Chapter 11 Health IT & Quality PDF

CHAPTER 11 Health Information Technology and Quality Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com.  Learning Objectives  The background and history of health information technology (HIT) in the United States.  Challenges with...

CHAPTER 11 Health Information Technology and Quality Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com.  Learning Objectives  The background and history of health information technology (HIT) in the United States.  Challenges with HIT implementation & key components required for successful HIT Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com implementation.  Initiatives and responses of the federal government to deal with implementation challenges.  The Office of the National Coordinator of Health Information Technology (ONC) structure and its role in HIT issues, implementation, and policy execution, & the role of computerized clinical decision support in quality and patient safety.  Differences of ICD-9 and ICD-10 in terms of depth and patient care, & trends in general and certified electronic health record adoption.  Use of health information exchanges in quality improvement & models  Organizations associated with quality in the United States & their role.  Seven pillars of quality in health care.  Key Concepts  The 1990: the period that commercially produced EHR systems became mass marketed and sold to healthcare institutions in high volume. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  The three essential components of a successful HIT implementation: technology, processes, and institutional and organizational culture.  Quality in health care: essential to the delivery of appropriate care to patients to reduce suffering and harm.  The Health IT Policy Committee: recommendations to the National Coordinator for Health IT on a policy framework for the development and adoption of a nationwide health information infrastructure, including standards for the exchange of patient medical information.  The driving concept behind EHRs’ potential: improving the quality & reduce the cost of HC  The Health Insurance Portability and Accountability Act (HIPAA) regulations → healthcare institutions’ willingness to share data with other institutions due to liability for patient privacy and security of patient data.  Background  U.S. government has facilitated many health information technology (HIT) initiatives for more than 50 years Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  2004: the Office of the National Coordinator for Health Information Technology (ONC) created by the federal government  The American Recovery and Reinvestment Act (ARRA) in 2009  Health Information for Economic and Clinical Health (HITECH) Act: designated $36.5 billion to promote the development of a nationwide network of EHRs.  - EHRs: computerized patient records to replace paper charts  HIT benefits to quality & HC cost: mixed  Historical challenges in implementing HIT  1990s: commercially produced EHR systems became mass marketed and sold to healthcare institutions in high volumes Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Purchase and operation of an EHR system: major investment for large healthcare organizations and small private physician groups  Small practice groups: anxiety about making decisions to convert from paper to electronic charting  May not directly benefit from the technology…  Healthcare system may also lose money by not receiving revenue for the duplicate tests not performed and for the expense they bear supporting the health information exchange (HIE) 1. Technology: mistaken belief that merely selecting the “right technology” is the important aspect of HIT implementation 2. Process: organization’s policies and Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com procedures describe and define the processes by which the work is carried out. Actual work may significantly differ from those officially documents. 3. Institutional/Organizational Culture: MOST SIGNIFICANT. Shift in culture towards transparent reporting of HIT Figure 11-1 The Three Essential Components failures and viewing them as learning of a Successful HIT Implementation opportunities Created by Richard Greenhill.  Federal Government’s response to HIT implementation (1/6)  HITECH Act  Medicare and Medicaid Electronic Health Record Incentive Programs Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Designated $36 billion Medicare & Medicaid Electronic Health Record Incentive Programs  Addresses a variety of HIT-related issues: certification, adoption, governance, meaningful use, privacy, security, quality measures, implementation.  CMS used funds to incentivize Eligible Professionals and Eligible Hospitals to adopt certified EHR technology to improve patient Figure 11-2 Key Legislation Impacting HIT care. Created by Richard Greenhill.  Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Federal Government’s response to HIT implementation (2/6)  Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Federal Government’s response to HIT implementation (3/6)  In 2009, the Office of National Coordinator for Health Information Technology (ONC) - designated as “the principal federal entity charged with coordination of nationwide Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com efforts to implement and use the most advanced health information technology and the electronic exchange of health information.”  ONC’s budget: $60 million in 2015.  The Centers for Medicare and Medicaid (CMS) provided financial incentives for the Meaningful Use Program; while ONC sets the Figure 11-3 Office of the National Coordinator for Health Information Technology Organizational Structure requirements. Created by Richard Greenhill. Data from the Office of the National Coordinator of Health Information Technology. About ONC. Updated March 12, 2021. Accessed August 19, 2021. https://www.healthit.gov/topic/about-onc#:~:text=ONC%20is%20the %20principal%20federal,electronic%20exchange%20of%20health%20information  Federal Government’s Response to HIT Implementation (5/6)  The Health IT Policy Committee makes recommendations to the Office of National Coordinator for Health IT on (ONC) a policy framework for the development and Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com adoption of a nationwide health information infrastructure.  The American Recovery and Reinvestment Act (ARRA; 2009) requires the Health IT Policy Committee to make recommendations on eight specific areas: standards, implementation specifications, certification criteria for the electronic exchange and use of health information.  To receive maximum incentive payment under Meaningful Use Program, Eligible Professionals who chose to participate in the Medicare Program had to achieve Stage 1 by 2012 or by 2014 for a reduced amount.  By November 2014, only 25.2% of Eligible Professionals and 43.1% of Eligible Hospitals met Stage 2 requirements.  Federal Government’s Response to HIT Implementation (6/6)  By 2017, CMS finalized the requirements for Stage 3, which included 8 objectives for Eligible Professionals and Eligible Hospitals. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Healthcare quality (1/2)  Essential to the delivery of appropriate care to patients to reduce suffering and harm.  WHO definition: “the degree to which health services for individuals and populations Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com increase the likelihood of desired health outcomes”  Institute of Medicine (2001)’s book acknowledges health services should meet 6 domains, plus integration: Healthcare quality (2/2) 3 main perspectives in the practice of health care: Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com 1. Patient perspective 2. Payer perspective 3. Health system perspective Quality is important to three main groups: 4. Health systems 5. The federal government 6. Patients  Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Key Organizations that have influence on quality in the U.S.  HIT opportunities (1/2)  A healthy human’s performance begins to measurably decrease in about 40 minutes while monitoring a continuous process. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Limitations explain regulations for work-time breaks needed; and no amount of training/will power can overcome these biological limitations.  Driving concept behind the potential of EHRs: to improve the quality and reduce the cost of health care  HIT opportunities (2/2)  Ultimate goal: to combine the intuitive strengths of humans with the limitless data retention and recall speed of computers to create a hybrid system that is intuitive with a tireless data processing capability. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  The computer provides the physician with a computerized clinical decision support system (CDSS).  Shown to improve ordering of age-appropriate screening tests, appropriate antibiotic prescribing for inpatients, appropriate advance directive discussions with patients, preventive care for hospitalized patients, weaning of patients from mechanical ventilators, etc.  Studies support that CDSS: the potential to improve physician performance in myriad healthcare venues.  Strong evidence that CDSS can improve the ordering and completing of preventive care and prescribing recommended treatments.  Health Information Exchanges (HIEs) (1/2)  Virtually none of the commercially available EHR systems in today’s market at large academic institutions can easily exchange patients’ health information with care providers outside of their institution. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Barriers to EHR interoperability become apparent when patient sees a number of different specialty physicians and attempts to coordinate the flow of information.  Some EHR vendors also actively block information transfer.  Regional health information organizations (RHIOs): attempting to create systems, agreements, processes, and technology to facilitate the appropriate exchange of healthcare information across different vendor platforms.  Actual implementation of real data exchange varies widely.  Actively functioning HIEs exist only at regional levels…  Health Information Exchanges (HIEs) (2/2)  NO national standard to facilitate electronic HIE…  Most institutions participating HIEs must build or configure “interface engines” that Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com convert an institution’s data to the format used by the HIE.  Logical Observation Identifiers Names and Codes (LOINC) standard in 1990s that uniquely defines codes for information. Now >70,000 LOINC-defined codes for laboratory tests…  Ex., 419 different codes to report blood pressure. LOINC enables computer systems receiving data to generate exact interpretations. It is called semantic interoperability.  Semantic interoperability: essential for patient record transmission from one EHR system to another so that the meaning of the data is not at risk of erroneous interpretation.  For HIE to transfer information correctly, each EHR system must make its own internal code for each datum to a standard code.  Using HIEs, designated member groups exchange data in a standardized format using a combination of standards.  Three models of HIE architecture: (1/6) 1. Centralized: All member institutions periodically send copies of their clinical data to one central repository where all the data reside together in one format. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Advantage: a patient’s comprehensive data can be maintained in one place and in one format. Disadvantage: frequency with which members contribute & update copies of the data can vary can make the HIE record potentially out of date.  Aggregating data from multiple institutions creates administrative complexity regards to HIPAA regulations.  The ability of the source institution to assert control over data contributed to the collective HIE: limited. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Figure 11-5 HIE Centralized Model  Three models of HIE architecture: (3/6) 2. Federalized or 3. Decentralized: allows contributing institutions to maintain control over data for which they are responsible under HIPAA. Institutional data Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com resides within each institution’s system. HIE database is small and contains only a master patient index (MPI) housing the identifiers for each patient in the form of each institution’s unique patient record numbers with patient demographic data. Advantage: a patient who has medical records at more than one institution in the HIE would have all medical record numbers from various institutions linked together in common MPI.  Allows for fast and accurate identification of patients.  Ensures data are collected securely, assembled into a comprehensive record and made available to authorized users in real time.  Three models of HIE architecture: (4/6)  Each institution has complete control over its data, simplifying compliance with HIPAA regulation. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Transinstitutional data can be up-to-the-minute accurate because each time a user requests access, the clinical data from all institutions are assembled in real time. Disadvantages: Most of the operating HIEs are heavily subsidized with federal research grant funding. There is still no business model that can be used in all communities to sustain their HIEs.  Some communities are resistant to allowing payer access to a data resource they believe should be solely dedicated to improving patient care and quality.  Many institutions’ HIT resources are dedicated to keeping up with current quality reporting requirements, meaningful use adoption and other HIT issues.  Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Figure 11-6 HIE Federated or Decentralized Model Institutions maintain copies of their own data at their site in the format used by the HIE. Individual transinstitutional patient records are assembled in real time by searching all institutions’ databases only when needed/requested by authorized users. Individual institutions can “opt out” of the HIE at any time by disabling access to their database.  The Veteran Health Administration Health Information System VHA model: a single-payer healthcare system in the U.S.  Supports only one payer, one pharmaceutical formulary, one provider group, and Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com one supplier of laboratory testing  All VHA physicians: employees of the same organization: new policies and practices can be communicated, implemented, & monitored much more easily & efficiently.  One universal EHR system  Able to code all data in one format that allows veterans who move from state to state to have their entire medical record follow them  Electronic health record adoption progress (1/2)  The National Center for Health Statistics (NCHS) has tracked the use of EHRs in outpatient settings since 2006. Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Defines two levels of adoption: 1) any & 2) basic  No definition of what “EHR adoption” actually means…  “Any” usually includes patient demographics, problem list, medication list, lab & radiology results  “Certified” EHRs store data in a structured format, partially or completely electronic without attached billing systems. (https://www.cms.gov/medicare/regulations-guidance/promoting- interoperability-programs/certified-ehr-technology)  Office of the National Coordinator (ONC) has been tracking hospitals’ adoption of EHRs since 2008 using standard definitions of “Certified” and “Basic” EHR systems.  All states, except six and the District of Columbia, have made progress to adopt a certified EHR.  8. Electronic health record adoption progress (2 of 2) Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com Figure 11-8 Certified EHR Adoption Among U.S. Figure 11-7 EHR Adoption Among U.S. Office-Based Office-Based Physicians, as of 2017 76 Physicians, as of 2017 76 Created by Richard Greenhill. Data from Myrick KL, Ogburn DF, Ward BW. Table. Percentage of office-based physicians using any Created by Richard Greenhill. electronic health record (EHR)/electronic medical record (EMR) system and physicians that have a Data from Myrick KL, Ogburn DF, Ward BW. Table. Percentage of office-based physicians using any electronic certified EHR/EMR system, by U.S. state: National Electronic Health Records Survey, 2017. National health record (EHR)/electronic medical record (EMR) system and physicians that have a certified EHR/EMR Center for Health Statistics. Published January 2019. Updated August 6, 2021. Accessed September system, by U.S. state: National Electronic Health Records Survey, 2017. National Center for Health Statistics. 10, 2021. https://www.healthit.gov/data/quickstats/office-based-physician-electronic-health-record- Published January 2019. Updated August 6, 2021. Accessed September 10, 2021. https://www.healthit. adoption#:~:text=As%20of%202017%2C%20nearly%209,had%20adopted%20a%20certified%20EHR gov/data/quickstats/office-based-physician-electronic-health-record-adoption#:~:text=As%20of%202017 %2C%20nearly%209,had%20adopted%20a%20certified%20EHR   As of 2016, 86% of office-based physicians had adopted “any” EHR.  80% had adopted a “certified” EHR: partially or completely electronic Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  ONC and CDC began tracking this adoption since 2014: steady increase over time.  More needs to be done to assist Figure 11-9 Trended EHR Adoption Option Among U.S. physician offices with the Office-Based Physicians, 2004–2016 Created by Richard Greenhill. administrative burden of adopting and Data from Office of the National Coordinator for Health Information Technology. Office-based physician electronic health record adoption. Updated August 6, 2021. Accessed August 20, 2021. https://www.healthit.gov/ maintaining an EHR. data/quickstats/office-based-physician-electronic-health-record-adoption  Future challenges  Inconclusive and negative studies showing patient harm associated with the installation of Computerized Provider Order Entry (CPOE) Copyright © 2023 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com  Ex., Mortality rate in NICU more than doubled after a CPOE system was installed at the Univ of Pittsburgh…  Other barriers to patient adoption include lack of personal health records (PHRs) management tools, difficulty in achieving semantic interoperability, problems vetting the identity of PHR users, patient privacy concerns, lack of a business model to support long-term operation of PHRs.  PHRs: patients create their own records in a standardized format.  Other challenges to physicians and patients: standardized data formats to facilitate data portability, work culture barriers, system costs, training issues.