Technology for the sake of technology has limited value, particularly in healthcare. The initial phase of EMR and information technology implementation by medical practitioners has been primarily focused on getting the technology in place and making sure it is deployed as comprehensively as possible. Once the EMR has been utilized for some time (1–2 years) and there is a level of comfort and familiarity amongst the users, there is usually a natural transition towards quality improvement and optimization. As with all adoption curves, there are always a small subset of users who tend not to progress in their use and remain “stuck” at a very basic level.
The questions then become much more focused on measurement. What metrics should be used to measure quality of care? How can these measures be applied consistently across a wide range of patients and clinical conditions? And how can one ensure that the measures are an accurate reflection of different components of care delivery? Ensuring trust related to measurements is key in terms of driving improvement initiatives. If users do not trust the results or if they believe the results indicate an unfair bias or reflect measures that are out of their control, they will discount the process, in the end not achieving any of the intended outcomes.
There are also two phases to quality improvement using measurement and analytics:
- Internal: EMR users need to develop a level of comfort and trust with the measures before their performance measurements are made available either to peers or administrators. It can be quite startling to see the cold hard facts compared against one’s perception. Users need time to absorb the data and to make adjustments in order to improve performance before they are individually compared against peers in similar practice settings. During this phase, it is useful to collate aggregated performance data and use this as a baseline for group performance. What this data also provides is a benchmark measure against which users can compare their individual scores.
- External: After sufficient time to analyze, absorb, and act upon the data (i.e. make changes to internal practices in order to modify patient management and measurable outcomes), EMR users can then be encouraged to continuously improve their clinical management practices by exposing the data more broadly. Using a graduated approach — practice level reporting, inter-practice and regional reporting, and then provincial reporting — serves two purposes. It allows providers to become progressively more accepting of their performance in comparison to peers and allows for a more refinable system in terms of progressively wider data reporting.
It is certainly possible to combine the two stages into a single phase; however, the risk of ostracizing providers is much higher — this is a significant change in the way that care is provided and measured. There are few providers who do not want to provide good quality care. If implemented too quickly and with insufficient planning, the result may be to discourage rather than encourage improvements in quality of care.
For the last few years, CIHI (Canadian Institute for Healthcare Information) has been working with groups and organizations across the country to develop a set of primary healthcare indicators that are increasingly being used as a reporting standard for clinical performance reported through EMRs. Expect this program to grow significantly by 2015.
A number of initiatives are also underway in the United States as part of the transition to EMR-based clinical care delivery. Health and Human Services (HHS) maintains the Health System Measurement Project that tracks critical government healthcare data in a number of areas. In addition, the Agency for Healthcare Research and Quality (AHRQ) is currently collecting information regarding current successful strategies and challenges regarding quality measurement enabled by health IT. The questions that are being asked to describe Health IT enabled quality measurement are well worth reading. In support of this work, AHRQ released a report entitled “An environmental snapshot — Quality Measurement Enabled by Health IT: Overview, Possibilities, and Challenges”. Download the .pdf
What is your experience with Quality Measurement using an EMR? Do you have any lessons or experiences to share? Click on the “Comments” link below to add your thoughts and feedback.