ASH Symposium on Quality Addresses Health IT Challenges for the Provider and the Patient

Surabhi Dangi-Garimella, PhD

A key finding of the Institute of Medicine Committee on the Quality of Health Care in America’s report, "Crossing the Quality Chasm: A New Health System for the 21st Century," published in March 2001,1 was that information and communication technology is essential to improve quality of care. Subsequently, billions of dollars were invested to assist physicians, hospitals, and other healthcare settings, in adopting health information technology (IT or HIT).

In the last decade, significant strides have been made to incorporate health IT into clinical practice. However, despite the emerging evidence of the impact of health IT on communication, healthcare quality, and efficiency, its impact on health-related outcomes is limited.

The Special Symposium on Quality at the 58th American Society of Hematology Annual Meeting & Exposition, looked at how health IT can be utilized to improve healthcare quality, enhance patient-provider shared decision-making, and facilitate efforts in quality research. Co-chaired by Anita Rajasekhar, MD, MS, Shands Hospital, University of Florida, and Vishal Kukreti, MD, Princess Margaret Cancer Centre, panelists included Hardeep Singh, MD, who heads the Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center, Houston, Texas; Douglas W Blayney, MD, Stanford Cancer Institute, Stanford University, Stanford, CA; and Doris Howell, PhD, RN, The Princess Margaret Cancer Centre, Toronto, Ontario, Canada.

Singh, who is also associate professor in the department of Medicine, Baylor College of Medicine, Houston, Texas, posed the question, “Why is there disillusionment in health IT?” He pointed out that while health IT changes clinical practice, implementation of changes is often prone to failure. Quality and safety benefits need a while to implement, Singh said, and then there often are unintended consequences that we are not prepared for.  

“However, the bottom line is to ensure patient safety,” Singh emphasized.
  1. Electronic health records (EHRs) must be safe
  2. EHRs should be used safely, and episodes of reckless copy/paste should be avoided
  3. EHRs should be used to improve safety.
Research conducted by Singh’s group found that there are human errors involved at various stages of EHR use. He cited examples such as communication gaps because the physician did not read the nurse’s notes, notes that are not accurate or are confusing, or wrong quality measures being implemented.

“Gaps in data and in communication result in data being lost in the bargain.” Singh explained this with an example of how physicians might open an alert raised by the EHR system, but may not necessarily follow-up on it. “Too many EHR alerts may lead doctors to miss them,” Singh said. “We have had some initial success in the VA and we are trying to prospectively use some algorithms to correct the situation,” he added.

Singh added that patient engagement in their care can significantly boost follow-up on their test results, and this can be achieved by sending patient data directly to patient portals. “However, the raw information might be difficult for patients to interpret.”

Singh stressed that there is no single solution to the existing EHR troubles that our healthcare system is facing. “We need to address every dimension of the EHR problems,” he said and provided the following solutions:
  1. Software: need better tools/functions and design of EHR
  2. Content: need smarter alerts and diagnostic decision support
  3. Usability: need better user interfaces; increase signal/noise ratio
  4. Workflow: needs improvement so there’s time for physician-patient interaction
  5. People: need both patients and providers to be better engaged
  6. Organization: need protocols for closed-loop test results follow-up
  7. External rules are very important such as reimbursement for cognitive work
  8. Evaluation and measurement: need to measure performance to ensure implementation and performance improvement
Blayney, who has in the past presided over the American Society of Clinical Oncology, serves on the CancerLinQ Physician Advisory Committee. CancerLinQ is a big data platform that aggregates EHR data for quality benchmarking and also to aid clinical decisions.2 He addressed the challenges faced by providers in the clinic with using health IT platforms.

“Poor usability, mismanagement, and misidentification can all lead to HIT problems,” Blayney said. “It’s important to note that user interfaces need to be improved and people need to be trained as well.” However, he emphasized that there needs to be an intuitive nature to using these interfaces, similar to using a mobile device, which is more user-friendly and intuitive in nature.

Blayney explained that while electronic data capture shifts the data entry burden, it does not reduce the number of steps involved in assimilating all of that data. “At Stanford, we have taken advantage of the data warehouse to develop curated analytic data sets. So the solution is to create access to data warehousing, use a curation engine, and create a documenting warehouse that can all help the process.” He acknowledged, however, that all of this does not come cheap and needs significant monetary and personnel investment.

It’s widely accepted, however, that without measurement there is no improvement. Blayney provided an example of a breast cancer staging compliance report that was sent to oncologists individually and then to the entire groups, to improve physician adherence to the staging module. “By inserting a curation engine, we were able to add cancer stage as a measurable field,” he said.

A team of experts at Stanford is also working on natural language processing to electronically extract data from clinical records.3 “Capturing unplanned hospitalizations and emergency department visits as part of an episode of care, which might be happening outside of Stanford’s network, is often difficult to capture.” But the team developed a system to gather this information from EHRs, “Although a significant amount of curating was need, including for ambiguous terms like ER, PR, and other acronyms,” Blayney told the audience. “It is important to reduce data mismanagement and to aggregate data across networks and nationally, and provide feedback to the physicians involved,” he added.
 
Finally, to speak about how health IT can enhance the patient experience was Howell, who is a health services researcher.

Patient engagement, she said, is about taking actions that help manage their health to gain benefit from healthcare. “It needs an active collaboration between patients and providers to design, manage, and achieve positive health outcomes,” Howell added.

Studies have shown that actively engaging patients in their own care does improve outcomes, it encourages them to use more preventive services, and they also experience better transitions between silos of care.

Historically, meaningful use emphasized increased EHR use; however, the current belief is that empowering patients and improving their engagement with providers is more important for meaningful use. Howell said that patients want to engage in technology to help improve their lives—such as appointment reminders, refills etc. But do patients have the tools or equipment to care for themselves?

Health IT can be used to support and empower patients via,
  1. Education tools and by providing them access to their data
  2. Data and information exchange among providers
  3. Data and information exchange between providers and patients on symptom management and virtual treatments
  4. Data and information exchange between providers and health systems
Howell told the audience that while health trackers/mHealth can help with early preventive intervention and help create a proactive model of care, issues such as data capture and health privacy remain.

The bottom line, though, is to think of the patient as a whole. “Quality of life and patient experience is as important as the toxicities and adverse events that are documented,” Howell said, adding that she is a firm believer in the potential of patient-reported outcomes measures.

References
  1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001.
  2. Miller R. CancerLinQ—ASCO’s rapid learning system to improve quality and personalize insights. Am J Manag Care. 2016;22(SP8):SP308-SP310.
  3. Obtaining clinical data for research. Stanford website. https://med.stanford.edu/researchit/services/data-extraction.html. Accessed December 4, 2016.
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