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Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US); 2001.
Crossing the Quality Chasm: A New Health System for the 21st Century.
Show detailsThroughout this report, the committee has emphasized that health care should be supported by systems that are carefully and consciously designed to produce care that is safe, effective, patient-centered, timely, efficient, and equitable. This chapter examines the critical role of information technology (IT) in the design of those systems.
IT has enormous potential to improve the quality of health care with regard to all six of the aims set forth in Chapter 2. In the area of safety, there is growing evidence that automated order entry systems can reduce errors in drug prescribing and dosing (Bates et al., 1997, 1998a, 1999). In the area of effectiveness, there is considerable evidence that automated reminder systems improve compliance with clinical practice guidelines (Balas et al., 2000; Shea et al., 1996), and some promising studies, although few in number, indicate that computer-assisted diagnosis and management can improve quality (Durieux et al., 2000; Evans et al., 1998). There are many opportunities to use IT to make care more patient-centered, for example, by facilitating access to clinical knowledge through understandable and reliable Web sites and online support groups (Cain et al., 2000); customized health education and disease management messages (Goldsmith, 2000); and the use of clinical decision support systems to tailor information according to an individual patient's characteristics, genetic makeup, and specific conditions (Garibaldi, 1998) (see Chapter 6 for additional discussion). Both patients and clinicians can benefit from improvements in timeliness through the use of Internet-based communication (i.e., e-visits, telemedicine) and immediate access to automated clinical information, diagnostic tests, and treatment results. Clinical decision support systems have been shown to improve efficiency by reducing redundant laboratory tests (Bates et al., 1998b). Finally, Internet-based health communication can enhance equity by providing a broader array of options for interacting with clinicians, although this can only happen if all people, regardless of race, ethnicity, socioeconomic status, geographic location, and other factors, have access to the technology infrastructure (Science Panel on Interactive Communication and Health, 1999).
The committee believes IT must play a central role in the redesign of the health care system if a substantial improvement in health care quality is to be achieved during the coming decade. This is a theme underlying many of the topics addressed in this report. Chapter 5 emphasizes the importance of a strong information infrastructure in supporting efforts to reengineer care processes, manage the burgeoning clinical knowledge base, coordinate patient care across clinicians and settings and over time, support multidisciplinary team functioning, and facilitate performance and outcome measurements for improvement and accountability. Chapter 6 stresses the importance of building such an infrastructure to support evidence-based practice, including the provision of more organized and reliable information sources on the Internet for both consumers and clinicians, and the development and application of clinical decision support tools. And Chapter 9 considers the need to build information-rich environments for undergraduate and graduate health education, as well as the potential to enhance continuing education through Internet-based programs.
Central to many IT applications is the automation of patient-specific clinical information. Efforts to automate clinical data date back several decades, and have tended to focus on creation of an automated medical record. For example, in 1991 the IOM set forth a vision and issued a strong call for nationwide implementation of computer-based patient records (Institute of Medicine, 1991). But progress has been slow. It is important to recognize that a fully electronic medical record, including all types of patient information, is not necessary to achieve many if not most of the benefits of automated clinical data. For example, use of medication order entry systems using data on patient diagnoses, current medications, and history of drug interactions or allergies can result in sizable reductions in prescribing errors (Bates et al., 1998a; Leapfrog Group, 2000). The automation and linking of data on services provided to patients in ambulatory and institutional settings (e.g., encounters, procedures, ancillary tests) would provide a rich source of information for quality measurement and improvement purposes.
The challenges of applying IT to health care should not be underestimated. Consumers and policy makers share concerns about the privacy and confidentiality of these data (Cain et al., 2000). The United States still lacks national standards for the protection of health data and the capture, storage, communication, processing, and presentation of health information (Work Group on Computerization of Patient Records, 2000). Sizable capital investments will also be required. Moreover, widespread adoption of many IT applications will require behavioral adaptations on the part of large numbers of patients, clinicians, and organizations.
The committee believes solutions to these barriers can and must be found given the critical importance of the judicious application of IT to addressing the nation's health care quality concerns. The time has come to establish a national health information infrastructure that will encourage public- and private-sector investments in IT while providing adequate safeguards for consumers. As discussed in Chapter 4, a sizable portion of the resources of the recommended Health Care Quality Innovation Fund (see Recommendation 6) should be invested in projects that implement and evaluate IT applications and are likely to contribute to quality improvements.
Recommendation 9: Congress, the executive branch, leaders of health care organizations, public and private purchasers, and health informatics associations and vendors should make a renewed national commitment to building an information infrastructure to support health care delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education. This commitment should lead to the elimination of most handwritten clinical data by the end of the decade.
POTENTIAL BENEFITS OF INFORMATION TECHNOLOGY
In less than 5 years, the IT landscape has changed dramatically. The share of households with Internet access grew from 26.2 percent in December 1998 to 41.5 percent in August 2000, an increase of 58 percent in 20 months (U.S. Department of Commerce, 2000). The explosive growth of the Internet has opened up many new promising applications that have implications for the roles of consumers, clinicians, and organizations in the delivery of health care services. A recent report by the National Research Council of The National Academies identified six major health-related application domains: consumer health, clinical care, administrative and financial transactions, public health, professional education, and research (see Table 7–1) (National Research Council, 2000). Many of the applications in these domains, such as online searching for health information by patients and providers, are commonplace. Others, such as remote and virtual surgery and simulations of surgical procedures, are in the early stages of development.
TABLE 7–1
Health-Related Applications for the Internet.
- Consumer Health. A September 1999 poll conducted by Harris Interactive found that 70 million of the 97 million American adults who were online had searched for health information in the last year (Cain et al., 2000). Consumers are using the Internet to search for health information, to obtain information useful in selecting a health plan or provider, and to participate in formal and informal support groups. Comparative performance data are available on the Internet for many health plans (National Committee for Quality Assurance, 2000), and depending on the geographic area of interest, there may be relevant information on hospitals and providers. The Internet can also be used to post customized health education messages according to a person's profile and needs (Kendall and Levine, 1997).
- Clinical Care. The Internet has the potential to make health care delivery more timely and responsive to consumer preferences. As discussed in Chapter 6, the Internet is playing an increasingly critical role in making scientific publications, syntheses of the evidence, practice guidelines, and other tools required to support evidence-based practice available to both patients and clinicians. Examples of information technologies that are of growing importance in the health care arena are reminder systems (Alemi et al., 1996); telemedicine applications, such as teleradiology and e-mail; and online prescribing (National Health Policy Forum, 2000; Schiff and Rucker, 1998).
- Administrative and Financial Transactions. To date, the area in which information systems have been used most extensively in health care has been to improve the service and efficiency of various administrative and financial transactions (Starr, 1997; Turban et al., 1996). In 1999, almost 65 percent of the 4.6 billion medical claims processed by private and public health insurance plans were transmitted electronically (Goldsmith, 2000).
- Public Health. IT can be used to improve the quality of health care at the population level. Applications include incident reporting, videoconferencing among public health officials during emergency situations, disease surveillance, transfer of epidemiology maps and other image files for monitoring of the spread of disease, delivery of alerts and other information to clinicians and health workers, and maintenance of registries.
- Professional Education. The Internet can be a powerful tool for undergraduate, graduate, and continuing medical education for all types of health professionals. A variety of Internet-based educational programs have made their curricula and training materials available on the Web. There are also educational videos, lectures, virtual classrooms, and simulation programs to teach surgical skills.
- Research. The Internet opens up many options for improving researchers' access to databases and literature, enhancing collegial interaction, and shortening the time required to conduct certain types of research and disseminate results to the field. These applications are already gaining widespread acceptance.
Of course, not all computer health applications are Internet-based. There are computerized order entry systems, reminder systems, and other applications that run on legacy systems (older IT systems, often built around mainframes, owned by some hospitals, medical centers, and group practices) (Turban et al., 1996). In the future, however, the Internet will likely be the platform of choice for many if not most health applications because of the ready access it provides to both consumers and clinicians, as well as other financial and technical considerations.
It must be acknowledged that although the potential benefits of IT are compelling, the evidence in support of these benefits varies greatly by type of application. As discussed in Chapter 6, there is strong evidence to support the effectiveness of computerized reminder systems in improving compliance with practice guidelines. For computerized medication order entry systems, recent studies substantiate reductions in errors and unnecessary services, but such studies are few in number (Bates et al., 1998a). A recent review of 80 controlled trials carried out between 1966 and 1996 concluded that telephone-based distance medicine or telemedicine technologies are beneficial in the areas of preventive care and the management of osteoarthritis, cardiac rehabilitation, and diabetes care (Balas et al., 1997). In a review of 15 controlled trials in which diabetic patients received computer-generated information, it was found that 12 of the 15 trials documented positive clinical outcomes, such as improved hemoglobin and blood glucose levels (Balas et al., 1998).
In summary, the strength of the evidence on the effects of various IT applications is highly varied. Many applications, such as simulation of surgical procedures for educational purposes and remote and virtual surgery, are in the early developmental stages. Others may be highly promising, but their adoption and testing are hampered by the lack of computerized patient information (e.g., computer-aided diagnosis), regulatory or legal impediments (e.g., e-mail communications across state lines), and payment issues (e.g., for e-visits). Still other applications, such as telemedicine, have not been rigorously evaluated (Grigsby and Sanders, 1998; Institute of Medicine, 1996).
AUTOMATED CLINICAL INFORMATION
Much of the potential of IT to improve quality is predicated on the automation of at least some types of clinical data. Automated clinical data are required by many of the most promising IT applications, including computer-aided decision support systems that couple medical evidence with patient-specific clinical data to assist clinicians and patients in making diagnoses and evaluating treatment options (see Chapter 6) (Burger, 1997; Weed and Weed, 1999). Automated clinical data also open up the potential to glean medical knowledge from patient care (Institute of Medicine, 2000). An example is the extraordinary gains in cancer survival for children as compared with adults, attributable in part to the participation of virtually all pediatric cancer patients in clinical trials that systematically collect, pool, and analyze data and disseminate results to all participants (Simone and Lyons, 2000). Automated clinical and administrative data also enable many types of health service research applications, such as assessment of clinical outcomes associated with alternative treatment options and care processes; identification of best practices; and evaluation of the effects of different methods of financing, organizing, and delivering services.
Both private- and public-sector groups have identified the need to move forward expeditiously with the automation of clinical information. In 1991, the IOM issued a report concluding that computer-based patient records are an “essential technology” for health care and that electronic records should be the standard for medical and all other records related to health care. In that same year, the U.S. General Accounting Office issued a report stating that automated medical records offer great potential to improve patient care, increase efficiency, and reduce costs, and calling for the development of standards to ensure uniform electronic recording and transmission of medical information. A 1993 report of the U.S. General Accounting Office called for leadership and the acceleration of efforts to develop standards. In 1997, a revised edition of the 1991 IOM report noted the strides that had been made in the power and capacity of personal computers and other computer-based technologies, the remarkable growth of the Internet for research and some health applications, the increasing level of computer literacy among health professionals and the public, and the linkage of organizations and individuals in local and regional networks that were beginning to tackle the development of population databases.
Some health care organizations have made important advances, but overall progress has been slow. In a few large systems—most notably the health systems of the Department of Veterans Health Affairs—integrated electronic records systems have been implemented. There are also examples of robust, well-integrated hospital-based information systems (National Research Council, 2000), such as Intermountain Health Care (in Salt Lake City, Utah), but they are few and notable for their rarity. Many other organizations have automated major portions of clinical information systems—laboratory data, order entry, and the like—and others are on their way to becoming paperless in the next few years (McDonald et al., 1997; Warden and Lawrence, 2000).
There are numerous barriers to the automation of clinical information. The remainder of this section addresses four of these barriers: privacy concerns, the need for standards, financial requirements, and human factors issues.
Privacy Concerns and the Need for Standards
Two of the greatest impediments to the widespread automation of clinical information are the absence of national policies pertaining to privacy, security, and confidentiality and the lack of standards for the coding and exchange of clinical information (e.g., definitions and nomenclature, patient identifiers, and electronic transfer) (Dwyer, 1999; Kleinke, 1998; McDonald, 1998; U.S. Department of Commerce, 1994). Indeed, the issues of protecting privacy and data standardization are closely interrelated. In 1998, for example, plans of the Department of Health and Human Services to issue recommendations for establishing unique patient identifiers were put on hold in response to public outcry over potential violations of medical privacy (Goldman, 1998).
There is general agreement that privacy protections are needed for consumers, but there is also recognition that unless carefully balanced, such protections may limit the future prospects of IT (Detmer, 2000a). Public opinion polls conducted during the last decade document high and increasing levels of concern about privacy, raising questions about whether people's fear of violations of their privacy may lead some to forego seeking necessary health services or to withhold personal information from clinicians (Goldman, 1998). Others point out that, if too stringent, privacy protections will impede the adoption of many IT applications critical to addressing health care quality concerns (Detmer, 2000a).
The demands of health care with regard to security and availability are both more stringent and more varied than those of other industries (Institute of Medicine, 1994). Automated records can make it much easier for hackers to assemble lists or to find (or alter) information about individuals. At the same time, there are many different sources and types of health data, and clinical information must be available to all clinicians and others involved in care delivery whenever needed. Well-crafted policies can be implemented to ensure timely access for those with a valid need to access the data, including treating clinicians and patients, while denying access to unauthorized users. Information security technologies, such as encryption, authentication of both the sender and receiver of data, and audit trails to detect unauthorized users, are available to support such policies (Detmer, 2000a; National Research Council, 1998; U.S. General Accounting Office, 1999). Legal enforcement of privacy and confidentiality rights with strong remedies can serve as both a deterrent to unauthorized users and a method of redress for individuals whose privacy rights have been violated.
The lack of commonly accepted definitions and nomenclature for the collection and coding of data and standards for the exchange of information has also been recognized as an obstacle to broad adoption of clinical information technologies (Dwyer, 1999; Kleinke, 1998; McDonald, 1998; U.S. Department of Commerce, 1994). Data standards are needed to facilitate sharing and communication of the data across different health care information systems, and to ensure that the data are complete, accurate, and comparable (National Committee on Vital and Health Statistics, 2000). Numerous groups, including the American National Standards Institute's Healthcare Informatics Standards Board, High Level 7, the American Sociey for Testing and Material, the American Standards Committee, the Institute of Electrical and Electronics Engineers, international organizations, and numerous governmental groups, have developed standards for claims forms, datasets, diagnostic and procedure classifications, vocabularies, and messaging formats (Agency for Healthcare Research and Quality, 1999; Cushman and Detmer, 1998). The Library of Medicine has made extensive efforts to standardize vocabulary (including the construction and maintenance of a metathesaurus as part of the unified medical language system). But these efforts, as important as they are, amount to a patchwork of standards that address some areas and not others, and are not adhered to by all users.
To begin addressing the need for comprehensive national standards, Congress passed the Health Insurance Portability and Accountability Act in 1996, creating a federal mandate to develop standards for all electronic health transmissions (Health Care Financing Administration, 2000). The law directed the Secretary of Health and Human Services to make recommendations to Congress regarding the privacy of individually identifiable health information by August 1997, and if Congress failed to pass privacy legislation by August 1999, the Secretary of DHHS was directed to issue health privacy regulations by January 2000. The law also provided that the National Committee on Vital and Health Statistics was to report to the Secretary of DHHS by August 21, 2000, on recommendations and legislative proposals pertaining to data standards for patient medical record information (National Committee on Vital and Health Statistics, 2000).
Congress failed to enact legislation implementing a comprehensive package of privacy protections by the August 1999 deadline. Therefore, DHHS worked to develop these regulations, based on the Secretary's recommendations to Congress in 1997 (U.S. Department of Health and Human Services, 1997). These regulations were extremely controversial and generated over 50,000 comments when published in proposed rulemaking form. However, DHHS was able to finalize and announce them in December 2000 (U.S. Department of Health and Human Services, 2000).
DHHS also has efforts under way to develop national standards for the definition, collection, coding, and exchange of patient medical record information, but progress has been slow. In July 2000, the National Committee on Vital Health Statistics forwarded a report to the Secretary of Health and Human Services addressing a variety of process, technical, organizational, financing, and other issues related to the development of national standards (National Committee on Vital and Health Statistics, 2000). Some progress has been made toward developing coding standards for data elements; however, none has emerged as a comprehensive standard (Institute of Medicine, 1997), and, as noted above, the adoption of a standardized health identifier has been suspended. Chief information officers and other health care executives have reported they do not believe that health records can be restructured to comply with electronic formats in the time frame required by the law (Shinkman and Jonathan, 2000).
In the absence of strong national leadership in establishing standards and defining appropriate legal and regulatory structures for an IT-driven health care delivery system, states and various branches of the federal government have responded to issues and concerns primarily on an ad hoc basis. For example, more than two-thirds of states have made legislative efforts to affect various types of health information practices, resulting in an increasingly complex array of laws (Cushman and Detmer, 1998). In other instances, existing legal and regulatory structures are being applied to IT issues, creating confusion and probably ineffective oversight. For example, online pharmacies, whereby the physician enters orders into pharmacy computers often using a handheld wireless electronic prescription pad, have given rise to a set of jurisdictional issues. These issues relate both to federal and state responsibilities and, at the federal level, to questions about the responsibilities of different agencies (i.e., Federal Trade Commission, Food and Drug Administration, Drug Enforcement Administration, Department of Justice, U.S. Customs Service, and U.S. Postal Service) for consumer protection, rooting out of fraud and misinformation, drug quality, advertising of prescription drugs, and importation and domestic mailing of pharmaceutical products (National Health Policy Forum, 2000).
Financial Requirements
The 21st-century health care system will require a significant financial investment in information technology—far greater than current investments by most health care organizations. Capital will be needed to purchase and install new technology, while installation of the new systems is likely to produce temporary disruptions in the delivery of patient care and result in sizable short-term costs to manage the transition. Some specialized training and education will also be needed to help the workforce adapt to the new environment.
In addition, some health care organizations have invested heavily in legacy systems—older computer systems built around mainframes (Turban et al., 1996). There is no easy way to shift from such systems to state-of-the-art information systems based on an open client-server architecture, personal computer networks, and more flexible, nonproprietary protocols. These are important considerations for all health care organizations when making decisions about investing in IT. Recent reductions in Medicare payments under the 1997 Balanced Budget Act have likely contributed to an even more cautious approach to long-term investment in technology on the part of many health care institutions.
Access to capital may be particularly limited for certain types of health care organizations. Not-for-profit hospitals and health plans must obtain capital from bond rather than equity markets. Many small physician group practices have a limited ability to obtain capital. Large for-profit health plans may have ready capital to invest in IT, but absent strong, long-term partnerships with provider groups, lack the leverage and incentive to implement such systems.
These capital decisions are also being made in an environment in which benefits are difficult to quantify. Unlike billing or pharmaceutical transactions, clinical transactions have only an indirect effect on profitability, and demonstrating the value of clinical information systems in improving the quality of care has been difficult although, as discussed above, evidence has begun to accumulate about their usefulness in specific settings and applications. Moreover, as discussed in Chapter 8, current payment policies do not adequately reward improvements in quality.
There are some indications that the use of IT is slowly becoming more widespread. In 1997, the health information technology industry sold $15 billion worth of products to health care organizations (Kleinke, 1998). The development of Web-based applications for use on the Internet may also open the door to new forms of financing the expenses of IT. For example, if IT shifts from an equipment purchase to a service expense, it can be bought on a monthly basis and upgraded easily in response to both technological advances and changes in medical practice. Maintaining up-to-date applications that reflect the evolution of technology and the knowledge base and making them available by subscription at a Web site rather than requiring users in individual organizations to purchase and maintain them is likely to provide great impetus for the development and use of these systems.
Human Factors Issues
One of the most challenging, and least understood, barriers to the application of useful information technologies in health care relates to human factors. These barriers include both workforce and patient issues.
The health care sector is labor-intensive, with about 700,000 physicians, over 2 million nurses, and many other health care workers being involved in the delivery of patient care to varying degrees (Health Resources and Services Administration, 2000). The workforce is highly variable in terms of IT-related knowledge and experience, and probably also in terms of receptivity to learning or acquiring these skills. Some clinicians may also be wary of embracing new IT applications because of frustrating experience with earlier IT applications that failed to prove useful in solving diagnostic and therapeutic problems (Kassirer, 2000). Moreover, the development of new data infrastructures and the incorporation of new IT applications into clinical practice generally entails disruptions in patient care, resulting in lost revenues for many clinicians.
Many IT applications require the forging of new relationships between clinicians and institutional providers, which may be slow to develop. For example, some have observed that the deeply ingrained economic distrust and cultural conflict between physicians and hospitals has impeded the adoption of IT applications that require Web-based integration (Kleinke, 2000).
IT will undoubtedly alter the clinician and patient relationship, and in some cases, these changes may be threatening to clinicians. The standardization and automation of various types of clinical data opens up many new opportunities to make comparative quality data available to consumers who must chose among clinicians, sites of care, and treatment options, and to bolster oversight and accountability programs (Kleinke, 2000). The availability of clinical knowledge on the Internet will lead to more informed patients who will be increasingly likely to question clinician recommendations.
Not all patients will embrace these new roles of IT. Although consumers are migrating to the Internet at a rapid pace, there will likely be some proportion of individuals who do not have access either by personal choice or because of economic or other constraints (Conte, 1999). Consequently, there will be a need for the health system to operate in the old and the new, automated ways in parallel for the foreseeable future (Ferguson, 1999).
NEED FOR A NATIONAL HEALTH INFORMATION INFRASTRUCTURE
Many developments now under way augur well for the future adoption of IT by the health care sector. A growing body of evidence supports the conclusion that various types of IT applications lead to improvements in safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Some progress is being made on the specification of standards for protecting privacy, and various private- and public-sector standardization efforts are being undertaken to provide the foundation for a more expansive effort focused on achieving national consensus. The extraordinary growth of the Internet has opened up a plethora of new applications; provided a highly accessible platform for tapping the clinical knowledge base, running applications, and sharing data; and lowered capital requirements.
Nonetheless, IT has barely touched patient care. The vast majority of clinical information is still stored in paper form. Only a fraction of clinicians offer e-mail as a communication option to patients (Hoffman, 1997). Few patients benefit even from very simple decision aids, such as reminder systems, which have been shown repeatedly to improve compliance with practice guidelines. Many medical errors, ubiquitous throughout the health care system, could be prevented if only clinical data were accessible and readable, and prescriptions were entered into automated order entry systems with built-in logic to check for errors and oversights in drug selection and dosing. The pace of change is unacceptably slow. Much more can and should be done.
To achieve a substantial improvement in quality, the United States, like other industrialized countries, will need to begin developing a comprehensive national health information infrastructure (Detmer, 2000b). As defined by the National Committee on Vital and Health Statistics, such a structure is “a set of technologies, standards, applications, systems, values, and laws that support all facets of individual health, health care, and public health (Work Group on Computerization of Patient Records, 2000). A national health information infrastructure is not a centralized government database, but rather “rules for the road” that offer a way to connect distributed health data in the framework of a secure network.
As discussed above, some elements of such a structure are in various stages of development, but at the current pace, many more years will be required for its completion. To further the development process, the country must move forward expeditiously with the promulgation of national standards to protect data privacy. Moreover, these standards should be reevaluated and fine-tuned periodically to strike the right balance between protecting consumer privacy and providing access to clinical data for legitimate purposes, such as care delivery, quality evaluation, research, and public health (Detmer, 2000a). A high priority for the coming 2 years should be to achieve national consensus on comprehensive standards for the definition, collection, coding, and exchange of clinical data.
As technological barriers are overcome, much greater attention should be focused on legal, societal, organizational, and cultural issues (Work Group on Computerization of Patient Records, 2000). Legal and regulatory structures that have the unintended consequence of impeding the adoption of useful IT applications must be identified and modified (Moran, 1998). Health care organizations and the health professions will need strong leadership and a clear direction as they move forward with what will be a dramatic transformation of care delivery (Shortliffe, 2000).
Finally, efforts should also be made to better inform the American public about IT issues, and to ensure that all individuals have the opportunity to benefit from the extraordinary innovations now under way. The American public should be fully informed of both the benefits and risks of automated clinical data and electronic communication, as well as the various options available for protecting privacy. Steps must also be taken to ensure that all Americans have ready access to the Internet, should they so desire, and that the benefits of IT reach practice settings that serve a disproportionate share of the most vulnerable populations.
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- Using Information Technology - Crossing the Quality ChasmUsing Information Technology - Crossing the Quality Chasm
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