The Office of the National Coordinator for Health Information Technology Health IT Playbook

Section 7

Quality & Patient Safety

Quality health care is doing the right thing for the right patient, at the right time, in the right way to achieve the best possible results. Patient safety practices protect patients from preventable harm associated with health care services. Together, care quality and patient safety improvement activities can help the health care team achieve the six aims described in the National Academy of Medicine’s (formerly the Institute of Medicine) Crossing the Quality Chasm: safe, effective, patient-centered, timely, efficient, and equitable care.

Electronic health records (EHRs) facilitate improvements in health care quality and safety compared to paper records. EHRs enable clinicians – as well as patients, and their proxies - to have access to relevant information about the patient as well as integrated best practice support in the form of electronic Clinical Decision Support (CDS). CDS provides persons involved in care with general and person-specific information, intelligently filtered and organized, at appropriate times, to help improve care outcomes by making the information needed to support sound decisions available when it is most useful to the care team.

When implemented and used correctly, EHRs provide more legible documentation that can more easily follow the patient from one point of care to another and drive EHR functionalities that improve care. EHR functionalities such as electronic prescribing and automated support for drug-drug and drug-allergy interaction checking are welcome advancements for patient safety.

EHRs also play a role in improving population health by supporting trend and outlier analysis in large amounts of aggregate health data, allowing clinicians and public health professionals to take action within their scopes of practice to improve outcomes. These population health activities are becoming increasingly important as we look to improve our nation’s health. As new care models evolve focusing on both population and patient outcomes, EHRs make meeting quality reporting program requirements more efficient for clinicians by increasingly automating the harvest of performance measurement information from data routinely captured in the course of care. Clinical quality measures that are specified in standard format for automatable, interoperable electronic reporting from the EHR are referred to as electronic clinical quality measures (eCQMs).

Like all powerful tools, EHRs carry risks with their use. However, unintended consequences can be minimized by following best practices for the design, implementation, user training, and use of EHRs. Planning is needed to get the most out of your EHR investment and to ensure its safe use. The resources provided throughout this Playbook provide clinicians with a place to start making fuller use of EHRs to improve care quality and safety.

Patient safety is freedom from accidental or preventable injuries associated with health care services. EHRs provide tools to help clinicians improve patient safety. An EHR is used as part of a larger system including the clinical team, the patient, and the supporting workflows that happen every day. The analysis of EHR safety should therefore consider the system as a whole when looking for ways to make the system safer.

ONC has worked with RTI International to produce a series of 10 webinars focusing on health IT safety. Topics include medication management, electronic ordering, documentation and usability, among others. These webinars are a great introduction to the various ways in which we can work to improve patient safety with health IT. Check back for additional resources, including an upcoming report on the safe usage of “pick lists” that are commonly used in health IT to select patients and medications.

ONC has also developed and published a set of guides aimed at helping health care organizations improve both EHR safety and the safe use of the EHR through the implementation of best practices. The SAFER (Safety Assurance Factors for EHR Resilience) Guides are organized into three broad groups. Each guide includes a self-assessment for users to help identify areas in need of improvement. Most organizations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. The guides are available as interactive PDF files that can be downloaded, filled out, saved, and shared among team members.

SAFER Guides

The SAFER Guides consist of nine guides organized into three broad groups. These guides enable healthcare organizations to address EHR safety in a variety of areas. Most organizations will want to start with the Foundational Guides, and proceed from there to address their areas of greatest interest or concern. The guides identify recommended practices to optimize the safety and safe use of EHRs. The content of the guides can be explored here, at the links below, or interactive PDF versions of the guides can be downloaded and completed locally for self-assessment of an organization's degree of conformance to the Recommended Practices. The downloaded guides can be filled out, saved, and transmitted between team members.

Foundational Guides

Infrastructure Guides

Clinical Process Guides

Resources

Summary: “Usability” is a term frequently used when discussing software, and is a very important factor in the success of an EHR implementation. The International Organization for Standardization (ISO) defines usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency, and satisfaction in a specified context of use.” In the context of health IT, usability refers to the extent to which the system supports the cognitive work of the end user, and the extent to which the design of the user interface makes it easy for the user to complete tasks while minimizing the chance of user error.

The National Center for Cognitive Informatics & Decision Making in Healthcare at the University of Texas, with funding support from ONC, created a book, Better EHR, that addresses the usability and cognitive support issues with EHR technology. The book is available for free download in PDF or iBook format from this University of Texas website.

Quality improvement is an important and established practice in healthcare. Opportunities for EHR-enabled quality improvement can be found throughout all phases of care. Clinical decision support tools help clinicians improve quality by managing and making actionable information available during care, and electronic clinical quality measures (eCQMs) help to assess important aspects of care, such as the degree to which patients have received care consistent with evidence-based clinical practice guidelines or the proportion of a clinician’s patients whose hypertension is well controlled, over a certain period. EHRs are also, increasingly, able to help streamline or even automate sharing of data with clinical data registries that use information about patient health status and care received to help clinicians choose the best courses of treatment. Here we will explain these capabilities and present how to best use your EHR to accomplish these goals.

Clinical Decision Support

Clinical decision support (CDS) refers to information and tools used to support clinicians and others in clinical decision making at the point of care. At its most basic, CDS could refer to using a reference text to double check a treatment algorithm. In the context of an EHR, CDS mechanisms can be more sophisticated, presenting relevant information at different points during the care process in order to be more useful to the clinician. CDS tools can present both general and person-specific information, intelligently filtered and organized, at appropriate times to appropriate people, including clinicians, practice staff, and patients.

Examples of CDS tools in EHRs include: health maintenance reminders; drug-drug and drug-allergy interaction checks; electronic presentation of clinical guidelines; condition-specific order sets; focused patient data reports and summaries; documentation templates; diagnostic support such as differential diagnosis tools; and contextually relevant reference information.

It is important to plan which CDS tools will be most helpful to your practice. If selecting an EHR, carefully review its CDS capabilities to see if it fits your practice needs. If you already have an EHR implemented, work with your EHR developer to enable and optimize the available CDS tools that will most benefit your patients.

Clinical Quality Measures

Clinical quality measures (CQMs) are used to measure and track the quality of health care services to find areas that need improvement, and are increasingly examined by payers as our health care system evolves. They are typically expressed as a numerator and a denominator. For example, a quality measure focusing on hypertension control for one doctor might have a denominator of “all patients with hypertension” and a numerator of “patients at target blood pressure.” CQMs generally have a target percentage and are based on evidenced-based professional guidelines. They are used in a variety of quality improvement and public reporting programs, including the Centers for Medicare & Medicaid Services (CMS). ONC currently certifies health information technology, including EHRs, to be capable of accurately calculating and reporting specified eCQMs. When implemented correctly, EHRs enable the electronic calculation of quality measures, which can be displayed to the clinician for practice improvement, and can also be transmitted to payers, thus streamlining quality reporting. For clinicians who prefer to participate in a clinical data registry for support in measuring and improving their care quality performance, properly implemented EHRs can electronically extract and transmit data captured in the course of normal care and documentation to the registry, facilitating measure calculation and feedback at a lower burden than is possible with manual methods of quality measurement data abstraction for registry participation.

Electronic Clinical Quality Improvement

Electronically facilitated clinical quality improvement uses a variety of processes and tools to help continuously improve care and support improved health. It is not only a set of health IT tools but also a process model that make effective use of technology to sustain continuous improvement cycles. The cycle begins with the delivery of care; then, measure its safety, quality, and where possible its outcomes; after this plan and implement interventions; then monitor whether these interventions are effective and adjust as needed to continuously improve results.

The current electronic quality improvement ecosystem is primarily focused on electronic clinical quality measures (eCQMs) that look back at recent activities to determine whether the evidence-based standard of care was adhered to for each patient. The next stage of healthcare quality includes advanced CDS and increasing use of end-to-end electronic quality measurement and reporting. Rather than limiting quality improvement to retrospective measurement, CMS and ONC are working to provide standards to enable CDS that uses evidence-based medicine and the patient’s own history, preferences, and data to truly customize care. This advanced CDS will be informed by the data collected through eCQM reporting, and will in turn help inform future eCQM reporting priorities as a fundamental cycle in the learning health system.

Resources

The following tools and links are provided here as references to help further your understanding of electronic clinical quality improvement.

ECQI Resource Center

Overview
This site provides access to extensive eCQI resources and connections with the community of professionals who are dedicated to clinical quality improvement for better health. The resource center has excellent introductory material describing the basics of the technical aspects of electronic clinical quality measure reporting, in addition to in depth technical details. Note: this resource contains more technical information and may not be as useful as an introductory resource

Who it’s for
Quality Improvement / health IT professionals and clinicians who want to understand more about the technical specifications for eCQM reporting

When it’s used
When planning an EHR implementation, when deciding upon and improving upon clinical quality measures

Check out the ECQI Resource Center

eCQI: What It Is and How It Can Help You

Overview
Explains electronic quality improvement (eCQI) and how medical and health professionals can use this approach to optimize Health IT applications in support of continuous quality improvement

Who it’s for
Providers and health IT professionals

When it’s used
Understanding what a practice or organization needs to do to improve upon clinical quality measures; ongoing

Visit eCQI: What It Is and How It Can Help You site

Guiding Principles for Big Data in Nursing

Guiding Principles for Big Data in Nursing

Overview
Explains role of nurses and nurse leaders in strategic planning and implementation of health information technology especially in capturing health and care data in a structured manner to use it for multiple care management and quality improvement purposes

Who it’s for
Nurses and nursing leaders, hospitals

When it’s used
Planning and implementation of Health IT or considering big data and population health strategies

Download Guiding Principles for Big Data in Nursing [PDF - 503 KB]

Health IT-enabled eCQI (Ambulatory)

Health IT-enabled eCQI (Ambulatory)

Overview
A template designed to aid in documenting and analyzing approaches to quality improvement in the ambulatory setting

Who it’s for
Ambulatory providers and health IT implementers

When it’s used
When planning quality improvement goals and enhancements

Download Health IT-enabled eCQI (Ambulatory) [PDF - 2.5 MB]

Health IT-enabled eCQI (Inpatient)

Health IT-enabled eCQI (Inpatient)

Overview
A template designed to aid in documenting and analyzing approaches to quality improvement in the inpatient setting

Who it’s for
Inpatient providers and health IT implementers

When it’s used
When planning quality improvement goals and enhancements

Download Health IT-enabled eCQI (Inpatient) [PDF - 2.7 MB]

Learning Guide: Capturing High Quality Electronic Health Records Data to Support Performance Improvement

Learning Guide: Capturing High Quality Electronic Health Records Data to Support Performance Improvement

Overview
Focuses on key considerations and implementation steps that individual physician practices and communities can use to improve EHR data quality

Who it’s for
Physician practices, hospital system and its affiliated practices, other provider organizations that are responsible for delivering high-quality care to a population of patients

When it’s used
During EHR implementation or when optimizing EHR to improve the quality of data stored in EHRs

Download Learning Guide: Capturing High Quality Electronic Health Records Data to Support Performance Improvement [PDF - 386 KB]

An example of EHR facilitated clinical quality improvement: Million Hearts®

Million Hearts® is a national initiative with an ambitious goal to prevent 1 million heart attacks and strokes by 2017. The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) co-lead the initiative on behalf of the U.S. Department of Health and Human Services (HHS).

Million Hearts® aims to prevent heart attacks and strokes by:

  • Improving access to effective care
  • Improving quality of care for the ABCS of heart health:
    • Aspirin when appropriate
    • Blood pressure control
    • Cholesterol management
    • Smoking cessation
  • Focusing clinical attention on the prevention of heart attack and stroke
  • Activating the public to lead a heart-healthy lifestyle
  • Improving the prescription and adherence to appropriate medications for the ABCS

Million Hearts® Infographic

Million Hearts® Infographic

Visit the Million Hearts® website

Hypertension Control Change Package

Hypertension Control Change Package

Overview
Lists process improvements that ambulatory clinical settings can implement as they seek optimal hypertension (HTN) control; aslo includes how to use EHRs to improve processes

Who it’s for
Ambulatory practices

When it’s used
When implementing population health initiatives

Download Hypertension Control Change Package [PDF - 680 KB]

Million Hearts® EHR Optimization Guides

Overview
Illustrates how providers can use their EHRs to find, use, and improve data on Million Hearts® clinical quality measures. Cerner, NextGen and Allscripts provide guides for their products

Who it’s for
Ambulatory practices

When it’s used
When implementing population health initiatives

Visit the Million Hearts® EHR Optimization Guides site

Million Hearts® Resource Center

Overview
Provides resources for providers and practices about the Million Hearts® initiative; Includes Million Hearts® EHR optimization guides as well as information about how Regional Extension Centers (RECs) are supporting the Million Hearts® Initiative

Who it’s for
Ambulatory practices

When it’s used
When considering or implementing population health initiatives in the ambulatory setting

Visit the Million Hearts® Resource Center site

Section 7 Recap

Provide safe, effective, patient-centered, timely, efficient, and equitable care.

  • Use health IT to improve patient safety
  • Learn about usability
  • Improve quality with EHR technology

Join the conversation.

Let us know how we can improve and expand on Quality and Patient Safety.

Content last updated on: January 23, 2017