The Impact of Health Information Technology on Quality: Considerations for Long Term Care

1. “The Impact” of Health Information Technology on Quality: Considerations for Long Term Care Kevin Warren SVP, Operations TMF Health Quality Institute

2. Objectives • Discuss recent literature discussing the impact of Health Information Technology (HIT) on Quality of healthcare • Describe current activities performed by Quality Improvement Organizations (QIOs) targeting HIT adoption and implementation in multiple clinical settings • Discuss potential next steps on the HIT adoption pathway for long term care and “food for thought”

3. HIT and Quality “Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care” • AHRQ funded literature review (contract no. 2002) • MEDLINE (1995 – January 2004); Cochrane Register of Controlled Trials; Cochrane Database of Abstracts of Reviews of Effects; hand-searched personal libraries; unpublished literature; newly published articles (April 2005) • 867 Articles reviewed; 257 articles met search inclusion criteria • Approximately 25% of studies were from 4 academic institutions • The Regenstrief Institute • Brigham and Women’s Hospital/Partners Healthcare • The Department of Veteran Affairs • LDS Hospital/Intermountain Healthcare • Review the evidence on the effect of health information technology on quality, efficiency, and costs of healthcare Annals of Internal Medicine (May 16, 2006); Vol. 144:Issue 10

4. Annals Systematic Review:Findings (Quality) • The major effect of HIT on quality of care was its role in increasing adherence to guideline based care and decision support associated with preventive (primary and secondary) care • “Improvements in processes of care delivery ranged from absolute increases of 5 to 66 percentage points, with most increases clustering in the range of 12 to 20 percent”. • Studies demonstrated the impact of HIT on reduction in hospital acquired pressure ulcers, post-operative infections, reduction of adverse drug events and medication errors. • “Effect on time utilization is mixed” • “The major efficiency benefit has been decreased utilization of care” Annals of Internal Medicine (May 16, 2006); Vol. 144:Issue 10

5. HIT and Quality Evidence Report/Technology Assessment: No. 132 “Cost and Benefits of Health Information Technology” • Prepared by the Southern California Evidence-based Practice Center, Santa Monica, CA • From 256 articles, 84 were selected that addressed: study of quality of care as data outcome, use of electronic health record, and the ambulatory setting • “Structure, Process and Outcome” was used as review framework • “The studies demonstrate how provider performance can be improved when the clinical information management and decision support tools are available within an EHR system.” • “A recurrent theme in these studies was the capacity of EHRs to store data and to make those data readily accessible, and to help translate them into context-specific information that can empower providers in their work.” AHRQ Publication No. 06-E006 (April 2006)

6. HIT Impact on Quality: Important to Long Term Care? “Health Information Technology: Are Long Term Care Providers Ready?” • Prepared by Health Management Strategies Inc., for the California Healthcare Foundation • Methods of data collection included: literature review, focus groups, provider surveys and interviews • Providers do believe HIT can “have an impact on quality of care delivery and daily operations”. • “Providers do not see concrete evidence that it (HIT) will have a positive impact on quality of care and operational efficiencies in the long term care environment”. • Variation among providers as to the valuation of HIT benefits to improving quality Hudak, S., Sharkey, S. (April 2007)

7. Objectives • Discuss recent literature supporting/refuting the impact of Health Information Technology (HIT) on Quality of healthcare • Describe current activities performed by Quality Improvement Organizations (QIOs) targeting HIT adoption and implementation in multiple clinical settings • Discuss potential next steps on the HIT adoption pathway for long term care and “food for thought”

8. HIT Role of Quality Improvement Organizations (8SOW) Doctors Office Quality Information Technology (DOQ-IT) • Over 4000 Physician Practices nationwide • Increasing the adoption of clinical information systems • Adoption of care management process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual’s health needs • Small (1-3), medium (4-8), and large (9 or more) practices

9. HIT Role of Quality Improvement Organizations (8SOW) Inpatient/Rural/Critical Access Hospitals (CAH) • Engage hospital leadership in the PPS hospitals and/or reporting CAHs in using: • Computerized Physician Order Entry • Barcoding • Telehealth systems • “QIOs shall provide technical support to hospital leadership to help them develop the business case and shall educate (identified hospitals) about all aspects of: • Infrastructure requirements, funding opportunities, staffing requirements, associated costs, available applications,network partnerships and successful examples)” CMS Statement of Work Version #020106-A

10. HIT Role of Quality Improvement Organizations (8SOW) Home Health • Work with 8% of state home health agencies to implement and/or utilize telehealth as a tool to help reduce Acute Care Hospitalization. • Telehealth as defined for the SOW: phone monitoring and telemonitoring (use of telemonitoring equipment and technology) CMS Statement of Work Version #020106-A

11. HIT Role of Quality Improvement Organizations (8SOW) Nursing Home • Nursing Home Improvement Feedback Tool (NHIFT) • Process of Care Documentation and Data Submission to QIO Clinical Warehouse: • Skin inspection and pressure ulcer risk assessment • Depression screening and treatment • Evaluation of and alternatives to Physical Restraints • Pain Assessment and Treatment • Advancing Excellence Campaign

12. Objectives • Discuss recent literature supporting/refuting the impact of Health Information Technology (HIT) on Quality of healthcare • Describe current activities performed by Quality Improvement Organizations (QIOs) targeting HIT adoption and implementation in multiple clinical settings • Discuss potential next steps on the HIT adoption pathway for long term care and “food for thought”

13. “Change would be easy if it weren’t for all of the people.” Balestracci and Barlow

14. Prepare to Protect the Investment Nursing Home Concerns: Survey, bottom line, quality Community Care depends on physicians visit (when available) Resident information is limited to the chart No links to community agencies or resources Lack of specific protocols or lack of staff awareness to protocols We tell residents/family how to manage daily illness (didactic communication) Uninformed resident and/or family? Frustrating Interactions Unprepared staff? Undesirable Outcomes? Model based on: Ed Wagner, MD; Improving Chronic Care (2000)

15. Is Long Term Care “Ready”?

16. The Roadmap elearning.qualitynet.org

17. Care Management • Full utilization of the technology allows us to practice evidence-based medicine every time • Understanding how to deal with the frail, well, chronically unstable, or young present different challenges for clinicians • How do we hope to do this without some assistance? • How do we manage different chronic diseases AND keep the patient/resident involved … along with other caregivers?? • Chuck Parker (2007) TOMA Annual Conference

18. PLAN PLAN DO DO ACT ACT STUDY STUDY Care Management—In Practice Culture Change HIT Workflow Redesign Self Management Patient/Resident Caregivers Care Team HIT ClinicalDecisionSupport • Chuck Parker (2007) TOMA Annual Conference

19. Organizational Redesign There are five main areas of redesign that need to be addressed: • Patient/Resident Flow • Point-of-care (POC) documentation • Internal and External Communication • Document Management • Chart Abstraction / Migration “How will these changes impact the resident?”

20. Lessons from other Providers and Programs Additional Resources • State Quality Improvement Organizations (QIOs) www.ahqa.org • Rural and Critical Access Hospitals • Multiple responsibilities, CPOE, Bar-coding • Home Health Agencies • Telehealth, chronic care management • Physician Offices • National IT adoption/implementation push, work flow • Others??

21. Thank You Kevin Warren, MHA, CPHQ Senior Vice President, Operations TMF Health Quality Institute Austin, Texas 512-334-1660 Kwarren@txqio.sdps.org