Using health IT to improve patient-centered outcomes: a population health perspective

Introduction/Background

Scope of issue

How the Health IT can be used effectively to increase the satisfaction, overall patient experience, and other patient reported outcomes?. This paper is attempting to study and examine in detail the missing opportunities in using the Health IT to bring about the patient satisfaction, and also where any project within this broad scope has been taken up and failed to achieve the objectives?.

One of the triple aims of the Institute of Health Care Improvement(IHI) is to improve the patient experience of the care, the other two are aimed at improving the health of the population, to reduce the cost of the health care. In fact, improving the patient experience of the care is ordered as  the first of the priorities. In the present models, there are not very many examples where the patient experience is properly measured and health care provider or the hospital is incentivized penalized financially for that. The present model of healthcare revolves around  the effective ways of meeting the cost of the healthcare, and the ways to reduce them. Once the policies aim at reducing the cost of the healthcare, it is important that we measure the quality of care and patient experience of care and ensure that these two are not negatively affected when we aim to reduce the cost of the healthcare for the population.

Current literature/current practice

Institute of Medicine’s “Quality Chasm” report outlines the following six aims of the core healthcare need. They are Safe, Effective, Patient Centered, Timely, Efficient, Equitable. The “Patient-Centeredness’” is defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions”[1]. Picker’s institute has identified 8 principles of patient centeredness of the health care. They are 1. Access to care, 2. Continuity and transition, 3. Involvement of family and friends, 4. Emotional support, 5. Physical comfort, 6. Information and education, 7. Coordination and integration of care. 8. Respect for patient’s preferences. These dimensions are often called Picker’s principles of patient centeredness of the healthcare[2]. According to Gerteis et al., the term “quality of care” consists of two aspects in general 1. Technical ability or skills of the staff and system to achieve what it is meant to achieve professionally. 2. Subjective experience of the patient who undergoes this experience in a health care system. The second aspect is called the Patient-centeredness in the health care2. This concept of patient-centeredness is the response to the growing specialisation, sophistication and segmentation of the medical profession and the resulting perceived dehumanisation and associated frustration of the patients2. Increasingly the patient centred care is adopted by many countries to improve their quality of the healthcare to the patients. Insurance payments are increasingly linked to the patient centred care. Patient centred care is the art of the personal, professional and organisational relationships. Ronald et al criticizes that the electronic health records per se cannot be considered to improve the health care unless they improve the one of the identified aspects of the patient centred care, like if it improves the patient-clinician relationship, promotes the communication about the things that matter, giving more information about their health to patients[3]. Hudon et al in their publication in Annals does a comprehensive review of the methods to measure the patient centeredness and assess them for meeting the necessary standards of the patient centeredness. Finally he concludes that many of the measuring tools and surveys don’t address the concept of the patient centeredness clearly or fully. One of the reason for that is the confused understanding of the patient centeredness[4][5].

For comparing the overall quality of the health care among the various entities, consumer assessment of health plan survey(CAHPS) is widely adopted in the united states. This only includes 3 questions about the patient centred care. To improve the patient centred care, we need to adopt more standardised surveys designed to assess the patient centred care, standardised patients, direct observation are required to assess the PCC. The patient centred care should be developed working with the patient, families, clinicians, health systems[6]45[7].Patient reported outcomes, such as health related quality of life, satisfaction with care, trust, psychological well being and utility of preferences are important things to be considered4[8][9]

Focus of this paper

This paper  proposes a Health IT solution, to use standardized measuring instrument, either like PPPC of Canada or CCM of Great Britain and getting the feedback in the questionnaire from the patients either immediately after the consultation or by sending a mail with the link, after consultation is over, so as to capture the feedback in the questionnaire and synthesize an comprehensive score created through population health analytics tools. This ‘individual interaction score’ is assigned  to each patient-provider interaction or each patient-hospital interaction. The hospital or the provider also will be assigned a calculated cumulative comprehensive score calculated by the analytics algorithms keeping all aspects of the patient centered care in perspective and by accumulating the individual interaction scores.

Methods

Literature search strategy

The literature search is taken up using the Welch Library resources to search for the relevant article. I used the PubMed database. In addition to this I used Google Scholar Search also. But most of my results are from the PubMed search. Initially I used the search term “Patient Centered Care”, “Population IT Patient Centered Care”, “Health IT”, “Health IT  Patient Centered Care”, “Health informatics  Patient Centered Care”. There are 223 articles in total returned after the search. Initial scrutiny was done by studying the research headlines. Many of the articles are individual research articles focused on a single study question. I have narrowed down to 32 articles. I studied their abstracts and then the relevant articles in my judgement were 11. Those articles were read completely. In addition to the PubMed Search, some of the important documents from the Institute of Medicine, WHO are all downloaded from their respective sites after a direct google search.

I focused on the 1). Hudon et al’s Measuring Patients’ Perceptions of Patient-Centred Care4: A Systematic Review of Tools for Family Medicine, which gave the overview of the different scales used in the PCC and graded them based on the Stewart’s model. 2) Institute of Medicines “Quality chasm” report of 2001 which in detail discussed the concept of the patient centred care and different aspects of the PCC1. 3) Dr Karan Lux ford’s article Patient centred care[10]: Improving quality and safety by focussing care on patients and consumers. In the discussion paper, the author gave 16 policy recommendations in the Australian context to implement the PCC effectively and nationwide. This helped me to understand where the policy areas one needs to intervene to implement this concept nationwide. 4)Ronald et al’s editorial article “The values and value of patient centred care” explains about the confusion around this concept and how different stake holders are understanding this concept differently. He gave thorough clarity of the concept and addressed the perceived  conflict this concept has with evidence based clinical practice. 5). The Gogovar’s article explains the concept, implementation and challenges in the Canadian context in a small group2. 6). Long’s article Patient Satisfaction and Healthcare Utilization Using Telemedicine in Liver Transplant Recipients studies the implementation of the telemedicine in the liver transplant patients and the conducts the survey to measure the patient satisfaction and arrives at the conclusions about the patient centered care in this aspect[11].

In addition to that I read all the reference articles I have included in the endnote as they are connected to either the concept of the patient centered care or health IT implementation in the patient centered care.

Conceptual framework

1. Standardizing and using a specific scale which is enabled to measure all the recognized dimensions of the Patient centered care and brings out a comprehensive score for hospital or for the provider.
2. Integrating this scale with the existing EHR software, so that the survey is conducted at the end of the patient-provider interaction or at the end of the patient-hospital interaction for inpatients. This collected questionnaire shall be included as part of the patient record linking it with their ID(Primary Key).
3. Using suitably designed population health analytics software and algorithms to bring about a comprehensive score for hospitals, providers based on the patient survey and to accurately reflect all aspects of the PCC enlisted in Stewart’s model of PCC5.
4. The policy changes required to bring about incentives based on the collective patient centered care score earned by the provider or the hospital, so that the patient centered care is measured and incentivized.
5. The plan will be implemented through the health IT system. Mobile devices will be used to administer these questionnaires in their personal devices. The suitable algorithm and analytics software will be modeled to predict the scores accurately using  inhouse software engineers.

Results

Gaps in literature or practice

1. Concept: Key dimensions of the patient centered care, as per the Pickers institute for common wealth fund are 7 fold. They are as follows. (1) respect for patients’ values, preferences and expressed needs; (2) coordination and integration of care; (3) information, communication and education; (4) physical comfort; (5) emotional support and alleviation of fear and anxiety; (6) involvement of family and friends; and, (7) transition and continuity. There are totally 7 articles can be clubbed under this category.
2. Methods of measurement: These all the dimensions can be measured either by direct observation, clinician observation, patient observation. Among these, the patient observation is found to be the effective  way of obtaining the feedback. 4 articles can be clubbed into this category.
3. Scale: Then comes the standardisation of the questionnaire and best practices around the world. 3 articles can be clubbed into the category.
4. Integrating Health IT: Finally the use of Health IT to capture the information and integrate them with the existing population health software to use it for population health analytics and better patient centred care for the population. There are not many articles in this dimension. The existing articles are also about the small scale implementation in the research context[12]. 4 articles can be approximately clubbed into this category.

A range of international organizations provide frameworks and tools to implement the Patient Centered Care. Examples include the US based Institute for patient and family centered care and planetree. Although they provide on the patient centered care, use of health IT to implement the patient centered care is not well covered.

Proposed health IT solution

Proposed health IT solution is to administer a standardized questionnaire to get the feedback from the patients and administer them through a mobile based app. This standardized questionnaire will be linked using the patient ID as the unique ID.  This will be part of the existing Electronic health records of the patient. The questionnaire will appear in the app or through an email link or message link to the patient’s mobile devices as soon as patient completes the provider-patient interaction or hospital-patient interaction. A individual provider- patient interaction score will be generated through a software using population health analytics and combined institutional score will be generated using appropriately designed population analytics software. The individual interaction score  generated by the computer algorithm will be stored for each interaction. Cumulative score will be prepared for each provider or the hospital.

Data sources and variables:

The data source will the survey questionnaire. These are mainly categorical variables for each question. This will be formatted through the drop down box in the form. The computer model will calculate the total score based on the inputs for each question. Total cumulative score will reflect how well all the dimensions of the patient centered care is served by the hospital. How satisfactory is the interaction. Possible patient reported outcomes can also be categorized and it can be served as drop down menu on the questionnaire. All the answers to the questionnaires will be categorical variables.

Interoperability:

The questionnaire must be programmed using the front end application and language used for the EHR, and the same underlying relational database. But the question of interoperability will be an issue if the information has to be exchanged through HIE to for example other hospital, where they may be using different systems. To solve this issue, it’s important to standardize the questionnaire and standardize the answers, preferably assigning codes for each question and answers in the background. These standardized codes then can be easily exchanged across multiple systems and can be stored in the central server and retrieved.

Challenges:

The most important challenges will be to standardize the questionnaire and the responses. How accurately the cumulative score on the patient centered care is calculated based on the inputs in the questionnaire. How accurate this score reflects the patient centered care covering all dimensions. Second most challenge will be to standardize the questions and answers, further assigning standard codes to them. Third how these questions will behave in the real world with patients who have variety of socio economic conditions and backgrounds. There will be subjective difference in understanding these questions. How we will be accounting for these variances. Last challenge will be to design the algorithm to bring about an individual interaction score and cumulative hospital or provider score which reflects all aspects of the PCC by the Stewart’s model.

Standardization of the questionnaire is not the challenge of the IT department.  I think this must be done in something similar manner like we handled the International Classification of Diseases standards/codes, or other similar codes for procedures, prescriptions, SNOMED etc. We need to form the national association or professional body which should deliberate and form the codes and standards. Till then, if we are implementing this at the smaller level for example in a Accountable Care Organization level, then we can form our own standards after internal committee deliberations, till such a national standard is available.

Discussion

Implications

It will function well within the organization like accountable care organization, patient centered medical home, managed care organization set up, because there will be no interoperability issues. The issues will crop up only when we are exchanging the data, then we need to standardize the responses and use codes for each response. Once these codes are adopted across the platforms then interoperability problem will be solved. Without the necessary policy changes to incentivize or link the payments with the patient centered care goals, this will only act as an internal feedback mechanism for the hospitals. Hence it’s important to bring about policy changes as suggested by Luxford in Australian context10, specific policy changes linking payment with achieving the different dimensions of the patient centered care.

This health IT Solution will measure the patient centered care into a numerical score one an individual interaction score and another a cumulative score for the hospital or the provider. It will enable policy makers to use this score to change the processes or systems, or train the staff to achieve all the dimensions of the patient centered care.

Limitations

1. Literature review is mostly about the questionnaire and concept. There are not many examples of implementation of the health IT available or documented in the literatures. So, we could not take lessons from the successful and failed models.
2. Proposed health IT solution will help the administrators to quantify and measure the patient centered care duly weighing all dimensions. But the real change in the systems or processes will happen generally after a policy changes which decides on the incentives and penalties for performance based on the score.

Future Work / Next Steps

We have to deliberate and arrive upon the codes for these questions and answers for easy interoperability and also to standardize the questionnaire. Suitably programming the algorithm to calculate the individual interaction score and a cumulative institutional or provider score which accurately relates to all aspects of the  Stewart’s model of patient centered care will take considerable amount to time to build models for accurate prediction.

Next important challenge is to bring about policy changes to bring about incentives or penalties in the payment system so that the organizations take this PCC Scores seriously and bring about process and system changes.

References

:References

[1] Institute of Medicine. (2018). Quality chasm 2001 report Institute of Medicine. Retrieved from http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf

[2] Gogovor, A., Valois, M., Bartlett, G., & Ahmed, S. (2018). Support for teams, technology and patient involvement in decision-making associated with support for patient-centred care. International Journal for Quality in Health Care, doi:10.1093/intqhc/mzy224

[3] Epstein, Ronald M., MD|Street, Richard L., PhD. (2011). The values and value of patient-centered care. Annals of Family Medicine, 9(2), 100-103. doi:10.1370/afm.1239

[4] Hudon, Catherine, MD, MSc, CFPC|Fortin, Martin, MD, MSc, CFPC|Haggerty, Jeannie L., PhD|Lambert, Mireille, MA|Poitras, Marie-Eve, RN, MSC. (2011). Measuring patients’ perceptions of patient-centered care: A systematic review of tools for family medicine. Annals of Family Medicine, 9(2), 155-164. doi:10.1370/afm.1226

[5] Stewart, M., Brown, J. B., Donner, A., McWhinney, I. R., Oates, J., Weston, W. W., & Jordan, J. (2000). The impact of patient-centered care on outcomes. The Journal of Family Practice, 49(9), 796. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11032203

[6] Poitras, M., Maltais, M., Bestard-Denommé, L., Stewart, M., & Fortin, M. (2018). What are the effective elements in patient-centered and multimorbidity care? A scoping review. BMC Health Services Research, 18(1), 446-9. doi:10.1186/s12913-018-3213-8

[7] Wilkins, C. H., Villalta-Gil, V., Houston, M. M., Joosten, Y., Richmond, A., Vaughn, Y. C., . . . Wallston, K. A. (2018). Development and validation of the person-centeredness of research scale. Journal of Comparative Effectiveness Research, doi:10.2217/cer-2018-0046

[8] Weingessel, B., Schütze, C., Haas, M., Wienerroither, N., & Vécsei-Marlovits, P. V. (2018). A novel method to evaluate quality of care from the perspective of cataract patients. Eye (London, England), doi:10.1038/s41433-018-0295-9

[9] Christalle, E., Zeh, S., Hahlweg, P., Kriston, L., Härter, M., & Scholl, I. (2018). Assessment of patient centredness through patient-reported experience measures (ASPIRED): Protocol of a mixed-methods study. BMJ Open, 8(10), e025896. doi:10.1136/bmjopen-2018-025896

[10] Luxford, K., Safran, D. G., & Delbanco, T. (2011). Promoting patient-centered care: A qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. International Journal for Quality in Health Care, 23(5), 510-515. doi:10.1093/intqhc/mzr024

[11] Le, L. B., Rahal, H. K., Viramontes, M. R., Meneses, K. G., Dong, T. S., & Saab, S. (2018). Patient satisfaction and healthcare utilization using telemedicine in liver transplant recipients. Digestive Diseases and Sciences, , 1-8. doi:10.1007/s10620-018-5397-5