December 2005, Vol 95, No. 12 | American Journal of Public HealthSequist et al. | Peer Reviewed | Race, Genetics, and Health Disparities | 2173
RACE, GENETICS, AND HEALTH DISPARITIES
Information Technology as a Tool to Improve the
Quality of American Indian Health Care
| Thomas D. Sequist, MD, MPH, Theresa Cullen, MD, MS, and John Z. Ayanian, MD, MPP
The American Indian/
Alaska Native population
experiences a dispropor-
tionate burden of disease
across a spectrum of condi-
tions. While the recent Na-
tional Healthcare Disparities
Report highlighted differ-
ences in quality of care
among racial and ethnic
groups, there was only very
limited information avail-
able for American Indians.
The Indian Health Service
(IHS) is currently enhancing
its information systems to
improve the measurement
of health care quality as well
as to support quality im-
We summarize current
knowledge regarding health
care quality for American
Indians, highlighting the
variation in reported mea-
sures in the existing litera-
ture. We then discuss how
the IHS is using information
systems to produce stan-
dardized performance mea-
sures and present future
directions for improving
American Indian health care
quality. (Am J Public Health.
THE AMERICAN INDIAN
population is experiencing a
growing chronic disease burden.
While the epidemic of diabetes
is widely publicized,1–3American
Indians also suffer from an in-
creased incidence of coronary
heart disease, cancer, influenza,
pneumonia, and infant mortality.
This disproportionate disease
burden contributes to the Ameri-
can Indian population’s low me-
dian lifespan, which is 5 years
shorter than among White
While the base of scientific
evidence about how to improve
patient outcomes is large and
growing, practice has lagged be-
hind substantially. Only 79% of
patients with newly diagnosed di-
abetes receive appropriate glyce-
mic monitoring, and only 55%
undergo appropriate eye exami-
nations.5Similar findings of un-
deruse exist for cancer screening,
vaccination, and a wide spectrum
of other conditions.6The mea-
surement and improvement of
health care quality is a relatively
recent imperative,7and there is
currently limited information re-
garding quality of care for Amer-
ican Indians/Alaska Natives. The
initial National Healthcare Dis-
parities Report released in 2003,
for example, was unable to pro-
vide reliable data for American
Indians in many important areas,
including receipt of influenza
and pneumococcal vaccines and
treatment of diabetes, coronary
heart disease, and hypertension.8
Information systems have
been cited by the Institute of
Medicine as an important qual-
ity improvement tool.9Many
large integrated health care or-
ganizations, including Kaiser-
Permanente Northern Califor-
nia10and the Veterans Health
Administration,1 1have adopted
the use of electronic information
systems to improve quality. When
used in combination with other
quality improvement strategies,
these efforts have resulted in re-
markable improvements in qual-
ity of care.12The Indian Health
Service (IHS) is well positioned
as an integrated health system to
use information systems to pro-
vide data both on the current
state of health care quality for
American Indians and to direct
quality improvement efforts.
In this article, we summarize
the current state of health care
quality for American Indians
and describe ongoing efforts by
the IHS to enhance its existing
information technology infra-
structure to support improved
performance measurement. We
then present case examples to
illustrate how these systems
can improve care and discuss
barriers and future directions
for quality improvement
within the IHS.
THE INDIAN HEALTH
The IHS has functioned to ful-
fill the federal government’s obli-
gation to provide comprehensive
health care to members of feder-
ally recognized American Indian
tribes since 1955.13The IHS
consists of 3 units: (1) the feder-
ally operated IHS direct care sys-
tem, (2) tribally operated health
December 2005, Vol 95, No. 12 | American Journal of Public HealthSequist et al. | Peer Reviewed | Race, Genetics, and Health Disparities | 2179
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