Opinion: Leverage HIT to Improve Care Management

The ever-increasing number of publicly reported measures of some aspect of quality or patient safety is one of the most concrete signs of the rising expectations of the public, employers, and payers. These provide a large set of targets for improving care, and much of the same patient information is required to measure performance as to deliver safe, high-quality care consistently.

Luckily, the pace of progress on the electronic health record—long envisioned by the Institute of Medicine and others as key infrastructure for provider organizations in the journey toward safer, higher quality care—has picked up considerably thanks to the HITECH incentive program. More and more patient data is being captured electronically and providers are reaching the stage that electronic support can become part of the toolset for clinicians at the point of care.

But putting the EHR to work to improve clinical performance at the bedside requires breaking down some of the traditional silos in our approaches to using HIT in the hospital.

The key to harnessing the value of clinical data and HIT in the interest of improving clinical performance is bringing quality reporting from the background (and after the fact) to the bedside, delivering actionable information about risks of care deficiencies or potentially poor outcomes to the clinicians caring for the patients in time for them to intervene. It also involves a focus on capturing key information needed for care management and quality reporting that still resides for the most part in paper documentation, free-text electronic notes, or in separate databases that capture documentation in the emergency room, surgical suite, or intensive care unit.

When the often similar logic of measurement and clinical decision support can be applied to this integrated patient information in real-time and clinicians at the bedside notified when action is likely warranted, it becomes possible for deficiencies in care to be identified in time to address them. In some cases, medical evidence and clinical experience are also sufficient to develop more complex logic to identify patients at risk of future, avoidable adverse events.

One of the highest priority targets for leveraging the EHR to enable better care management, sepsis, provides an excellent example of how this should work because hours, even minutes, matter in preventing or ameliorating resulting major organ dysfunction in at-risk patients. Sepsis is the biggest cause of death in hospital ICUs and many cases are preventable.

Efforts such as the Surviving Sepsis Campaign provide the basis for algorithms that can be used for early identification of at-risk patients and to check for consistent use of protocols for prevention and treatment.

Next-generation care management will require the coordinated action of different participants, each supported by the EHR according to their role, as described below for sepsis.

+Or other individual or staff responsible for patient tracking and quality reporting.

In many high-risk situations in hospital care (as in the example involving sepsis), there are many factors to be considered in detection and treatment, new information becomes available every few minutes, and quick recognition and intervention is critical to the best possible outcome for the patient. This type of situation with a large and constantly updated data set, complex logic, and the need to continually reevaluate is where computers excel.

Put to work in this way, the EHR will enable next-generation quality management at the bedside.

As efforts to implement the EHR move forward in every hospital, leadership should take note of the following four steps; each step provides an opportunity to make progress on next-generation care management.

1. Formally link all strategies and plans for EHR roll-out with quality goals (the examples above, plus at least a subset of all measures required by the Joint Commission and CMS provide a starting point).
2. Involve all of the key roles in planning, design, and implementation support. Next-generation care management will require not just physicians and nurses, but also case managers, quality nurses, and data management and analysis specialists, all working as a team.
3. Ensure that EHR roll-out and quality management initiatives are making progress in parallel and that meaningful use of each increment of EHR implementation ensures that added capabilities (more data for patient identification and tracking, new uses of clinical decision support) are put to work.
4. Build real-time data analytics into the IT infrastructure and ensure that the necessary searchable data store is appropriately structured and searchable. This may require influencing the product development plans of the major EHR vendor partner or implementing one or more additional applications.

Jane Metzger and David Classen are with CSC. They can be reached at jmetzger2@csc.com and dclassen@csc.com, respectively.