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September 2013 (Volume 91)
September 2013 | Bradford H. Gray
Health care providers in the United States are moving from paper to electronic medical records, a transition that already has occurred at some leading organizations. Kaiser-Permanente, Intermountain Healthcare, Geisinger Health System, and the Veterans Health Administration are among the more notable examples. In the past, The Milbank Quarterly has published both optimistic and cautionary articles about electronic health records (Blumenthal 2002; Greenhalgh et al. 2011).We begin this issue, however, with an example of the positive effects that the adoption of information technology can have on health care.
In “Improving Quality and Safety of Care Using ‘Technovigilance’: An Ethnographic Case Study of Secondary Use of Data from an Electronic Prescribing and Decision Support System,” Mary Dixon-Woods and her colleagues present a case study of how the electronic prescribing and decision-support system in a large British hospital was used to create a safety-improvement system that the authors call technovigilance. The article is based on extensive observations and informal conversations in clinical settings as well as interviews with senior executives and a review of relevant documents. The authors describe and analyze the crucial steps, which began with the creation of a database from a system that was designed for functional clinical purposes (the electronic ordering of prescriptions) and led to improvements in patient care.
These steps included the creation of performance measures (e.g., the number of omitted doses of prescribed medications) that could be linked to particular individuals, teams, and clinical services; the provision of feedback to the relevant individuals; and the development of systems to improve safety and quality. Dixon-Woods and her colleagues explain how patient care was improved through the secondary use of the information in an electronic prescribing system, and they also describe the possible undesired and unintended consequences of this approach, such as the loss of attention to aspects of patient care not made visible by the monitoring system.
The article by Dixon-Woods and her colleagues is followed by a brief commentary by David Bates in which he provides some American context for their example. He notes that the computerization of medical care will make it possible to routinely assess performance on many key processes—the use of medications being one—as well as how providers respond to such forms of clinical decision support. He also argues that if electronic health records are to improve quality, they must either include or be linked to tool kits that facilitate the kinds of activities that Dixon-Woods and her colleagues describe.
The next article in this issue—”High-Reliability Health Care: Getting There from Here” by Mark Chassin and Jerod Loeb—is also concerned with quality improvement. As leaders of the Joint Commission, a major health care–accrediting organization in the United States, Chassin (the president and CEO) and Loeb (the executive vice president for health care quality evaluation) describe the quality problems pervasive in American health care organizations, as well as the characteristics and principles of organizations from fields other than health care that have achieved high reliability in achieving safety and preventing errors.
Chassin and Loeb then outline a quality improvement framework with three dimensions of change: leadership, safety culture, and robust process improvement. Each of these dimensions has multiple components (a total of fourteen), which are differentiated as four stages of maturity against which an organization can be measured. This framework, the authors say, underlies the Joint Commission’s approach to moving health care further and faster toward high reliability, which is important to health care providers, professional organizations, regulators, payers, and patients alike.
The next article in this issue is concerned with why people use health services. This is both one of the oldest topics in health services research and an important element of many strategies to improve service use and contain costs. The topic has been explored by researchers with clinical, economic, and sociological perspectives. Psychologists’ insights have been much less common, but these are the subject of “Is Personality Associated with Health Care Use by Older Adults?” by Bruce Friedman, Peter Veazie, Benjamin Chapman, Willard Manning, and Paul Duberstein. The article briefly reviews the existing research evidence and reports the results of a survey conducted in nineteen counties in West Virginia, Ohio, and western New York State as part of the evaluation of the Medicare Primary and Consumer-Directed Care Demonstration. The survey collected data allowing the researchers to link individuals’ use of health services to a set of (1) predisposing characteristics, (2) enabling factors, and (3) need variables. The predisposing variables included a widely used sixty-item personality inventory whose dimensions included Openness to Experience, Conscientiousness, Neuroticism, Extraversion, and Agreeableness. The authors found several relationships between personality traits and different types of health care use, providing evidence that efforts to understand, and perhaps to modify, patients’ use of health services should consider the role of personality traits in addition to other factors. This research could have significant implications for the design of insurance benefits and efforts to improve appropriateness in the use of health services.
Ethical principles for allocating scarce resources have not been prominent in health care policymaking in the United States, and explicit mechanisms for rationing are uncommon. Organ transplantation, in which the need for and the supply of organs are discrepant, has been an exception. Both bioethicists and the United Network for Organ Sharing, which oversees the allocation of organs for transplantation, have tried to establish principles for deciding which patients should be given priority for available organs. This issue was in the headlines this year with the highly publicized Pennsylvania court case concerning the relative priority given to a pediatric patient awaiting a lung transplant.
The next article in this issue, “Tragic Choices and Moral Compromise: The Ethics of Allocating Kidneys for Transplantation” by Barry Hoffmaster and Cliff Hooker, offers a fresh analytic perspective on this topic. Although almost 100,000 people are on the waiting list for kidney transplants, fewer than 17,000 received transplants in 2012, necessitating difficult decisions about the allocation of the scarce organs. Hoffmaster and Hooker apply Calabresi and Bobbitt’s framework from their landmark 1978 book Tragic Choices to current allocation policies as well as to several alternative policies. The heart of Hoffmaster and Hooker’s article is their assessment of three allocation methods, optimization, balancing, and compromise. Their focus is on how two key considerations, equality and efficiency, apply to different approaches to the allocation of scarce organs, and they argue that the compromise approach is the most satisfactory solution.
The next article in this issue is “Shifting the Paradigm: Using HIV Surveillance Data as a Foundation for Improving HIV Care and Preventing HIV Infection” by Patricia Sweeney and her colleagues. The authors, most of whom are in the HIV-AIDS prevention program at the Centers for Disease Control and Prevention (CDC), discuss how ethical and policy considerations regarding the use of HIV surveillance data are being changed by progress in the treatment and prevention of HIV/AIDS.
Health care providers and laboratories have long been required to report positive HIV test results to state public health agencies, which in turn report the data to the CDC, but the uses of that information have been quite limited for privacy reasons and concerns about possibly reducing people’s willingness to be tested. Sweeney and her colleagues explain why restricting the use of HIV surveillance data has had to be reconsidered because of more effective treatment and the success of some interventions in reducing the disease’s transmission. They point to the evidence that a large proportion of people who have been diagnosed as HIV positive are not being treated. Surveillance data could be linked with treatment data to identify and facilitate contact with such people, many of whom are not even aware of their HIV status. The paradigm shift to which the title of their article refers is the move from using HIV information for traditional public health surveillance purposes (i.e., to track the spread of the disease) to using it to improve the care of HIV-infected individuals.
The translation of research evidence into policy and practice has been a prominent theme in The Milbank Quarterly over the past decade, and our 2011 special “virtual issue” on that topic included some twenty-two articles (Gray 2011). This issue concludes with one more article on this topic: “How Contexts and Issues Influence the Use of Policy-Relevant Research Syntheses: A Critical Interpretive Synthesis” by Kaelan Moat, John Lavis, and Julia Abelson. Evidence briefs that summarize the current knowledge on a given topic are increasingly used for providing information to policymakers. Moat and his colleagues systematically reviewed articles examining how contextual and issue-related factors influence the usefulness of issue briefs as perceived by their intended users. The results of their review are organized around themes pertaining to the contentiousness and salience of the issue, the types of available evidence, contextual factors, and the mechanisms and pathways by which the evidence comes to users. The themes related to issues and contexts should influence the production or use of issue briefs, and the review by Moat and his colleagues of the evidence about evidence briefs should help improve the practical use of research findings.
Bradford H. Gray
Blumenthal, D. 2002. Doctors in a Wired World: Can Professionalism Survive Connectivity? The Milbank Quarterly 80(3):525–46.
Calabresi, G., and P. Bobbitt. 1978. Tragic Choices. New York: Norton.
Gray, B.H., ed. 2011. Virtual Issue: Facilitating the Use of Research Evidence. The Milbank Quarterly.
Greenhalgh, T., J. Russell, R.E. Ashcroft, and W. Parsons. 2011. Why National eHealth Programs Need Dead Philosophers: Wittgensteinian Reflections on Policymakers’ Reluctance to Learn from History. The Milbank Quarterly 89(4):533–63.
Author(s): Bradford H. Gray
Read on Wiley Online Library
Volume 91, Issue 3 (pages 419–423)
Published in 2013
Improving Quality and Safety of Care Using “Technovigilance”: An Ethnographic Case Study of Secondary Use of Data from an Electronic Prescribing and Decision Support System
Notes on Contributors