Healthcare Quality HW

Chapter 1: Connecting the Strategic Dots: Does HIT Matter? Overview • Data, Information and Knowledge • HIT strategic alignment • Operational effectiveness: making HIT work • Strategic competitive advantage: building HIT for the future Copyright 2013 Health Administration Press Learning Objectives • List and define five major challenges

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facing healthcare delivery systems today. • Describe the complexity of these interrelated challenges for healthcare and HIT. • Illustrate the history, development, and current state of healthcare information systems. • Name and describe the four categories of healthcare information systems. • Analyze the key priorities of healthcare information systems today that will affect their future. Copyright 2013 Health Administration Press The Future Is Now! • The healthcare industry is information intensive, and the management of healthcare organizations is improved by strategic use of information for: – – – – Quality patient care Financial management Strategic planning Operations management Copyright 2013 Health Administration Press Current Challenges • • • • • Healthcare costs Medical errors and poor quality Access and health disparities Evidence-based medicine Broad organizational changes Copyright 2013 Health Administration Press Healthcare Costs • Trend of upward costs for 45 years • Cost increases may make the US economy less competitive • Government and private payers implement cost controls • Variance in use and costs provides indirect evidence that we can control costs Copyright 2013 Health Administration Press Medical Errors and Poor-Quality Care • Excess of preventable deaths demonstrated by Institute of Medicine in 1999 • Problem persists today despite greater awareness and discussion • Solutions are elusive Copyright 2013 Health Administration Press Access and Health Disparities • Information systems can assist in providing better access to care. • Solving access problems will strain the system, however. • Providing care to approximately 50 million will require better information exchange and coordination of care. Copyright 2013 Health Administration Press Number of Uninsured Fell by 1.3 Million in 2011 Copyright 2013 Health Administration Press Evidence-Based Medicine • Defined: “An information management and learning strategy that seeks to integrate clinical expertise with the best evidence available to make effective clinical decisions that will ultimately improve patient care”(Landry and Sibbald 2001) Copyright 2013 Health Administration Press Evidence-Based Medicine • Evidence-based medicine is changing clinical processes • Use of information is essential but has both benefits and costs • Book helps managers collect and provide evidence for more informed management decisions Copyright 2013 Health Administration Press Broad Organizational Change • • • • Market-driven healthcare reform Increased market competition Managed care was the solution in the 1990s. The future is uncertain, and organizations need leadership to adapt to an uncertain future. Copyright 2013 Health Administration Press Future Challenges for Healthcare Information Systems Five major challenges: • Healthcare system change • Consumer empowerment • Connectivity • Transparency • Tourism Copyright 2013 Health Administration Press Healthcare System Changes • Patient Protection and Affordable Care Act of 2010 had initial emphasis on access for uninsured • Other elements have broader seeds for change, such as – – – – – – Access to care for uninsured primary emphasis Bundled payments Payment for outcomes Accountable care organizations Patient-centered medical homes Comparative effectiveness research Copyright 2013 Health Administration Press Consumer Empowerment Consumers taking active role in care decisions: • Internet provides access to information, giving patients more control • Need for uniform, national information infrastructure, such as electronic health records, evidence-based clinical practices, and quality information • Generating need for information management in healthcare Copyright 2013 Health Administration Press Connectivity • Social media adding to the ability to send and receive information – – – – E-mail Text Tweet Other • Federal Communications Commission exploring opportunities and challenges Copyright 2013 Health Administration Press Transparency Driven by value-driven healthcare • Interoperable HIT • Public reporting of provider quality information • Public reporting of cost information • Incentives for value comparisons Copyright 2013 Health Administration Press Tourism International and regional tourism • Send historical patient health information • Receive patient health information • Compete with centers of excellence • Financial incentives from employers (Walmart) contracting for care on the basis of price and quality Copyright 2013 Health Administration Press Categories of Information Systems 1. 2. 3. 4. Clinical information Management information Strategic decision support Electronic networking and e-health applications Copyright 2013 Health Administration Press Healthcare Information System Priorities Today • • • • • • Ch. 2: External Environment Ch. 3: Government Policy and Healthcare Reform Ch. 4: Leadership Ch. 5: HIT Governance and Decision Rights Ch. 6: HIT Architecture and Infrastructure Ch. 7: HIT Service Management Copyright 2013 Health Administration Press Healthcare Information System Priorities Today (cont’d) • Ch 8: Systems Selection and Contract Management • Ch. 9: Electronic Health Records • Ch. 10: Management/Administrative and Financial Systems • Ch. 11: HIT Project Portfolio Management • Ch. 12: Knowledge-Enabled Organization • Ch. 13: HIT Value Analysis Copyright 2013 Health Administration Press Web Resources • Agency for Healthcare Research and Quality (www.ahrq.gov) • Bureau of Labor Statistics (www.bls.gov) • Care Continuum Alliance (www.carecontinuumalliance.org/index/asp) • Centers for Medicare & Medicaid Services (www.cms.gov) • Institute for Healthcare Improvement (www.ihi.org) • National Association for Healthcare Quality (www.nahq.org) • National Committee for Quality Assurance (www.ncqa.org) Copyright 2013 Health Administration Press Chapter 2: External Environment Learning Objectives • Define the ways in which the external environment influences the operation of the healthcare delivery system. • Define the healthcare triangle, and demonstrate how it relates to management of healthcare organizations and the healthcare information technology function. • Describe the interdependent challenges of cost, quality, and access currently facing the US healthcare system. • Analyze the implications of the cost, quality, and access challenges for the management of healthcare information systems. • Assess the relative importance of evidence-based management, organizational change, and international comparisons in the current and future management of healthcare delivery organizations. • Assess how well healthcare system challenges and their implications align with healthcare information system priorities. Copyright 2013 Health Administration Press Overview • • • • Healthcare triangle: cost, quality, and access Evidence-based management Organizational change International comparisons Copyright 2013 Health Administration Press The Healthcare Triangle Copyright 2013 Health Administration Press Triangle: Overall • Systems approach—interrelated goals: – Cost, – Quality, and – Access. • Consequently, information systems need to report: – More data – Wider ranging data on all three dimensions Copyright 2013 Health Administration Press Triangle: Overall (cont’d) Management implications: • HIT and leadership must collect, analyze, and report clinical and administrative data • Include conventional and new types of data demanded in the future Copyright 2013 Health Administration Press Triangle: Costs National health expenditure (NHE) • NHE reached $2.6 trillion in 2010. • NHE represented 18% of GDP in 2010. • Exhibit 2.4 shows historical levels and expected increases in NHE per capita and as percentage of GDP. • Exhibit 2.5 demonstrates that change in NHE exceeded change in GDP in all decades since 1960. Copyright 2013 Health Administration Press Per Capita NHE and NHE’s Share of GDP: 1960–2015 $12,000 $10,000 $8,000 $6,000 $4,000 $2,000 $0 $10,272 $8,402 $4,878 $2,854 $147 $356 1960 5.2% 1970 7.2% *Projection $1,100 1980 9.2% 1990 12.5% 2000 13.8% 2010 17.9% 2015* 18.2% Year and Percentage of GDP Copyright 2013 Health Administration Press NHE and GDP Growth Rates, 1970–2015 Copyright 2013 Health Administration Press Major Components of Healthcare Costs Percentage of NHE by major components in 2010: • Hospital services accounted for 31.4%. • Physician services accounted for 19.9%. • Prescription drugs accounted for 10.0%. • Nursing home care accounted for 5.5%. See Exhibit 2.6. Copyright 2013 Health Administration Press NHE by Major Service: 2010 27.5% 31.4% 5.7% 5.5% 10.0% 19.9% Copyright 2013 Health Administration Press Hospital Services Physcian Services Prescription Drugs Nursing Home Care Research/Construction All Other Increases in Components of NHE Components of care increased at different annualized rates between 2000 and 2010: • Prescription drugs increased most rapidly at 7.6% per year. • Hospital services increased more per year than overall NHE (6.7% versus 6.3%, respectively). • Nursing home care increased at 5.2% per year. Copyright 2013 Health Administration Press Annualized Changes in Major Categories of NHE and GDP: 2000–2010 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 7.6% 6.7% 6.3% 5.7% 5.2% 3.8% Hospital Services Physician Services Prescription Drugs Nursing Home Care NHE Copyright 2013 Health Administration Press GDP Decomposition of NHE Increases Between 2000 and 2010: • Population increases contributed to 14.4% of overall NHE increase. • General inflation increases contributed to 37.3% of overall NHE increase. • Real GDP increases contributed to 22.4% of overall NHE increase. • Relative healthcare price increases contributed to 25.6% of overall NHE increase. Copyright 2013 Health Administration Press Triangle: Quality • Quality assessment and improvement is a primary challenge as indicated by IOM report in 1999. • Healthcare quality was conceptualized by Donabedian in the 1960s. • Multiple domains, including: – – – – – – Patient safety Patient-centeredness Timeliness Efficiency Effectiveness Equity Copyright 2013 Health Administration Press Triangle: Quality (cont’d) • Quality measurement is data and information intensive. • National Quality Measures Clearinghouse (Exhibit 2.10): – Thousands of metrics collected – Classified by scheme: • Disease/condition • Treatment/intervention • Health administration • Many other organizations collect and present quality and quality improvement information for healthcare. Copyright 2013 Health Administration Press Quality Improvement Organizations Select quality improvement organizations: • Agency for Healthcare Research and Quality (AHRQ): www.ahrq.gov • National Association for Healthcare Quality (NAHQ): www.nahq.org • National Committee for Quality Assurance (NCQA): www.ncqa.org • National Quality Forum (NQF): www.qualityforum.org • American Society for Quality (ASQ): www.asq.org • The Joint Commission (TJC): www.jointcommission.org • Institute for Healthcare Improvement (IHI): www.ihi.org • Institute of Medicine (IOM): www.iom.edu • Leapfrog Group: www.leapfroggroup.og • National Initiative for Children’s Healthcare Quality (NICHQ): www.nichq.org • American Medical Association Physician Consortium for Performance Improvement (AMA-PCPI): www.ama-assn.org/ama/pub/category/2946.html • Ambulatory Care Quality Alliance (AQA): www.aqaalliance.org • Nursing Quality Network: www.nursingqualitynetwork.org Copyright 2013 Health Administration Press Triangle: Access Multiple types of access problems: • Remote, rural locations based on distance or travel time • Underdeveloped resources causing crowding • Lack of insurance • Fear of public programs • Literacy and cultural competence Copyright 2013 Health Administration Press Triangle: Access (cont’d) Financial access is major focus (see chart in Chapter 1). Those without insurance: • • • • • Use emergency department as their regular source of care Obtain fewer health screenings and less preventive care Delay or forgo medical services Are typically sicker and die younger Pay more for medical services Copyright 2013 Health Administration Press Number of Uninsured Fell by 1.3 Million in 2011 Copyright 2013 Health Administration Press Triangle: Impact on HIT • Documentation of the value obtained for care delivered requires detailed data on outcomes and resources consumed. • Improving quality requires greater accuracy, reliability, and timeliness of clinical information. • Access will require capacity expansion to care for approximately 50 million additional people and collecting and sharing information across diverse organizational settings. Copyright 2013 Health Administration Press Evidence-Based Management (EBM) • Like medicine, management needs a foundation in empirical evidence. • Evidence can partially replace experience, judgment, intuition, and political sense. • New method of managerial decision making relies on systematically gathered, stored, analyzed, and reported information. • EBM can reduce variation in care. Copyright 2013 Health Administration Press Organizational Change Use of information technology is needed to support: • Secure information from physicians, hospitals, and post-acute providers on cost, quality, and outcomes • Employing scientific evidence for recommended treatment • Coordination of care • Actualizing consumer decision making regarding type and location of care delivery Copyright 2013 Health Administration Press International Comparisons International comparisons create stress on US healthcare delivery system: • Growing evidence that US does not compare favorably, based on – – – – – Patient perspectives Outcomes Access Efficiency Expenditures Copyright 2013 Health Administration Press International Comparisons (cont’d) International firms compete for patients by advertising that you can: • Save on medical costs • Avoid long waits for medical services • Receive better quality medical or diagnostic services • Protect patient privacy Copyright 2013 Health Administration Press International Comparisons (cont’d) Reasons for adverse international comparisons concentrate on HIT and other challenges: • USA is a decade late in making HIT a national priority. • USA has not relied on centralized government role in supporting HIT adoption. • USA invests less per capita on HIT than other countries do. Copyright 2013 Health Administration Press Web Resources • • • • • • • American Health Quality Association (www.ahqa.org) American Society for Quality (http://asq.org/index.aspx) The Commonwealth Fund (www.commonwealthfund.org/About-Us.aspx) Henry J. Kaiser Family Foundation (www.kff.org) Institute of Medicine (www.iom.edu/About-IOM.aspx) National Quality Measures Clearinghouse (www.qualitymeasures.ahrq.gov/index.aspx) Robert Wood Johnson Foundation (www.rwjf.org/en/aboutrwjf.html) Copyright 2013 Health Administration Press Chapter 3: Government Policy and Healthcare Reform Learning Objectives 1. Describe a justification for government intervention in business processes. 2. List five major types of government intervention into the healthcare business, and explain the need for government to invest in healthcare information management and HIT. 3. Describe the eight components of the administrative simplification portion of the Health Insurance Portability and Accountability Act. 4. Assess your organization’s readiness for transactions and code set development. 5. Analyze why privacy and security are important and why HIT has a key role in protecting privacy and security. 6. Assess four key questions to answer in developing privacy policies. 7. Describe HIT leadership’s role in responding to legislation. Copyright 2013 Health Administration Press Government Policy and Reform Items to develop: • Government’s role in HIT – Justification of governmental intervention in business processes • Specific healthcare legislation – Health Insurance Portability and Accountability Act (HIPAA) – Health Information Technology for Economic and Clinical Health Act (HITECH) – Patient Protection and Affordable Care Act (PPACA) • HIT leadership Copyright 2013 Health Administration Press Government Intervention • Government intervenes if markets fail to allocate resources effectively. • Common reasons for intervention: – Public goods – Correct externalities – Imperfect information – Monopoly Copyright 2013 Health Administration Press Types of Government Market Intervention Purpose Government Initiative Provide public goods Funding of medical research Correct for externalities Tax on alcohol and cigarettes Impose regulations Federal Drug Administration Enforce antitrust laws Limit hospital mergers Sponsor redistribution programs Medicare and Medicaid Operate public enterprises Veterans Administration hospitals Copyright 2013 Health Administration Press Healthcare Is Different • Broad obligation to protect health and welfare of public • Challenges of (high) cost, (poor) quality, and (limited) access justify intervention Copyright 2013 Health Administration Press Government Policy: Benefits HIT may benefit from government involvement: • No compelling business case exists for investment in HIT. • The potential savings from implementing HIT do not accrue to providers making the investments but rather benefit insurers and others (public good). • For system benefits from HIT investment to be realized fully: – All components of the fragmented US healthcare delivery system must participate. – Interoperability among providers is a necessary step for true sharing to occur. – Government needs to impose common communication standards. Copyright 2013 Health Administration Press Select Legislation: HIPAA Portability and Simplification Sections • Portability was designed to enable individuals to retain insurance when they changed jobs. • Administrative simplification did not have a high profile but became a big deal for HIT. – Established national standards for electronic healthcare transactions and national identifiers for providers, health plans, and employers – Addressed the security and privacy of health data – Goal of improving efficiency and effectiveness of healthcare system via electronic data interchange Copyright 2013 Health Administration Press HIPAA: Simplification Provisions • Standards for electronic health information transactions • Provider and health plan mandate • Privacy • Preemption of state law • Penalties Copyright 2013 Health Administration Press Standards for Electronic Health Information Transactions Within 18 months of enactment, the Secretary of HHS is required to adopt standards from among those already approved by private standards-developing organizations for certain electronic health transactions, including claims, enrollment, eligibility, payment, and coordination of benefits. These standards also must address the security of electronic health information systems. Copyright 2013 Health Administration Press Provider and Health Plan Mandate and Timetable Providers and health plans are required to use the standards for the specified electronic transactions 24 months after they are adopted. Plans and providers may comply directly or may use a healthcare clearinghouse. Certain health plans, in particular workers’ compensation, are not covered. Copyright 2013 Health Administration Press Privacy Provision The Secretary is required to recommend privacy standards for health information to Congress 12 months after enactment. If Congress does not enact privacy legislation within three years of enactment, the Secretary will promulgate privacy regulations for individually identifiable electronic health information. Copyright 2013 Health Administration Press Preemption of State Law The bill supersedes state laws, except where the Secretary determines that the state law is necessary to prevent fraud and abuse, is necessary to ensure appropriate state regulation of insurance or health plans, addresses controlled substances, or is necessary for other purposes. If the Secretary promulgates privacy regulations, those regulations do not preempt state laws that impose more stringent requirements. These provisions do not limit a state’s ability to require health plan reporting or audits. Copyright 2013 Health Administration Press Penalties The bill imposes civil money penalties and prison for certain violations. Copyright 2013 Health Administration Press Government Policy: Privacy • Privacy Act of 1974 established key provisions. • Current concept of privacy: – – – – – Control of information concerning personal life Freedom from intrusion upon “seclusion” Limits on publicity that places one in a false light Prevention of identity theft and likeness Right to keep personal information confidential Copyright 2013 Health Administration Press Specific Legislation: HITECH Act • Part of American Recovery and Reinvestment Act (ARRA) – Passed February 2009 • Designed to promote electronic health record adoption—social benefits: – Complete and accurate information – Better access to information – Patient empowerment Copyright 2013 Health Administration Press HITECH Act: Meaningful Use • Meaningful use offers incentives for adoption and implementation of electronic health records • Total incentives for eligible providers: – $44,000 if start in 2011 or 2012 – $39,000 if start in 2013 – $24,000 if start in 2014 Copyright 2013 Health Administration Press HITECH Act: Meaningful Use (cont’d) • Meaningful use comes in stages: – Stage I: Install certified information systems, capture structured patient data, and share data with patients/other providers – Stage II: Greater data collection and reporting to advance clinical processes – Stage III: Demonstrate improved outcomes Copyright 2013 Health Administration Press HITECH Act: Core Measures To qualify, providers must report 15 core measures: 1. Implement computerized physician order entry 2. Perform drug–drug and drug–allergy checks 3. Maintain an up-to-date problem list of current and active diagnoses 4. Use e-prescribing (eRx) 5. Maintain active medication list 6. Maintain active medication allergy list 7. Record demographics 8. Record and chart changes in vital signs 9. Record smoking status for patients aged 13 or older 10. Report ambulatory clinical quality measures to CMS/states 11. Implement clinical decision support 12. Provide patients with an electronic copy of their health information, upon request 13. Provide clinical summaries for patients for each office visit 14. Establish capability to exchange key clinical information 15. Protect electronic health information Copyright 2013 Health Administration Press HITECH Act: Menu Objectives To qualify, providers must report five of ten menu objectives: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Submit electronic data to immunization registries Submit electronic syndromic surveillance data to public health agencies Perform drug formulary checks Incorporate clinical lab test results Generate lists of patients by specific conditions Send reminders to patients for preventive/follow-up care Provide patient-specific education resources Provide electronic access to health information for patients Perform medication reconciliation Maintain summary-of-care record for transitions of care Copyright 2013 Health Administration Press HITECH Act: Quality Measures To qualify, providers must report six quality measures: 1. 2. 3. 4. Diabetes: Hemoglobin A1c poor control Diabetes: Low-density lipoprotein (LDL) management and control Diabetes: Blood pressure management Heart failure (HF): Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy for left ventricular systolic dysfunction (LVSD) 5. Coronary artery disease (CAD): Beta-blocker therapy for CAD patients with prior myocardial infarction (MI) 6. Pneumonia vaccination status for older adults 7. Breast cancer screening 8. Colorectal cancer screening For full list, see Exhibit 3.9. Copyright 2013 Health Administration Press Special Legislation: Patient Protection and Affordable Care Act • • • PPACA signed March 23, 2010, as HR 3590 and accompanying HR 4872 Many features with immediate and far-reaching implications. Key features: – Expand health insurance coverage to 30 million Americans – Change incentives to effect delivery system reform (enhance quality, reduce costs, improve care coordination) – Reduce rate of increase in Medicare and Medicaid spending – Expand healthcare workforce and graduate medical education – Fund wellness and prevention – Address quality, health disparities, and comparative effectiveness – Reduce fraud and abuse with regulatory oversight – Expand revenue through taxes on high-cost health plans and selected fees Copyright 2013 Health Administration Press Patient Protection and Affordable Care Act: Implications for HIT • Special stress for HIT: – Accountable care organizations: Assign financial responsibility for care to an ACO even if care delivered by other organizations. IT must find patient, exchange information with other organizations/providers, and maintain privacy and confidentiality of information. – Pay-for-performance initiatives demand linkage between provider cost and clinical performance both within and across organizations. These data are not uniformly collected and reported in a timely manner. – Expansion of covered lives creates IT challenges because of both greater numbers of individuals and a new population unfamiliar with the systems and documentation needed to process care. – Timing and uncertainty of PPACA implementation. Copyright 2013 Health Administration Press Government Policy and Reform • • • • Environmental scanning and organizational education Information security policies and procedures Disaster protection and recovery procedures Protecting information privacy and confidentiality Copyright 2013 Health Administration Press Environmental Scanning and Organizational Education • Determine breadth and scope of impending or actual legislation • Assess current organizational readiness for impact • Perform gap analysis within organization • Recommend strategies to meet legal/regulatory changes • Identify clinical and other resources within the organization that will be necessary to meeting standards • Outline timeline for implementation with key dates and milestones Copyright 2013 Health Administration Press Information Security Policies and Procedures Healthcare organizations must establish enterprise-wide standards to maintain data security and protect the privacy and confidentiality of health information (patient records). 1. Protect against system failures or external catastrophic events, such as fires, storms, and other acts of God, as well as deliberate sabotage, and where critical information could be lost, and 2. Prevent access to computer files by unauthorized personnel. Copyright 2013 Health Administration Press Disaster Protection and Recovery Procedures • Steering committee must ensure that effective data backup and recovery procedures are implemented. • CIO develops a data backup plan for approval by the steering committee. The plan should specify which files require duplication, frequency of duplication, and recovery procedures to be used if catastrophic events occur. • Disasters include: – Natural – Terror attacks – Computer viruses Copyright 2013 Health Administration Press Protecting Information Privacy and Confidentiality • Physical security – Hardware – Data files • Technical safeguards – Passwords – Encryption – Audit logs • Management policies – Written security policy – Employee training – Disciplinary actions for violations Copyright 2013 Health Administration Press Elements of Confidentiality Policy • • • • • Assign rights (who has access and why) Release of information Special handling for select information (HIV) Special handling for select patients (VIPs) Availability and retention policy for medical information • Integrity of medical information • Methods for communication of medical information Copyright 2013 Health Administration Press Web Resources • • • • • • • American National Standards Institute (www.ansi.org) Center for Democracy & Technology, Health Privacy (www.healthprivacy.org) Data Interchange Standards Association (www.disa.org) IRM International (www.irminternational.com/rptcard.html), a checklist for disaster recovery National Committee on Vital and Health Statistics (http://ncvhs.hhs.gov/index.htm) National Uniform Claim Committee (www.nucc.org) US Department of Health and Human Services: – – – • Office of Civil Rights (www.hhs.gov/ocr/office/news/index.html) offers news releases announcing all of the major settlements of privacy and security breaches. HealthCare.gov (www.healthcare.gov) provides information on evolving health insurance options available. Centers for Medicare & Medicaid Services (www.cms.gov) points to detailed information about CMS’s core programs and to research and data of value to HIT professionals. General HIPAA information can be found here: www.cms.gov/Regulations-and-Guidance /HIPAA-AdministrativeSimplification/HIPAAGenInfo/index.html. Details of the EHR incentive programs are posted at www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html. Workgroup for Electronic Data Interchange (www.wedi.org) Copyright 2013 Health Administration Press
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