Notes 1-4.pdf

The Challenge U.S. healthcare spending outgrowing GDP Costs in the United States continue to be the highest in the world Pace of quality improvement is slow Healthcare disparities persist Failure to implement known methods to improve patient care  The Opportu...

The Challenge U.S. healthcare spending outgrowing GDP Costs in the United States continue to be the highest in the world Pace of quality improvement is slow Healthcare disparities persist Failure to implement known methods to improve patient care  The Opportunity While the current US health system presents numerous challenges, opportunities for improvement are emerging as well: Informatics and digital health Big data and analytics Supply chains and the relationships among health plans, healthcare systems, and individual providers are changing through mergers, partnerships, and acquisitions Primary care redesign and telemedicine Evidence-based medicine Population health with active and engaged consumers Health disparities improvement  Series of Interconnected Systems that Influence the Delivery of Clinical Care Patient: hands on care to the patient Environment Microsystem: team of health Level D professionals, tools that team has to diagnose and treat, Organization Level C logic for determining appropriate treatments and Microsystem Level B processes to deliver that care Organization: leadership by Patient senior staff Level A Environment: market competition, government regulation, demographics, and payer policies  System Stability and Change (Peter Senge—The Fifth Discipline) Elements in each layer of this system interact. Peter Senge provides a useful theory for understanding the interaction of elements in a complex system such as healthcare. The structure of a system is the primary mechanism for producing an outcome Ex: organized structure of facilities, trained professionals, supplies, equipment, and EBM care guidelines leads to a high probability of producing an expected clinical outcomes No system is ever completely stable Each system’s performance is modified and controlled by feedback Senge defines feedback is “any reciprocal flow of influence” In systems thinking it is an axiom that every influence is both cause and effect Feedback can be one of two types: reinforcing or balancing Reinforcing feedback prompts change that builds on itself and amplifies the outcome of a process, taking the process further and further from its starting point Balancing feedback prompts change that seeks stability. A balancing feedback loop attempts to return the system to its starting point. A confounding problem with feedback is delay  System with Reinforcing Feedback Employee motivation + + Financial Salaries performance, + profit Increased salaries provide an incentive for employees to achieve improvement in performance level This improved performance leads to enhanced financial performance and profitability for the organization, and increased profits provide additional funds for higher salaries, and the cycle continues In contrast, a poor supervisor could cause employee turn over, possibly resulting in short staffing and even more turnover  System with Balancing Feedback − Actual Add or staffing reduce level staff − Compare actual to needed staff based on patient demand Inpatient unit staffing levels that determine where in a hospital patients are admitted is a case of balancing feedback Delays may occur when interruptions arise between actions and consequences Ex: Emergence department  Chemotherapy as an Example of Linkages within the Healthcare System Changes are made in care Chemotherapy process and Payers want New payment support treatment needs to reduce method for systems to to be more costs for chemotherapy maintain efficient to meet chemotherapy is created quality while payment levels reducing costs Environment Organization Clinical Microsystem Patient Many subsystems in the total healthcare system are interconnected These connections have feedback mechanisms that either reinforce or balance the subsystem’s performance This exhibit shows a simple connection that originates in the environmental segment of the total health system Each process has both reinforcing and balancing feedback Framework for Effective Operations Management in Healthcare Setting goals and executing strategy Fundamental healthcare operations High performance issues Performance improvement tools, techniques, and programs Effective operations management in healthcare consists of highly focused strategy execution and organizational changes accompanied by the disciplined use of analytical tools, technique, and programs Combined to attack the fundamental challenges of operating a complex healthcare delivery organization  Operations Management in Healthcare Organizations Costs of care and level of services delivered are increasing Expectation of quality care without defects or failures Being pursued by government and other stakeholders, driving need to produce higher quality service at reduced cost Only an improved utilization of resources through effective operations management will meet this need  Operations Management For many of the aims identified by the US healthcare system to be achieved, essentially all healthcare providers must adopt tools and techniques, many of which have enabled other service industries and manufacturing sectors to improve efficiency and effectiveness. What is operations management? Operations management is the design, implementation, and improvement of the processes and systems that create and deliver the organization’s products and services. Operations managers plan and control delivery processes and systems within the organization.  Systems View Transformation INPUT Process OUTPUT Feedback Labor Goods or Material Services Machines Management Capital This book takes a systems view of service provision and delivery, as illustrated in this exhibit, and focus on knowledge-based management (KBM) – using data and information toward basing management decisions on facts rather than on feelings or intuition – to frame that view.  Knowledge Hierarchy Importance Wisdom Morals Understanding Principles Knowledge Patterns Information Relationships Data Learning The knowledge hierarchy relates to the learning that ultimately underpins KBM. The knowledge hierarchy consists of the following five categories.  Data: symbols or raw numbers that simply exist; they have no structure or organization. Entities collect data with their computer systems; individuals collect data through their experiences. At this stage of the hierarchy, one can presume to know nothing because raw data alone are not adequate for decision making. Information: data that are organized or processed to have meaning. Information can be useful, but it is not necessarily useful. It can answer such questions as who, what, where, and when – in other words, know what. Knowledge: information that is deliberately useful. Knowledge enables decision making – know how.  Understanding: a mental frame that allows use of what is known and enables the development of new knowledge. Understanding represents the difference between learning and memorizing - know why. Wisdom: a high-level stage that adds moral and ethical views to understanding. Wisdom answers questions to which there is no known correct answer and, in some cases, to which there will never be a known correct answer – know right.  Important Events in Performance Improvement  Mass Production Two men use Men work on Ford Two men assembling hammers on Ford on assembly line car in Ford factory factory assembly and then drive line away Mass production allows for significant economies of scale, as predicted by Smith. Before Ford set up his moving assembly line, each car was assembled by a single worker and took about 12 hours to produce. However, after the introduction of assembly line, this time was reduced to 93 minutes. The standardization of products and work not only led to a reduction in the time needed to produce cars but also significantly reduced the costs of production.  Frederick Taylor The Principles of Scientific Management (1911) “Wasted” human effort Incentive schemes Four principles Standard work Training Cooperation Planning  Four principles of scientific management Develop and standardize work methods on the basis of scientific study, and use these to replace individual rule- of-thumb methods Select, train, and develop workers rather than allowing them to choose their own tasks and train themselves Develop a spirit of cooperation between management and workers to ensure that the scientifically developed work methods are both sustainable and implemented on a continuing basis Divide work between management and workers so that each has an equal share, where management plans the work and workers perform the work.  Frank and Lillian Gilbreth Frank, who worked in the construction industry, noticed that no two bricklayers performed their tasks the same way. He believed that bricklaying could be standardized and the one best way determined. Time and motion studies Bricklaying Applied to surgery Time-saving ideas one type of sock for all 12 of their children  Project Management Discipline of project management began with the development of the Gantt chart (early 1900s) To illustrate the duration of project tasks and display scheduled and actual progress Not ideal for very large, complicated projects Program Evaluation and Review Technique (PERT) (1950s) U.S. Navy to address the desire to accelerate the Polaris missile program Probability distribution (Beta distribution) for task times Most useful for estimating project completion time Critical Path Method (CPM) (1950s) Developed by DuPont and Remington Rand Project network and point estimate of task duration Most useful when task times can be estimated with certainty  Quality Gurus Plan PDCA Do Cycle Walter Shewhart Act Check Grandfather Both Deming and Juran studied under Shewhart, and much of their work was influenced by his ideas SPC and PDCA Management and production practices need to be continuously evaluated, and then adopted or rejected on the basis of this evaluation, if an organization hopes to evolve and survive. Deming’s cycle of improvement, known as plan-do-check-act (PDCA), was adapted from Shewhart’s work.  W. Edwards Deming Father of the quality revolution After World War II, Deming’s ideas lost popularity in the United States, mainly because demand for all products was so great that quality became unimportant 1970s energy crisis was turning point Two types of variation: Special cause: resulting from a change in the system that can be identified or assigned and the problem fixed Common cause: deriving from the natural differences in the system that cannot be eliminated without changing the system  14 points for medical services Deming System of Profound Knowledge to transform organizations, the individuals in those organizations need to understand the four parts of this system Appreciation for a system: Everything is related to everything else, and those inside the system need to understand the relationships in it. Knowledge about variation: This part of the system refers to what can and cannot be done to decrease either of the two types of variation. Theory of knowledge: The theory highlights the need for understanding and knowledge rather than information. Knowledge of psychology: People are intrinsically motivated and different from one another, and attempts to use generic extrinsic motivators can result in unwanted outcomes.  Joseph M. Juran Juran was a contemporary of Deming and a student of Shewhart. Juran’s Quality Handbook was first published in 1951 and remains a standard reference for quality. Juran was among the first quality experts to define quality from the customer perspective as “fitness for use.” His contributions to quality include the adaptation of the Pareto principle to the quality arena 80% defects caused by 20% problems Focus on the “vital few” to gain the most benefit The roots of Six Sigma programs can be seen in Juran’s (1986) quality trilogy: Quality planning Control Improvement  TQM (CQI) → Six Sigma Total quality management (TQM) refers to a management philosophy or program aimed at ensuring quality—defined as customer satisfaction—by focusing on it throughout the organization and for each product or service life cycle TQM programs have decreased in popularity in the US and have been replaced with more codified programs such as Six Sigma, Lean, and Malcolm Baldrige Award Six Sigma and TQM both based on the teachings of Shewhart, Deming, Juran Both emphasize top management support and leadership Both focus on continuous improvement as a means to ensure the long-term viability of an organization Define-measure-analyze-improve-control cycle of Six Sigma has it roots in TQM Six Sigma goal of 3.4 defects per million opportunities Six Sigma took the theory and tools of TQM and codified their implementation, providing a well-defined approach to quality that organizations can quickly and easily adopt.  Quality Certification and Awards ISO 9000 is primarily concerned with quality management, or how the organization ensures that its products and services satisfy the customer’s quality requirements and comply with applicable regulations. The standards are specifically concerned with the processes of ensuring quality rather than the products or services themselves. A significant number of US hospitals are now using the ISO 9001 Quality Management Program to achieve Medicare accreditation. The Malcolm Baldrige National Quality Award: Its aim was to raise awareness about the importance of quality as a competitive priority and help disseminate best practices by providing examples of how to achieve quality and performance excellence. The award was originally given annually to a maximum of three organizations in each of three categories: manufacturing, service, and small business. In 1999, the categories of education and healthcare were added. The healthcare category includes hospitals, health maintenance organizations, long-term care facilities, healthcare practitioner offices, home health agencies, health insurance companies, and medical and dental laboratories. A main purpose of the award is the dissemination of best practices and strategies.  JIT → Lean → Agile Just In Time (JIT) Inventory management strategy aimed at reducing or eliminating inventory. It is one aspect of Lean manufacturing, whose goal is to eliminate waste, of which inventory is one form The term originally used for Lean production in the US, where industry leaders noted the success of the Japanese auto manufacturers and attempted to copy it by adopting Japanese practices Lean Its goal is to eliminate all waste in the system. Although Lean production originated in manufacturing, the goal of eliminating waste is easily applied to the service sector Many healthcare organizations are using the tools and techniques associated with Lean to improve efficiency and effectiveness Agile Ability to respond quickly to changing conditions  Supply Chain Management § Supply chain management encompasses the planning and management of all activities involved in sourcing and procurement, conversion, and all logistics management activities. § It also includes coordination and collaboration with channel partners, which can be suppliers, intermediaries, third-party service providers, and customers. In essence, supply chain management integrates supply and demand management within and across companies. This definition makes apparent that SCM is a broad discipline, encompassing activities outside as well as inside an organization. SCM has its roots in systems thinking. Systems thinking is based on the idea that everything affects everything else Copyright © 2022 Foundation of the American College of Healthcare Executives. Not for sale. § SCM became increasingly important to manufacturing organizations in the late 1990s, driven by the need to decrease costs in response to competitive pressures and enabled by technological advances § SCM was significantly enabled by technology, beginning with the inventory management systems of the 1970s. As industry moved to increasingly sophisticated technological systems for managing the flow of information and goods, its ability to collect and respond to information about the entire supply chain expanded and firms could now actively manage their supply chains. § SCM is becoming increasingly important in healthcare as well, with its growing focus on reducing costs and the need to reduce those costs through the development of efficient and effective supply chains  Big Data and Analytics Appeared in 1997 with launch of Google search engine Big data is typically characterized by the so-called three Vs. Volume: data sets were becoming huge Variety: many types of data being stored Velocity: data enter computer at increasing rate of speed Increasingly sophisticated data analysis Growth of mobile Internet usage New devices being connected to the Internet Cloud computing and AI algorithms  Performance Improvement Today Hospitals, health systems, and other healthcare delivery organizations face increasing pressures from consumers, industry, and government to provide their services in an efficient and effective manner, and they must adopt these philosophies to remain competitive In healthcare today, organizations such as the Institute for Healthcare Improvement and AHRQ are leading the way in the development and dissemination of tools, techniques, and programs aimed at improving the quality, safety, efficiency, and effectiveness of the US healthcare system  Evidence-Based Medicine (EBM) and Value Purchasing EBM is the conscientious and judicious use of the best current evidence in making decisions about the care of individual patients Delivering care using EBM is known as value-based care and is the foundation for many payment systems today Wide-scale application of EBM was slow until the introduction of the electronic health record, which also facilitated adoption of value payment systems In almost all cases, the broad application of EBM not only improves clinical outcomes for patients but also reduces systemic costs The Challenge of Medical Progress Before wide –scale adoption of evidence-based medicine; The expansion of clinical knowledge has three major phases: First, basic research is undertaken in the lab and with animal models Second, carefully controlled clinical trials are conducted to demonstrate the efficacy of a diagnostic or treatment methodology that emerges from the preliminary research Third, the successful or promising clinical trial results are translated to clinical practice Translation to clinical practice is where system often breaks down Result—widespread variation in clinical costs and quality  Evidence-Based Medicine (EBM) 1. Basic research conducted in the laboratory 2. Carefully controlled clinical trials demonstrate efficacy and safety 3. Results are translated into clinical practice 4. Use of clinical guidelines (e.g. EBM) is now widespread and well accepted 5. They are maintained by a variety of healthcare organizations (e.g., the National Institutes of Health) and by professional societies Standard and Custom Patient Care One historical criticism of EBM is that all patients are unique and EBM is “cookbook” medicine that only applies to a few patients. All clinical care is a mix of custom and standardized care processes High-quality organizations Master the art of custom care Optimize the science and consistent delivery of standard care Next examples show the four currently used models that blend these two approaches.  Model A: Separate and Select Provides an initial sorting by patients themselves Those with standard problems are treated with standard care using EBM guidelines Examples: Laser eye surgery Minute clinic Patients who do not fit the provider’s homogeneous clinical conditions are referred to other providers who can deliver customized care Source: Bohmer, Richard. 2005. Custom Standard Sorting Re-sorting “Medicine’s Service Challenge: Blending Custom and Standard Care.” Healthcare Management Review Oct.–Dec. Model B: Separate and Accommodate Combines the two methods inside one provider organization Example: Duke Cardiology Clinic Developed standard protocols for its cardiac patients Patients are initially sorted, and those who can be treated with the standard protocols are cared for by nurse practitioners using a standard care model Cardiologists care for the remainder using custom care. However, on every fourth visit to the nurse practitioner, the cardiologist and nurse practitioner review the patient’s case together to ensure that standard care is still the best treatment approach Custom Standard Sorting Re-sorting Model C: Modularized Used when the clinician moves from the role of care provider to that of architect of care design for the patient Example: Andrews Air Force Base Clinic Physician serves as architect—care designer Physician performs evaluation and creates plan Standard care provided by other organizations and departments Hypertension modules: weight control, diet, drug therapy, stress modification, surveillance Each component may be provided by a separate professional and sometimes a separate organization What makes the care uniquely suited to each patient is the combination of components Custom Standard Sorting Re-sorting  Model D: Integrated Combines standard care and custom care in a single organization. In contrast to Model B, each patient receives a mix of both custom and standard care as determined by her condition Example: Intermountain Healthcare Identified 62 standard processes—90 percent of inpatients Standard processes built into its electronic health record Physician encouraged to override standard care as needed Overrides are recorded, analyzed, and used to improve standard process Custom Standard Sorting Re-sorting  Financial Implications of EBM EBM has the potential to not only improve clinical outcomes but also decrease total cost in the US healthcare system Savings in the system can be achieved by consistent, high-quality outpatient treatment and disease management, which prevents unneeded hospitalizations The Agency for Healthcare Research and Quality (AHRQ) developed a set of prevention quality indicators (PQIs) to assist providers in reducing the number of potentially preventable hospitalizations for chronic and acute conditions A patient who is admitted to a hospital and has a PQI code is an individual whose hospitalization or other severe complication is potentially preventable when good, evidence-based outpatient care is delivered  Prevention Quality Indicators (PQIs) In addition, PQIs can serve the following purposes: Can be used to identify potential healthcare quality problem areas that might need further investigation as well as for comparative public reporting, trending, and pay-for- performance initiatives Can provide a check on primary care access or outpatient services in a community by using patient data found in a typical hospital discharge abstract or data set Can help public health agencies, state data organizations, healthcare systems, and others interested in improving healthcare quality in their communities  Chronic Care Model One of the most widely accepted models for chronic disease management Population-based outreach ensures that all patients in need of chronic disease management receive it Treatment plans are created that are sensitive to each patient’s preferences The most current evidence-based medicine is employed The patient is encouraged to change risky behaviors and improve the management of his health The CCM has now been widely deployed and updated. The Institute for Healthcare Improvement (IHI) has developed a model for instituting changes in the approach to chronic illnesses, healthcare settings, and target populations These changes include: Self-management support Train providers and other key staff on how to help patients with self- management goals Use self-management tools that are based on evidence of effectiveness Delivery system redesigns Use planned interactions to support evidence-based care Ensure regular follow-up by the care team Comprehensive decision support systems Embed evidence-based guidelines into daily clinical practice Integrate specialist expertise and primary care  Comprehensive health information system Share information with patients and providers to coordinate care Provide timely reminders for providers and patients Strong organizational leadership Senior leaders visit the clinical teams and speak about improvement efforts in all-staff meetings Participate in writing the aims and goals of the initiative and provide guidance for the clinical team Community support Encourage patients to participate in effective community programs Form partnerships with community organizations to support and develop interventions that fill gaps in needed services  EBM and Comparative Effectiveness Research Evidence for EBM has long been medical research that is published in respected and refereed journals However, these studies usually are initiated by a single investigator’s interest, and thus the efficacy of many common clinical approaches has never been adequately tested Medical research community has held historical and understandable biases toward developing technologies that are designed to address intractable diseases and mysterious diagnostic challenges  Many aspects of routine healthcare have therefore never been sufficiently evaluated ACA – Patient-Centered Outcomes Research Institute (PCORI) PCORI’s focus is on the application of EBM to specific healthcare technologies and treatments to ascertain which, among alternative therapies for a given medical condition, produce the best clinical outcomes This specific focus is known as comparative effectiveness research Three priorities: 1. Accelerating patient-centered outcomes research and methodological research 2. Assessment of prevention, diagnosis, and treatment options 3. Communication and dissemination research  Tools to Expand the Use of EBM Organizations that are outside the healthcare delivery system itself, such as payers and government, have used the increased acceptance of EBM as the basis for new programs designed to encourage its implementation These programs referred to as Value-based purchasing Public reporting of clinical results Pay for performance – Value-based purchasing To help third-party payers determine the value delivered by healthcare providers  Public Reporting Although strongly resisted by clinicians for many years, public reporting has come of age CMS now report the performance of Hospitals Long-term care facilities/home health services Medical groups Many private health insurance plans also report performance and the prices charged by providers in their networks to assist their plan members, particularly those with consumer-directed health insurance products, in choosing how and from whom they receive treatment or preventive care Issues surround public reporting Risk adjustment: most providers feel their patients are “sicker” than average and that contemporary risk adjustment systems do not adequately account for this factor in reimbursement Patient compliance  Pay for Performance – Value Purchasing Pay-for-performance systems add payments to the amount that would otherwise be reimbursed to a provider Gives providers additional payments based on care if meeting clinical EBM goals Goals measured by either process or outcome While preferred by providers, outcome is more difficult to measure due to varying results, as some outcomes need to be measured over many years Process measures backed by EBM are often used to assess performance in the treatment of many conditions A patient with diabetes whose blood pressure is maintained in a normal range tends to experience fewer complications than one whose blood pressure is uncontrolled. Blood pressure can be measured and reported at every visit, whereas complications occur infrequently Implemented to improve health outcomes and lower costs General Payment Reform Model  Keys to Value Purchasing Success Majority of financing systems for health services in the United States likely will move completely from FFS to value purchasing Transition of many healthcare organizations from volume to value-based payment is difficult for most organizations as their financial health has been built on the foundations of creating optimal revenue from the volume of services delivered Successful organizations shared these traits: Organizational history of success with financial risk Willingness to move to a primary goal of improved clinical outcomes and patient satisfaction Regional connections to other successful organizations Synergies with other organizational activities Ability to attract new physicians Investment in electronic health records and analytics  Potential Pathways to Move from Volume to Value Most organizations start in the lower left corner and move to the upper right over time. Although organizations can remain on the left-hand side of the diagram, their financial results and market share likely will diminish over time because of the increasing use of value payment systems  Medicare Value Purchasing Medicare has been a leader in value purchasing with its Hospital Value-Based Purchasing (VBP) Program Hospital VBP Program encourages hospitals to improve the quality, efficiency, patient experience and safety of care that Medicare beneficiaries receive during acute care inpatient stays by: Eliminating or reducing adverse events Incentivizing hospitals to improve patient experience It rewards hospitals based on quality provided to Medicare patients Withholds participating hospitals’ Medicare payments by a percentage specified by law (2%) Uses the estimated total amount of those reductions to fund value- based incentive payments to hospitals based on their performance in the program  Measures used to score each hospital’s quality performance include: Mortality and complications Healthcare-associated infections Patient safety Patient experience Efficiency and cost reduction (CMS 2021)  Implications for Operations Management One clear advantage of FFS was its clean lines of accountability for services—if you provided the service, you got paid. Value purchasing breaks this link as the service provider does not get paid directly. Hence, improved operational structures need to be built to accommodate these payment systems Strategy execution A useful management strategy is blended balanced scorecard strategy Converts general strategies (e.g., reduce readmission rates) into specific projects (e.g., acquire predictive analytics capability), which are then connected in a strategy map Improved modeling and analytics New environment requires more sophisticated systems of analysis than in the past EHR is a significant advancement in helping an organization understand its care patterns and patient outcome Although traditional accounting systems were adequate for the FFS environment, much more detailed costing systems are now needed, such as activity-based accounting. Patient behavior models were historically built on groups (e.g., men aged 65 or older) but now must be built with individual predictive modeling capabilities  Summary The use of EBM is becoming well accepted by clinicians Clinical results are being made transparent and easily accessible to the general public. It has been demonstrated that EBM can increase quality and decrease costs Efforts to increase the use of EBM include: Payers are implementing systems that reward value Providers are installing clinical decision support systems to help in their practices Effective use of EBM identifies high-performance healthcare organizations, and its widespread use is a key to the provision of high-quality, cost-effective care  Use of Technology in Healthcare Delivery Health Information Technology (HIT) collectively refers to software solutions used in the healthcare sector. HIT is used to manage information flows in an organization and has a significant impact on organizational processes. HITs have documented benefits on care delivery including reduced costs, improved quality of care, conformance to protocols, and patient experience. However, adoption and assimilation of HITs causes disruptions in existing work routines making it costly and time-consuming.  HITECH Act The Health Information Technology for Economic and Clinical Health (HITECH) Act was passed in 2009 to incentivize hospitals to adopt HITs. This legislation provided stimulus payments to hospitals for adoption and use of HITs. These incentives have accelerated HIT adoption in healthcare. Electronic medical record (EMR) use for acute care hospitals increasing from about 15% in 2008 to over 95% in 2017 EMR use by office-based physicians increasing from 40% in 2008 to over 85% in 2017  Types of Information Flows Two different types of information flows—administrative and clinical. Administrative information flow is composed of operational data that is created as a result of administrative processes within the hospital. Examples include data related to human resource, billing, procurement, inventory, etc. Administrative data is primarily organization specific. Clinical data deals with patient medical records covering their profile, medical history, diagnosis and treatment. Generated, updated, and accessed by multiple caregivers within and across the organization. HIPPA regulations impose a high level of privacy and security requirements.  Administrative HITs Deal with administrative information flow. Examples include accounting and financial management systems. Mature technologies with similar products in existence in other sectors. Administrative data is primarily organization specific, reducing need to high levels of interoperability.  Clinical HITs Handle clinical data. Subclassified into Basic Clinical and Augmented Clinical depending on their primary functionality and users. Basic Clinical HITs Primarily deal with patient data collection either through manual entry of the data or data generated through diagnostics and testing Primarily used by technicians and caregiving assistants Examples include a CT scan machine Augmented Clinical HITs Generate integrated patient records and build advanced functionality like data visualization, reporting, decision support, and analytics Primarily used by physicians and nurses Electronic Medication Administration Record, Clinical Decision Support HIT System Architecture Exhibit 4.1 Exhibit 4.1 shows the association among different types of HITs with the corresponding information flows. Administrative HITs manage the flow of administrative data with inputs on clinical episodes of care for billing purposes. Clinical data is housed in a central repository, which is updated by basic clinical HITs and used for higher- order functions like reporting and decision support by augmented clinical HITs. Patient scans are stored in a picture archiving and communication system because of their different storage format.  Impact of HITs HITs improve process efficiency and workforce productivity through faster and more effective processing of information. The value of HITs increases as the volume and complexity of information processing needs with an organization increase. Benefits of HITs are enhanced with integration of stand- alone technologies and better integration of HITs into the work routines of users. HITs have been documented to have a positive impact on Process quality Cost Patient experience Clinical quality  Adoption of HITs Involves decisions on procurement and rollout of new HITs. Decisions include: Sourcing strategy (single- vs. multi-sourcing), The timing of adoption (early vs. late adopters), and The rollout speed of the technology  Assimilation of HITs Requires technology adaptation – a recursive process, often requiring multiple mutual adaptations in the technology and its associated work routines. Require close collaboration between users and developers of the technology Adaptations in technology may require changes in programmatic assumptions, logic, user interfaces, etc., and are implemented through software patches. Workflow adaptation may require changes in interactions between users, changes in interactions between users and customers, standardization, and increased reliance on technology for information and decision support.  Challenges with HIT use Interoperability Interoperability implies that patient data housed in an EMR system can be digitally transmitted to other systems within and across hospitals in real- time. Lack of a universal medical ID and inconsistent data standards are challenges to achieving interoperability. Data security Multiple entry and access points for patient data along with central storage in EMR systems has increased data privacy and security challenges. Data security concerns can be reduced through better access control, data encryption, patch management, use of decentralized databases, etc. User interfaces Interfaces for HITs have been documented to have non-intuitive designs and present too much data. Engaging caregivers in interface design may help resolve this issue.