Quality informatics

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Quality informatics is the study of use of information in understanding and improving the quality and safety of health care. It seeks to measure the quality of health care.


Many information systems do not involve computers or software at each step. Rather, techniques of approaching quality related issues involve a structured, thoughtful approach where

  • purpose is defined and problems are diagnosed and modeled;
  • metrics for understanding both the problem and success are defined;
  • an intervention is devised and implemented;
  • an evaluation is completed; and
  • the cycle repeats.

The system defined by these steps is called Quality Improvement, and there are a set of informatics-related needs at each step and for the process overall.

Many people focus on the informatics aspects of the metrics and the intervention, but each step requires consideration of the information system used.

Major topics in Quality Informatics



As part of this wiki, we have a set of quality improvement project examples.

For students of BMI 537, please see BMI537 template for an example project. Add yours to this text.


written by Donabedian, A. 1980, Seven Pillars of Quality

  • Efficacy: the ability of care, at its best, to improve health;
  • Effectiveness: the degree to which attainable health improvements are realized;
  • Efficiency: the ability to obtain the greatest health improvement at the lowest cost;
  • Optimality: the most advantageous balancing of costs and benefits;
  • Acceptability: conformity to patient preferences regarding accessibility, the patient-practitioner relation, the amenities, the effects of care, and the cost of care;
  • Legitimacy: conformity to social preferences concerning all of the above; and
  • Equity: fairness in the distribution of care and its effects on health. (Donabedian, 1990)

In a similar fashion, Maxwell defined the six dimensions of quality health care:

  1. Access to services
  2. Relevance to need (for the whole community)
  3. Effectiveness (for individual patients)
  4. Equity (fairness)
  5. Social Acceptability
  6. Efficiency and Economy (Maxwell, 1984)

One of the most widely accepted definitions of quality healthcare was offered by the Institute of Medicine in their 2001 “Crossing the Quality Chasm” report (IOM, 2001). They outlined six dimensions of healthcare quality:

  • Safe: Patients should not be harmed by the care that is intended to help them, nor should harm come to those who work in health care.
  • Effective: Integration of the best research evidence with clinical expertise and patient values, avoiding under-use of effective care, and over-use of ineffective care.
  • Efficient: Care should be given without wasting equipment, supplies, ideas, and energy.
  • Timely: Waiting times should be continually reduced for both patients and those who give care. In addition to emotional distress from long waits, physical harm may result, for example, from a delay in diagnosis or treatment that results in preventable complications.
  • Patient-Centered: Encompasses qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient.
  • Equitable: Care should not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status.

With multiple dimensions and attributes ascribed to quality health care, it is of note that physicians themselves tended to judge the quality of care on the basis of the technical sophistication of the health care delivered, and placed an emphasis on the quality of the interaction between the physician and the patient.(Blumenthal, 1996)

Measuring Structure, Process, Outcomes

The many descriptions and factors involved in producing quality health care makes it difficult to determine which of these attributes or characteristics should be assessed. A seemingly natural candidate for measurement would be treatment outcomes. After all, outcomes are usually not debatable when considering whether a patient lived or died, recovered, or remained impaired. Because outcomes are rarely subject to interpretation, measurement of outcomes is considered to be desirable. (Donabedian, 1966)

However, there are limitations to studying treatment outcomes. The application of medical science to a problem may or may not result in the best outcome for that patient. A patient may not receive all of the benefits that were anticipated for a treatment. In addition, measuring the patient as being among the survivors for a given condition can lead to faulty assumptions if the person survived, but was otherwise severely impaired. The measurement of the outcome of survival alone would not produce reliable information. (Donabedian, 1966)

Some treatment outcomes take years to come to fruition, which may not be taken into account at the time that the quality assessments are being made. Multiple non-medical factors may also influence outcome. When assessing outcomes it is necessary to make sure that the non-medical impacts are accounted for, holding as many external variables constant as possible. (Donabedian, 1966)

Donabedian did believe that outcomes were the most effective measures of the quality of medical care, but he also focused on the process of delivering medical care. The more subjective measures of process involve the interaction between the health care provider and the patient. Judgments are made as to the quality of the history, physical exam, the differential diagnosis, the treatments ordered, as well as technical competence in procedural activities, such as surgery. Measuring these processes are difficult and more subjective than outcome measurement, but processes are important because they indicate whether or not quality medicine is being practiced.

While Donabedian focused primarily on outcomes and processes, the setting in which health care was delivered was also an obvious component of the delivery of quality health care. Measurement of the facilities, the qualifications and numbers of the staff, the presence or absence of certain equipment, and even hospital administration was combined into what Donabedian called the "assessment of structure". The problem is that it does not automatically follow that having good facilities and staffing results in high quality health care, nor does the absence of certain equipment indicate that health care is not of high quality. However, the measurements of structure involve factors that are more tangible and concrete than processes, and can be more easily evaluated.

The Institute of Medicine (2001) defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” [1] Unfortunately, there is substantial variation in the experience of recommended care. On average 55% of the people receive recommended care, but only 11% of people with alcohol dependence receive recommended care (McGlynn, 2003). This variability holds for preventive, acute, and chronic conditions. [1] Hence, there is a need to measure outcomes continuously to gauge the performance of our health care delivery system.

Meaningful use

Center for Medicaid and Medicare services has announced incentives for providers and organizations demonstrating “meaningful use” of Electronic Health Records and those that report on selected core measures. These selected measures can be organized using the IOM framework (2001), under the domains of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity so that the connections between measuring selected outcomes and quality of care can be established. An example of how the IOM model can be used to measure outcomes at the client and system level in a behavioral health delivery system follows.

IOM Domains


providing services based on scientific knowledge

a. Client Outcomes i. Did clients receive care based on Evidence-based programs ii. Maintain medication list iii. Measure client progress over time using standardized tools with respect to: Education, work situation, well-being, criminal justice involvement, Functioning

b. System Outcome

i. Percent of clients that received care based on Evidence-based programs

ii. Percent of clients that show improvement on standard assessments over time

iii. Percent of clients with complete histories so that the most appropriate levels of service can be delivered

iv. Percent of clients for whom medication lists are completed

===Efficiency=== – avoid waste

a. Client Outcomes

i. Did client complete treatment regimen

ii. Time from request to face-to face appointment

iii. Appropriate and accurate level of care placements of patients

b. System Outcomes

i. Achievement of contract capacity

ii. Time from request to face-to face appointment on average


avoid injury and harm to people

a. Client Outcomes

i. Reduced hospitalizations

ii. Reduced emergency department contact

iii. Reduced reports of critical incidents

b. System Outcome

i. Processes and protocols implemented to improve safety and avoid errors in identification and medication

ii. Automated systems that identify errors before they happen


provide care that is respectful of & responsive to individual preferences

a. Client Outcome

i. Consumer satisfaction with services

b. System Outcome

i. Number of person centered plans

ii. Creating a culture that fosters coordinating care across patient conditions, services, and settings over time


reduce wait time

a. Client Outcomes

i. Time from referral to placement

ii. Timely and accurate data collection

b. System Outcome

i. Timely communication and exchange of results across practitioners


provide care that does not vary in quality because of personal characteristics

a. Client Outcomes

i. Compare the demographics of consumers from each city/town receiving services with the overall population demographics of the city/town in order to flag over- or under-representation.

b. System Outcome

i. Ensuring quality and access to services across patient populations and geographic locations

ii. Compare outcomes by various demographic subgroups, such as gender, race, ethnicity, geographic location, etc.

Submitted by Minakshi Tikoo



  1. 1.0 1.1 Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century.
  1. American Medical Association, Council of Medical Service. Quality of care. JAMA 1986;256:1032-1034.
  2. Blumenthal, D. (1996). "Quality of Care--What is It?-Part One of Six." New England Journal of Medicine 335(12): 891.
  3. Donabedian A. Explorations in quality assessment and monitoring. Vol. The definition of quality and approaches to its assessment. Ann Arbor, Mich.: Health Administration Press, 1980.
  4. Donabedian, A. (1966). "Evaluating the quality of medical care." The Milbank Memorial Fund Quarterly 44(3): 166-20
  5. Donabedian, A. (1969). "Quality of care: problems of measurement. II. Some issues in evaluating the quality of nursing care." American Journal of Public Health 59(10): 1833.
  6. Donabedian, A. (1990). "The seven pillars of quality." Archives of Pathology & Laboratory Medicine 114(11): 1115.
  7. Institute of Medicine. (2001). "Crossing the quality chasm: A new health system for the 21st century."
  8. Larson, J. S. and A. Muller (2002). Managing the Quality of Health Care. Journal of Health & Human Services Administration, Southern Public Administration Education Foundation. 25: 261-280.
  9. Lohr KN, ed. Medicare: a strategy for quality assurance. Washington, D.C.: National Academy Press, 1990. Maxwell, R. (1984). "Quality assessment in health." British Medical Journal 288(6428): 1470-1.
  10. Maxwell, R. (1984). "Quality assessment in health." British Medical Journal 288(6428): 1470-1.
  11. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks, J, DeCristofaro A, and Kerr EA, “The Quality of Health Care Delivered to Adults in the United States,” New England Journal of Medicine, Vol. 348, No. 26, June 26, 2003, pp. 2635–2645.

Submitted by William Hogg