Plugging Healthcare Gaps

For patients, navigating the healthcare system can be a perilous journey. Gaps in care — between family doctor and specialist or hospital and long-term care facility, for example — can lead to clinical errors or readmission to hospital.

Health information technology was supposed to address these issues. Electronic medical records, computerized physician order entry systems, clinical decision support systems, and the like have been put in place to boost efficiency and quality of care. By making health information available electronically when and where it is needed, health IT offers something for everyone. Physicians spend less time on secondary activities, such as gathering redundant information about patients’ histories, and more time delivering coordinated care. Patients get secure access to information through portals and experience fewer medical errors. Funders spend less money on unnecessary hospitalizations and tests.

Promising as they are, health IT systems don’t seem to be fulfilling their promise. They suffer from the same problem that they’re trying to solve: a lack of integration. “Many health IT systems are called integrated but they’re not really integrated,” says Shamel Addas, an assistant professor at Smith School of Business.

For Addas, an integrated health IT system shares data, information, and knowledge within practices and externally across the care network to all healthcare providers with whom patients may be interacting — from the specialist to the hospital or medical lab.

Externally integrated health IT “enables computerized surveillance and monitoring of changes in patients’ conditions across the healthcare system and identification of high-risk patients,” says Addas. “This can facilitate preventive care treatment and further improve quality of care.”

Integrated IT in Action

Addas, with research colleagues Alain Pinsonneault, Christina Qian, Robyn Tamblyn (all from McGill University) and Vijay Dakshinamoorthy (Telus Communications), had a chance to study an integrated health IT system up close. The setting: an ambulatory care environment involving outpatients, physicians, hospitals, and pharmacists. Given the many players involved, incomplete medication information, prescription problems, and delays in the detection chronic illness are ongoing issues.

Their study was a natural experiment involving 31,252 patients examined over two years. Half were enrolled in the integrated health IT system and consented to allow their primary care physician to electronically access information on their medical and hospital visits and medications. The other half were part of a control group. As each patient was enrolled in the system, a control patient who visited within two days with the same primary care physician and had similar characteristics was selected. Each matched pair was followed up for a year for assessment of outcomes.

The research team focused on two intermediate measures of quality of care — continuity of care and therapeutic duplication errors — and two key quality of care outcomes —odds of hospitalization and emergency room visits.

Continuity of care refers to patients’ perception that providers know their medical history, that different providers agree on a management plan, and that a provider who knows them will care for them in the future.

Medication errors carry serious consequences such as adverse drug events, hospital admissions, or even mortality.  

The Link to Quality Care

When the researchers studied the data, their hunches were confirmed. They found that integrated health IT had a direct effect on the quality of healthcare: those enrolled in integrated health IT were less likely to visit an emergency department. (There was little change in the likelihood of hospitalization.)

Integrated HIT also had an indirect positive effect on quality of care. There were more frequent interactions among healthcare partners in the care cycle and better continuity of care due to shared care plans and treatment protocols. A strong continuity of care was associated with a decrease in the odds of having a prescribing error.

“These systems enforce common treatment protocols and guidelines that are lacking in many healthcare systems because of paper-based communication and coordination,” says Addas.

Integrated systems can empower primary care providers to coordinate continuity of care with their patients, but only if they have the proper support

The study offers healthcare administrators two key messages. First, when designing health IT initiatives, organizations should seek an integrated solution that spans practice areas. Implementing isolated components will yield mixed results at best.

“We hear these different terms — such as EMR (electronic medical records) or EHR (electronic health records) — being offered as solutions, without a clear understanding of what they offer or how the different technology components can be deeply integrated,” says Addas. “Some think EMR is all that’s needed. But what’s important is not only internal integration but external integration as well.”

Second, given that primary care providers are naturally best positioned as the hub of a patient’s care, they should be trained and motivated to use health IT effectively. Addas says integrated systems can empower primary care providers to coordinate continuity of care with their patients, but only if they have the proper support.

Indeed, human behaviour will throw a spanner in the works of any health IT system. Many studies show doctors continue to resist technology, Addas says. Some prefer to delegate computer-based work to an administrator rather than take charge themselves. At the other extreme, some doctors focus on inputting information into a computer at the cost of paying attention to the patient in front of them.

“The notion of having integrated HIT is critical, and if it’s truly integrated it could reduce some of the barriers for doctors to adopt it,” says Addas. “But it doesn’t take the place of the human factor. There are still lots of question marks. If the behavioural issues are not resolved, it will not have a lasting impact.”

— Alan Morantz