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The Triangle Model for evaluating the effect of health information technology on healthcare quality and safety

Jessica S Ancker,1,2,3 Lisa M Kern,2,3,4 Erika Abramson,1,2,3,5 Rainu Kaushal1,2,3,4,5

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ABSTRACT With the proliferation of relatively mature health information technology (IT) systems with large numbers of users, it becomes increasingly important to evaluate the effect of these systems on the quality and safety of healthcare. Previous research on the effectiveness of health IT has had mixed results, which may be in part attributable to the evaluation frameworks used. The authors propose a model for evaluation, the Triangle Model, developed for designing studies of quality and safety outcomes of health IT. This model identifies structure-level predictors, including characteristics of: (1) the technology itself; (2) the provider using the technology; (3) the organizational setting; and (4) the patient population. In addition, the model outlines process predictors, including (1) usage of the technology, (2) organizational support for and customization of the technology, and (3) organizational policies and procedures about quality and safety. The Triangle Model specifies the variables to be measured, but is flexible enough to accommodate both qualitative and quantitative approaches to capturing them. The authors illustrate this model, which integrates perspectives from both health services research and biomedical informatics, with examples from evaluations of electronic prescribing, but it is also applicable to a variety of types of health IT systems.

INTRODUCTION The potential for health information technology (health IT) to improve the quality and safety of healthcare is the primary impetus behind the federal electronic health record (EHR) incentive program.1 2 However, previous research on the effects of health IT on healthcare delivery has had mixed results, with some studies finding improve- ments and others showing no effect or adverse effects on quality or safety.3e8

Mixed findings such as these may be in part due to the evaluation frameworks that have been used to assess associations between the quality and safety outcomes and the predictor variabledthat is, the health IT itself. For example, several of these studies were beforeeafter studies, which examined the outcomes of interest before and after the introduction of a technology. However, it may not be sufficient simply to categorize a study period by whether or not a specific technology was present. For example, two similar healthcare delivery settings with EHRs or computerized provider order entry (CPOE) systems may be very different from each other, because even the same product will be

customized with site-specific configuration of features such as order sets and interfaces with other clinical systems. Training and implementation procedures also differ between institutions and time periods. Furthermore, the technology is not only a predictor variable but also a confounder that can interact with other variables. Technology alters clinical workflow, staffing levels, and user percep- tions and attitudes; conversely, organizations can customize technologies to support specific organi- zational priorities, such as quality measurement or patient safety. Many of these factors may be potential explana-

tions for the observed differences in quality and safety outcomes for health IT. However, unfortu- nately, we cannot necessarily be sure of the role of any of these factors unless they are measured reli- ably and validly. We suggest that research on the impact of health ITon the delivery of healthcare will be stronger if potential predictor variables such as these are captured systematically and prospectively during the evaluation process. In this paper, we outline the Triangle Evaluation

Model, an evaluation model designed to capture the dimensions of assessment necessary to explain the quality and safety effects of health IT, and describe examples of how this model has informed our evaluation work.

MODEL FORMULATION AND THEORETICAL GROUNDING The rapid acceleration in use of health IT nation- wide, fueled by the federal ‘meaningful use’ policy,1

has resulted in an increased desire to understand how these systems are affecting the quality, safety, and efficiency of healthcare across a variety of healthcare delivery settings. In our view, a joint evaluation approach combining informatics and health services research is the most effective way to answer these research questions. In developing an evaluation model, we reviewed

the literature on published studies evaluating the effects of health ITon quality and safety as well as both evaluation and implementation models specific to health IT. We identified excellent guid- ance from previous evaluation models and imple- mentation researchers about evaluating a number of aspects of health IT, including technical opera- tions,9 diffusion, adoption, and fit,9e13 cognitive effects,14 15 social, organizational, and workflow impacts,9 16e20 and the general concept of ‘infor- mation systems success’.21 In addition, we drew from our own experience conducting quality and safety research in the field of health IT, and

1Department of Pediatrics, Weill Cornell Medical College, New York, New York, USA 2Department of Public Health, Weill Cornell Medical College, New York, New York, USA 3Health Information Technology Evaluation Collaborative (HITEC), New York, New York, USA 4Department of Medicine, Weill Cornell Medical College, New York, New York, USA 5New York-Presbyterian Hospital, New York, New York, USA

Correspondence to Dr Jessica S Ancker, Weill Cornell Medical College, 402 E 67th St, LA-251, New York, NY 10065, USA; [email protected]

Received 20 May 2011 Accepted 26 July 2011 Published Online First 20 August 2011

J Am Med Inform Assoc 2012;19:61e65. doi:10.1136/amiajnl-2011-000385 61

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