Understanding 'Safety' and 'Quality' to Evaluate Care Improvements with EHRs

When I first entered the health IT side of health care, I was very na?ve as to the complexity of health information technology solutions and more specifically, electronic health records (e.g., EHRs). When I entered this field in 2004, my strength was in understanding nursing care delivery. I knew how to be a nurse that operated with the goals of giving safe care and of the highest quality that I could provide to my patients. Yet, I learned after my first few years working with EHRs, that I didn’t really know how to define safe care or quality care in a way that could be measured and evaluated to demonstrate improvements.

I started to have questions of 'how do we know that care is safer?’ and 'how do we know that we are driving safer, higher quality care?' that I could not answer for myself.

Well, shortly after having these questions, I became enrolled in a Ph.D. program at Duke University School of Nursing. In that first semester, I learned the importance of definitions. I learned that one cannot evaluate for improvements with a concept such as safety or quality without first being able to define each term at a conceptual level and an operational level. The operational level is what helps you to identify how one can measure that concept. Additionally, the state of the science paired with your research question will help inform the method in which you approach that concept (e.g., quantitative or qualitative).

I read To Err is Human and Crossing the Quality Chasm and learned how the terms 'safety' and 'quality' were defined by those Institute of Medicine reports. More importantly, I learned that safety is part of quality. Thus, the two concepts are not of equal value. Quality encompasses safety as well as five other concepts. Those five other concepts include: efficiency, effectiveness, equity, timeliness and patient-centeredness. Each one of these terms comes with their own definition. As you begin to understand the meaning, you can begin to determine how each can be measured through research and/or quality improvement.

Thus, as we look toward EHRs and other health IT solutions to evaluate the impact of quality on outcomes of care delivery, consider at least one of these 6 concepts and understand the role that EHRs and other health IT solutions might have in driving improvements in care. Lastly, also understand where we are in terms of structure, process and outcomes. We cannot evaluate outcomes without first understanding the processes by which we delivery care each day. Those processes are dependent on the structure of the health care organization.

I published an article in 2011, Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care in the Journal of Nursing Scholarship. A key finding in that article was that we had just begun to understand the processes of care delivery with EHRs. I believe we still have significant work to do in that domain before leaping toward the use of advanced algorithms and population based tools to measure outcomes from the data within the EHRs. How the data enters the EHR, why it is entered and who it is intended to be used by, are some key questions that can only be answered when evaluating care processes (e.g., workflows) using labor intensive research methods. Without such insights, we may miss some of the essential care delivery components at an individual patient level and their impact on health outcomes. Thus, consider the importance of understanding the individual patient’s outcomes as well as the patient population’s outcomes. Both require different approaches to evaluate for quality care delivery.

**This topic is discussed in further detail within my book, “Electronic Health Records for Quality Nursing and Health Care”.**

This article can also be found on Dr. Kelley's blog, Know My Voice on www.nightingaleapps.com