Photo by Jon Tyson | Unsplash
Many people in health care do not have a positive view of the electronic health record (EHR). Just think about any recent “go live” effort in your hospital or health system. The experience is rarely fondly remembered.
Efforts to improve clinical care can get mired in an EHR incapable of producing meaningful data to help clinicians provide better care and improve system performance. And those who try to change the EHR risk getting stuck in their IT team’s long queue of projects.
Yet, the EHR and other technologies have incredible potential to support and improve patient care delivery.
Measurement is fundamental to systematic change and improvement, and years ago that meant manual effort — paper and spreadsheets — to capture the necessary information about how our systems were performing. Our thinking was that no one should (or had to) wait to begin improving. Focusing on electronic solutions used to delay essential improvement activities, but that has been changing over the years.
In the early 2000s, only 5 to 10 percent of US hospitals and an even smaller number of clinics were using an EHR. Today, according to a report released in 2022 by the US Office of the National Coordinator for Health Information Technology, 96 percent of non-federal acute care hospitals and nearly four in five office-based physicians have adopted a certified EHR as of 2021.
Admittedly, the EHR was created primarily for billing purposes to track activities carried out in the clinical encounter. Increasingly, however, the EHR and the wider electronic data environment in clinical settings captures vital information about ongoing interactions with our patients. This information can be used to understand what care patients are receiving, the quality and timeliness of that care, and how the patient and staff experience that care. And this information is now often available in close to real time. A major sea change in how we use information technologies to support patient care is needed to spur necessary upgrades and improve system performance and reliability.
Some of these efforts are already underway and can inspire us to consider more ambitious possibilities. For example, over 100 American hospitals have integrated into their EHRs electronic versions of the Institute for Healthcare Improvement (IHI) Global Trigger Tool, an approach to measuring safety that uses standardized chart review and clinical “triggers” to identify when adverse events occur. Originally developed to be done through manual case review, these electronic versions of the Global Trigger Tool alert clinicians to the risk of harm by automatically scouring electronic health records for evidence of harm events or possible harms in real time.
Other health systems are also harnessing the power of the EHR. The University of Washington (Seattle, Washington, USA) has embedded data tools to help surgical teams reduce use of high-carbon footprint anesthetic gases. Albert Einstein Israelita Hospital (São Paulo, Brazil), uses the EHR to calculate early warning scores for patients coming into the emergency department with suspected sepsis, and the hospital’s order entry and medication dispensing systems use the EHR to track how quickly antibiotics are delivered to patients. At Jefferson Health (Philadelphia, Pennsylvania, USA), routine clinical and operational information from teams closest to the point of care is fed into real-time dashboards so clinical managers can see where care is being delayed and where high-risk situations might emerge.
In addition to these examples that integrate real-time clinical and operational data into improvement efforts, there are also novel ways of using electronic records and other data assets to build the kind of learning systems that have been frequently called for, but rarely created. In such systems, these electronic assets are sources of information as well as tools to stimulate improvements in care seeking and care delivery.
One such learning system is the rapid randomized quality improvement unit at NYU Langone Health, where faculty use the EHR to supply data to quality improvement teams working on local experiments to identify the most effective interventions. Once a promising practice is identified, the EHR can then facilitate scaling this better practice throughout the health system.
In a case example presented in a 2023 paper (“Using Rapid Randomized Trials to Improve Health Care Systems”), the NYU team describes testing an improvement for preventative service follow-up by randomizing patients to receive a phone call versus a patient portal electronic reminder versus no intervention. They found that a phone call or providing a patient portal reminder encouraged patients to get their preventative care. This is not a terribly surprising finding, but because the data was available locally within their site, their administration could see, endorse, and then broaden the improvement initiative so that now many more patients in the NYU system will get patient portal reminders and automated phone calls to help close care gaps. This work leveraged the EHR to its full potential to understand what improvements would optimize care and then used the patient portal and automated calls to help implement the improved practice systemwide.
Another example is from Kaiser Permanente, a longtime IHI partner, which, some years ago, identified an opportunity to improve preventative service delivery across their entire population, particularly for colorectal cancer screening. They identified patients who had no cancer screening as well as those who were screened but did not follow up with their provider for a result. They also discovered that some patients with an abnormal result were never connected to follow-on care.
These kinds of gaps happened for tens of thousands of patients. And, because these data were captured in their electronic health records, Kaiser Permanente could use that information to power improvement activities. They invested in making provider-specific reports available. They used PDSA cycles to learn which improvement activities were generating good results. They used the electronic record to identify where to focus their efforts and as an ongoing source of information to validate whether improvement initiatives were achieving their goals.
In a study published in 2022, Kaiser Permanente reported that they had reduced mortality from colorectal cancer by 24 percent after seven years. They not only improved individual care processes to accomplish this, but they also improved follow-up and reduced perioperative mortality. As the lead author of the study, Michael Kanter, MD, Professor and Chair of Clinical Science at the Kaiser Permanente Bernard J. Tyson School of Medicine, said, “If a new drug or surgical procedure reduced deaths this dramatically, it would be hailed as a major breakthrough.”
What else might we accomplish by strategically using the EHR to improve the quality of care? For over two decades we have poured resources into the implementation and development of our health care electronic data environment. It is time to reap the full benefits of that investment. We must be thoughtful about how we do this. We must safeguard against the risks of inequitable distribution of these tools. We must be mindful of the risks for potential errors. But we can no longer try to change health care without enhancing and fully utilizing the technology-driven systems that are essential to so much of what we do for our patients every day.
Editor’s note: Look for more each month from IHI President and CEO Kedar Mate, MD, (@KedarMate) on improvement science, social justice, leadership, and improving health and health care worldwide.
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