health it success stories ahrq conference september 29, 2010 rebecca roper

Health ITSuccess Stories

AHRQ Conference

September 29, 2010Rebecca Roper

Success Stories

Easy-to-understand summaries of research project and its momentum to go forward– Enable Layman’s understanding of who and how

health IT implementation was beneficial– Illustrations– Demonstrated, significant improvement in

outcome(s)– Resiliency, Adaptability, Sustainability,

Transferability of intervention, etc.– Quotes from different perspectives

Plus, succinct, substantive ~2-page detail discussion

Two Reports:

Using Health IT: Eight Quality Improvement Stories– Contract No. HHSA 290200900019I, T.O. 3– Prepared by: Mathematica Policy Research – http://healthit.ahrq.gov/SuccessStoriesTHQIT (October

2010)

Success Stories from the AHRQ-Funded Health IT Portfolio (CY 2009)– Contract No. HHSA 290200900018I, T.O. 3– Prepared by: John Snow, Inc (JSI)– http://healthit.ahrq.gov/SuccessStoriesCY2009

(November 2010)

http://healthit.ahrq.gov/SuccessStoriesTHQIT

http://healthit.ahrq.gov/SuccessStoriesCY2009

Transforming Healthcare Quality through Health IT (THQIT):

118 Individual Projects

Transforming Healthcare Quality through Health IT (THQIT):

September 2004 – January 2010

40 Cooperative Agreements, THQIT Implementation I (HS-04-011)– $ 53.6 Million from AHRQ, plus in-kind support– 24 No-cost extensions

24 R-01 THQIT Value Grants (HS-04-012)– $ 33.0 Million from AHRQ– 22 No-cost extensions

38 P-20 THQIT Planning Grants (HS-04-010)– $ 7.1 Million from AHRQ – 15 No-cost extensions

16 Cooperative Agreements, THQIT Implementation II (HS-05-013)– $ 22.5 Million from AHRQ, plus in-kind support– 14 No-cost extensions

Quality Improvement

THQIT Implementation

EMS Responders Use Health IT to Improve Cardiac Care

Nursing home Health IT Reduces Pressure Ulcers and Increases Staff’s Job Satisfaction

Project Echo: Extension for community Healthcare Outcomes Through Telemedicine

Network of Rural Hospitals in Iowa Redesign Patient Care Workflow to Use EHR

The Problem:

Many heart attack patients do not receive needed treatment in the recommended timeframe

The Health IT Contribution:

Clinical Decision Support Software– Helped paramedics quickly determine proper treatment

Web-Based Quality Reporting System – Combined data from the prehospital and hospital experience– Data was used to tailor quality improvement programs

Project Director: Dr. Harry Selker Project Location: Massachusetts AHRQ Grant: UC1 HS015124 http://healthit.ahrq.gov/FRPT_Selker_UC1HS015124



Results: 150% increase in the

number of patients receiving treatment in less than 90 minutes

Improved quality of care provided by paramedics

Sustainability/Transferability: Technology was used in

new communities and to address other conditions

The system was integrated with other health IT

The Problem:

Pressure ulcers are a prevalent and preventable condition for nursing home residents


Electronic documentation – Part of larger On-Time quality improvement program – Documented residents’ behavior, weight, and skin integrity – Produced reports to help identify residents at high-risk of

pressure ulcer development

Project Director: Dr. Susan Horn Project Location: Multi-stateAHRQ Grant: UC1 HS 015350 http://healthit.ahrq.gov

/FRPT_Horn_UC1HS015350

Nursing Home Health IT

http://healthit.ahrq.gov/


Results: Decreased percent of

residents with high-risk pressure ulcers

Improved job satisfaction

Sustainability/Transferability: 67 additional facilities have

implemented or are starting to implement the technology

On-Time Manual being created

On-Time emphasizes communication, you know the residents are better cared

for; families are happy.

~ Quote from a staff member

[At the beginning of the project] we had to practically beg [health IT] vendors to

incorporate the set of On-Time reports into their system. Since then there has been a

growing recognition that the value of health IT comes from impacting clinical decision making, not just automating the paper

documentation process, and On-Time reports can add value to a vendor’s system.

~Quote from Principal Investigator


More information:– http://ahrq.gov/research/ontime.htm– http://innovations.ahrq.gov/content.aspx?id=2153

http://ahrq.gov/research/ontime.htm

http://innovations.ahrq.gov/content.aspx?id=2153

The Problem:

Rural residents often have problems accessing specialty care for complex conditions


Project ECHO: Extension for Community Healthcare Outcomes through Telemedicine – Enabled patients to be treated long-distance– Provided a platform for rural providers to hone their clinical skills

Project Director: Dr. Arora Sanjeev Project Location: New MexicoAHRQ Grant: UC1 HS 015135

http://healthit.ahrq.gov/FRPT_Arora_UC1HS015135

Telemedicine Connects Rural Residents to Specialty Care


Results: Improved access to care for

4,000 patients with hepatitis C

Sustainability/Transferability: Expanded program to other

conditions Project selected as winner in

search for Disruptive Innovations in Healthcare-New Models

We’re developing our knowledge networks so that every doctor can provide best practice care without being an expert in all chronic diseases.

~Quote from Principal Investigator.


Original Focus: Hepatitis C 21

Expanded to these Conditions and Facilities

Asthma/Pulmonary 16

Child, Adolescent, and Family Psychiatry 32

Child, Adolescent Psychology 14

Chronic Pain/Headache 9

Diabetes/Cardiovascular Risk Reduction 19

High-Risk Pregnancy 21

HIV/AIDS 17

Integrated Addiction/Psychiatry 14

Medical Ethics 7

Occupational Medicine 5

Pediatric Obesity 43

Psychotherapy 4

Rheumatology 11


Original Focus: Hepatitis C 21

Expanded to these Conditions and Facilities

Asthma/Pulmonary 16

Child, Adolescent, and Family Psychiatry 32

Child, Adolescent Psychology 14

Chronic Pain/Headache 9

Diabetes/Cardiovascular Risk Reduction 19

High-Risk Pregnancy 21

HIV/AIDS 17

Integrated Addiction/Psychiatry 14

Medical Ethics 7

Occupational Medicine 5

Pediatric Obesity 43

Psychotherapy 4

Rheumatology 11

Facility Count=233

The Problem:

If EHR functions are not used effectively, preventable quality and safety issues may persist


Enhance use of EHR functions, examples: – 54 clinical decision support rules were added to the system – Pharmacists from the rural referral center use the EHR to remotely check

medication dosing and drug alerts at critical access hospitals – Nursing documentation functionality added– Electronic ordering of tests and medications added

Project Director: Dr. Donald Crandall Project Location: IowaAHRQ Grant: UC1 HS 015196 http://healthit.ahrq.gov/FRPT_Crandall_UC1HS015196

Enhancing Use of EHR Functions to Improve Quality of Care

http://healthit.ahrq.gov/FRPT_Crandall_UC1HS015196

http://healthit.ahrq.gov/FRPT_Crandall_UC1HS015196

Results: Improved the timeliness of

indwelling catheter removal

Sustainability/Transferability: Implemented additional

clinical decision support rules

Enhanced EHR function use in other system hospitals

Enhancing Use of EHR Functions to Improve Quality of Care

Planning and Implementation THQIT Grants

Public-Private Partnership Creates Web-Based System to Improve Rural Children’s Access to Health Care Through a Medical Home

Replication of Health Information Exchange Framework Across Oklahoma

Public-Private Partnership: Web-based System Improves

Childrens’ Access

The Problem:

Rural, lower income children lack access to appropriate healthcare


iReach web-based system– Tracks patients enrolled in a program that helps children

obtain insurance and links children to providers (Access El Dorado)

Project Director: Dr. Gregory Bergner Project Location: California AHRQ Grants: P20 HS 014908 (planning) UC1 HS 016129 (implementation)http://healthit.ahrq.gov/FRPT_Bergner_P20HS014908

http://healthit.ahrq.gov/FRPT_Bergner_UC1HS016129

http://healthit.ahrq.gov/FRPT_Bergner_P20HS014908

http://healthit.ahrq.gov/FRPT_Bergner_UC1HS016129

Public-Private Partnership: Web-based System Improves Childrens’ Access

Results: iReach reduced errors by

Access El Dorado staff 23% reduction in time to

manage a single case

Sustainability/Transferability: Health care providers are

funding ongoing operating costs for program

I feel that iREACH has been extremely efficient. I just know from

before, it’s a much less tedious process, more streamlined….The

paper process was bogging us down.

~ Quote from a user

A great success [of the AHRQ-funded planning process] was creating a

community of trust and commitment among the partners, so that they

perceived those being served as “our” patients rather than “yours” or “mine.”~ Quote from ACCEL program director

The Problem:

Patients often see multiple providers and their care becomes fragmented


Health Information Exchange (HIE)– Local groups of providers use an established framework to develop

an HIE– Local HIEs are connected to create a “network of networks”

Project Director: Mark Jones Project Location: OklahomaAHRQ Grant: P20 HS 015365 (planning) UC1 HS 016131 (implementation)http://healthit.ahrq.gov/FRPT_Jones_P20HS015364 http://healthit.ahrq.gov/FRPT_Jones_UC1HS016131

HIE Spreads Across Oklahoma

http://healthit.ahrq.gov/FRPT_Jones_P20HS015364

http://healthit.ahrq.gov/FRPT_Jones_UC1HS016131


Results: HIE has 49 member organizations and data

on 3 million patients

Sustainability/Transferability: In 2011, HIE is expected to cover 70% of

Oklahoma Central Florida providers use “network of

networks” model

This started as 1 network with 4 health facilities and 400,000 records, and it grew to 5 networks across Oklahoma with 49 health facilities and 37 million records in 2.5 years.

~ Quote from Principal Investigator

Value Grants

Electronic Prescribing: Lowering Patients’ Prescription Drug Costs

Integrated Telemedicine System Demonstrates Reduction in Children’s Emergency Department Visits

The Problem:

Prescription drug costs can put much-needed medication beyond the reach of low-income patients and those with chronic conditions


Electronic-Prescribing – Color-coded drug list indicating the relative cost of drugs

Project Director: Dr. Joel Weissman Project Location: Massachusetts AHRQ contract: R01 S015175 http://healthit.ahrq.gov/FRPT_Weissman_R01HS015175

Electronic-Prescribing Lowers Drug Costs

Electronic-Prescribing Lowers Drug Costs

Results: $3.26 saved per electronic prescription

Sustainability/Transferability: Health plans offered the system free of charge to

more providers

[The study findings indicate that] doctors want to do the right thing, but they don’t always have the right information available.


The Problem:

Children often exhibit symptoms of illness and school staff are unable to decide which students need to be sent home

Wages lost when parents care for children who could be at school can be detrimental for low income families

Low income parents, needing to quickly return to work, often seek attention from costly EDs


Telemedicine – Schools and child care centers have access to telemedicine equipment – PCPs provide remote consultations

Project Director: Dr. Kenneth McConnochie Project Location: New YorkAHRQ Contract: R01 HS 015165 http://healthit.ahrq.gov/FRPT_McConnochie_R01HS015165

Telemedicine Reduces Children’s ED Visits

http://healthit.ahrq.gov/FRPT_McConnochie_R01HS015165


Results: 83% of providers were equally confident in their

telemedicine diagnoses and in-office diagnoses Children with access to telemedicine sites had

24% fewer ED visits

Sustainability/Transferability: Payers started reimbursing telemedicine visits Telemedicine program is expanding to other

settings

It’s both convenience—health care when and where you need it—and continuity—by people you trust. Who couldn’t use more of that from health care?



Visits for Illness: Total: 22.9 % increaseEmergency Department: 23.6 % decrease

Costs of illness visits: 3.0 % decrease


Number and Cost of Medical Care Visits, by Type of visit, For Children Enrolled in Health-E-Access vs. Comparison Children

THQIT Synthesis

Grantee Surveys (early 2011)

Group of Follow-up Grantee interviews– Depth, Clarification

Tool/Guideline: – Use of EHR and HIE in rural hospitals

AHRQ’s Interest

No expiration date

Send articles to AHRQ [email protected]

Include grant citation in your presentations and publications

mailto:[email protected]

Questions?

Success Stories from the AHRQ-Funded Health IT Portfolio (CY 2009)

Contract No. HHSA 290200900018I, T.O. 3– Prepared by: John Snow, Inc (JSI)– http://healthit.ahrq.gov/SuccessStories

CY2009 (November 2010)



Research Grants

Larry Garber: SAFEHEalth, A Health Information Exchange Improving Health Care Delivery in Central Massachusetts

Pascale Carayon: Using Human Factor Research to Increase the Success of a Health Information Technology Implementation

Denni McColm: Measuring Quality in Physicians’ Practices in Southwestern Missouri Using and Electronic Health Record

SAFEHealth: A Health Information Exchange Improving Health Care Delivery

in Central Massachusetts

Regional HIE that securely transfers patient health information in “real time” between providers

Dr. Lawrence Garber, AHRQ grant (UC1

HS015220)

SAFEHealth: A Health Information Exchange Improving Health Care Delivery in Central

Massachusetts

Goal: Improve patient safety, quality of care, and health care efficiency, while protecting patient privacy

Data exchange includes medication lists, allergies, vital signs, lab results

SAFEHealth: Steady Increase in Number of Documents Exchanged

No more huge piles of paper. I can set up a follow-up with a Fallon Clinic specialist based on the ER note…. Essentially, we have cut

out the middle man – talk about GREEN and LEAN!~ Quote from primary care physician at Fallon Clinic

Figure 1: Total number of documents transferred from Fallon Clinic to HealthAlliance

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20,000

25,000

0 20 40 60

Weeks since SAFEHealth went live

# of

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umen

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From Fallon Clinic to HealthAlliance

Figure 2: Total number of documents transferred from HealthAlliance to Fallon Clinic

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1,500

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SAFEHealth Key Decisions/Success Factors

Available through different EHRs

Single Opt in, automated at patient registration, revoke at any time/any or all organizations

Developed internally, costs shared by partners

SAFEHealth: Continuing as a Successful HIE

Still continues as an active HIE Key is to instill trust and value to

stakeholders Must integrate into workflows of patients,

registration staff and providers Patients will see greater value as more

organizations participate Providers are most satisfied when data is

easy to find, so data should be sorted by sections into EHR

Using Human Factor Research to Increase the Success of a Health IT Implementation

CPOE can reduce medication errors

Success is tied to how well CPOE is designed and integrated into workflow

Examined impact of implementation in ICUs on quality of care and safety, staff tasks and perceptions, and financial value

Conducted human factors research to evaluate and identify issues with interface and workflow

Dr. Pascale Carayon, AHRQ grant R01 HS 015274

CPOE

Impact

Decrease in some errors while increase in others

Increase timeliness of antibiotic medication administration

Short term negative staff perception, disappeared after 12 months.

Staff tasks changed No impact on financial value, no

difference in ICU costs or physician productivity

CPOE

Human Factors Research: Leading to More Effective Technology

Identified potential problems with the system

Addressed issues by changes in workflow or design interface

Identified potential negative impact on patients & providers before the system went live in the ICUs.

‘I thought this was a very useful process with different perspectives generating good discussion

of potential issues”~ Geisinger Employee

CPOE

EHRs have potential to provide reliable, valued clinical data for quality measurement

Challenge lies in having unstructured documentation, often in many places within EHR– complicates search

algorithms & makes for confusing results

Aim: To use pre-existing EHR technology to facilitate quality measurement

Measuring Quality in Physicians’ Practices in Southwestern Missouri Using an EHR

Denni McColm, AHRQ grant (HS017094)

Ambulatory EHR System Used in Quality Measurement for PQRI Reporting

Participants included 15 practices within Citizens Memorial Healthcare (CMH)

Toolkit was developed to help w/ implementing quality measures into CMH’s EHR

EHR data elements were standardized

Automated data extraction was developed

Efficiency/accuracy of automated vs. manual data extraction was evaluated

Accurate quality measurement for PQRI reporting through an ambulatory EHR system

Compared manual to automatic for 3 diabetes measures

Coding completeness 20% for manual coding compared to 100% for automated data extraction

Automated data extraction also more accurate in reporting results

Outcomes and Lessons

Without accurate documentation; quality of care may not be accurately reflected– 62 quality measures built into documentation and

workflow Automated data extraction relied heavily on the

use of custom documentation queries– Toolkit was expanded and refined to include custom

queries Various strategies can improve physicians’

documentation within the EHR system.– Web-based report on aggregate organizational

performance (developed through this project)– Additional training on quality measures and effective

use of the EHR (as was done in this project)

Research Contracts

Dr. Lynne Nemeth: Electronic Standing Order in Primary Care Physician Offices Boosts the Delivery of Adult Vaccinations and Other Health Maintenance Services

Dr. Doug Bell: Electronic Referrals Show Promise for Improving Quality Care in Outpatient Settings

E-Standing Orders

Dr. Lynn Nemeth– 10 am – Salon E

Electronic Standing Orders in Primary Care

Services (screening tests, adult immunizations, diabetes care) often overlooked. Implemented and and examined effectiveness of electronic standing orders (SO)

SOs triggered by a patient visit and authorize appropriate medical staff to carry out services

Dr. Nemeth AHRQ Contract (HHSA290200710015)

EHR Integration of SO

Customized EMR page to integrate SOs and display health maintenance (HM) items

HM table indicates a patient’s need for a preventive service.

Overdue items are highlighted in red for easy viewing, serving as electronic reminders.

Improvement of Practice Performance

Participating practices reported:

• 8-17% increase in adult immunizations

• 6-10% increase in preventive care screenings

• Up to 18% increase in diabetes care measures

The project made us more aware that our patients were missing

regular health maintenance....we did not

realize that we missed this. We are now keeping up with their

health maintenance issues, and patients realize that they are

cared about. ~Participating Physician

Figure 1. Immunization Performance Measures Over Time:Monthly Medians Across All 8 SO-TRIP Practices

0%

10%

20%

30%

40%

50%

60%

70%

80%

0 3 6 9 12 15 18 21

Month

Pe

rfo

rma

ce

(%

)

Pneumococcal (>=65 y.o.) Influenza (>=50 y.o.)

TD vaccine (>= 12 y.o.) Pneumococcal (18-64 y.o. high risk)

Influenza (18-49 y.o. high risk) Zoster Vaccine (>= 60 y.o.)

* P< 0.05 for increasing trend over time

*

*

*

*

Electronic Referrals Show Promise for Improving Quality of Care in Outpatient

Settings

Lack of communication between referring providers & specialists causes fragmented patient care

eReferral is a web-based service that streamlines and facilitates

communication between clinics and thereby has the potential to increase efficiencies and improve clinical outcomes

Assessment of how electronic referral systems can best be used to support improvements in health care processes and outcomes

Dr. Bell, AHRQ Contract (HHSA290200600017)

eReferral Process

PCP submits electronic referral

Consult reviewed electronically by specialist

Appropriate specialty referralAND

Pre-referral work-up complete

PCP can manage with guidanceOR

Pre-referral work-up incomplete

Schedule next available

Overbook

Nonurgent Urgent Not scheduledOR

More information requested

PCP re-submits referral

Scheduled Never scheduled

Improving Quality of Care in Outpatient Settings

38%

35%

44%

59%

71%

89%

19%

49%

37%

22%

42%

16%

9%

10%

5%

30%

5% 6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Time spent submitting

Access for urgent issues

Wait time for new appointment

Access for non-urgent referrals

Guiding pre-visit work up

Ability to track referrals

Better No difference Worse

“It just keeps everything organized…It really helps me track everything a lot more easily than what we used to have…It’s an electronic trail that is very logically set up.” – Specialty Reviewer

“I think the patient’s visit is more productive because the specialists have already done some of the initial diagnostic work. - Referring Physician

Future Considerations

Generalizability to other settings will depend on EMR infrastructure and financial incentives

Successful implementation requires careful consideration of end user workflow

User education is critical to support realistic expectations and long-term adoptability

Learning curve impacts use of new technology and its outcomes

Contracts

Anne Peterson: Building Bridges Workshop: Healthcare Consumer Needs and the Design of Health Information Technology

Jeffrey Kerwin: Healthcare Consumers’ Perspectives on the Design and Use of Health Information Technology

Cheryl McDonnell: Strategies for Integrating Usability in Electronic Health Records

Building Bridges Workshop: Consumer Needs and the Design of Health IT

Consumer-based health care has been identified as a critical strategy to improve health outcomes

Empowering healthcare consumersis critically dependent on the ability to collect, store, and manage “personal health information” (PHI)

A 2-day workshop (July, 2009) was held to bring togethera multi-disciplinary group of experts to address and promote the design of consumer health IT systems based on a solid understanding of consumers’ PHIM practices

Anne Peterson, AHRQ Contract (#HHSA290200710072T )

3 Themes Emerged

Defining PHIM – Systems needs to be flexible and accessible to different types of users, across different settings.

Design Issues – Systems need to take into account the particular needs of the consumer, rather than the needs of the physician, insurance company, or some other entity with a stake in the patient’s health care.

Steps for the Advancement of Consumer Health IT - Additional research on consumers’ PHIM practices and increased sharing of info within the technology field is needed to lead to better, more efficient designs.

Future Opportunities

Field of PHIM still in its infancy: no existing systems, models, or classifications

Time is ideal to incorporate consumers’ needs into the PHIM framework – “Who & what are we designing

for?” User-centered PHIM tools can:

– empower patients as partner in their own health care,

– improve patient-doctor communication, and

– Make tools and systems more widely available to all consumers

One of the most underused

resources in health care in America is

the consumer.~Carolyn Clancy, Director, AHRQ

Health Care Consumers’ Perspectives on the Design and

Use of Health IT

Surveys suggest the publiccould be better informed regarding health IT capabilities and how physicians use EHRs

20 focus groups offered patientperspectives on health IT – Awareness, beliefs, perceptions, fears of health IT– At what point patients want to be engaged in

development of health IT

Dr. Jeffrey Kerwin, PhD, Contract PSC TO TO#07R000131, IAA Number 06-443R-06

Consumer Perspectives

“…my doctor comes in … she has, like, a big, thick [file] because I've been

going to her for years … But, if she had a laptop or

something, she'd be able to go back to that date and time

and just pull that up and it would pop right up. It would be easier for her, as far as being organized and being

systematic.”-Focus Group Participant

Almost complete agreement that patients should have a say in how data is shared/used

General Agreement that health IT would improve efficiency, reduce errors.

Little agreement about the role of patients in the design/ use of health IT

Fears / Concerns

“That's your personal information. You should

have every right to say how it's used.”

Consumers feel that patient health info belongs to the patients

Concerns raised over privacy, security, interpersonal impact

Doubts in cost savings – fear of rising costs

Uncertainty re: how health IT can enhance health care decisions

“Everything else has been hacked. Government files have been hacked; banks have been hacked. My credit cards have

been stolen. What else is left?”

Suggestions for Engaging Consumers in Health IT Design & Use

Engage consumers early in process More surveys and focus groups on

consumer opinions or perspectives Involvement of patient advocacy orgs Consumers involved in advisory

committees More public education on health IT, its

impact on patients, and security/privacy issues

Strategies to Integrate Usability in EHRs

EHRs revolutionize medicine, however lack of usability data to inform design and practice

A panel of multidisciplinary EHR experts & vendors was convened to participate in informal interviews

This is AHRQ’s first initiative to guide EHR innovations in usability

Dr. Cheryl McDonnell, AHRQ Contract (HHSA2900710073T)

Reports Document Expert Recommendations

Three documents were developed to focus on key areas of interest to policymakers, researchers, and EHR developers:• Framework Evaluation• Interface Design • Vendor Practices and

Perspectives

“There is strong evidence (outside health care) that usability testing in the design and

development phase is more

effective and less expensive than

after market release.” - Expert Panel

Member

Findings

Framework Evaluation: definition of categories for usability and evaluation

Interface Design: incorporation of recommendations for evidence-based lessons from other fields

Vender Practices and Perspectives: description of usability engineering processes and engagement of end users throughout the product life cycle

Dissemination of Findings

Chart 1. EHR UsabilityPublication Coverage by Media Type

39% (32)

38% (30)

23% (18)

Blogs Online Version New s Websites

health it success stories ahrq conference september 29, 2010 rebecca roper

Documents

ahrqfunded health

acronym thqit

cost extensions

thqit planning grants

thqit value grants hs

massachusetts ahrq grant

cardiac care results

areas of prehospital