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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 Improved Cost reduced Throughput/Flow increased Quality(defects/Scrap) reduced Inventory Reduced Space reduced Lead time reduced 60-90% 35-50% 50-90% 25-55% 60-90% 50-90% 45-75%

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 coordinated 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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