Reducing Disparities in Health Care Quality in Underresourced Settings
Expert Meeting Summary
As the Department of Health and Human Services' lead on improving the safety, quality, efficiency, and effectiveness of care for all Americans, the Agency for Healthcare Research and Quality (AHRQ) has a strong role in implementation of evidence-based tools and strategies.
In October 2009, AHRQ convened a small group of researchers, policymakers, and experts in health IT and health care disparities. The goal was to inform our short- and long-term research and action strategies to reduce disparities while improving health care quality, with a specific focus on the potential for using health IT as a tool in underresourced health care delivery settings.
This document provides a summary of the themes and major conclusions of this meeting.
Infrastructure Characteristics That Promote Quality Improvement and Health Information Technology in Underresourced Health Care Delivery Settings
Health IT Implementation Strategies
Potential AHRQ Roles
Meeting the pressing needs for health care quality improvement within an increasingly diverse U.S. population will require clear strategies and close collaboration with private and public stakeholders
The AHRQ-sponsored meeting, "Reducing Disparities in Health Care Quality in Under-Resourced Settings Using Health IT and Other Quality Improvement Strategies," was held October 22-23, 2009, at the John M. Eisenberg Building in Rockville, Maryland. Among the 42 participants were representatives from Federal agencies, a State rural health agency, health services researchers with expertise in quality improvement and disparities reduction, patient advocates, provider organizations representing potentially underresourced health care delivery settings (URS), employer groups, and other organizations. URS were loosely defined for purposes of the meeting and papers. However, URS are generally considered to be settings that provide care for people who have insurance with low reimbursement rates or those who have no insurance, thus leading to a relatively low level of resources to make the required capital and human resource investments. Select for Evidence Report on the costs and benefits of using Health IT.
Results of five commissioned papers that assessed the evidence base on using health IT to reduce disparities and improve quality in URS were presented and discussed, and meeting participants were assigned to three breakout groups with each group asked to address one of the following themes:
- Infrastructure characteristics that promote quality improvement (QI) and health information technology (health IT) in URS.
- Strategies that work across specific disparities (i.e., access, secondary prevention, and patients' experiences of care).
- Suggested models of health IT and QI that can be applied to URS.
For each theme, the groups were asked to answer the following questions:
- How can AHRQ implement a research and action agenda that includes a rigorous evaluation?
- What can be implemented now?
- What are the research gaps to address in the future?
The value of using health IT to reduce disparities in health care quality in underresourced settings was strongly supported by many meeting participants. Most suggestions from the group addressed the steps necessary to ensure that health IT would be implemented in a way that would be most likely to result in better quality and health outcomes for patients seen in these settings.
To begin the work of improving health IT infrastructure in URS, meeting participants emphasized the need to:
- Better define underresourced settings.
- Identify the aims of a high-quality, low-disparities health care system.
Underresourced settings need to be better defined in order to be identified as places for implementation research. Achieving the second aim could include developing a model or framework for health care disparities reduction, potentially by combining frameworks for quality improvement with those for disparities reduction. Framework development could be enhanced with lessons learned from conducting more studies to reduce disparities within health care quality in underresourced health care settings.
Participants also identified three main areas of consideration for reducing disparities in URS through improved health IT infrastructure:
Experts noted the importance of applying a multifaceted approach that recognizes and preserves cultural sensitivity. Implementers should be aware that health IT may clash with cultural values and that health IT implementation can change environments in both positive and negative ways. Experts also noted that health IT should never become a substitute for well-functioning organizations with optimal cultural sensitivity.
Participants emphasized the importance of thinking across providers, patients, and communities to develop health IT to connect and improve care for all three. Efforts to apply health IT to reducing disparities should focus on developing strategies or studies that encompass integration and collaboration across agencies as well as partnering with the private sector (e.g., foundations), especially considering medical home initiatives. Implementers should consider social determinants of health as an integral issue because many URS are an integral part of wider neighborhoods.
Meeting participants suggested that research into using health IT to reduce disparities should be conducted with increased rigor using the lenses of patient-centeredness and health care provider teamwork. The research community needs to conduct rigorous research studies of interventions to reduce health care disparities within a quality improvement context and funders need to foster and support such research in collaboration with URS and health IT vendors. Implementers should consider both process and outcomes of care in both research and practice and include nontraditional health care practice settings in health IT implementation and research.
Experts cautioned that randomized controlled trials (RCTs) are not necessarily the best designs for studying interventions to reduce health care disparities within a quality improvement context. RCTs typically try to control for the implementation context and ignore the importance of implementation processes, when greater understanding of these factors is critical for further spread of seemingly successful interventions. Participants suggested that one way to avoid the dangers of "projectitis" (i.e., the funding of unrelated, noncomparable, individual site-specific studies) was to conduct a Framingham-like study project (http://www.framinghamheartstudy.org/about/index.html) for URS that would collect data on context, health IT implementation strategies of different types, and outcomes in addition to or instead of.
Participants identified the following specific research needs:
- Increasing patient empowerment using health IT.
- Using tools that are already in place (e.g., New York City was provided as an example).
- More testing of electronic medical records in URS serving priority populations.
- Examining technology development and policy
- Understanding what's needed for maintenance once the IT is in place.
- Applying the business case.
- Exploring the role of disease registries.
Elimination of disparities in health care quality requires a strong focus within larger efforts to improve care delivery and outcomes. These larger efforts include using health IT to improve quality and access.
Understanding the Problem
Meeting participants identified the need for greater understanding in the following areas:
- How social and environmental contexts in URS and communities they serve affect effective implementation.
- How to assess the needs of solo, small, Medicaid, or uninsured dominant practices and providers in other URS.
- Identify how small, solo, and underresourced practice providers can use their networks to increase effective health IT implementation.
- How to assess the health care needs diverse patients who receive services in URS.
Health IT Conceptualization and Design
Participants stressed the need for designing health IT with the users in mind. They advised examining the process and delivery of care and then designing health IT to fit that process. An initial step might be to conduct a needs assessment of specific target populations to determine their wants and needs for specific health issues, what they would use, and how they prefer to use various IT tools. Some technology needs to be in the hands of patients as well as health care providers to be effective (e.g., used in the home), and its development needs to be informed by the intended users. Participants urged that health literacy and the patients' belief systems be considered carefully in the development of health IT. All players will also need to acknowledge that technology changes rapidly and can quickly become outdated. Finally, implementers should consider the characteristics of URS in the development and use of health IT and ensure interoperability, (e.g., between primary care and specialty providers).
Meeting participants emphasized the importance of developing health IT tools that foster patient-centered care and good patient-provider communication (e.g., using a tablet PC with a pen so that the physician can maintain eye contact with patient while taking notes). They added that health IT should be considered as a means of communication between the patients and health care system or providers.
The communication aspect of health IT development is becoming increasingly important in health care, since patients are being discharged from hospitals quickly after procedures. Patient or consumer characteristics and needs should drive the development of health IT, given its utility in helping the patient's family take over the care of the patients. Participants noted that health IT should be available, engaging, vivid, easy to use, informative, and affordable, particularly when managed care plans are able to absorb the cost.
Participants recommended developing broader strategies (as well as health IT studies that address social networking sites such as Facebook™ and Twitter™ among consumers or patients) that also encompass disparities reduction and improving quality in nonmedical settings such as the home. Finally, valid and reliable measures of various patients' experiences with health-related communications are needed as well as studies on improving health IT incentives for provider-patient communications between visits.
The goal of health IT should be to get doctors, patients, and organizations to "do the right thing" According to participants, training patients, doctors, and organizations to use health IT will help foster optimal usage. Appropriate training for clinicians and practitioners will stress that health IT does not replace human touch and good bedside manners.
Furthermore, URS providers may benefit from social networking sites or learning networks. URS providers will need sustained health IT and other basic infrastructure supports to remain effective.
Framing Study Results and Outcome Measures
Outcome measures in all QI intervention studies, including those using health IT, should always address the intervention's impact on disparities, and adverse consequences. Discussion of all QI intervention studies and evaluation should include negative (i.e. what did not work) as well as positive results.
Participants and paper authors suggested a variety of models using health IT to improve quality that could be further explored for disparities reduction in URS. These include surveillance and monitoring systems to discover problems and to show where to intervene. Community health centers have used this type of system. Another example is the Cancer Bioinformation Grid or caBIG—an information network that enables researchers, physicians, and patients to share data and knowledge.
Other models named specifically by meeting participants include those that support collaboration, information exchange, and disease-specific information that could be shared among patients, providers, or organizations. Examples of these models include patient portals such as the Comprehensive Health Enhancement Support System (CHESS) program in Wisconsin, My HealtheVet, and Baby CareLink. All of these connect patients with health care workers, get health information out to consumers, and support information exchange between the health care providers and the consumers, as well as facilitate contact with and among consumers.
There are also examples of patient portal interventions to bring about behavioral change such as smoking cessation interventions. Some interventions have used cell phones and other patient portals to bring about behavioral change by issuing reminders.
On the provider organization side, the Community Health Centers' Disparities Collaboratives that Marshall Chin and Bruce Landon evaluated are examples of models that use technology such as patient registries. These learning collaboratives are based on Institute for Healthcare Improvement models and foster the sharing of information.
Finally, other suggested models include decision support and telemedicine, which can facilitate access to subspecialties; this and other technology can help feedback from specialists to primary care providers as well.
Meeting participants suggested the following as possible directions for AHRQ to pursue:
- Focus funding opportunities on small, low-reimbursement practices, and other URS.
- Consider whether the funding process can be accelerated so changes in health IT can converge with research efforts.
- Study how to facilitate partnerships among URS, researchers and evaluators, and health IT experts.
- Provide guidance on study designs that are both rigorous and relevant.
- Create a task force to continue work on disparities, URS, health IT, and QI.