An Evaluation of the impact of health

information technology and timely availability

of visit diagnoses from ambulatory visits on
patient experience and outcomes.

1. Select three quality improvement techniques and discuss how

they may be applied to examine the effect the time to availability
of clinical information has on the quality of overall health care
delivery.

The use of sophisticated HIT could, in theory have potential significant

beneficial impacts on both the quality of the patient experience and upon
healthcare outcomes. Potential quantifiable quality benefits could
include:-

• Real time collection of clinical information for monitoring and

surveillance of the spread of catastrophic infectious diseases like
bird flu or natural disasters like hurricane Katrina.

• Improving patient experience and healthcare outcomes through

1. Improving communication and coordination between different

clinicians and Health care providers in the supply chain

2. Improving perceived patient satisfaction with healthcare quality

3. Quicker access to relevant data at point of care

4. Reducing likelihood of misdiagnosis from missing clinical data

5. Quicker correct identification and decision support diagnosis

6. A standardisation in approach and in data recording

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Three relevant quality improvement techniques that would enable these
improvements to be quantified and improvements in them to be
measured are:-

1] The application of the Six Sigma Approach using DMAIC

This approach involves the application of the six sigma structured

methodology of defining problems, measuring and analysing data,
improving and controlling process performance. The concept focuses upon
the elimination of system defects or customer dissatisfaction. It achieves
this through analysis and elimination of process variations. It is a deep
level evidence based approach to continuous process improvement.

In the context of applying this approach to examine the effect the time to
availability of clinical information has on the quality of overall health care
delivery, it focuses attention in on a number of structured steps/activities
that need to be happen.

[1] We define what the problem is and is not. We could define and group
different HIT systems i.e. basic, intermediate, and sophisticated. Establish
whether the data exists that would allow the impact that different HITs
have on timely availability of data to be collected and how this might be
analysed to understand the impact upon health outcomes. This scopes the
problem and allows for a consideration of what the issues are and are not.

[2] Measuring and Analysis of the problem. We validate the scope

problem by collecting data to refine the problem and its route causes and
determine if the exercise will yield the benefits anticipated. Here it is
useful to identify what different HIT systems are operated at different
localities and whether data can be collected on the adoption of HIT and
the timeliness of clinical data. This may be dependent upon issues like
training, take up and adoption methods and wider behavioural issues and
may be worth examining at different health centres to establish if there
are variations that need examining.

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[3] Improve and Control. Once the root causes and the hypothesis for
improvement have been formulated they can be implemented and
measured to understand their impact on the process. The whole cycle
then starts again.

Diagram 1 – Illustration of Conceptual framework of DMAIC

2]. SPC or the Use of Process Control Charts

Statistical Process Control (SPC) is another powerful technique

underpinning the six sigma approach to continuous quality improvement.
It relies upon the application of statistical techniques to measure and
determine the impact of changes in performance upon variables such as
time, defects, or complaints. Process control Charts visually show
variation around a statistical mean. There are two causes of variation
identified through SPC, the first set is common causes of variation, which
are purely random and unavoidable. The second set is assignable or
controllable variations and result from variables that can be identified and
eliminated.
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In this context, this technique is very powerful at analysing time series
data and measuring the impact of change on key variables such as
availability of data, type of HIT, and health outcomes over time. It is
particularly useful in showing real time data graphically. By using upper
and lower tolerances the impacts of changes in key variables like
availability of lab reports, scans, tests and other data can be easily
observed and quantified.

3]. Benchmarking

Because of the difficulty in accessing the impact of the adoption of HIT

within the health care sector, and its impact upon health outcomes, there
is some merit in adopting a common approach and in comparing
performance between different providers (external benchmarking)and
performance over time(internal benchmarking). This requires that a
common standardised framework of data collection of diagnosis’s and of
processes are agreed so that it is possible to then collect together
relevant data, analysis it and then benchmark or establish average and
upper and lower quartile performance. The use of benchmarking as a
measurement tool can be a key driver for improvement through providing
key information for planning activities to more accurately predict
operational factors and react faster to problems. The result is an
improved ability to reduce costs and an improvement in the quality

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In the context of this case study, benchmarking has already been applied
within the internal data analysis process. This shows that over time
availability of data has improved for different types of HIT. In turn this
allows for the evaluation of the reasons underlying different performance
levels and generates further investigation and analysis to understand the
key drivers of excellent performance. In the future benchmarking of the
impact of more timely data on individual medical outcomes would enable
the relationship between these variables to be measured and the benefits
to be quantified.

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2. Critically appraise how a leaner health care operation may be
achieved beyond the use of health information technology such as
in developing sophisticated electronic medical records. Suggest
suitable improvements with reference to appropriate just-in-time
(JIT) techniques.

The successful application of emerging sophisticated HIT coupled with the

development of electronic medical records (EMR) has the potential to
significantly impact upon the key variables of quality, timeliness, costs
and safety for patient health care. It has been shown that it can help to
reduce the time taken to correctly diagnose individual treatment(x),
standardise the process of diagnoses and treatment(y), reduce the
number of misdiagnoses (or defects) (z). It can also assist in the
elimination of waste in different processes through business process
reengineering and the reduction of repeat visits and over medication.

Lean management principles developed by Japanese manufacturing

companies are as applicable and relevant to service based industries as to
production lines. This is because Lean principles focus upon meeting
customer/patient needs through driving out waste and adding value in
every process. A process in this sense can be considered as a set of
actions or steps that accomplish complex tasks and provide value to the
patient/customer. In a lean culture these principles are achieved through
streamlining processes, reducing costs, improving quality and timeliness.
The impact of applying lean principles within manufacturing environment
is shown over.

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Table 1 The impact of lean principles in Industry

Validated Industry Averages potential range of impacts

Direct Labour/ Productivity 45-75%

Improved

Cost reduced 25-55%

Throughput/Flow increased 60-90%

Quality(defects/Scrap) 50-90%
reduced

Inventory Reduced 60-90%

Space reduced 35-50%

Lead time reduced 50-90%

Source Virginina Mason Medical Centre (a)

Suitable continuous improvements (known as kaizen) within the

ambulatory healthcare setting could be to ensure that communication
processes are streamlined. Both within the supply chain between
laboratory and health providers and also importantly between different
healthcare providers. This could be achieved through the application of
standardisation of health care recording, and systematic and wholesale
computerisation of patient records, and of diagnosis and treatment. It
could be designed or engineered to ensure that where patient’s records
indicate health issues, these could be flagged to ensure that reporting
procedures for critical and important results were appropriate and
proportionate and standardised.

This would help to confirm correct diagnosis and assist healthcare

practitioners to identify the right and correct prognosis, in light of the
patient symptoms and medical history. This could ensure that only

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appropriate and timely tests were carried out and those results were
electronically transferred to practitioners in sufficient time to assess and
correctly medicate patients. If reporting procedures for critical laboratory
responses were appropriate, and electronic notes and procedural notes
were available to aid diagnosis, there could be an increase in quality and
a reduction in waste either in time or in number of misdiagnoses.

However it is equally important to recognise that the introduction of HIT

and the computerisation of patient records will not of itself automatically
generate a leaner health care operation. It requires intelligent thought
from start to finish and involves the application of leadership and cultural
change.

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3. Assess the alternative capacity plans in coping with demand
fluctuations in ambulatory visits.

There are 3 pure alternative capacity plan options available to an

organisation according to Slack et al, these are

1. Level Capacity planning – ignoring fluctuations in demand and

supply and keep activity level constant

2. Chase Demand Planning – Adjust capacity to reflect the fluctuations

in demand

3. Demand Management – Attempt to change demand to fit capacity

In practise organisations use a mixture of all three strategies or tactics,

although often one predominates.

Level Capacity Planning.

Is more usually applied to manufacturing rather than a service area, when

demand is low production can be stored as inventory to meet demand
when it exceeds production capacity. In the context of an outpatient’s
service where in the short term the number of doctors is fixed, if capacity
is set at a high level, then there will be considerable waste as a result of
periods of low utilisation. Alternatively if capacity is set at below forecast
peak demand then a waiting list must be applied and customer service
and satisfaction may deteriorate.

Chase Demand Plan.

This strategy centres around adapting capacity to chase or meet forecast

demand, through the use and application of varying levels of resources.
This has serious constraints if the input resources are limited as in this
case, and brings with it issues around maintaining quality and consistency
of customer service levels.

Manage Demand Plan

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This strategy seeks to influence demand through the application of pricing
strategies, such as discounts and promotions. Although successful in
some service based sectors, where demand is seasonal likes hotels, and
holidays, its relevance here is not obvious, since price is not normally a
consideration in making an outpatients visit. However if viewed from the
perspective that appointments are managed through the use of a queuing
system then the relevance and application this strategy to outpatients
visits becomes more obvious.

Alternative Capacity Plans applicable to Outpatient visits

Background

This area is a service based, customer focused process. The operating

capacity of the surgery or outpatient’s clinic is relatively fixed and stable
in the short term, with operating times usually being limited to normal
office hours, but with perhaps some flexibility to remain open early
morning or late evening to see those patients that work during the day.

Patients are generally given time slots and need to pre-book, a waiting
list process is employed and urgent cases are usually prioritised. There is
some additional capacity during the day as a result of did not attend DNA.
In 2000/1 there were 44 million outpatient appointments to consultant led
clinics in England, in addition 6 million patients (DNA) their outpatient
appointment DNA. (b).

There may be a degree of fluctuation during certain seasonal times of the

year when flu or viral deceases are more prevalent, at which time the
surgery may call on more shared locums, peripatetic or part time staffing
resources. The job is reasonably highly skilled, takes a high level of
education and has a limited pool of staffing resources available.

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Any demand fluctuations during the day, the week, the month are
predominantly dealt with by managing demand through the use of waiting
lists, queuing, and the enhanced role of nurses in medical support roles as
specialised nurse practitioners. This allows demand fluctuations during the
day to be managed. There is a trade off between the quality of the patient
experience and the length of time that they wait. The use of chase
demand capacity plans enables peaks and troughs of extraordinary
seasonal demand fluctuations to be effectively dealt with through bringing
into use additional part-time staffing capacity.

Impact of HIT on Capacity Plans

The introduction of sophisticated HIT and EMR could have two significant
impacts upon the planning, delivery and management of this service.

The first is an improvement in the productivity and experience of service

for outpatients. These include improvements in the management of
average waiting time, the actual time consumed by direct patient contact,
the timely availability of patient test results, the first time successful
diagnosis, medication and treatment of patient illnesses, the reduction in
repeat visits, and the reduction of over medication, incorrect medication
and other diagnosis delays and errors.

Secondly quantitative analysis of the root and cause of patient visits can
provide useful predictive data to identify and implement longer term
successful healthcare preventative actions and strategies to influence
ongoing demand for certain services as well as to adapt capacity and
coping behaviours to match future demand i.e. dealing with certain
healthcare needs through the employment of a surgery nurse, prescribing
gym memberships and targeting people with family histories of fatal and
debilitating illnesses such as Cancer and heart disease.

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4. Referring to the case, analyse how an appropriate TPS can ensure
efficient performance at the level of the individual appointment /
treatment.

An appropriate Transactional Processing System (TPS) is essential within

any organisation. Its primary role is performing and recording daily
transactions, through the collection, editing, correction, manipulation,
processing, storage and document production of basic business
transactional data. The basic type of healthcare data held will be data on
patients including identity, gender, date of birth, national insurance
number, address, basic visit diagnosis, socio demographic data, date and
time of clinic visit, family doctor, previous medical history, results from
other medical tests and interventions, visit notes and current medication
and prescriptions. It has a secondary role in providing key data to more
advanced decision support systems and to other information systems.

In the case study it is recognised that the use of advanced HIT improved
the timely entry of diagnosis on the day of visit from 13% to 96% over
the period from 2004 to 2006 (1). This is an example of the improved
online data entry, processing and manipulation of sophisticated HIT over
more basic HIT. The more timely production of patient visit data at the
point of care ensures that the quality of patient treatment is more
effective and efficient. The case study identifies 3 main potential sources
of delay within the process:-

1] Clinician and systematic delay, this is addressed by more timely entry

of data, and a reduction in the data input steps required

2] Clinical information delay, this is addressed by the swift access of

results from laboratories and radiology’s to both the ordering clinician and
other health care providers

In certain situations such as patients presenting and representing within a

short space of time with a chronic disease that requires the input of more

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than one medical practioner, TPS potentially allows better communication,
co-ordination of care and medical management. As patient records are up
to date, it is possible medical treatment of the patient to be effectively co-
ordinated between a range of practioners at different medical institutions
or within different specialism within the same institution.

In addition TPS can be used to standardise processes to reduce and

eliminate medication errors. The Audit Commission(5) identified that

“medication errors may occur from the initial decision to prescribe to

the final administration of the medicine... Most errors are caused by
the prescriber not having immediate access to accurate information
about either the medicine (its indications, contraindications,
interactions, therapeutic dose, or side effects); or the patient
(allergies, other medical conditions, or the latest laboratory results).”

It is possible for a TPS to identify incorrect data, i.e. data outside of

normal ranges, to force clinicians to follow a systematic process and not
cut corners, to validate errors of omission, commission and transposition
upon data entry and to identify if medication is required or should be
stopped. It is however possible for errors incorrectly attributed to a
patient at the time of charting to be carried over without resolution or
challenge. The use of TPS ensures the elimination of Hand-written notes
which could be illegible, incomplete, subject to transcription errors. The
reduction in serious medication errors as a result of TPS has been
estimated at 53% - 83%.(5)

Other studies indicate that regular computer tracking of dosages could cut
errors anywhere from 28 percent to 95 percent. In addition computerized
physician order entry (CPOE) - has the potential to prevent up to 84
percent of dosage mistakes (6). This highlights the importance of real
time TPS in supporting decision support systems to reduce medication
errors. Clinicians require immediate access to high quality timely EMR

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combined with real-time alerts on medication use to order to identify
errors of omission and commission.

TPS can also enhance the productivity and quality of the ambulatory
system by providing functions like enhanced referral tracking and
automatic reminders aimed at reducing missed appointments. The cost to
the NHS in 2000 from missed appointments or DNA is significant at
around 12.5% of all outpatient appointments in 2000. This adversely
impacts on the NHS’s ability to plan and deliver timely service provision
(Wanless Review).

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5. Identify and evaluate two strategic advantages that the Health
IT (HIT) could deliver (either as it is, or with your recommended
enhancements).

Two strategic advantages the HIT could deliver are firstly the
development of effective, national and local focused strategies for the
implementation of appropriate early preventative health intervention and
secondly in the identification, surveillance and monitoring of infectious
diseases and in dealing with natural disasters,

The development of Predictive Modelling and preventative healthcare

The availability of high quality timely and consistent information through

electronic databases is of enormous strategic use in the early prevention
of deceases and their treatment. This data can be warehoused and made
available for data mining. It offers a powerful means to deliver assist in
the identification of trends and the generation of data that could be used
in to determine cause and affect scenarios for different deceases.

• The NHS could predict who is at-risk for developing certain

conditions.

• It could also identify patients already diagnosed, who are most

likely to develop future complications, and provide preventive
interventions instead of more expensive treatments that may
otherwise be required for acute episodes.

• It could discover previously unrecognised patterns

• It can be used be used to review, monitor and compare the

performance of different clinicians in different parts of the country
and highlight instances of best practice.

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A prerequisite for this to happen is the development and availability of
high quality EPR. This would provide data mining with large volumes of
structured data including coded clinical information, laboratory test and
results, observations, and evidence based clinical assessments. This data
would form the foundation of improved “business intelligence” that could
be used successfully to improve national health care and to prioritise
scarce resources to where they would have most benefit.

2. Identification, surveillance and monitoring of infectious diseases and in

dealing with natural disasters,

Improved systematic data gathering would improve the availability,

timeliness and frequency of data analysis. Manual and basic HIT systems
would make this process administratively difficult, costly and would have
taken too much time. Internally generated and externally monitored
quality improvements will, of course, not only improve patient experience
and outcome but they will, as in all organisations, contribute to cost
containment and improved resource allocation.

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