Senior Consultant Kaiser Permanente USA.
The delivery of healthcare has been largely unchanged in fundamental aspects for decades. Despite significant advances in science, medical diagnostic tools, surgical interventions and pharmacology, the basic transaction has remained almost solely face-to-face interaction between healthcare professionals and patients in institutional settings.
In almost all other spheres of business and industry, electronic information systems coupled with the Internet have driven fundamental shifts in how business is conducted and healthcare will not be different.
In 1999, the Institute of Medicine published To Err is Human followed by Crossing the Quality Chasm in 2001. These publications attracted broad attention to quality and safety problems in American healthcare and identified four key factors underlying these quality gaps: (1) The increasing complexity of science and technology, (2) The rise in the incidence of chronic conditions, (3) A poorly organised delivery system and (4) A lack of critical information technology supports. Concerns about the failure to deliver quality care have been linked with concerns about escalating costs in the minds of policy analysts, governmental agencies, purchasers and patients. Most recently, the US government forecast that healthcare spending will increase to 17.6 per cent of the economy in 2009. This combination of escalating costs, poor outcomes and 15 per cent of the population without health insurance is unsustainable and has drawn understandable scrutiny and criticism from many quarters.
Today, Electronic Health Records (EHR) has capabilities that can be brought to bear on the key factors that drive system quality. At the same time, an enhanced appreciation of the connection between quality and cost has made the question of mass-market penetration of the EHR an issue of broad importance. President Obama has included significant funding for the implementation of EHR as part of his healthcare reform plan designed to stabilise healthcare costs and extend health insurance coverage.
In the US, services for patients with chronic disease now account for 75 per cent of total healthcare expenditures. This is a consequence of the mastery of many aspects of the treatment of acute disease, and the increasing life expectancy of the populations we serve. Treatment of chronic disease requires longitudinal tracking of treatment and outcomes both for individual patients and identifiable populations made feasible via an EHR.
The increasing complexity of medical science creates a burden for individual physicians to stay current. As knowledge in diagnosis and treatment expands, the time and processing speed required to achieve an optimal level of quality performance exceeds any individual’s capability. The number of years it takes for a medical advance to be broadly adopted into regular practice has been estimated at 17 years. In contrast, the EHR with clinical decision support has the capacity to summon current information, recommendations and research instantly at the point of care.
At the same time that duplicative tests and services are eliminated, information technology can leverage scarce and specialised clinical resources via virtual consultations regardless of geography and time zone constraints. KP HealthConnect, combined with an integrated disease registry for chronic conditions has made it possible for a single nephrologist to oversee and consult on the care of the chronic renal failure patients for a population base of over 250,000, significantly improving clinical outcomes by delaying renal dialysis.
In 2005, the Institute for Healthcare Improvement in Boston, Massachusetts launched the ‘Saving 100K Lives Campaign’ to improve hospital care and prevent complications by ensuring the reliable delivery of evidence-based care. EHR-imbedded documentation templates and evidence-based orders make this task consistent and efficient. A recent study of 41 hospitals in Texas reported the correlation of the level of sophistication of the EHR used with lower mortality and complications, lower costs and shorter hospital stays. While many clinical processes will be vastly improved by standardisation and the EHR, patient involvement and customisation are also readily supported. The easy availability of information on medical conditions and recommended care helps patients and families make knowledgeable choices based on personal preferences, constraints and values.
Transitions in care are a time of particular risk in healthcare. Nurse shift changes, general medicine referrals to medical or surgical specialists, and hospital discharges are all vulnerable times. Personal communication style, verbal versus written communication and variation in what information is conveyed and where it is documented all contribute to the risk that critical information may be omitted or misinterpreted. The EHR provides the vehicle and the opportunity to design a consistent information flow to enhance safety and efficiency. Dozens of staff nurses learned techniques to design a process for shift change that is now the standard process in Kaiser Permanente hospitals. After incorporating information from patient and family interviews, a template was developed that is now imbedded in the hospital EHR. All clinical staff can access a single place for the same information on each patient. A similar process is underway to redesign the hospital discharge process informed by over 100 interviews including patients and families at home after discharge as well as doctors, nurses and pharmacists both in the hospital and in their medical offices.
Fundamentally, the EHR has the capacity to integrate and organise all patient information, facilitate its instantaneous distribution among all participants in the healthcare system including patients, and inform and support the work of practitioners with the most current evidence. In doing so, it will simultaneously change industry work processes, improve quality, patient safety and satisfaction, and alter our understanding of the process and cost of delivering healthcare in the 21st century.
Louise L Liang, a 25 year veteran in healthcare administration and operations, speaks, writes, and consults on a broad set of healthcare issues including electronic information systems, quality, safety, service, and practice redesign. From 2002 to 2009, Louise served as Senior Vice President, Quality and Clinical Systems Support, Kaiser Foundation Health Plan and Kaiser Foundation Hospitals, where she oversaw the national quality agenda and led development and implementation of a US$ 4 billion+ organisation wide electronic health record.