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FY 2004: Research on Health Care Costs, Quality and Outcomes (HCQO) (continued)
AHRQ promotes widespread distribution and implementation of its information and research products through a variety of methods: publication in professional journals; development of provider and consumer materials, media events and outreach; interviews and story placement with medical/trade press and organizations' newsletters; and articles in the popular press. AHRQ also employs public-private partnerships, direct mail, and the World Wide Web to distribute its information.
Publishing. AHRQ publishes the results of its research in numerous forms. All AHRQ research findings are highlighted monthly in AHRQ's flagship publication, Research Activities. This is distributed to over 50,000 researchers, libraries and other organizations monthly. In addition, AHRQ develops tools and products for a variety of audiences to promote the adoption and implementation of activities that improve the quality of health care. All materials are developed in print and are posted to the AHRQ Web site. Examples of tools include materials that can be used by health systems to implement prevention programs, materials for consumers and patients to assist them in making informed decisions and in tracking their personal decisions regarding health care. All consumer materials are translated into Spanish and other languages as appropriate. For providers, AHRQ develops and publishes rating and severity scales, and tools for health systems, such as quality indicators. AHRQ also publishes complete scientific reports sponsored through contracts and the results of other deliverables from contract research, such as evidence-based practice reports. AHRQ provides outreach to professional organizations through its exhibit program. In FY 2002, AHRQ exhibited at over 50 professional/scientific meetings and distributed thousands of publications through this channel.
Media Outreach. AHRQ employs a wide-range of activities to encourage the media to cover its programs. Stories in the media build awareness of the Agency and its activities, as well as serving an intermediary vehicle for AHRQ's messages and information. To reach the media, AHRQ employs a broad range of techniques including press releases; in 2002, AHRQ issued 57 press releases. The Agency also sent out 58 "pitches"—targeted information to selected reporters—on a variety of broad range of topics, including smoking, prevention, hospital quality, and patient safety. AHRQ also set up interviews in major general, trade and broadcast media with experts on AHRQ's staff and grantees.
As part of this outreach, AHRQ also worked to reach Hispanic and African American media. To that end, the Agency developed targeted materials appropriate for the audience and set up interviews and media tours with Hispanic and African American print and broadcast media outlets.
Partnership Activities. AHRQ also worked extensively with public and private sector organizations in partnership to promote AHRQ resources and information. For example, AHRQ worked with the American Association of Pediatrics to develop and promote a new fact sheet titled 20 Tips to Help Prevent Medical Errors in Children. AHRQ also developed dissemination partnerships with a wide-range of organizations, such as the Association of Clinicians for the Underserved and Partners in Corporate Health, to promote its Put Prevention Into Practice materials.
AHRQ also has created a weekly Electronic Newsletter which provides AHRQ news and information to more than 15,000 subscribers.
AHRQ's Web Site. Use of AHRQ's Web site continued to increase in FY 2002, with more than 30.5 million hits, compared with 22.6 million hits the previous year. User sessions also rose by a million visits—3.4 million, up from 2.4 million in FY 2001. Page views increased to more than 13.2 million, compared with 8.9 million the previous year. Overall workload increased some with 5,314 files and documents uploaded to the Web site, compared with 5,068 for FY 2001.
AHRQ handled 2,890 electronic inquiries during FY 2002 through its Web site mailbox. These inquiries included requests for Agency information products, funded research, consumer health issues and concerns, technical assistance, referrals to other resources, and requests to use AHRQ electronic content on other Web sites or in electronic or print products.
The AHRQ Web site provided access to the summaries of reports issued by the Evidence-based Practice Centers and U.S. Preventive Services Task Force recommendations. The full text of these reports can be obtained at the National Library of Medicine, accessible through the AHRQ Web site. The Agency continued to work with the National Library of Medicine to upload evidence reports, technology assessments, and preventive services materials for clinicians on the full-text retrieval system HSTAT.
The Web site provided content on health services research issues for policymakers at the State and local level, including online workshop briefs, interactive sessions, and a learning module relating to quality performance measures in child health programs.
A popular feature on the Web site is the Spanish button, Información en español, which provides translations of AHRQ consumer health and patient information materials. These materials are accessed by the Spanish-speaking public as well as clinicians with large Hispanic patient populations for use in patient education.
Nearly 16,700 external Web sites link to the AHRQ Web site home page or content within the site, up from 10,900 the previous year. Three government portals prominently featured on the AHRQ site provide referrals to the Agency's online consumer health and patient information materials: USA.gov, developed by the General Services Administration; the healthfinder® gateway site, developed and maintained by the Department of Health and Human Services; and MEDLINEplus®, developed and maintained by the National Library of Medicine.
Based on user feedback, various audience groups came to the AHRQ site for:
- Clinical research resources to improve practice and health outcomes.
- Summaries of evidence-based information for medical practice.
- Consumer and patient decision-making materials.
- New funding opportunities and subsequent award announcements.
- Press releases with contact information on key staff involved.
- Informative electronic newsletters on research activities.
- Strategic planning to establish priorities and directions for State health programs.
- Support of health services research at the university level.
- Capacity building within the nursing research community.
- Preventive services recommendations and clinical practice support.
- Research information related to treatment of specific health conditions.
- Recommendations on improving the quality of health care.
- Updates on medical errors and patient safety initiatives.
- Explanations of quality measurement issues and tools.
- Up-to-date information on the changing health care system.
- Best practices for reducing the cost of providing health insurance.
- Data and statistics on health care costs and use.
Requests from outside organizations for use of electronic content from the AHRQ Web site included:
- Consumer materials on specific conditions and the health care system for numerous consumer health Web sites as well as corporate intranets for employees.
- Clinical materials for medical Web sites for clinicians, hospitals, and health plan systems.
- Clinical and research materials for course packs in medical education and graduate training in public health issues.
- Information on reducing medical errors for managed care organizations' Web sites and newsletters.
- Information on preventive services for adults and children to be distributed by health plans and employers.
User Liaison Program. AHRQ's User Liaison Program (ULP) synthesizes and distributes research findings to local and State policymakers so they can use it to make evidence-based decisions about health care. ULP holds small workshops, sponsors telephone and Web-supported audio conferences, and distributes other information to provide recent research findings to policymakers on the critical issues confronting them in today's changing health care marketplace. Topics are chosen with input from legislators, executive agency staff, and local officials.
- In FY 2002, ULP sponsored 20 different activities: 10 National workshops, 6 State-based workshops, and 4 Web-assisted audio conferences. The activities were attended by 2,534 health care policymakers from all 50 States, the District of Columbia, Puerto Rico, Palau and Guam.
- In FY 2001, ULP sponsored 23 different activities: 12 National workshops, 7 State-based workshops, one telephone conference, and one Web-assisted audio conference. The activities were attended by 2,376 health care policymakers from all 50 States, the District of Columbia, American Samoa, the Virgin Islands, and Guam.
- In FY 2000, ULP sponsored 17 training events for 1,145 attendees from 50 States and the District of Columbia.
In addition to providing information and tools to make informed health policy decisions, the ULP serves as a bridge between State and local health policymakers and the health services research community by bringing back to the Agency the research questions being asked by key policymakers. ULP workshops are user-driven, user-designed, and highly interactive, with an emphasis on information sharing between participants and presenters.
AHRQ often receives feedback from workshop and audioconference participants on how they used the information shared at these events. For example, the director of the Office of Community Health Services, Mississippi State Department of Health, shared materials and information for a ULP workshop on managed care with the State's Office of Regulation. The materials were used, along with materials from other sources, to initiate a meeting with the State Insurance Commissioner to explore how the State can carry out similar activities with its fledgling HMO industry.
Outcomes of a ULP Conference
The October 2000 ULP State-specific conference, Strengthening the Safety Net: A Financial Analysis of New Hampshire Community Health Centers (CHCs), sponsored by AHRQ, resulted in the State of New Hampshire undertaking a number of followup activities designed to strengthen and stabilize its CHCs. The conference was co-sponsored by the New Hampshire Department of Health and Human Services, AHRQ's User Liaison Program, and the Robert Wood Johnson Foundation State Initiatives in Health Care Reform and Access Projects.
Since the October 2000 conference, a number of activities have taken place:
- A second conference held in December 2000, "The Health of New Hampshire's Community Hospital System: A Financial and Economic Analysis." The successful event emphasized the theme of community support and collaboration in strengthening CHCs and New Hampshire's health care safety net. The State is working with its Rural Health/Primary Care program to broadly disseminate the CHC information shared at the conference to other States.
- Joint efforts with private-sector foundations and financial officers to identify long-term capital needs, secure access to long-term sources of funding, and identify and guarantee short-term lines of credit.
- Enrollment of eligible patients in Medicaid and the State Children's Health Insurance Program, and ongoing efforts to expand private health insurance coverage to people who cannot afford insurance coverage.
- Development of new and expansion of existing partnerships between New Hampshire's community hospitals, businesses, charities, and foundations to provide direct and in-kind support to CHCs.
||FY 2002 Actual
||FY 2003 President's budget
||FY 2004 Request
||Increase or Decrease
|PHS Evaluation Funds
Funding for the Research on Health Costs, Quality and Outcomes program during the last 5 years has been as follows.
|1999 ||$139,314,000 ||212|
|2000 ||$165,293,000 ||243|
|2001 ||$226,385,000 ||262|
|2002 Enacted ||$247,645,000 ||272|
|2003 President's budget ||$194,000,000 ||272|
|2004 Request ||$221,000,000 ||272|
Sources of Research on Health Cost, Quality and Outcomes funding follow.
||1 Percent Evaluation
|1999 || 97,967,000 ||41,347,000 ||$139,314,000|
|2000 ||107,717,000 ||57,576,000 ||$165,315,000|
|2001 ||102,255,000 ||124,130,000 ||$226,385,000|
|2002 ||-0- ||247,645,000 ||$247,645,000|
|2003 Proposed Law ||-0- ||194,000,000 ||$194,000,000|
|2004 Request ||-0- ||221,000,000 ||$221,000,000|
Rationale for AHRQ's FY 2004 Request
The FY 2004 request provides an increase of +$27,000,000 for the Research on Health Costs, Quality and Outcomes budget activity. These components are:
- Research and Training Grants: + $13,424,000
(Non-Competing Patient Safety Grants) (-$32,026,000)
(New Patient Safety/Hospital IT Grants) (+$46,886,000)
(New Non-Patient Safety Research and Training Grants) No Change
(Patient Safety Supplements) (-$1,436,000)
- Non-MEPS Research Contracts and IAAs: + $ 13,576,000
(Patient Safety Contracts and IAAs) (+$10,576,000)
(Protected Non-Patient Safety Contracts and IAAs) (+$ 3,000,000)
(Unprotected Non-Patient Safety Contracts and IAAs) No Change
- Research Management: No Change
The FY 2004 request provides an increase of $13,424,000 for research and training grants over the FY 2003 President's budget level of $83,796,000. This includes:
- $49,886,000 for a new patient safety hospital program ($25,886,000 of this total comes from expiring patient safety grants and $24,000,000 in new funds).
- A redirection of $10,576,000 in expiring patient safety grants and supplements into patient safety contracts.
- A reduction of $10,820,000 to non-patient safety non-competing research and training grants commitment base.
No funds are requested for new competitive research and training grants in other areas.
Non-Competing Research and Training Grants (-$32,036,000)
Patient Safety. The FY 2004 portion of existing non-competing patient safety research and training grants are fully funded at $8,374,000. The $32,026,000 in expiring patient safety grants was redirected within the total patient safety budget as follows:
- $25,886,000 to Patient Safety Hospital Information Technology Initiative.
- $9,140,000 to patient safety contracts to fund the initiative to improving patient care and safety through the use of technology. (An additional $1,436,000 in expiring patient safety grant supplements increase the amount available for patient safety contracts to $10,576,000).
Non-Patient Safety. The FY 2004 request maintains the non-patient safety non-competing research and training grants at the FY 2003 President's budget level of $38,960,000. At this level, a reduction of up to 15 percent of committed non-patient safety grants will be required.
New Research and Training Grants ($49,886,000)
New Patient Safety Research Grants—Patient Safety Hospital Information Technology Initiative ($49,886,000 in total, an increase of $46,886,000 over the FY 2003 President's budget). In FY 2004, all of AHRQ's new grants will be used to fund the Patient Safety Hospital Information Technology Initiative. In FY 2004, AHRQ's programs will make important contributions to the Secretarial and Presidential Initiatives on improving the quality and safety of health care, costs, use and access to health care.
In March 2001, an Institute of Medicine (IOM) study, Crossing the Quality Chasm: A New Health System for the 21st Century, addressed the issue of quality in the U.S. health care system. In this report, the IOM assessed the quality of health care in the United States and concluded that there were serious problems that needed to be fixed. Many of these problems stem from an outmoded health care delivery system that does not provide high-quality care on a consistent basis. The IOM committee concluded, "In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves." Just as important, however, the committee stressed that "these problems come from poorly designed systems ... not bad people." If Americans want safe, dependable, and high-quality health care, then a significant redesign of the U.S health care delivery system will have to take place, which will require changes in four critical forces:
- Clinical Knowledge.
- Professional Workforce.
- Information Technology.
The IOM committee also recommended a national commitment to building an information infrastructure to support:
- Health care delivery.
- Consumer health.
- Quality measurement and improvement.
- Public accountability.
- Clinical and health services research.
- Clinical education.
Evidence has shown that computerized information systems with decision support can improve patient safety and quality of care. These systems range from computerized reminders about preventive services to alerts about drug-drug interactions to systems that improve self-management of chronic diseases.
Health care has lagged far behind many other industries in harnessing the capabilities of IT to improve knowledge, communication, services, outcomes, quality, and efficiency. However, given the complexity of modern medicine, it is inevitable that IT will need to play an ever increasing role if we are to achieve improvements in health care quality as envisioned by the IOM. As noted by the IOM's Committee on Quality Health Care in America, the widespread adoption of IT has the power to transform the provision of health care. A major re-engineering of the health care delivery system will be needed if significant progress is to be made, which will require changes in technical, sociological, cultural, educational, financial, and other important factors.
In FY 2004, AHRQ is requesting $49,886,000 for a Patient Safety Hospital Information Technology (IT) Initiative that will support a variety of activities aimed at improving health care quality and patient safety by promoting and accelerating the development, adoption and diffusion of IT in a variety of important health care settings. Specifically, AHRQ will set-aside $25,886,000 for small and rural hospitals. The funds set-aside will help assure that these hospitals can implement and use IT to improve patient safety and quality of care. Funds will also be used to support innovative research and demonstration projects that will improve patient safety and quality of care in a wide variety of practice settings.
Improving IT in the Clinical Setting. This program will provide planning and demonstration grants, as well as assistance for hospitals and other health care entities to acquire and improve IT systems that support quality improvement and patient safety. This program will support the implementation and evaluation of established and emerging IT systems. In an effort to support the National Committee on Vital and Health Statistic's vision of creating an interconnected national health information infrastructure, these systems would have to comply with national clinical data standards and be interoperable with other clinical and public health information systems. To further support the diffusion of IT, projects would also address barriers to successful adoption of proven IT solutions, assess the impact of IT on important clinical and patient-centered outcomes, document the costs and resources associated with adopting and maintaining proven IT applications, generate solutions to help eliminate the digital divide, and evaluate transferability to other health care settings.
This work will require collaboration with other Federal agencies, State and local governments, provider organizations, private sector partners, clinicians, researchers, and IT developers and vendors. Support for these projects will help to inform provider, payer, and policy decisions regarding the impact of IT in health care, facilitate more rapid implementation of proven technologies, promote development and evaluation of emerging technologies, and inform commercial developers/vendors about the unmet needs of consumers, providers and payers.
To be eligible for funding under this program, small and rural hospitals would have to commit to an extensive evaluation of the impact of the IT tools on outcomes and costs, as well as an assessment of the barriers to implementation and practical methods to help overcome these barriers. Rural health care entities would be asked to track and demonstrate significant improvements in safety and quality of care. This rural initiative will focus on clinical IT systems with a proven evidence base regarding improvements in patient safety and quality of care, such as the use of computerized physician order entry (CPOE) with decision support. It is anticipated that many of these rural systems will not have the expertise to carry out these projects on their own. Therefore, extensive technical assistance will be made available all grantees.
In general, the proposed Patient Safety Hospital IT investment program would include demonstrations that will focus on established and emerging information technologies that improve patient safety and quality of care. Based on AHRQ's evidence report entitled, "Making Health Care Safer: A Critical Analysis of Patient Safety Practices," numerous information technologies have been effective at improving patient safety such as:
- Computer monitoring for potential adverse drug events.
- CPOE with clinical decision support.
- Computer-generated reminders to discuss advanced directives.
- Simulator-based training.
- Automated medication dispensing devices.
- Medication bar-coding.
- Unit-dose distribution systems for medications.
- Patient self-management using home monitoring devices.
Many of the proven patient safety practices that do not currently rely on IT could also be significantly enhanced through the use of IT. Some examples where IT could make these practices more effective and efficient include:
- Use of IT could allow rapid, accurate, and complete transfer of important patient information to pharmacies nationwide;
- Appropriate prophylaxis for venous thromboembolism could be improved through evidence-based, computerized decision-support programs that recommend therapy, calculate the appropriate dose of medication, and provide monitoring recommendations;
- Protocols for notification of test results to patients could be improved through automated electronic reporting of test results, with explanations of abnormal results, to all patients within a certain time frame after a visit (e.g., 3 days). In a manner similar to how consumers are able to receive financial information from their investment companies, patients could be notified that their test results are available, and then they could log on to the data source (using their log-on and password information) to access their results at their convenience;
- Limitations on inappropriate antibiotic use could be improved through clinical decision support tools that provide recommendations on antibiotic use when clinicians are ordering medications. This has been achieved very successfully at LDS hospital in Salt Lake City, UT, resulting in improved quality of care and cost savings of approximately $100,000 per year.
- Protocols for the use of high-risk drugs could be improved through clinical decision support tools that provide recommendations on when medications should be used, the correct medication dosage, and appropriate monitoring.
- Standardized, structured sign-outs for physicians could be improved by capturing important patient information on a handheld computer, which can be automatically downloaded to the on-call physician from any location that has access to the network. The sign-out can also incorporate reminders and other decision support tools to help the on-call physician (who does not know the other clinicians' patients), manage them more effectively. Some medical residency programs have already begun supplying their residents with Palm Pilots and are using them for this purpose. To date, there has been no evaluation of their impact on patient safety and other important outcomes.
There are also emerging technologies with an evolving evidence base, including projects funded through AHRQ's:
Some of these technologies include: handheld computers with clinical decision support; electronic medication prescribing; computer simulation training; remote monitoring devices with wireless technology and decision support capabilities; computerized disease management programs; and electronic communication between patients and providers. By the end of this year, we will be able to provide further detail on the additional evidence for newer, emerging technologies that are currently under way. AHRQ would also propose research and demonstration projects that will enhance the connectivity and interface between the clinical health, consumer health, and public health systems to improve bioterrorism preparedness using tools that facilitate automated data capture, analysis, and decision support.
Measuring Success in Improving IT. There are many performance measures that HHS could use to gauge the effectives of the IT investment program, including:
- Increasing the number of hospitals using Computerized Physician Order Entry (CPOE) systems by 10 percent within 5 years, and by 25 percent over 10 years.
- In hospitals receiving demonstration funds for CPOE systems, increase the use of providers using the system from none to over 50 percent within 5 years.
- In hospitals receiving demonstration funds for CPOE systems, increase the rate of detection of significant medication errors by at least 100 percent within the first year. (The national baseline error rate in U.S. hospitals is 3.13 medication errors per 1,000 orders written and 1.81 significant medication errors per 1,000 orders written. However, because most errors in health care remain undetected, a successful program will initially result in a substantial increase in the number or errors detected.)
- In hospitals receiving demonstration funds for CPOE systems, once a true baseline error rate is established through improved detection, reduce the rate of significant medication errors per 1000 orders written by 50 percent within 2 years and maintain this lowered error rate in years 3 to 5.
- In hospitals receiving demonstration funds, once a true baseline rate of adverse drug events (ADEs) is established through improved detection, reduce the rate of adverse drug events per 100 admissions by 20 percent within 2 years and by 50 percent within 5 years. (The national baseline rate is 6.5 ADEs per 100 admissions. However, because most adverse drug events related to preventable errors in health care remain undetected, a successful program will initially result in a substantial increase in the number of adverse events detected.)
- Improve the rate of specific, pre-defined preventive measures (e.g., recommended immunizations, lipid profile measurement, aspirin use in at-risk patients, use of venous thromboembolism prophylaxis) by 50 percent within 2 years.
- Decrease the rate of redundant lab tests by 10 percent within 2 years.
New Non-Patient Safety Research and Training Grants. No new funds are requested for non-patient safety research and training grants.
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