1. VA Health Services Research & Development Center of Excellence
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”
Question
Hypothesis
Study
Publications
Changes in Practice
| Years |

5. IOM, NAE and the IT Revolution
To Err Is Human (2000) drew attention to the importance of health professionals’ using IT to develop safer systems
Crossing the Quality Chasm (2001) elaborated on importance of IT to all aspects of health care: administrative and financial transactions, clinical decision making, consumer health, public health, professional education, and research
Improving the Quality of Long-Term Care (2001) noted the importance of automated information systems in improving care in nursing homes
Health Professions Education (2003) articulated “using informatics” as one of five core competencies all health professionals need (Who Will Keep the Public Healthy, which also was published in 2003, listed informatics as a core competency for public health professionals
Keeping Patients Safe (2004) reaffirmed the importance of nurses as knowledge workers creating learning organizations supported by IT

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

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

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., 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;
2) implement EHR for information integration;
3) improve electronic communications and
documentation;
4) address issues related to security, especially with
increasing use of wireless networks and devices.
GAO. Use of Information Technology for Selected Health Care Functions

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. Informatics Technology For Clinical Guideline Implementation:
Perceptions Of Multiple Stakeholders
Facilitators of
Computer Use
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
Administrators
Clinicians
Providers
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. 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. 10th Street, Indianapolis, IN 46202
(317)