Informatics’ Promise to Improve
Quality: The VA Example
Steven Asch MD MPH
VA Greater Los Angeles Health System
Academy Health
June 2009
“We will restore science to
its rightful place and wield
[information] technology's
wonders to raise health
care's quality...”
(APPLAUSE)
-President Obama’s Inaugural Speech
NY Times, Jan 2009
Overview
Defining Health Information
Technology (HIT)
• Evidence from the literature
• The VA experience
• Lessons learned
What Is HIT?
– Wide range of functions─e.g.,
• Adminstration: Billing, registration, supply
• Communication: Email and telehealth
– We focus on clinical HIT functions that might
directly affect quality of care – e.g.,
• Electronic medical records
• Computerized order for medications (CPOE)
• Decision-support systems
Overview
• Defining Health Information
Technology (HIT)
Evidence from the literature
• The VA experience
• Lessons learned
RAND Study Found ¼ of the 183 Good
Studies Come from 4 HIT Leaders
Intermountain Health
HIT Interactive Database
http://healthit.ahrq.gov/tools/rand
HIT Systems Have Improved
Aspects of Quality at Leaders’ Institutions
Example: Partners
•Computerized physician order entry and decision systems
– 24% reduction in redundant lab tests
– 86% reduction in serious medication errors
– 21% increase in ordering the appropriate test
– 38% decrease in time until treatment was ordered
HIT Systems Have Improved
Aspects of Quality at Leaders’ Institutions
Example: Regenstrief
•Added computerized reminders to an existing electronic
health record system
– 10%-20% increase in screening and prevention activities
by general internists
– 10%-20% increase in the rates of advanced care
directives and advanced care plans
– Computer-based standing orders were even more
effective than reminders at improving vaccination
Organizational Context
• “Context and confounders lie at the very heart
of the diffusion, dissemination, and
implementation of complex innovations. They
are not extraneous to the object of study; they
are an integral part of it.”
Trish Greenhalgh
Milbank Quarterly,2004.82(4)581-629.
Technology Is Only One Part
of a Successful HIT System
• What technology is
being tested?
Technology
• What technology is
already in place?
• How does the new
technology fit in the
existing system?
Human Factors Are also Important
Technology
Human
factors
• Is the HIT system
usable?
• How well is it
supported?
Human factors study of reminders
• Barriers
• Coordination between
nurses and providers
• Satisfying reminders
while not with the
patient
• Workload
• Inflexibility
• Poor usability
•Facilitators
•Limit the number of
reminders
•Position computer
workstations
strategically
•Improve integration
of reminders into
clinical workflow
•Feedback
mechanism
Saleem JJ, Patterson E S, Militello L, Render ML, Orshansky G, and Asch SA.
J Am Med Inform Assoc. 2005;12(4):438-47.
Effective Management Is
Necessary for Success
Technology
• How must
management
change to make HIT
successful?
Management
Human
factors
Organization and Culture
Must Be Supportive
• How can HIT
become part of an
organization’s
culture?
Organization
and culture
Technology
Management
Human
factors
Overview
• Defining Health Information
Technology (HIT)
• Evidence from the literature
The VA experience
• Lessons learned
The Veterans Affairs Health Care
System
• Cares for more than 5 million veterans
– ~150 hospitals
– >1000 clinics
• Doctors are salaried
• VA both pays for and provides care
• Clinical transformation in early 1990’s
VA Implemented HIT and Other
Systemic Reforms Contemporaneously
• Tracking performance in key areas
• Accountability for providers and
managers
• Researcher-administrator partnership
• HIT innovations
A Brief History of Major VA HIT Innovations
• 1982- Official deployment of small components in
– Lab, pharmacy, scheduling
• 1992- VistA Imaging
• 1994- Order Entry / Results Reporting
• 1996- CPRS GUI and Clinical Reminders
• 2000-Bar Coded Medication Administration
• 2004-My HealtheVet ( PHR) in 2004
• 2006- Bi-directional Health Information Exchange
29 June 2009
19
Example: Improving HIV Testing Rates
• HIT decision support: Clinical reminder to test at-risk patients
• Organizational changes
– Standardized VHA HIV informed consent
– Streamlined, scripted counseling & nurse-based counseling
– Telephonic notification of negative test results
– Assured HIV clinic f/u for new HIV+ pts
• Provider activation : Academic detailing & social marketing
• Audit-feedback: Clinic level reports of HIV testing rates
• Clinical Reminder
VISN 22: Pre- vs Post Incident HIV Testing Rate
Program implementation increases HIV testing rates two – three fold at all sites
Reminder Resolution (%)
80%
HIV testing
70%
HIV evaluation without testing
60%
50%
40%
30%
20%
10%
0%
-1
1
2
-1
1
2
-1
1
-1
1
2
-1
1
Intervention Year
Site A
Site B
Site C
Control
Site D
Site E
Example of the Heparinizer: Decision Support Tool
Spins Off Orders and Progress Note
Heparin Errors and Decision Support
16
Number of Errors
14
12
10
8
6
4
2
0
FY2001
FY2002
FY2003
Fiscal Year
FY2004
FY2005
29 June 2009
25
My HealtheVet Wellness Reminders
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Hypertension
Influenza Vaccine
Pneumococcal Vaccine
Colorectal Cancer Screening
Lipid Measurement
LDL Control
Body Mass Index (BMI)>25.0
Diabetes Foot Exam
Diabetes Hemoglobin A1C
Diabetes Retinal Exam
Mammography Screening
Cervical Cancer Screen
• Empower patients
• Improve access to information
• Promote patient and health care
team collaboration
• Improve health outcomes
Did it Work?
VA Compared to Medicare
VA, %
2000
Medicare, %
2000-2001
Mammography
90
77
Pneumococcal Vaccination
81
64
Annual A1c
94
70
Timely aspirin after
myocardial infarction
93
84
Aspirin at discharge
98
84
Beta-blocker at discharge
95
78
ACE inhibitor for EF<40%
93
66
Jha et al. NEJM 2003
Did it Work?
VA Compared to Community
80%
70%
60%
50%
40%
30%
20%
10%
0%
73
53 56
58
64
44
VA
Community
Acute Care
Chronic
Care
Asch et al. Annals of Internal Medicine, 2004
Preventive
Care
Overview
• Defining Health Information
Technology (HIT)
• Evidence from the literature
• The VA experience
Lessons learned
HIT & the VA: Lessons Learned
• Literature that some HIT functionalities in leadership
organizations associated with improved quality
• HIT helped transform VA, but it is inextricably intertwined
with other transformative elements:
− Culture that values quality
− Culture of scientific evidence
− Accountability and performance measurement
− Health services clinician researchers who were active
HIT developers
− Incentives are aligned: the VA pays for HIT and
benefits from cost savings
• From EMR inception to now has been 25 years