the need to write or type vital signs. Character expansion allows for the ability to translate a few characters into phrases, sentences, or paragraphs and can decrease typing time. For example, the provider can type a few letters, such as WNL, which can be converted to within normal limits or an entire paragraph describing the normal assessment parameters. System integration allows for pulling forward of historical information and can reduce data collection time. Clinical decision rules can be written to prompt for duplicate labs to reduce redundant laboratory testing.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

22. Efficiency: Case Review
Event: The emergency department (ED) staff at a community hospital used a large whiteboard mounted on the wall that could be quickly updated with felt-tip markers to track patients and treatments. The problem was that staff could not obtain information from the board unless they were physically standing in front of it. In addition, information on the board only reflected what was already known by the ED staff.
In fast-paced healthcare settings, such as emergency departments and operative suites, a tracking board can help to streamline throughput (or admission, discharge, or transfer activity). Think about a situation in which the Emergency Department (ED) staff at a community hospital used a large whiteboard mounted on the wall that could be quickly updated with felt-tip markers to track patients and treatments. The problem was that staff could not obtain information from the board unless they were physically standing in front of it. In addition, information on the board only reflected what was already known by the ED staff.
Consider how you would address this issue.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

23. Quality Improvement Introduction to QI and HIT
What They Did
System Change: The hospital implemented an automated ED patient tracking system that used business intelligence technology. This technology enabled more efficient patient flow using real-time data.
In response to this event, the hospital implemented an automated ED patient- tracking system that used business intelligence technology. This technology enabled more efficient patient flow using real-time data.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

24. HIT & Optimizing Efficiency
Hope Memorial Hospital implemented an electronic picture archiving and communication system (PACS) for requesting radiological examinations and displaying images. They saw a reduction in repeat chest X-ray films at outpatient appointments.
Hope Memorial Hospital implemented an electronic Picture Archiving and Communication System (PACS) for requesting radiological examinations and displaying images. They saw a reduction in repeat chest X-ray films at outpatient appointments.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

25. Enhancing Equity with HIT
Data capture
Monitoring by population characteristics
Can uncover health care disparities
Tailor to Patient Needs
Competency-based patient education
Can tailor information to educational background and development status
Multi-Modal functionality
Various ways for patients to get health information
Can decrease health care disparity
Decision support
Drug cost information
Can assist providers in selecting alternatives for low income patients
Finally HIT can enhance equity of healthcare and services. Data capture can allow for monitoring by population characteristics to uncover healthcare disparities. The multi-modal functionality of systems can allow for various ways for patients to get health information to decrease health care disparities. Competency-based patient education can tailor information to the patient’s educational background and developmental status. Decision support can offer drug cost information to assist providers in selecting alternatives for low- income patients.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

26. Quality Improvement Introduction to QI and HIT
Introduction to Quality Improvement and Health Information Technology Summary─Lecture c
All healthcare settings can benefit from the assistance of HIT professionals in identifying electronic solutions to quality concerns.
This concludes Lecture c of Introduction to Quality Improvement and Health Information Technology. In summary, all healthcare settings can benefit from the assistance of HIT professionals in identifying electronic solutions to quality concerns.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c

27. Quality Improvement Introduction to QI and HIT
Introduction to Quality Improvement and Health Information Technology References—Lecture c
References
Institute of Medicine. Crossing the quality chasm. Washington DC: National Academy Press, p
Images
Slide 3: What is Health Care Quality? Courtesy Dr.Anna Maria Izquierdo-Porrera
No audio.
Health IT Workforce Curriculum Version 3.0/Spring 2012
Quality Improvement Introduction to QI and HIT
Lecture c