Achieving measurable care quality improvement is a healthcare imperative. Electronic clinical quality improvement (eCQI) is an approach to this goal that optimizes Health IT applications, including clinical decision support (CDS – helping clinicians, patients and others make effective care decisions) and electronic clinical quality measurement (eCQM – helping to evaluate care provided) within widely used clinical quality improvement (CQI) processes [PDF - 1.7 MB].

This page outlines helpful steps that office practices, hospitals, and their partners can take to enhance care processes and outcomes targeted for improvement.

  

Start QI Journey

Understand Health IT-enabled QI

Select Target(s); Initiate QI Project

Document / Analyze Flows, Indentiy Improvements

Implement & Evaluate Changes

Synthesize / Apply Learning

Start QI journey

• Cultivate a shared commitment within your team to improving care delivery and results, including fully leveraging Health IT capabilities. Successful QI efforts deliver a ‘win-win-win’ for patients and their care teams, as well as broader organizational goals.
• Identify and address barriers to collaboration on effective process improvement among all concerned, including providers, care delivery and quality staff, partners (e.g., health IT vendors), and patients.
• Layer the approach and tools below onto your QI methodology. If no QI framework is in place, consider building out an approach through options provided in the primer, Continuous Quality Improvement (CQI) Strategies to Optimize your Practice.

Understand Health IT-enabled QI

• Build a shared understanding about the following within your organization, and use this foundation to underpin your QI work:
  • CDS is about supporting care decisions and actions, not about interrupting workflow. There are many different ways to provide this support (e.g., CDS intervention types), and the goal is to make appropriate decisions and actions the easy ones. See the CDS tipsheet page [PDF - 1 MB] for more details, such as a CDS definition and some example intervention types.
  • CDS 5 Rights framework: a best practice QI approach to support decisions and actions that drive performance targeted for improvement. It asserts that optimizing care processes and outcomes requires getting the right information to the right people in the right formats through the right channels at the right times. The tools and approaches outlined below help organizations implement this framework and enhance the contributions, experience and results for those involved in care delivery.
• Focus on People, Process, and Technology (in that order), recognizing that engaging everyone involved is critical for success.
  • Tasks and Key Lessons [PDF - 67 KB] from each chapter in “Improving Outcomes with Clinical Decision Support, and Implementer’s Guide, 2^nd Edition” provide detailed guidance on critical things to know and do for successful CDS-enabled QI programs and interventions.
  • See this document [DOCX - 29 KB] for tips on how to cultivate collaboration among provider organizations, quality organizations, and HIT vendors.
• Become familiar with the Health IT-enabled QI (eCQI) worksheets, which will underpin subsequent work:
  • The Essential eCQI worksheet is best used for initial documentation and analysis of target-focused information flows and workflows and improvement opportunities. There are versions for both inpatient [PDF - 2.1 MB] and outpatient [PDF - 2.1 MB] targets.
    • View the Tutorial [PPTX - 957 KB] [PDF - 868 KB] on how to use the worksheet
    • See a completed Outpatient Essential eCQI Worksheet Example: [Ellsworth hypertension QI case study [DOCX - 1.3 MB]]
  • Enhanced QI worksheet: similar in concept to Essential version, but with additional space to document/review optimal care activities for the target, and the individual CDS 5 Rights dimensions for the current state. Enhanced worksheets also come in versions for inpatient [PDF - 831 KB] and outpatient [PDF - 1 MB] targets. Consider using only after you are comfortable with the Essential version.
    • View the Tutorial [PDF - 10 MB]: on how to use this worksheet [Note: due to the tutorial’s large file size, we recommend that you download the file onto your computer to view in Adobe Acrobat]
    • See a completed Outpatient Example:
      • CHC Inc. hypertension QI case study [XLSX - 29 KB]
    • See a completed Inpatient Example: 
      • Society of Hospital Medicine VTE prophylaxis recommendations [XLSX - 35 KB]
• Review additional information and tools as needed by following these links:
  • Integrating Clinical Decision Support Tools into Ambulatory Care Workflows for Improved Outcomes and Patient Safety [PDF - 3.2 MB]
  • White paper from AHRQ: Using Health Information Technology to Support Quality Improvement in Primary Care [PDF - 815 KB]
  • CDS Intervention Sharing
  • How-To Guides for Clinical Decision Support (CDS) Implementation
  • Clinical Decision Support Starter Kit [PDF - 196 KB]
  • Reference Taxonomy of Clinical Workflows [PDF - 407 KB]

Select Target(s); Initiate QI Project

• Consider targets associated with reimbursement programs, such value-based payment initiatives from the private sector and CMS (including the Value-based payment modifier and EHR Incentive Programs (‘Meaningful Use’))
• Examine local performance gaps and improvement opportunities when reviewing payment drivers noted above and selecting targets
  • See this figure [PDF - 405 KB] from HIMSS guidebook "Improving Outcomes with CDS" for examples of local factors to consider in selecting targets for quality improvement intervention.
• Measure and understand your baseline performance on your target(s)
  • See eCQI Measurement page for further details

You should select quality improvement targets based on evidence, including quality measures results that show current gaps, and on practice guidelines recognized by relevant professional societies or expert advisory panels such as the USPSTF. 

Document/Analyze Flows; Identify Improvements

• Examine patient-specific and population management information flows and workflows (as well as foundational activities such as EHR configuration, policies, staff training, etc.) that are producing sub-optimal performance on the target.
  • Walk through the care process (with special attention to how the patient experiences it) and document results in the Essential QI Worksheet.
    • Inpatient [PDF - 2.1 MB] Essential version
    • Outpatient [PDF - 2.1 MB] Essential version
  • Engage all care team members in the workflow/information flow and improvement analysis– including the patient, if possible.
  • Consider using the Enhanced QI Worksheet instead of, or in addition to, the Essential Worksheet for a deeper dive into the ‘optimal state’ and the details of each CDS 5 Rights dimension. Enhanced worksheets also come in versions for both 
    • Inpatient [PDF - 831 KB] Enhanced version
    • Outpatient [PDF - 1 MB] Enhanced version
• Analyze this ‘current state’ to identify opportunities to improve target-focused information flow, workflow and results; i.e., to better address the CDS 5 Rights. Document these potential enhancements in the worksheet.
  • Consider available best practice guidelines for the target:
    • CDC Hypertension Control Change Package
    • SHM recommendations on VTE prophylaxis [XLSX - 35 KB]
  • Review case examples of successful target-focused care strategies (e.g., QI case studies published by ONC):
    • Hypertension control at CHC, Inc. [PDF - 562 KB]
    • Hypertension control at Ellsworth Medical Clinic [PDF - 249 KB]
    • Tobacco use screening and smoking cessation support at Miramont Family Medicine [PDF - 191 KB]
    • EHR Innovations for HTN Challenge results
  • Define potential enhancements by combining ‘top down’ (i.e., best practices) and ‘bottom up’ (i.e., current state analysis) approaches.
• Prioritize identified enhancements to implement
  • Identify the several that are most likely to deliver the greatest benefit in the shortest time with the least effort for initial implementation (that is, use the “low hanging fruit” approach).

Implement & Evaluate Changes

• Use a QI methodology [e.g., PDSA cycles] to implement and evaluate the prioritized changes. Pay careful attention to do this work with all the stakeholders and not to them (i.e., seek and act on team members’ (and patients’) input and feedback throughout the process).
  • Be ready to modify clinical and quality workflows, intervention details (across any of the CDS 5 Rights dimensions), and other parameters if needed as improvement cycles unfold.
• Monitor implementation activities with structured tools that help you document and manage who’s doing what when, as well as the results. See also the eCQI Measurement page for additional information about quality measurement.
  • Sample monitoring tools:
    • Worksheets [ZIP - 2 MB] from Chapter 8: Putting Interventions into Action and Chapter 9: Measuring Results and Continuously Refining the Program in “Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. Second Edition”
    • IHI PDSA
      http://www.ihi.org/resources/Pages/Tools/PlanDoStudyActWorksheet.aspx

Synthesize/Apply Learning

• Discuss project with team as it concludes to better understand what worked well, what could have been done better, and what useful tools were created.
• Apply this learning and these results to strengthen further efforts on the current target and other target-focused QI initiatives.
  • Incorporate proactively the insights and results from each QI project into subsequent QI projects.
    • Although a particular target-focused QI project may be time-limited, the QI and clinical teams should remain alert for ways to continually improve care across all targets.
  • Learning from a QI project might indicate opportunities to more broadly modify clinical and quality work and roles as well as Health IT configurations (including feedback to developers about broadly needed enhancements)

eCQI: What It Is, and How It Can Help You