improving quality through clinician use of health it

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AHRQ Health Information Technology Ambulatory Safety and Quality | IQHITi

www.ahrq.gov HEALTH IT

Findings and LessonsFrom the Improving QualityThrough Clinician Useo Health ITGrant Initiative

AHRQ Health Inormation echnology

Ambulatory Saety and Quality
http://healthit.ahrq.gov/


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AHRQ Health Information Technology Ambulatory Safety and Quality | IQHITii

Tis document is in the public domain and maybe used and reprinted without permission exceptthose copyrighted materials that are clearly noted in

the document. Further reproduction o those copy-righted materials is prohibited without the specicpermission o copyright holders.

Suggested Citation:Findings and Lessons From the Improving QualityTrough Clinician Use o Health I Grant Initiative.(Prepared by Westat Under Contract No. HHSA290200900023I.) AHRQ Publication No. 13-0042-EF. Rockville, MD: Agency or Healthcare Researchand Quality. May 2013.

Prepared or:Agency or Healthcare Research and QualityU.S. Department o Health and Human Services540 Gaither RoadRockville, MD 20850www.ahrq.gov

Contract No. HHSA 290200900023I

Prepared by:WestatRussell Mardon, Ph.D., Project Director

AHRQ Publication No. 13-0042-EFMay 2013

Tis project was unded by the Agency or Healthcare Research

and Quality (AHRQ), U.S. Department o Health and Human

Services. Te opinions expressed in this document are those othe authors and do not reect the ocial position o AHRQ or

the U.S. Department o Health and Human Services.
http://www.ahrq.gov/http://www.ahrq.gov/


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AHRQ Health Information Technology Ambulatory Safety and Quality | IQHITiii

Improving Quality Trough Clinician Use oHealth I (FOA HS-07-006), which supported

research related to the development, implemen-tation and use o health I to assist clinicians,practices, and systems in improving the quality andsaety o care delivery in ambulatory care settings.

Enabling Patient-Centered Care Trough HealthI (FOA HS-07-007), which was designed toinvestigate approaches to improve the patientexperience o care through the use o health Iin ambulatory care settings.

Improving Management o Individuals with Com-

plex Healthcare Needs Trough Health I (FOAHS-08-002), which was aimed at clinician andpatient and amily use o health I in ambulatorysettings to improve outcomes through more efec-tive decision support or care delivery or patients

with complex health care needs.

Tis is one in a series o ve reports highlightingndings and lessons rom the health I-ocused ASQgrant initiatives. Tese reports summarize the projects ineach initiative and identiy practical insights regardingthe use o health I to improve saety and quality in

ambulatory settings.

Preace

Te Improving Quality Trough Clinician Use oHealth I initiative is part o the Agency or Health-

care Research and Qualitys (AHRQs) AmbulatorySaety and Quality (ASQ) program. Te purpose othe AHRQ ASQ program is to improve the saetyand quality o ambulatory health care in the UnitedStates. Te programs components, with the excep-tion o the risk assessment grant initiative (FOAHS-07-003), emphasize the role o health inorma-tion technology (I). Te ASQ program includedthe ollowing grant initiatives:

Enabling Quality Measurement Trough Health

I (FOA HS-07-002), which ocused on strategiesor the development o health I to assist clini-cians, practices, and systems to measure the qualityand saety o care in ambulatory care settings.

Ambulatory Care Patient Saety Proactive RiskAssessment (FOA HS-07-003), which supportedresearch in risk assessment and modeling to iden-tiy preventable patient injuries and harms, andto inorm the development and deployment ointervention strategies to reduce threats to patientsaety in ambulatory care settings and during tran-

sitions o care.


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AHRQ Health Information Technology Ambulatory Safety and Quality | IQHITiv

Acknowledgments

Tis report was developed through a collaborativeprocess that would not have been possible without

the contributions o many individuals. Te projectdirector would especially like to thank the ollowing keyparticipants who contributed to and guided the work:

Te Improving Quality Trough Clinician Useo Health I (IQHI) grantees whose workin advancing the use o health I or qualityand saety improvement inspired and inormedthis report.

Erin Grace, M.H.A., AHRQ senior manager andlead or the IQHI grant initiative, whose eed-

back and guidance shaped the report.

External reviewer Kathleen R. Stevens, Ed.D.,R.N. or her valuable comments.

Te Synthesis eam, a group o Westat senior staf,including Ernest Carter, M.D., Ph.D.; BrendaLeath, M.H.S.A.; Russell Mardon, Ph.D.; EricPan, M.D.; Jonathan Ratner, Ph.D.; Helga Rip-pen, M.D., Ph.D.; and Larry Stepnick, M.B.A.,o Te Severyn Group; and Westat project staf,including Julie Bergmann, M.H.S.; Nathan Botts,Ph.D.; and Lauren Mercincavage, M.H.S.


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AHRQ Health Information Technology Ambulatory Safety and Quality | IQHITv

Table o Contents

Executive Summary 1

Introduction 3

The Improving Quality Through Clinician Use o Health IT Grant Initiative 3

Providing Patient-Specic Inormation,

Clinical Knowledge, and Decision Support 6

Background 6Highlights From the Projects 6

Interventions That Oered Multiple Forms o Support Including CDS 6

CDS to Support Specic Clinical Processes 7

Supporting Clinical Workfow 11

Background 11

Highlights From the Projects 11

Coordinating Care 13

Background 13


Understanding the Impact on Outcomes 15

Background 15


Impact on Outcomes 16

Process Outcomes 16

Delivering Evidence-Based Care 16

Increasing Clinician Use o Health IT 17

Increasing Eective Clinician Communication 18

Intermediate Outcomes 18

Controlling Chronic Diseases 18

Clinician Perceptions o Health IT Useulness and Clinician Satisaction 18

Health Outcomes 19

Conclusion 20

Reerences 21

Appendix 23


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AHRQ Health Information Technology Ambulatory Safety and Quality | IQHITvi

Figures

1 Grant Initiative Areas o Interest Addressed Across Projects 4

2 Funding Preerence Areas Addressed Across Projects 4

3 IOM Priority Areas Addressed Across Projects 5


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Findings and Lessons From the Improving Quality Through Clinician Use of Health IT Grant Initiative

AHRQ Health Information Technology Ambulatory Safety and Quality | IQHIT1

Executive Summary

Tis report highlights key ndings and lessons romthe experiences o 24 projects awarded in 2007 underthe Agency or Healthcare Research and Quality(AHRQ) Improving Quality Trough ClinicianUse o Health I (IQHI) initiative (FundingOpportunity Announcement [FOA] HS-07-006,http://grants.nih.gov/grants/guide/ra-les/RFA-

HS-07-006.html). Tis initiative was designed toinvestigate approaches or using health inormationtechnology (I) to support clinicians in makingpatient care decisions and coordinating care with aocus on efectively incorporating evidence-based

inormation at the point o care. It is part o AHRQsAmbulatory Saety and Quality (ASQ) program,which was designed to improve the saety and qualityo ambulatory health care in the United States.

Tis report summarizes the extent to which theprojects addressed the areas o interest o the IQHIinitiative and identies practical insights regardingthe use o health I to improve clinical decisionmak-ing and care coordination in the ambulatory setting.It presents illustrative project ndings in an efort

to inorm research discussion and provide guidanceto other entities implementing health I systemsthat help clinicians improve the quality o patientcare. As the researchers continue to disseminatendings rom these projects, additional lessonsmay become evident.

Te body o the report is organized around the ourmain areas o interest in the FOA, plus a sectionon understanding the impact o health I on out-comes in ambulatory care. Each area o interest isdescribed below:

Providing patient-specic inormation, clinicalknowledge, and decision support, addressed in15 projects, includes the provision o clinical recom-mendations and guidelines and clinical inormationabout specic patients rom registries and othersources to help clinicians and patients make deci-sions that improve outcomes.

Supporting clinical workow, addressed in sevenprojects, reers to the study o how the implementa-tion o health IT systems can support efective andecient clinical workows, taking into accountorganizational actors in ambulatory settings.

Coordinating care, addressed in three projects, isdened as the deliberate organization o patientcare activities between two or more participants(including the patient) involved in a patients careto acilitate the appropriate delivery o health careservices (AHRQ, 2007).

Understanding the impact o health IT on out-comes in ambulatory care settings, addressed in twoprojects, includes research to better understand howclinician use o health IT can impact outcomes.

Te IQHI initiative also specied several undingpreerence areas including two priority areas: oneor projects ocused on medication managementand a second or project sites serving vulnerablepopulations. Tere was also a unding preerenceor projects being conducted at or by practice-basedresearch networks (PBRNs). A total o 24 projects

were awarded under the initiative. Te projects werecarried out in a variety o ambulatory care settings,including primary care and specialty care oces andclinics. Tey addressed a range o relevant care topics,including several priority areas or health care qualityimprovement identied by the Institute o Medicine(IOM, 2003).

Te names o the principal investigators, theirinstitutions, and the project titles are shown in the

Appendix, along with links to additional inormationabout the projects on the AHRQ National ResourceCenter or Health I Web site (http://healthit.ahrq.gov/portolio).
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.htmlhttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.html


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Te ndings and lessons rom the IQHI initiativecan inorm researchers and ront-line implementers

who use health I to help clinicians achieve better

health care outcomes. Te projects demonstratedsignicant progress toward addressing AHRQs goalo advancing understanding o how clinicians canuse health I to improve the quality o patient care.Tey developed and tested a range o approachesor enhancing clinical decision support, providingclinical inormation at the point o care, and improv-ing care coordination, while also studying how tointegrate health I systems into clinical workows.Several projects showed a positive impact on process

outcomes related to the delivery o evidence-basedcare or the use o health I. In addition, severalprojects showed a positive impact on intermediate

outcomes such as chronic disease control, clinicianperceptions o health I useulness, and cliniciansatisaction. Other projects demonstrated improve-ments in health outcomes such as health status andadverse drug events. Te continuing rapid pace otechnological change and the continuing interestin use o health I or improving health and healthcare delivery make the results o this body o researchtimely and relevant.


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Introduction

Tis report highlights key ndings and lessons romthe experiences o 24 projects awarded in 2007 underthe Agency or Healthcare Research and Quality(AHRQ) Improving Quality Trough ClinicianUse o Health I (IQHI) initiative (FundingOpportunity Announcement [FOA] HS-07-006,http://grants.nih.gov/grants/guide/ra-les/RFA-

HS-07-006.html). Tis initiative was designed toinvestigate approaches or using health inormationtechnology (I) to support clinicians in makingpatient care decisions and coordinating care with aocus on efectively moving evidence-based inorma-

tion to the point o care. Te IQHI initiative is parto AHRQs Ambulatory Saety and Quality (ASQ)program, which was designed to oster research onthe use o health I to improve the saety and qualityo ambulatory health care in the United States.

Tis report summarizes the extent to which theseprojects addressed the areas o interest o the IQHIinitiative and identies practical insights regardinguse o health I to improve health care quality inthe ambulatory setting. Te report presents illustra-

tive ndings in an efort to inorm uture researchand provide guidance to other entities implementinghealth I systems to help clinicians improve the qual-ity o patient care. Te report is organized around theour main IQHI initiative areas o interest. Eachsection includes a brie background on the topic, ol-lowed by a description o how the projects addressedthe topic, plus illustrative examples rom the projects.In addition, the report includes a synopsis o keyndings rom the projects as measured by severaltypes o outcomes, including process outcomes, inter-mediate outcomes, and health outcomes.

Te names o the principal investigators, their insti-tutions, the project titles, and the IQHI areas ointerest addressed in each project are included in the

Appendix, along with links to additional inormationabout the projects on the AHRQ National ResourceCenter or Health I Web site (http://healthit.ahrq.gov/portolio).

The Improving Quality ThroughClinician Use o Health IT Grant InitiativeEach IQHI study ocused on improving qualitythrough clinician use o health I. Te IQHI initia-tive solicited grant applications to investigate novelmethods or evaluate existing strategies to incorporateevidence-based inormation at the point o care,including the use o clinical alerts and reminders, andthe electronic exchange o key inormation betweenclinicians to support care coordination. AHRQ wasinterested in advancing knowledge regarding theimpact o health I on outcomes in ambulatory

settings and across high-risk transitions in care, inthe use o health I to support novel approaches toproviding high-quality care, and in the developmento strategies or health I adoption in ambulatorysettings. Te projects were designed to demonstratehow quality improvement approaches using healthI improve health outcomes, patient saety, and bothclinician- and patient-reported experiences, as wellas ways to implement health I without negativelyafecting clinical workows. Researchers were encour-aged to ocus on the ollowing areas o interest:

Providing patient-specic inormation, clinicalknowledge, and decision support. Tis includesthe provision o clinical recommendations andguidelines and clinical inormation about specicpatients rom registries and other sources to helpclinicians and patients make decisions that improveoutcomes.

Supporting clinical workow. Tis reers to thestudy o how the implementation o health Isystems can support efective and ecient clinical

workows, taking into account organizational ac-tors in ambulatory settings.

Coordinating care. Tis is dened as the deliber-ate organization o patient care activities betweentwo or more participants (including the patient)involved in a patients care to acilitate theappropriate delivery o health care services(AHRQ, 2007).
http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.htmlhttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://healthit.ahrq.gov/portfoliohttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.htmlhttp://grants.nih.gov/grants/guide/rfa-files/RFA-HS-07-006.html


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Understanding the impact o health I on out-comes in ambulatory care settings. Tis includesresearch to better understand how clinician use o

health I can impact outcomes.Te IQHI initiative also specied several undingpreerence areas including two priority areas: one orprojects ocused on medication management and asecond or project sites serving vulnerable populations.Tere was also a unding preerence or projects beingconducted at or by practice-based research networks(PBRNs). A total o 24 projects were awarded underthe initiative. Te projects were carried out in a varietyo ambulatory care settings, including primary careand specialty care oces and clinics. Tey addressed a

range o relevant care topics, including several priorityareas or health care quality improvement identied bythe Institute o Medicine (IOM, 2003).

Many projects addressed more than one area ointerest. As shown in Figure 1, the most commonlyaddressed area was providing inormation and decisionsupport, addressed in 15 projects. Seven o the projectsstudied clinical workfow, while three ocused on carecoordination and two worked to develop understand-ing o the impact o health I on outcomes.

As shown in Figure 2, 18 projects were unded underthe medication management preerence area, eightunder the vulnerable populations preerence area,

and six under the PBRN preerence area. In addition,three other projects addressed areas related to medi-cation management and another three ocused onvulnerable populations.

wenty-one o the 24 projects took place in primarycare settings including pediatric practices. Te otherthree projects took place in specialty care settingssuch as mental health clinics or dentist oces. Orga-nizationally, the study settings included physicianoces, urgent care centers, academic medical centers,and Community Health Centers, including Federally

Qualied Health Centers.

As shown in Figure 3, the projects also addresseda range o priority areas or health care qualityimprovement identied by the Institute o Medicine(IOM, 2003). Each project addressed at least oneInstitute o Medicine (IOM) priority area.

FIG.

1

Grant Initiative Areas

of Interest Addressed

Across Projects*

16

14

12

10

8

6

4

2

0

CareCoordination

3

Informationand DecisionSupport

15

UnderstandingImpact onOutcomes

2

Numb

erofProjects

7

Areas of Interest

* Some projects addressed multiple IQHIT areas of interest.

FIG.

2

Funding Preference Areas

Addressed Across

Projects*

Practice-BasedResearchNetworks

MedicationManagement

Numb

erofProjects

VulnerablePopulations

Funding Preference Areas

18

16

14

12

10

8

6

4

2

0

6

18

8

* Some projects addressed multiple funding preference areas.


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FIG.

3

IOM Priority Areas Addressed Across Projects*

25

20

15

10

5

0

NumberofProjects

6

Diabetes Self-Manage-

ment/Health

Literacy

1

CancerScreening

1

FrailtyAssociated

With Old Age

1

Immunization

21

MedicationManage-

ment

5

IschemicHeart

Diseease

7

Hyper-tension

MajorDepres-

sion

11

Pregnancyand

Childbirth

TobaccoTreatment

3 3 3

CareCoor-

dination

IOM Priority Areas

* Some projects addressed multiple priority areas.


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Providing Patient-Specic Inormation,Clinical Knowledge, and Decision Support

BackgroundWith the rapid growth in the publication o medi-cal research and the development o evidence-basedclinical practice guidelines, clinicians ace a challengein maintaining current knowledge o prevention andtreatment recommendations on a wide range o top-ics relevant to care delivery in the ambulatory setting.Trough the IQHI initiative, AHRQ was interestedin improving understanding o how health I canbring together relevant inormation about evidence-

based practices with important inormation abouteach patients history, values, and preerences to guideand support clinical decisionmaking.

One approach that may be used to provide evidence-based inormation to clinicians at the point o care isthe development o electronic clinical decision sup-port (CDS) systems. CDS reers to the provision oclinical knowledge and patient-specic inormationto help clinicians and patients make decisions thatenhance patient care (Osherof et al., 2005). In mostcases, CDS systems match patient-specic inorma-

tion (e.g., current medication regimen, a recent labo-ratory result) to an evidence-based clinical knowledgeset (e.g., known drug interactions, clinical contrain-dications), and then generate customized assessmentsor recommendations that can be communicated toclinicians in a variety o ways (e.g., via alerts, remind-ers, or order sets). CDS has the potential to improvequality and reduce costs by increasing adherence toevidence-based practices (Berner, 2009).

Highlights From the ProjectsFiteen projects ocused on providing inorma-

tion and decision support to increase the deliveryo evidence-based care by addressing the barriers tothe efective use o CDS systems and other types ohealth I. Several developed and tested interventionsthat ofered multiple orms o support such as pro-viding clinical inormation at the time and place othe delivery o care, guideline-based alerts or recom-mendations, order sets, documentation templates,reminders, and retrospective eedback, includingcomparisons o perormance to benchmark(s) and

lists o patients in need o services. Other projectscreated and assessed CDS systems that emphasizedone or a ew o these orms o support or ocused onspecic clinical processes. What ollows are illustra-tive examples o both approaches.

Interventions That Oered MultipleForms o Support Including CDSFour projects were based on interventions that oferedmultiple orms o inormation, support, and eedback

David Baker, M.D., M.P.H. (R18 HS 017163)tested the impact on outcomes o a CDS system toimprove quality measurement and provide accu-rate point o care reminders and valid, actionableeedback to clinicians about their perormance onselected quality measures. Te rst phase o the studyincluded reminders about needed services, along withtools or documenting exceptions, such as reusals,inability to aford medications, contraindications, oradverse reactions to the recommended intervention.It also ofered linked order sets that make it easy or

physicians to order needed services at the point ocare. For each physician the system also providedretrospective eedback in the orm o quarterlyperormance reports and monthly lists o patientsnot prescribed essential medications. Te secondphase included a list o each patients unmet qualitymeasures to be reviewed by the physician prior toentering the examination room and decision sup-port or patients who reused a recommended serviceby providing inormation about its benets and anoutreach call to urge reconsideration.

Christopher Forrest, M.D., Ph.D. (R18 HS 017042)developed and tested the impact on outcomes o anEHR-based CDS system combined with retrospectiveperormance eedback on the quality o otitis mediacare. Te system included a visual display o prior epi-sodes and treatments, a structured data collection orm,guideline-based recommendations, acilitated orderentry, and individualized patient instructions. Tesystem also provided inormation based on patient riskactors to help guide care. During the nal 10 months


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o the project, physicians received six retrospectiveperormance reports. wo study team members hand-delivered the reports, answered clinician questions, and

obtained their input on the value o the reports and theCDS system. Reports highlighted individual clinicianperormance compared to that o the entire practice, anetwork o practices, and the top-perorming providers.

Based on ndings rom semistructured interviewswith providers, Helene Kopal, M.P.A., M.P.H. (R18HS 017167) evaluated the impact o implementing aCDS system to support providers in caring or patients

with hypertension. Te system included the ollow-ing: alerts about elevated blood pressure; a templatethat shows the inormation that should be collected

rom the patient related to hypertension and acili-tates documentation; medication adherence ormsto prompt support staf to ask patients about takingtheir medications and to document their responses;a hypertension order set that allows ordering o testsand treatments through a single screen; and clinicalreminders to screen or tobacco use and/or updateindicated laboratory tests. Te researchers also sent toproviders retrospective eedback via quarterly reportsthat show individual physician perormance on vari-ous hypertension-related metrics, such as the percent-

age o hypertensive patients with visits in the previousquarter who have their blood pressure under control.

David Mehr, M.D., M.S. (R18 HS 017035) createdand evaluated the impact on outcomes o condition-specic dashboards, accessible rom a section withina commercial electronic health record (EHR) sys-tem, that provided key inormation or managingthe condition, along with data on whether qualitymetrics have been achieved or the individual patient.Te dashboard also included easily accessible decisiontrees outlining standard care management or thecondition and electronic templates or creating visitnotes. Te system also ofered perormance reportsthat gave practice-wide and physician-specic data,along with a list o individual patients with out-o-range values. wo report delivery approaches wereevaluated: one that required the doctor to go into theelectronic record to see the inormation and list opatients and one that was delivered automatically toeach physician via email.

CDS to Support Specic ClinicalProcessesEleven projects developed and/or evaluated point o

care support or specic clinical activities.

James Fricton, D.D.S., M.S. (R18 HS 017270)ofered decision support to dentists and their patientsin order to improve the quality o dental care orpatients with selected chronic conditions that mayafect dental health and/or dental care. Dental ocesreceived an alert within the electronic dental record

whenever a patient with a chronic health conditionthat might afect the course o his/her dental carescheduled a dental appointment. When the dentistopened the electronic dental record, the alert dis-

played the patients relevant chronic health conditionsand included links to customized, condition-specic,evidence-based guidelines that specically addressedthe implications or the dental encounter. In additionpatients received a secure email within their personalhealth record (PHR) or a mailed letter, i not regis-tered or the PHR, ahead o the visit that noted thepossible presence o the relevant medical condition(s)and urged the patient to discuss the condition(s) withthe dentist at the upcoming appointment and toremind the dentist to review the alert.

On June 21, 2011, AHRQ hosted a national Web

conerence on using health IT to improve chroni

disease management eaturing Dr. Fricton and M

Kopal. Inormation about this national Web con

ence can be ound at:

http://healthit.ahrq.gov/chronicdiseasemgmttel-

econerence

William Gardner, Ph.D. (R18 HS 017258) testedan interactive voice response (IVR) system thatcontacted amilies o children 6 to 17 years old a

week ater being prescribed an antidepressant togather relevant clinical inormation about the medi-cation. Te system called the amilies 7 times over3 months, with the goal o monitoring medicationadherence, side efects, and patient symptoms. Tesystem automatically notied triage staf on the
http://healthit.ahrq.gov/chronicdiseasemgmtteleconferencehttp://healthit.ahrq.gov/chronicdiseasemgmtteleconferencehttp://healthit.ahrq.gov/chronicdiseasemgmtteleconference


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research team i any o the responses suggested a needor ollowup. Ater receiving the notication, clinicstaf accessed a Web-based decision support applica-

tion to review the inormation rom the IVR call andaccess a module o suggested ollowup questions oreach patient-reported concern. Tese modules guidedthe ollowup interview, which ocused on gatheringadditional details about specic symptoms. Atercollecting the needed inormation, the triage personassessed the level o risk and developed a plan toaddress detected risks.

Kevin Johnson, M.D., M.S. (R18 HS 017216)developed and integrated a pediatric dose roundingalgorithm into an e-prescribing system to address the

complexity o calculating the correct medication doseor children and inants. Te research team used aDelphi approach to generate expert consensus abouteach rounding recommendation based on balancingthe goals o therapy with the potential or side efectson a medication-by-medication basis. Te CDS algo-rithm also took into account the medication ormalong with patient age and weight. Tis algorithmeliminated the need or manual rounding to thenearest measurable and easily administered amount,

which can lead to possible over or underdosing. Phy-

sicians remained largely unaware o the change, as itt into existing work processes and did not requirethem to take additional steps.

Kate Lapane, Ph.D. (R18 HS 017150) developedalgorithms or use in electronic prescribing (e-pre-scribing) systems to identiy potential medicationmanagement issues or geriatric patients using medi-cation history data rom community pharmacies. Teresearchers ocused on 15 drugs with saety or limitedecacy concerns or older adults. Tey developedalerts or a commercial e-prescribing system that wereeasy to view, relevant, concise, and consistent withother elements o the onscreen display. Tey thenstudied how clinicians used this inormation duringpatient encounters and the extent to which physi-cians overrode the alerts.

David Lobach, M.D., Ph.D., M.S. (R18 HS017072) developed a CDS system that took inorma-tion rom multiple sites and used 40 rules within anetwork-wide knowledge base to identiy instances

o likely medication non-adherence or six chronicconditions (persistent asthma, diabetes, hypertension,congestive heart ailure, ischemic heart disease, and

stroke), taking into account medical indications andcontra-indications. Te system generated two typeso medication adherence reports. Te rst alerted pri-mary care providers to potential non-adherence a dayin advance o a scheduled appointment, with the goalthat non-adherence issues would be discussed duringthe patient visit. Te second report alerted care man-agers about patients who did not appear to be adher-ing to their medication regimens and have not seentheir primary care provider on a weekly basis, allowingthe care manager to ollowup with the patients.

Jonathan Nebeker, M.D., M.S. (R18 HS 017186)used qualitative methods and simulation studies tocollect and later evaluate inormation about providersmental models regarding medication management,including behaviors and goals related to searchingor inormation, generating hypotheses, and order-ing. Tis inormation guided eforts to rene the userinterace and logic behind the Integrated MedicationManager, an inormation management and decisionsupport tool designed to support clinicians in medica-tion management or chronic conditions.

Eleanor Schwarz, M.D., M.S. (R18 HS 017093)developed a CDS system to prevent medication-related birth deects based on ndings rom ocusgroups with physicians and patients. Te system ea-tured use o tablet computers immediately beore anoce visit to collect data rom women o child-bear-ing age about their reproductive plans. Te responsesappeared on a paper report given to the primary carephysician prior to seeing the patient. Because thetablet did not interace with the EHR, an oce stafmember had to enter the patients answers manually

into the EHR. In addition, physicians received oneo two types o alerts whenever they attempted toorder a drug that could potentially interere with aetus development. One alert noted that concernhas been raised about the use o this medicationduring pregnancy. Te second alert incorporatedpatients responses to produce a more tailored warn-ing with an accompanying link to a structured orderset. Te alerts were designed to require the physiciansacknowledgment. While alerts were triggered or both


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new prescriptions and renewals, they appeared onlyor the rst potentially dangerous medication orderedduring each encounter so as to avoid alert atigue.

Tomas Sequist, M.D., M.P.H. (R18 HS 017075)evaluated the impact on appropriate ollowup careo providing electronic alerts to primary care doctorsseeing patients with a chie complaint o chest pain(identied by a trained medical assistant within thepractices). For those identied, the system automati-cally calculated the Framingham Risk Score, extract-ing relevant inormation rom the EHR, includingage, sex, total and high-density lipoprotein (HDL)cholesterol, smoking status, systolic blood pressure,presence o antihypertensive therapy, and presence

o diabetes. Te substance o the alert varied basedon the risk score. For those designated as low risk (aFramingham score o less than 10 percent), the alertrecommended against a cardiac stress test i the physi-cian attempted to order one (due to its low diagnosticyield). For patients with high risk (a score above 10percent), the alert recommended an electrocardiogramand administration o aspirin and acilitated one-clickordering o each. Te alerts appeared in both passiveand active orms within each patients electronic chart.Te active alert displayed when clinicians accessed the

ordering module and required acknowledgement romphysicians to proceed. Te passive alert could be seenat any point during an encounter through the elec-tronic visit summary screen.

Steven Simon, M.D., M.P.H. (R18 HS 017201)identied barriers to and acilitators o laboratorymonitoring and timely ollowup on abnormal results,and then designed, implemented, and evaluatedpoint o care alerts that address these barriers in a

widely used, commercially available EHR system.Te intervention included both real-time medication

alerts, occurring at the time o e-prescribing dur-ing a visit, as well as alerts that can be viewed whenthe clinician opens the record at the beginning o

each encounter where a patient is receiving one othe designated medications, but does not have therecommended laboratory tests ordered or results inthe record.

Madhukar rivedi, M.D. (R18 HS 017189) pro-vided and tested the use o decision support inte-grated in an EHR to assist with assessment andtreatment o depression (particularly medicationmanagement) at community mental health clin-ics. Te system eatured a user-riendly, interactiveapplication. A rules engine translated guidelines-

based clinical algorithms into specic rules basedon inormation entered by the clinician. Te systemgenerated recommendations and also eatured mea-surement tools to monitor symptoms, side efects,treatment adherence, and unctional status; remind-ers about needed ollowup and preventive care;alerts about potential medication errors and adversedrug events (ADEs); and electronic documentation,record-keeping, and inormation-retrieval unctions.

James Veline, M.B.A. (R18 HS 017149) evaluated

the implementation o an e-prescribing system thatallowed the physician to access the patients medica-tion history, select the appropriate medication anddosage using medication decision support, review anyalerts and consider the potential adverse reactions,and nalize the prescription including selecting themedication and preerred pharmacy. Providers couldthen monitor whether the prescription had beenprocessed by the pharmacy and whether the patientobtained the medication as an indication o adher-ence to the medication regimen.


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Medication ManagementHealth IT has the potential to improve medication

management phases such as prescribing and

ordering, order communication, dispensing,

administration and monitoring as well as

education and reconciliation through use o

both clinician and patient-ocused applications

(McKibbon et al., 2011). Eighteen projects were

unded under the medication management

unding preerence area. Three other projects

also addressed areas related to medication

management. All 21 researchers studied the use

o health IT to improve aspects o medication

management in their projects as described below:

Evaluating the design and operation o e-pre-

scribing systems, testing the impact o medica-tion saety alerts and acilitating the transmis-

sion o medication orders to the pharmacy.

(Investigators: Dr. Carrow, Dr. Lapane, and

Mr. Veline)

Evaluating improvements in the design o clini-

cian interaces or e-prescribing and medication

management components o EHRs, using qual-

itative methods and simulation studies. (Investi-

gators: Drs. Fischer, Gorman, and Nebeker)

Supporting medication reconciliation through

communication and sharing o inormation in

ambulatory settings or during transitions rom

the hospital setting to ambulatory care. (Inves-

tigators: Drs. Fox, Gurwitz, Kaushal, Ornstein,

Pohl, and Singh)

Improving patient adherence to medication

regimens by reporting instances o potential

non-adherence to clinicians and acilitatinginterventions with those patients. (Investigators:

Drs. Baker, Gardner, and Lobach)

Enhancing the capabilities o EHRs to support

appropriate prescribing, dosing, or monitor-

ing o medications. (Investigators: Drs. Forrest,

Johnson, Schwarz, Sequist, Simon, and Trivedi)


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Supporting Clinical Workfow

BackgroundTe implementation o health I systems can havea major impact on clinical workow, the sequenceo physical and mental tasks perormed by vari-ous people within and between work environments(Carayon, 2010). For health I to be efective, itneeds to be integrated into the multiple levels o

workow that exist in ambulatory health care settingsin ways that support the cognitive work o clinicians,and are designed to t the specic organizationalcontext and patient population o a practice. HealthI systems may not achieve their ull potential dueto a lack o integration into clinical processes in a

way that supports the workow during a patientvisit, within a clinic, and across organizations (e.g.,between a clinic and community pharmacy) (Karsh,2009). In contrast, health I implementations thatdo take into account workow may achieve gains inquality, saety, or eciency as measured by guidelineadherence, access to and sharing o clinical inorma-tion, clinician and staf workload, and coordinationamong members o the care team.

Highlights From the ProjectsSeven projects addressed workow-related issues.Tese projects purposeully aimed to develop andimplement health I systems that integrated into

workow in order to improve quality. Project teamsdid this by taking into account clinician concernsabout the potential to disrupt their normal workowat the point o care and organizational actors associ-ated with successul adoption and implementationo health I systems. Specically, researchers assessedcurrent clinical workows and/or organizational

readiness or new health I systems. In some cases,project teams also worked with practice sites toimprove workows to better take advantage o thebenets o health I.

Dr. Baker spent signicant efort designing areminder system that took into account currentclinical workow. Te design made it easy or clini-

cians to see and react to reminders within the existingworkow while utilizing their current EHR system.Te system eatured nonintrusive reminders high-lighted in yellow on the side o the screen, along withstandardized ways to capture patient reasons (e.g.,reusals) or medical reasons not to provide a recom-mended therapy. o urther enhance the systemscompatibility with current workows, these excep-tions automatically suppressed uture reminders.

Grant Carrow, Ph.D. (R18 HS 017157) evalu-ated the saety, security, quality, and efectiveness o

electronic transmission o prescriptions or ederallycontrolled substances such as narcotics, stimulants,and sedatives in the ambulatory setting. Te researchteam ound a number o provider workow issuesafecting the ability to use the e-prescribing systemincluding provider identity authentication problems,inadvertent changes in operating system settings,and password changes. Te researchers worked withthe e-prescribing vendors to make renements to thesystems to address these issues.

On September 5, 2012, AHRQ hosted a nationa

Web conerence on e-prescribing and overcomi

associated barriers eaturing Dr. Carrow. Inorma

tion about this national Web conerence can be

ound at:

http://healthit.ahrq.gov/erximplementationteleco

erence

Dr. Lapane designed, in collaboration with sotware

vendors, geriatric medication alerts embedded withinthe e-prescribing sotware that allowed physicians tosee and react to the alerts as part o their usual work-ow. For example, physicians did not have to clickon any extra buttons to view the alerts. o integratethe alerts seamlessly, the development process involvedseveral iterations based on eedback rom system users
http://healthit.ahrq.gov/erximplementationteleconferencehttp://healthit.ahrq.gov/erximplementationteleconferencehttp://healthit.ahrq.gov/erximplementationteleconferencehttp://healthit.ahrq.gov/erximplementationteleconference


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Steven Ornstein, M.D. (R18 HS 017037) designedsaety measures which were implemented and laterevaluated in practice sites to encourage and support

process redesign and quality improvement. Supportconsisted o two hal-day site visits that includedacademic detailing, interactive discussions, review omeasures and perormance, dissemination o qualityimprovement strategies, and clinical decision supporttraining. Practices also met once a year to share bestpractices. With support rom the study team, partici-pating practices selected and implemented a varietyo workow and process improvements, includingenhanced medication reconciliation using the EHR,ormalized rell and EHR-based dosing protocols,

standing orders in the EHR or laboratory monitor-ing, patient activation and outreach strategies, andcomparative perormance reports on a set o medica-tion saety measures such as inappropriate therapy,inappropriate dosing, drug-drug interactions, drug-disease interactions, and ADEs.

Joanne Pohl, Ph.D., A.N.P.-B.C., F.A.A.N.,F.A.A.N.P. (R18 HS 017191) developed and useda partnership model to assist saety net practices,including Nurse-Managed Health Centers and Feder-ally Qualied Health Centers, in using their EHRs.

Te partnership ocused on implementing the EHRswithout having a negative efect on organizationalprocesses and provider workow and productivity.o that end, practices received technical assistanceover a period o several years, tailored to each sitesneeds. Preimplementation support generally includeda readiness assessment, technical inrastructurepreparation, organizational culture assessment andchange management planning, workow redesign,guided data preloading, sotware tailoring, integratedand upgraded billing, data exchange tools, and

assistance in negotiating and working with externalpartners. During implementation, support includedshared hosting o the EHR, training and retraining o

providers, ormative evaluation, regular perormanceeedback, and corrective actions. Ater implementa-tion, support included a leadership teleconerence,

annual partnership symposium, a centralized analyti-cal data warehouse, and research capacity-buildingand summative evaluations.

Gurdev Singh, Ph.D. (R18 HS 017020) employeda systems engineering approach to improving medi-cation saety. Te study team worked with a groupo our primary care practices, helping them toimplement a Web-based eam Resource Manage-ment System built on an existing platorm. Te teamocused on workow issues, supporting each practicein identiying and prioritizing hazards, and then

designing and implementing tailored interventions toimprove medication saety.

Dr. rivedi employed a three-stage process to developa CDS system to assist with assessment and treatmeno depression at community mental health clinics.Te process was explicitly intended to make sure thesystem t user needs and integrated into existing

workows. Stages included an end-user needs assess-ment; modication o the CDS system based on thisassessment; and building and integrating the systeminterace into the existing EHR. As part o this efort,the study team realized that clinicians did not havetime to administer the patient assessment and, con-sequently, designed the program so that nonphysi-cian staf could do so. Te team provided an array osupport with implementation, including an intensivetraining program or clinical staf on the principles oguideline-based care and the role that the CDS sys-tem can play in acilitating such care. Clinicians hadreal-time support during a trial period, with inor-mation on problems encountered during this periodused to inorm system modications. Clinicians and

staf could also participate in biweekly teleconer-ences that ofered additional training and providedan opportunity to give eedback on the system.


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Coordinating Care

BackgroundCare coordination is the deliberate organiza-tion o patient care activities between twoor more participants (including the patient)involved in a patients care to acilitate theappropriate delivery o health care services.Organizing care involves the marshalling opersonnel and other resources needed to carryout all required patient care activities and isoten managed by the exchange o inorma-tion among participants responsible or difer-ent aspects o care (AHRQ, 2007).

Tere are many ineciencies and costs associatedwith lack o care coordination, including duplicatetesting and procedures, lack o medication reconcili-ation, unnecessary emergency department visits, andpreventable hospital admissions and readmissions.Te IOM estimates that pursuing eforts that improvecare coordination could result in a nationwide averageannual savings o $240 billion (IOM, 2010).

One o the most important competencies or carecoordination is using health I (Antonelli et al.,2009). Health I can ensure that multiple providershave access to the right inormation at the right timeacross settings o care. It can also acilitate the devel-opment and oversight o care plans, and improvetracking and monitoring o the delivery o care.Care coordination has been prioritized under theMedicare and Medicaid EHR Incentive Program(CMS, 2012), reecting the importance o health Iin generaland health inormation exchange (HIE)in particularon the ability o clinicians to coordi-nate care.

Highlights From the ProjectsTree researchers studied the use o health I tosupport care coordination. wo o them ocused onensuring that primary care physicians receive timely,appropriate inormation ater one o their patientshas been discharged rom the hospital. Highlightsrom these projects ollow:

Paul Gorman, M.D. (R18 HS 017102) created asystem that connected e-prescribing applicationsrom multiple places to make sure that all providersand patients had an up-to-date medication list.Te system allowed independent devices and applica-tions to interact with each other, so that medicationchanges got automatically updated on the manydevices and applications used by providers across caresettings, allowing or improved communication andcoordination through the use o shared medicationmanagement tools. Any user could view the changesand update inormation without the need or repeti-tive data entry.

Rainu Kaushal, M.D., M.P.H. (R18 HS 017029)used an HIE intervention to notiy primary careproviders about a patient being discharged rom thehospital via an electronic alert sent to the providersEHR inbox. Te communication alerted the providerto the act that a patient had been hospitalized, listedhis or her discharge medications, and noted the timeand date o a ollowup appointment with the pro-vider. Te goal was to reduce the risk o medicationerrors or patients transitioning between health caresettings by improving care coordination and medica-tion management. Te intervention was tested via arandomized trial with one group receiving notica-tion prior to the scheduled ollowup visit and a sec-ond group not receiving the alert. Both groups hadaccess to the complete inpatient discharge summaryvia direct linkage to the outpatient EHR.

On August 27, 2010, AHRQ hosted a national W

conerence on health IT and underserved popula

tions eaturing Dr. Gorman. Inormation about th

national Web conerence can be ound at:

http://healthit.ahrq.gov/underservedpatientstele

conerence
http://healthit.ahrq.gov/underservedpatientsteleconferencehttp://healthit.ahrq.gov/underservedpatientsteleconferencehttp://healthit.ahrq.gov/underservedpatientsteleconferencehttp://healthit.ahrq.gov/underservedpatientsteleconference


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Jerry Gurwitz, M.D. (R18 HS 017203) developeda health I system that automated key steps in thetransition o care rom the hospital to home by pro-

actively notiying primary care providers ollowingthe discharge o an elderly patient rom the hospitalvia the primary care practices EHR. In addition tonotiying them about the transition rom hospitalto home, the system provided inormation aboutnew drugs added during the inpatient stay, warn-ings about drug-drug interactions, recommendationso dose changes and laboratory monitoring relatedto high-risk medications, and reminders to supportstaf to schedule a post-hospitalization oce visit.

Te system was designed to address the challenges omanaging inormation and coordinating data sharingacross multiple settings or older adults.

On August 18, 2011, AHRQ hosted a national W

conerence on health IT and medication manage

ment or elderly patients eaturing Dr. Lapane an

Dr. Gurwitz. Inormation about this national Web

conerence can be ound at:

http://healthit.ahrq.gov/elderlymedmgmttelecon

ence

Vulnerable PopulationsThe IQHIT initiative had a specic interest in

project sites serving vulnerable populations.1

These groups are at risk o not obtaining

necessary medical services because o nancial,

social, geographical, or health-related barriers.

Eight o the projects were unded under the

vulnerable populations unding preerence area.

Three other projects also ocused on vulnerable

populations. All 11 project teams designedinterventions to acilitate clinician use o health

IT to improve the quality o care or a variety o

vulnerable populations. Many o these projects

included more than one vulnerable population in

the study population. Vulnerable populations that

the projects ocused on include:

Low-income patients without insurance or on

Medicaid, many o whom are cared or by saety

net providers. (Investigators: Drs. Fischer, Fox,

Gardner, Kaushal, Lobach, and Pohl, and

Ms. Kopal)

Racial and ethnic minorities. (Investigators:

Drs.Fischer, Fox, Gardner, Kaushal, Lobach,

and Trivedi, and Ms. Kopal)

Frail, elderly patients, including those served by

saety net practices and/or living in assisted living

or skilled nursing acilities. (Investigators:

Drs. Gurwitz and Singh)

Rural primary care practices. (Investigators:

Dr. Fox and Mr. Veline)

1 As noted in the unding opportunity announcement ambulatory health care sites that serve vulnerable populations as those ambulatory health careentities that meet the IOM denition o saety net providers: those providers that organize and deliver a signicant level o health care and other relatedservices to the uninsured, Medicaid, and other vulnerable patients. Core saety net providers have an additional distinguishing characteristic in that theyeither by legal mandate or explicitly adopted mission, maintain an open door, oering access to services or patients regardless o their ability to pay(IOM 2002). Vulnerable patients, as dened by the Institute o Medicine (2002), are those populations served by health care entities that all outsidethe medical and economic mainstream, with little or no access to stable health care coverage. As stated in the unding opportunity announcementthese include the uninsured, low-income underinsured, Medicaid beneciaries, patients with special health care needs, minority populations, immigrantpopulations and geographically or economically disadvantaged communities. AHRQ recognizes that many rural and inner-city communities aremedically vulnerable as well.
http://healthit.ahrq.gov/elderlymedmgmtteleconferencehttp://healthit.ahrq.gov/elderlymedmgmtteleconferencehttp://healthit.ahrq.gov/elderlymedmgmtteleconferencehttp://healthit.ahrq.gov/elderlymedmgmtteleconference


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Understanding the Impact on Outcomes

BackgroundResearch has shown that the use o health I canimprove health care saety and quality in ambulatorysettings. However, the use o health I, such as EHRsor e-prescribing systems, does not ensure improve-ment in outcomes (Crosson et al. 2012, Lorenzi etal. 2009). Trough the IQHI initiative, AHRQ wasinterested in advancing understanding o the essentialstrategies or sae, successul, and productive healthI adoption in ambulatory settings, and the impacto health I implementation on outcomes. Tis is oparticular relevance since the majority o health care

is delivered in ambulatory settings, and health Iimplementation in these settings is expanding rapidly

with the majority o physicians reporting that theyhave implemented an EHR (Jamoom et al. 2012).

Highlights From the Projectswo o the projects aimed to improve understandingo the impact o health I on outcomes as describedbelow:

Michael Fischer, M.D., M.S. (R18 HS 017151)assessed physician attitudes about and behaviors

with various eatures o e-prescribing systems, suchas who is most likely to use such systems and why.Qualitative data were evaluated to identiy view-points that shaped the use o e-prescribing systems.System designers may be able to use this inormationin the uture to guide system development so thate-prescribing systems can be used more requentlyand efectively.

On August 27, 2009, AHRQ hosted a national

Web conerence on e-prescribing and medicatio

management eaturing Dr. Carrow and Dr. Fische

Inormation about this national Web conerence

can be ound at:

http://healthit.ahrq.gov/erxandmedmgmttelecon

erence

Karen C. Fox, Ph.D. (R18 HS 017233) designed astudy to determine whether utilization o health I,specically EHRs, in diabetes management wouldenhance the delivery o evidence based health careand improve health outcomes among low-income,mostly minority patients. Te study compared resultsat two medical clinics that used EHRs with two clin-ics that did not use EHRs. Te researchers extractedclinical data rom medical records to assess the poten-tial or EHRs to acilitate patient outcomes tracking,improve provider communication, reduce medical

errors, and improve the quality o care.
http://healthit.ahrq.gov/erxandmedmgmtteleconferencehttp://healthit.ahrq.gov/erxandmedmgmtteleconferencehttp://healthit.ahrq.gov/erxandmedmgmtteleconferencehttp://healthit.ahrq.gov/erxandmedmgmtteleconference


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Impact on Outcomes

Tis section summarizes the IQHI project ndingswith respect to their impact on the quality o careas measured by several types o outcomes, includ-ing process outcomes,2 intermediate outcomes,3 andhealth outcomes.4 Several projects showed a positiveimpact on process outcomes related to the delivery oevidence-based preventive and chronic care or the useo health I by clinicians. In addition, several projectsshowed a positive impact on intermediate outcomessuch as chronic disease control, clinician perceptionso health I useulness, and clinician satisaction.Other projects demonstrated improvements in healthoutcomes such as adverse drug events and unctionalstatus. Te ndings rom these projects are consistent

with those identied in a recent systematic review othe efect o CDS systems, which ound that bothcommercially and locally developed systems are efec-tive at improving health care process measures relatedto prevention, ordering, and prescribing across diversesettings (Bright et al., 2012, Lobach et al., 2012).

Selected results rom the IQHI grantees are high-lighted below.

Process OutcomesTe IQHI projects showed that health I interven-tions can have a positive impact on process outcomes,including but not limited to delivering appropriateevidence-based preventive and chronic care, includ-ing management o medication therapy; increasingclinician use o health I or decision support and/or documentation purposes; and increasing efec-tive communication among clinicians and betweenclinicians and patients. Illustrative examples appearbeginning in the next column:

Delivering Evidence-Based CareDr. Baker ound that the CDS system that com-bined point o care reminders about needed services

with documentation tools, order sets, and retrospec-tive eedback led to improvements in various processmetrics related to chronic disease management.During the year ater implementation, perormanceimproved or 14 o 16 such measures, a muchgreater rate o improvement than during the yearbeore implementation (when perormance on only8 o the 16 measures improved). In addition, the

rate o improvement in the year ater implementationsignicantly exceeded that in the year beore or9 measures, with only 2 showing a decline in the rateo improvement (and the rest showing roughly thesame rate). Improvements were driven by more peo-ple receiving recommended services and more excep-tions being documented. In phase 2, perormanceimproved signicantly or 8 o the 16 measures, allo which had also improved signicantly during therst phase.

2 Process outcomes include actions taken by members o a clinical team or by patients in the course o care delivery or sel-management.

3 Intermediate outcomes are indicators that are impacted by processes and that may precede or lead to health outcomes.

4 Health outcomes are symptoms and conditions that patients can eel or experience.

On April 28, 2011, AHRQ hosted a national Web

conerence on quality metrics and measurement

eaturing Dr. Baker. Inormation about this nation

Web conerence can be ound at:

http://healthit.ahrq.gov/qualitymetricsandmeasu

mentteleconerence
http://healthit.ahrq.gov/qualitymetricsandmeasurmentteleconferencehttp://healthit.ahrq.gov/qualitymetricsandmeasurmentteleconferencehttp://healthit.ahrq.gov/qualitymetricsandmeasurmentteleconferencehttp://healthit.ahrq.gov/qualitymetricsandmeasurmentteleconference


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Dr. Forrestound that practices using the CDSsystem or treatment o otitis media were signicantlymore likely to adhere to guidelines than practices in

the control group. Both CDS on its own and CDScombined with perormance eedback increased theprescribing o high-dose amoxicillin or children withotitis media (as compared to a control group).

Ms. Kopal ound that signicant improvementsoccurred in all process measures except or one (med-ication intensication) ater implementing the CDScomponent o the EHR. Improvements occurred inuse o metabolic exercise tests (79.1 to 92.2 percent),electrocardiograms (6.6 to 52.2 percent), lipid panels(69.1 to 78.7 percent), measurement o body mass

index (71.6 to 84.5 percent), and scheduling a ol-lowup appointment when elevated blood pressure isobserved (86.9 to 88.9 percent).

Dr. Ornstein ound that the practice-level retrospec-tive eedback provided to participating practices ledto statistically signicant improvements in peror-mance on three measures: avoidance o potentiallyinappropriate therapy (e.g., concurrent use o lithiumand thiazide, avoidance o NSAID or Cox 2 inhibi-tors in patients with hypertension), avoidance o

drug-disease interactions, and appropriate monitor-ing (e.g., o platelets in patients on anticoagulantsand o glucose in patients on antipsychotic medica-tions). rends toward improvement were evident inother measures as well. However, high baselineavoidance rates (approximately 100 percent), thesmall number o eligible patients, and greater vari-ability in perormance across practices, may havecontributed to a lack o statistically signicantchange in other measures.

Dr. Pohl ound that clinician use o the EHR led to

improvements in several processes associated withbetter patient saety and care, including entering allprescriptions into the oce-based electronic pre-scribing system, monitoring patients sent to imagingacilities, identiying at-risk patients in the oce, andproviding assistance to patients in obtaining educa-tional materials.

Increasing Clinician Use o Health I

Dr. Fischer ound that physicians became moreactive users o the e-prescribing system over time.

wo years ater implementation, between 60 and70 percent o prescriptions were delivered to phar-macies electronically, with no paper involved. Somephysicians initially converted e-prescriptions to axesbeore sending them to the pharmacy, although useo this approach decreased signicantly over time.Physicians using e-prescribing systems that wereintegrated into an EHR were signicantly more likelyto write prescriptions electronically most or all o thetime, as compared to those using standalone e-pre-scribing systems.

Dr. Forrestound wide variations in physicianadoption o the CDS system. Overall use was low.Tis was due, in part, to doctors perception thatthey already knew how to treat otitis media and,hence, did not need additional support. Overall,7 percent o doctors never used the tool, 75 percentused it or less than hal o visits, and only 18 percentused it in more than hal o visits. Te retrospectiveperormance eedback improved perormance on onequality metric and promoted the use o the tool.

In the study o the transition rom a locallydeveloped to a commercial e-prescribing system,Dr. Kaushal ound that the vast majority (morethan 90 percent) o physicians used the new systemto complete between 75 and 100 percent o theirprescriptions.

Dr. Pohl ound that use o the EHR varied signi-cantly across participating saety net practices. Forexample, the percent o visits that included a clinicalnote in the EHR ranged rom 39 to 97 percent acrossclinicians. Use o the diabetes template or structured

data entry and notetaking during oce visits alsovaried, with less use during diabetes visits in centers

with younger patients and lower rates o diabetes.Use o the cardiovascular template or hypertensivepatients was consistently low. Users ound the orm

was inconvenient to use and the researchers plan todevelop an alternative template. System use tended tobe higher in Nurse-Managed Health Centers than inFederally Qualied Health Centers.


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Increasing Efective Clinician Communication

Dr. Fricton ound that alerts or both dentists andpatients signicantly increased the rate at which

providers reerred to care guidelines (by 440 percentversus baseline or the provider alerts and by 221percent or the patient alerts), while the control groupexperienced no change in provider behavior. Tealerts triggered a response by 79 percent o dental pro-viders, although response rates lagged during the last3 months o the study, perhaps due to alert atigue orthe eeling among providers that they already under-stood the guidelines and did not need to access themany longer. Te alerts also increased the requency ocorrecting errors in the medical history based on pre-

and postimplementation comparisons.

Dr. Schwarzound that the alerts increased docu-mentation o amily planning services when a poten-tial teratogen (a drug that could harm a etus) wasprescribed (57 percent versus 28 percent), but not

when such a drug was not prescribed. Alerts had asimilar efect in both academic and community-basedpractices. Despite the interventions, women were notconsistently counseled about potentially teratogenicprescriptions. Te investigators believe there is a needto rene the approach, particularly to alert providers

repeatedly when multiple, potentially dangerous pre-scriptions are initiated, so as to prevent the substitu-tion o one potentially problematic drug with another.

Intermediate Outcomes

Controlling Chronic Diseases

Several projects had a positive impact on interme-diate outcomes, such as blood pressure, glycatedhemoglobin (HbA1c), or cholesterol levels. Illustra-tive examples include the ollowing:

Dr. Foxtested the impact o EHR systems on thecare and outcomes o diabetes patients in the Mis-sissippi Delta. Te study compared perormance onvarious metrics in our clinics using similar modelso diabetes caretwo with EHRs and two with-out (each group included one rural and one urbanlocation). Te evaluation ound mixed results, withEHR use showing a positive impact on low-densitylipoprotein levels and mixed ndings with respect toHbA1c and blood pressure.

Ms. Kopal ound that average diastolic and systolicblood pressure ell among hypertensive patients aterthe CDS system was implemented. Te proportion o

hypertensive patients with their blood pressure undercontrol at their last visit rose rom 50.9 percent beoreimplementation o the CDS system to 60.8 percentaterwards. Signicant improvements also occurred inthe proportion o hypertensive patients with diabetes

who had their blood pressure under control (rom33.3 percent beore implementation to 46.9 percentaterward). Controlling or other actors signicantlyassociated with blood pressure control, patients were1.5 times more likely to have their blood pressureunder control ater the intervention than beore.

Dr. Pohl ound that diabetes and hypertension out-comes showed improvement over time in the Nurse-Managed Health Centers, while scores remainedsteady in the comparison group. Te improvementsin diabetes scores were positively correlated with useo the diabetes management orm.

Mr. Veline ound that stand-alone electronic pre-scribing did not have an impact on hypertension con-trol. However, ater implementation o an EHR, theproportion o hypertensive patients with their blood

pressure under control increased to levels higher thanat baseline or during the period where only stand-alone electronic prescribing was ofered.

Clinician Perceptions o Health I Useulnessand Clinician Satisaction

Several projects evaluated clinician perceptions ohealth I, including their views on its useulness topatient care and its impact on their satisaction andproductivity.

Dr. Fischer assessed physician attitudes about and

behaviors with various eatures o e-prescribingsystems. Physicians elt e-prescribing had a positiveimpact on medication saety68 percent reported itmade medication reconciliation easier and 57 per-cent reported it reduced calls rom pharmacies aboutprescribing errors. Te vast majority (88 percent)

were satised with the e-prescribing system, withphysicians that had integrated systems signicantlymore likely to be satised than those with a separatee-prescribing system.


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Clinicians who used the pediatric dosing systemdeveloped byDr. Johnson described it as potentiallyuseul to assist with dosage rounding, but expressed

preerence or more exibility in the recommenda-tions or nonstandard medication schedules. Physi-cians in subspecialties that more requently prescribecompounded medications ound it useul that thesystem included these medications.

On July 23, 2010, AHRQ hosted a national Web

conerence on health IT and saety eaturing Dr.

Johnson. Inormation about this national Web con-

erence can be ound at:

http://healthit.ahrq.gov/saetyteleconerence

In the study byMs. Kopal, participating providersgenerally ound many o the system components tobe useul (although perceptions varied by providerand across components), including the alerts, ordersets, templates, clinical reminders, perormance eed-back, and training.

In the study byDr. Mehr, clinicians ound the diabe-

tes dashboard to be ecient and believed it improvedthe quality o care. In a study o 10 clinicians, thedashboard was ound to save time or providers, asit took only 1.3 minutes to nd all data elements

with the dashboard, compared to 5.5 minutes with-out it. Physicians using the conventional methodrequired 60 mouse clicks to gather needed inorma-tion, compared to just 3 clicks with the dashboard.In an unexpected nding, 55 percent o physiciansreported giving patients a printed copy o the dash-board at some visits. Almost two thirds o physicians

(64 percent) thought that the patient portal wouldincrease their workload, but ater implementation thevast majority (87 percent) believed it did not actually

do so. However, the proportion believing the patientportal would improve care decreased ater implemen-tation, rom 55 percent to 33 percent.

Dr. Pohl ound that clinician perceptions aboutthe potential benets o the EHR to the practice

were slightly negative during implementation, butimproved over time in the Nurse-Managed HealthCenters (except or one center with known imple-mentation issues and challenges). In general, provid-ers with high expectations prior to implementationtended to experience a slight decline in positive per-

ceptions over time, while those with signicant initialears about the EHR ound that these concerns werealleviated (particularly with respect to the impact onpatient-provider relationships).

Health Outcomeswo projects evaluated the impact o health I onhealth outcomes, such as health status and adversedrug events:

Dr. Foxound that patients at one site with an EHR

experienced a signicant, positive change in sel-reported health status between baseline and ollowup

Dr. Singh ound that participating practices experi-enced a decreasing trend in ADEs (rom 25.8 to 18.3per 100 patients per year), while the rate remainedthe same in a control group o non-participatingpractices. While the diference was not statisticallysignicant, the nding suggests that the program maybe efective in improving medication saety.
http://healthit.ahrq.gov/safetyteleconferencehttp://healthit.ahrq.gov/safetyteleconference


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Conclusion

Te IQHI projects demonstrated signicant prog-ress toward addressing AHRQ goals o advancingunderstanding o how clinicians can use health Ito improve the quality o health care. Tey devel-oped and tested a range o approaches or enhancingCDS, providing clinical inormation at the point ocare, and improving care coordination, while alsostudying how to integrate health I systems intoclinical workows. Several projects showed a positiveimpact on process outcomes related to the deliveryo evidence-based preventive and chronic care, or theuse o health I by clinicians. In addition, severalprojects showed a positive impact on intermediateoutcomes such as chronic disease control, clinicianperceptions o health I useulness, and cliniciansatisaction. Other projects demonstrated improve-ments in health outcomes such as adverse drug eventsand unctional status. Teir ndings and insightscan provide the oundation or advances in several othe priority areas in the National Quality Strategy,

especially making care saer, coordinating care, andpromoting the use o efective care (HHS, 2012), asthe IQHI researchers showed how clinician use ohealth I can improve outcomes in all o these areas.Te IQHI projects continue to build the evidencebase or clinician use o health I as they are consis-tent with the ndings o a recent systematic review oearlier research on the efects o clinician use o CDSsystems (Bright et al., 2012, Lobach et al., 2012).

Te ndings and lessons rom the IQHI initiativecan inorm researchers and implementers interested

in using health I to help clinicians improve thequality o health care. Te continued rapid pace otechnological change and the continued interest inthe use o health I to improve health and healthcare delivery make the results o this body o researchtimely and relevant to ongoing eforts to expand theuse o health I to improve the quality o health care


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Reerences

Antonelli RC, McAllister JW, Popp J. Making CareCoordination a Critical Component o the Pediatric

Health System: A Multidisciplinary Framework.Te Commonwealth Fund. May 2009.

Berner ES. Clinical decision support systems: stateo the art. Rockville, MD: Agency or HealthcareResearch and Quality. June 2009. AHRQ PublicationNo. 09-0069EF.

Bright J, Wong A, Dhurjati R, et al. Efect o clinicaldecision-support systems: a systematic review. AnnIntern Med 2012 Jul 3;157:29-43.

Carayon P, et al. Workow assessment or healthI toolkit. AHRQ. 2010. http://healthit.ahrq.gov/workfow. Accessed April 30, 2013.

Closing the quality gap: A critical analysis o qualityimprovement strategies: volume 7Care coordination,Structured Abstract. Publication No. 04(07)-0051-7, June 2007. Agency or Healthcare Research andQuality, Rockville, MD. http://www.ahrq.gov/clinic/tp/caregaptp.htm. Accessed October 18, 2012.

Crosson JC, Ohman-Strickland PA, Cohen DJ, et al.ypical electronic health record use in primary care

practices and the quality o diabetes care. Ann FamMed 2012 May-Jun;10(3):221-7.

Das M, Eichner J. Challenges and barriers to clinicaldecision support (CDS) design and implementationexperienced in the Agency or Healthcare Research andQuality CDS demonstrations. (Prepared by AHRQNational Resource Center or Health Inormationechnology under Contract No. 290-04-0016.)Rockville, MD: Agency or Healthcare Research andQuality. March 2010. AHRQ Publication No. 10-0064-EF.

Jamoom E, Beatty P, Bercovitz A, et al. Physicianadoption o electronic health record systems: UnitedStates, 2011. NCHS data brie, no 98. Hyattsville,MD: National Center or Health Statistics. 2012.

Karsh B-. Clinical practice improvement andredesign: how change in workow can be supported by

clinical decision support. AHRQ Publication No. 09-0054-EF. Rockville, Maryland: Agency or HealthcareResearch and Quality. June 2009.

Kern LM, Barron Y, Dhopeshwarker RV, et al.Electronic health records and ambulatory quality ocare. J Gen Intern Med 2013 Apr;28(4):496-503.

Lobach D, Sanders GD, Bright J, et al. Enablinghealth care decisionmaking through clinical decisionsupport and knowledge management. Evidence ReportNo. 203. (Prepared by the Duke Evidence-based

Practice Center under Contract No. 290-2007-10066-I.) Rockville, MD: Agency or Healthcare Researchand Quality, April 2012. AHRQ Publication No.12-E001-EF.

Lorenzi NM, Kouroubali A, Detmer DE, et al. Howto successully select and implement electronic healthrecords in small ambulatory practice settings. BMCMed Inorm Decis Mak 2009 Feb 23;9:15.

McKibbon KA, Lokker C, Handler SM, et al.Enabling medication management through healthinormation technology. Evidence Reports/echnologyAssessments, No. 201 (Prepared by the McMasterEvidence-based Practice Center under Contract No.290-2007-10060-I). Rockville, MD: Agency orHealthcare Research and Quality, April 2011. AHRQPublication No. 11-E008-EF.

National Strategy or Quality Improvement in HealthCare. Washington, DC: U.S. Department o Healthand Human Services (HHS), 2011.

National Strategy or Quality Improvement inHealth Care, Annual Progress Report to Congress.

Washington, DC: U.S. Department o Health andHuman Services (HHS), 2012.

Priority Areas or National Action: ransormingHealth Care Quality. Washington, DC: Institute oMedicine (IOM), 2003. National Research Council.Te National Academies Press.
http://healthit.ahrq.gov/workflowhttp://healthit.ahrq.gov/workflowhttp://www.ahrq.gov/clinic/tp/caregaptp.htmhttp://www.ahrq.gov/clinic/tp/caregaptp.htmhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Lorenzi+NM%2C+Kouroubali+A%2C+Detmer+DEhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Lorenzi+NM%2C+Kouroubali+A%2C+Detmer+DEhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Lorenzi+NM%2C+Kouroubali+A%2C+Detmer+DEhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Lorenzi+NM%2C+Kouroubali+A%2C+Detmer+DEhttp://www.ahrq.gov/clinic/tp/caregaptp.htmhttp://www.ahrq.gov/clinic/tp/caregaptp.htmhttp://healthit.ahrq.gov/workflowhttp://healthit.ahrq.gov/workflow


28/30



Osherof JA, Pier EA, eich JM, et al. ImprovingOutcomes With Clinical Decision Support:an Implementers Guide. Chicago: Healthcare

Inormation and Management Systems Society; 2005.Roundtable on Value & Science-Driven HealthCareTe Healthcare Imperative: Lowering costs andImproving Outcomes: Workshop Series Summary.Washington, DC: Institute o Medicine, 2010.Te National Academies Press.

Stage 2 Overview ipsheet. Centers or Medicare& Medicaid Services. August 2012. https://www.cms.gov/Regulations-and-Guidance/

Legislation/EHRIncentivePrograms/Downloads/

Stage2Overview_Tipsheet.pd.Accessed January 14, 2013.

Unequal reatment: Conronting Racial and EthnicDisparities in Health Care. Washington, DC: Instituteo Medicine, 2002. Te National Academies Press.

Velentgas P, Dreyer NA, Nourjah P, et al, eds.Developing a protocol or observational comparativeefectiveness research: a users guide. AHRQPublication No. 12(13)-EHC099. Rockville, MD:Agency or Healthcare Research and Quality; January2013. www.eectivehealthcare.ahrq.gov/Methods-OCER.cm
https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttp://www.effectivehealthcare.ahrq.gov/Methods-OCER.cfmhttp://www.effectivehealthcare.ahrq.gov/Methods-OCER.cfmhttp://www.effectivehealthcare.ahrq.gov/Methods-OCER.cfmhttp://www.effectivehealthcare.ahrq.gov/Methods-OCER.cfmhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdfhttps://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/Stage2Overview_Tipsheet.pdf


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Appendix: Improving Quality Through Clinician Use ofHealth IT Projects

PrincipalInvestigator (PI) Institution Project Title*

IQHIT Initiative Areas of InterestAddressed

Baker, David Northwestern

University

Using Precision Perormance Mea-

surement to Conduct Focused Quality

Improvement

Decision Support

Clinical Workfow

Carrow, Grant Massachusetts State

Department o Public

Health

Enabling Electronic Prescribing and

Enhanced Management o Medications

Clinical Workfow

Fischer, Michael Brigham and Women's

Hospital

Impact o Oce-Based E-Prescribing on

Prescribing Processes and Outcomes

Understanding Impact on Outcomes

Forrest, Christopher Children's Hospital o

Philadelphia

Improving Otitis Media Care with EHR-

based Clinical Decision Support and

Feedback

Decision Support

Fox, Karen Delta Health Alliance,Inc.

The BLUES Project: Improving DiabetesOutcomes in Mississippi with Health IT

Understanding Impact on Outcomes

Fricton, James HealthPartners

Research Foundation

eHealth Records to Improve Dental Care

or Patients with Chronic Illness

Decision Support

Gardner, William Children's Research

Institute

Pharmaceutical Saety Tracking (PhaST):

Managing Medication or Patient Saety

Decision Support

Gorman, Paul Oregon Health &

Science University

RxSae: Shared Medication Manage-

ment and Decision Support or Rural

Clinicians

Care Coordination

Gurwitz, Jerry University o

Massachusetts

Medical School

Worcester

Improving Posthospital Medication Man-

agement o Older Adults with HIT

Care Coordination

Johnson, Kevin Vanderbilt University STEPStools: Developing Web Services

or Sae Pediatric Dosing

Decision Support

Kaushal, Rainu Weill Medical College

o Cornell University

Electronic Prescribing and Electronic

Transmission o Discharge Medication

Lists

Care Coordination

Kopal, Helene Primary Care

Development

Corporation

Evaluation o a Computerized Clinical

Decision Support System and EHR-

Linked Registry to Improve Management

o Hypertension in Community-Based

Medical Centers

Decision Support

Lapane, Kate Brown University Optimizing Medication History Value in

Clinical Encounters with Elderly Patients

Decision Support

Clinical Workfow

Lobach, David Duke University Improving Quality Through Decision

Support o Evidence-Based Pharmaco-

therapy

Decision Support

Mehr, David University o Missouri-

Columbia

Using HIT to Improve Ambulatory

Chronic Disease Care

Decision Support

* To access descriptions o each project, please select the respective project title.
http://healthit.ahrq.gov/sites/default/files/docs/publication/baker_final_report_17163final.pdfhttp://healthit.ahrq.gov/sites/default/files/docs/publication/baker_final_report_17163final.pdfhttp://healthit.ahrq.gov/sites/default/files/docs/publication/baker_final_report_17163final.pdfhttp://healthit.ahrq.gov/ahrq-funded-projects/enabling-electronic-prescribing-and-enhanced-management-controlled-medicationshttp://healthit.a

improving quality through clinician use of health it

Documents