Using information systems to measure and improve quality

Abstract

Information systems (IS) are increasingly important for measuring and improving quality. In this paper, we describe our integrated delivery system's plan for and experiences with measuring and improving quality using IS. Our belief is that for quality measurement to be practical, it must be integrated with the routine provision of care and whenever possible should be done using IS. Thus, at one hospital, we now perform almost all quality measurement using IS. We are also building a clinical data warehouse, which will serve as a repository for quality information across the network. However, IS are not only useful for measuring care, but also represent powerful tools for improving care using decision support. Specific areas in which we have already seen significant benefit include reducing the unnecessary use of laboratory testing, reporting important abnormalities to key providers rapidly, prevention and detection of adverse drug events, initiatives to change prescribing patterns to reduce drug costs and making critical pathways available to providers. Our next major effort will be introduce computerized guidelines on a more widespread basis, which will be challenging. However, the advent of managed care in the US has produced strong incentives to provide high quality care at low cost and our perspective is that only with better IS than exist today will this be possible without compromising quality. Such systems make feasible implementation of quality measurement, care improvement and cost reduction initiatives on a scale which could not previously be considered.

Introduction

Health care costs are rising and all parties involved—government, insurers, hospitals and patients—are concerned. Costs must be reduced, but without major compromise of quality. However, quality measurement in healthcare has been an elusive goal and the current routine practice of quality measurement in healthcare is relatively primitive. Measuring quality without automated tools is time-consuming and labor-intensive, yet the new focus on lowering costs while maintaining or improving quality demands routine measurement [1]. Also, interventions to reduce costs and improve quality may be most successful if they are focused at the level of individual decisions, yet are non-intrusive, a difficult combination to achieve. Fortunately, information technologies can help with both quality measurement and quality improvement.

Regarding quality measurement, information systems represent an inexpensive way to collect information on all patients, rather than samples as is often required with chart review. Furthermore, such information can readily be grouped in different ways and manipulated. Perhaps most important, this information can be used directly to improve quality, for example to contact all eligible patients who have not had some preventive measure.

For improving quality directly with information systems, two other domains are particularly amenable to information-related approaches, specifically diagnostic testing and drug use. Diagnostic testing costs represent up to 25% of all hospital costs [2]. Test ordering is an area which physicians control and in which performance could be better. Studies of test-ordering [3], [4], [5], [6] have found that as much as 50% of diagnostic tests in teaching hospitals may be unnecessary. Despite a growing information base about what represents unnecessary utilization, physician behavior with respect to test ordering has been remarkably resistant to change over the long term.

A number of interventions have been attempted to decrease utilization of tests [2], [3], [4], [5], [6]. The major types of intervention studied have been feedback, education (including providing information about clinical decision-making and cost issues), rationing and financial incentives [7], [8]. Each of these strategies in the most successful studies have produced transient reductions of about 25% for targeted tests [8]. However, even the best-accepted interventions, those involving feedback and education, have had variable success [4], [9] and implementation has often been labor-intensive and costly [10]. The other major limitation for both types of intervention is that their effect tends to decay with time [8], [11] if the intervention program is not continued: the gains have not been held.

Thus, despite growing information about how to better use diagnostic tests [12], inappropriate use continues [13]. Why is this the case? The reasons can be divided into two primary categories: incentives and information. In the past, there were few direct incentives for physicians to modify behavior, but this is changing rapidly as a high percentage of patient care is now reimbursed under prepaid plans and hospitals are now focusing on the use of services. The reasons related to information can be further subdivided: (1) studies on the appropriate use of tests have been published in a wide array of sources and have not been widely incorporated into medical curricula [8]; (2) physicians have difficulty estimating risk and might make better decisions if they were better at it [14], [15], [16]; (3) the available interventions, such as review of utilization by senior physicians, have been time-consuming or difficult to incorporate in the long term [10], [11]; and (4) feedback is often separated in time from decision-making [10].

Similar to the laboratory, pharmacy is both a high volume and high expense component of health care where there is considerable variability in practice patterns. Guidelines are prevalent regarding when to treat and which drugs are most cost-effective. However, the impact of these guidelines on physician behavior is limited in part by the reluctance of physicians to utilize these sources of information. Furthermore, formularies differ among insurance plans. Thus the most cost-effective drug for a given clinical situation for a patient in one insurance plan may represent inappropriate utilization under another plan. The need for immediate access to overlapping guideline and formulary information makes pharmacy management a natural arena for information systems solutions.

The information-related reasons for inappropriate resource utilization can be addressed by combining a computerized order-entry system used by physicians with a computerized data review and ‘reminder’ system that provides needed information at the time decisions are made, makes suggestions and challenges orders when a potential problem is found. Specifically, using the computer to provide feedback and reminders to doctors is reliable and inexpensive, compared to manual review of practices. Also, order-entry is immediately generalizable to all physicians, once in place requires little maintenance and can be continued indefinitely. But most important, physician order-entry allows immediate feedback to physicians at the time they order tests. To be optimally effective, an intervention should occur as close in time to the event as possible and be constructive and non-judgmental [17]. Computerized feedback is ideal in both regards. Because physicians use their unique identification numbers to access the system, it is possible to track individual physician behavior before and after interventions designed to affect such behavior.

The goals of this paper are to describe changes which have already been made in one hospital in our new integrated delivery system and further changes which can be expected to have an impact for measuring and improving quality as the system is developed.