Employing Health Information Technology in the Real World to Transform Delivery

Published Online: November 26, 2013
Marsha Gold, ScD
Objectives: Strong leadership and a supportive culture are critical to effective organizational transformation, but organizations pursuing change also need the infrastructure and tools to do so effectively. As policy makers seek to transform healthcare systems—specifically the delivery of care—we explore the real-world connection between health information technology (HIT) and the transformation of care delivery.

Study Design and Methods: This study is based on interviews with diverse federal and health system leaders and federal officials. The work was funded by the Office of the National Coordinator for Health Information Technology as part of a global assessment of the Health Information Technology for Economic and Clinical Health Act.

Results: The functionalities supported by HIT are integral to creating the information flow required for innovations such as medical homes, accountable care organizations, and bundled payment. However, such functionalities require much more than the presence  of electronic health records; the data must also be liquid, integrated into the work flow, and used for analysis. Even in advanced systems, it takes years to create HIT infrastructure. Building this infrastructure and transforming delivery simultaneously is difficult, although probably unavoidable, for most providers. Progress will likely be slow and will require creative strategies that take into account the real-world environment of organizations and communities.

Conclusions: While the rapid transformation of delivery and infrastructure is appealing, both types of change will take time and will progress unevenly across the nation. Policy makers serious about transforming the delivery of healthcare can benefit by recognizing these realities and developing practical strategies to deal with them over a relatively long period of time.

Am J Manag Care. 2013;19(11 Spec No. 10):SP377-SP381
The fiscal stress of the past decade has led to a growing interest in maximizing the value of the nation’s healthcare spending. Accordingly, policy makers are seeking ways to transformhealthcare delivery and payment to make care more efficient and effective.1 The Patient Protection and Affordable Care Act of 2010 supports this transformation, which is especially critical for patients with diverse and complex healthcare needs. Prominent examples of transformation initiatives include patient-centered medical homes, accountable care organizations, and bundled payments based on episodes of care (such as, hospitalizations and post discharge care).

Research suggests that strong leadership and a supportive culture are critical to effective organizational transformation, but  organizations pursuing change also need the infrastructure and tools to do so effectively.2-4 The Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act, which promote the use and exchange of health information in practices across the nation, were intended to help build some of that infrastructure.5 This analysis examines the link between health information technology (HIT) and healthcare transformation.

The analysis was funded by the Office of the National Coordinator for Health Information Technology (ONC) as one component of a global assessment of the HITECH Act. The analysis uses qualitative methods to gain practical insight into how policy makers and  health system leaders view the connections between HIT and changing healthcare delivery. The main data source involves  semi-structured telephone interviews conducted with leaders at 7 diverse health delivery systems and with 4 senior staff at HHS with delivery reform responsibilities in  several US Department of Health and Human Services (HHS) agencies (Table). An analyst took detailed notes of each interview so that key themes could be identified. (Due to the fact that the number of interviews was small, we did not use formal coding, relying directly on the detailed notes to identify key themes.) We worked with ONC staff to identify diverse delivery systems engaged in change to interview. We also reviewed several recent reports and guides to delivery reform from an operational perspective; they were particularly valuable in identifying particular functionalities associated with reform and where HIT can support them. From these sources we identified 5 general points for policy maker attention that seemedto emerge from the evolving experience as reflected in interviews and the “grey literature.” We discuss each point below.


Information Flow Is Critical to Change in Healthcare Delivery

Delivery reform requires changes in processes of care. HIT is an important part of creating the infrastructure to make that happen. As one interviewee noted, “IT has been an enabler for us. Without it…we can’t align data to incentivize providers. Also, we can’t analyze opportunities for improvement.” Although each transformation model varies in the changes it requires to the delivery process, each change needs a corresponding information flow to support it.6 A strong HIT system can help make sure relevant information is available where and when it is needed to support providers in transforming the way they deliver care. Patient-centered medical homes, for example, encourage practices to assume responsibility for the population they treat. Assuming this responsibility requires information that links patients to practices (empanelment) as well as ways to analyze data to identify and understand patient subgroups, monitor referrals and test results, create patientspecific educational materials and reminders, and develop action reports to guide appropriate care management.7 Practitioners need systems that allow them to “query and pull” laboratory tests, medication lists, and other data in real time. Such systems should allow the storage and exchange of information, communication between members of the care team, performance monitoring, and decision support for providers.8 Robust electronic health records (EHRs) can support such information flows and functionalities.9

More broad-based reform of delivery that builds on medical homes and neighborhoods to support accountable care organizations (ACOs), and bundled care models create financial incentives to encourage providers to take responsibility for the care of patients, regardless of where the patients seek are. Providers in ACOs have to be able to track patients wherever they obtain care. Tracking patients may necessitate capabilities such as cross-continuum medical management, medical engagement, clinical informationexchange, quality and performance reporting, predictive modeling and analytics, and administrative and financial management systems.10 These capabilities require an infrastructure that moves beyond “point of care” and “encounter-based” functionalities and supports more robust information exchanges across settings, as well as more rigorous population-based analytics. With integrated systems, providers may be able to leverage internal systems to achieve these ends. Where such systems are not present (as in most of the country and some of our interviewees), providers will likely need new mechanisms for health information exchange that work across practices and settings and providers willing to use them.

HIT Involves More Than EHRs 

To be useful, HIT needs to be viewed as more than EHRs.  As one interviewee expressed it, “Data must be liquid, integrated into work flow, and used for analytics.” This requires practices to have an infrastructure that is sufficiently robust. For example, to judge the readiness of the infrastructure in  practices seeking to join the Comprehensive Primary Care initiative, policy makers from the Centers for Medicare & Medicaid Services (CMS) examined their ability to meet the stage 1 “meaningful use” requirements under HITECH. The agency saw this as the best metric for assessing the integration of EHRs into the practices’ work flow. The Health Resources and Services Administration, likewise, generally expects that federally qualified health centers will become primary care medical homes and adopt EHRs. But agency officials say EHRs are the means, not the end, to work flow changes needed to support quality improvement.

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Issue: Special Issue: Health Information Technology - Guest Editor: Farzad Mostashari, MD, ScM
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