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Remarks by Carolyn Clancy, M.D., Director of the Agency for Healthcare Research and Quality
eHealth Connecticut Inaugural Summit, Farmington, CT, March 23, 2006
Putting together the jigsaw pieces of the health care system is
what we're really here for today. Health information technology (HIT)
is the tool. But the real goal is something that transcends health IT.
It's better quality care. More cost-effective care. More
patient-centered care. The kind of care that's more rewarding for the
provider to deliver. And ultimately, not just better care, but better
a tall order. And health IT is just part of the answer. But it's an indispensable
part. We can't do the job without health information technology.
also can't do the job without starting right here—at the State level and
the local level, not to mention in the hospital and the clinic. Even in
Washington, I think we all know that this is where the real work gets done.
I want to thank you, and congratulate you, for being here.
Health IT and Heath Care Quality
"Health IT" is shorthand for many different things. It's electronic
health records, of course. It's computer ordering systems that can improve efficiency
and documentation. It's the technical capacity to exchange information among
It's also new ways of doing work in the clinic—the
interaction between people and computers. It's the protections to keep
patient information secure and private. And it's even the legal structures
to support this new way of doing business.
does health IT contribute to better health care quality? And how can we
be sure we really get better quality—not just more silos and not just
more tasks put onto the shoulders of our doctors and nurses?
of course, we're talking about the ability to make our health care records
complete, up-to-date, and always available. Once our full health records
are available whenever and wherever they're needed, clinicians will be
much better equipped to provide the right treatments without delay.
health information technology can help doctors and nurses make the right
choices about treatment. Decision support features can give providers
ready access to the information they need–and make it easier for them to
make the best treatment choices.
includes helping to avoid medical errors. Computer-assisted ordering can
help prevent errors in drug prescribing and other treatments. It can reduce
hazards ranging all the way from bad handwriting to dangerous drug interactions.
Health IT systems can also help different providers
work together for the patient. Most of us deal with multiple health care
providers—and for patients with chronic diseases, many different providers
can be brought together as a "team" by the shared patient record. That
means less duplication and confusion, better care, and lower costs.
One of AHRQ's grantees is actually demonstrating this
result in Connecticut. Rick Shiffman at Yale is using an electronic medical
record to better coordinate care for low-income children with asthma in
New Haven. The electronic medical record brings together not only the
primary and specialty care physicians and the emergency and hospital facilities
that serve these children, but also school clinics and local community
health clinics. This is a true patient "safety net," and this project
will help document the benefits.
IT can also help extend the reach of our medical resources. Telemedicine
and other sharing techniques can help us offer "best quality" medical care
to rural and remote areas where it wouldn't otherwise be available.
of course, health IT systems make it possible to measure performance quickly
and comprehensively. Health care providers and facilities can see in real
time how they measure up. They can identify problems and make improvements
quickly. And consumers can have access to the quality information they
should have when they're making decisions about their care.
most important, health IT can increase patients' involvement in their own
care. Consumers' access to their own health records can mean more patient-centered
care, starting with better communication between patient and provider.
in the future, it should be possible to use electronic health records to
put together large quantities of data, helping us detect patterns like
adverse drug reactions much more quickly. This can also greatly expand
our capacity to measure the effectiveness of different health care treatments
and learn what works best.
those are a few of the highlights of the quality potential. And this kind
of quality translates into more cost-effective care.
we have to confess—this is not really "new news." The potential for health
IT has long been visible.
Achieving Success in HIT
It's been nearly two generations since we began funding
something called "health informatics"—using giant computers with paper
punch cards to record health information. And for those of us who have
been close to the subject, it's been nearly a full generation since it
became clear that our health care system desperately needs what today's
information technology has to offer.
after all those years—with a few big successes, as well as a few jarring
failures—has the time finally arrived for information technology to become
an integral part of our health care system?
answer has to be "yes." More to the point, we have to make it "yes."
What has changed to make it possible for information technology to now become
an integral part of health care?
one thing, of course, it's
not every day that the President takes up your cause and puts it near the
top of the national agenda. But that has happened to health IT. Two
years ago, the President changed public awareness and created a new sense
of urgency about health IT.
Health and Human Services Secretary Mike Leavitt has
also taken on this challenge with vigor. As you know, he's created an "American
Health Information Community" (the AHIC) to bring together stakeholders
and provide broad-scale leadership.
But most important,, the sense of urgency that's been
created is taking root in States and communities across the country. The
same challenges and barriers that have held us back in the past are still
with us. But the willingness to tackle them, and to take the time and
the risks to overcome them, is new.
And when we see successes in a few leading States and
communities, others will follow.
My own agency has a similar mission in our health IT
initiative. This is a program of grants and contracts supporting health
IT projects of many different kinds—and designed to learn quickly from
the experiences of others.
Our projects (more than 100 of them in 41 States) are
a true cross-section:
- Some of our
grantees are using health IT for the first time. Others are building
on years of experience.
- Some of the
projects are in nationally-known hospitals. But a great many are in
rural and inner-city areas, showing how to put health IT to work for
all our citizens. I think it's crucial that we understand: health
IT is not a luxury reserved for the big health systems—it has the capacity
to improve care and health for all Americans.
- In some of our
projects, we're looking at the dynamics of establishing health information
exchanges. In others, we're measuring the value-added by various health
- In every project,
we're looking at the use of health IT on the ground level—because the
bottom-line goal is to learn what works best in actual clinical settings
so that we can help get health IT into practice rapidly.
The fact is: we need to prepare the human side, just
as we need to prepare the technical side, for health IT. Along with the
standards that will make health IT interoperable, we need a health care
sector that's ready to make health IT work.
One of our grantees has said that implementing health
IT is one part technology, and two parts work and culture change.
We need health professionals who will take the plunge.
And we owe them the best preview we can provide of what to expect and how
That's the heart of AHRQ's health IT initiative: a
"real-world" laboratory looking at real clinical settings, and delivering
findings based on day-to-day experience.
We're sharing our "lessons learned" through our National
Resource Center for Health IT. The Center and its Web portal are available
to all those who face decisions around implementing health IT. It's open
to the public at http://healthit.ahrq.gov.
Any way you look at it, the transition from paper to
paperless is one of the most profound changes the health care industry
has ever made. Every day, new steps are being taken and more is being learned.
But we're going to need to leverage every bit of our knowledge to keep
building momentum for health IT.
The truth is, IT may be the super-highway of the future
for health care. But we're still very much in the construction zone.
Who Is Using Health It?
Earlier this year, a study by the California Healthcare
Foundation reported that only 15 percent of physicians are writing E-prescriptions.
Another study from Harvard estimated that just 20 percent
of integrated delivery networks and 12 percent of stand-alone hospitals
have inpatient electronic health records. Even fewer have computerized
physician order entry systems.
For a variety of reasons that we're all too familiar
with—cost, complexity, organizational inertia—we've been on a plateau. If
we're going to reach broad levels of acceptance, we've got a lot of questions
The situation reminds me of an observation by that
noted American philosopher and baseball player, Yogi Berra, who said: "If
people don't want to come out to the ballpark, how are you going to stop
How are we going to get more of our doctors and hospitals
to come out to the health IT ballpark? And how are we going to do
it in an environment of competing resources and inevitable uncertainty?
As providers confront their individual decisions on
adopting health IT, they need more than rough estimates and good intentions.
They need evidence that practices like theirs can achieve real efficiencies
and serve their patients better. And when they make that investment, they
want to know that they can share in the new value that they're helping
At AHRQ, we're working with the Centers for Medicare & Medicaid
Services and others to build our understanding of new approaches that link
payment with quality of care—the "Pay for Performance" (P4P)
P4P is simple in concept—and complicated in practice. Our
goal at AHRQ is to help fill in the blanks as Congress and the Administration
look at the alternatives.
Whatever form our "value sharing" may ultimately
take, the key principle must be that we reward quality. Whatever reimbursement
tools we develop, we need to be sure that quality measurement and quality
rewards are in the picture. With them, we'll realize the true value that
health IT can bring. Without them, we'll miss the chance to enlist IT to
transform health care.
nothing less than "transformation" is our object.
Health Care Transformation
I'd like to look for a moment at what this "transformation"
can be, and why health IT is essential to make it happen. This is the
true long-term potential for the work you're doing today: nothing less
than a transformed health care system.
all know about the costs of health care—$2 trillion today and climbing
to $4 trillion by 2015.
We've heard those costs called "unsustainable."
But what is really unsustainable in our health care
system is that we deliver so much less than we could with the dollars we
truth is that, for all our health care problems, we're also in a time of
phenomenal opportunity—and we need to seize it.
We're in an amazing period of discovery in biomedicine.
We're in the process of putting quality at the center
of our health care system.
And at the same time, along with quality measurement,
we're looking toward health consumer empowerment. We're raising the expectation
of patient-centered care. And we can increase the momentum toward disease
prevention and healthy lifestyles.
These are genuine opportunities for better health and
They depend on good science and sensible incentives. And
they can help people across the spectrum of our society.
How do we get there?
How do we take a fractured system—keep up with scientific
developments—and turn hundreds of millions of individual decisions into
more value for the health care dollar?
I think there's some consensus today about an underlying
organizing principle for a better health care system has to be quality—delivering
the right care, at the right time, to the right patient. We need to define
quality, measure it, reward it, and insist on it.
get quality, we need a strong evidence-based foundation. Healing may involve
art—but medical care must be science-based. We need the best possible
information about what works—in illness care and in disease prevention. A
quality-centered system must be based on scientific evidence about what
make it all function: we need health IT . And health IT needs to be more
than just "available," like an ATM machine. It needs to be embedded in
the practice of medicine.
Three basic elements—and all three of them interlinked
"Quality-centered... evidence-based... and powered by
Where do we stand now on these three elements?
First of all—quality measurement and quality reporting
are now explicit goals of our health policy—and we're moving fast to put
them to use.
We want high-grade information about quality of care.
We want this information to be fair, accurate—and public.
And we want it to be comparable—for use by consumers
and payers … and equally important, by providers themselves.
There's plenty we don't know yet. We need to keep
learning how to define and measure quality. We also need to keep learning
which will be the best ways to reward high quality.
But we know the results we're after. And we have unprecedented
agreement, among some very different interests, about the questions that
need to be answered.
In a word, the "quality" ship is well launched. And
I'm happy that AHRQ is bringing decades‘ worth of research and experience
to this effort.
For the second element—evidence-based practice—we have
a strong foundation.
For many health conditions, we already have good evidence
about what works best. And in many instances, that information is already
being used to measure quality of care.
But to support a true quality-centered system, we need
We need a process for identifying our most pressing
effectiveness issues—the unresolved treatment questions that will make
the biggest difference for quality and value. We need to develop new information
in a timely way. And we need to produce results that are understandable
and useable—for providers and consumers alike.
At AHRQ last year, we launched a new program—the Effective
Health Care Program—to help reach those goals.
It was created in the Medicare Modernization
for the first time, it gives government the authority to compare the effectiveness
of alternative treatments for significant health conditions.
The point is to give consumers, providers, and payers
the best information possible about how different treatments compare. Which
ones work, for whom, and under what circumstances?
The program does not look at the costs of alternative
treatments, nor does it make recommendations about which treatments to
use. And it doesn't need to.
With unbiased comparisons of effectiveness, others
can do the math and make their own decisions about which treatments to
purchase. This should help create a more transparent, stronger marketplace
in health care.
Those are the first two elements. And health IT is
integral to both of them.
But what about our progress in health IT itself?
Let me suggest this model. As I see it, we're building
four kinds of foundational "structures" in health IT—all at once.
technical structure: To develop the common standards we need.
quality structure: Using health IT to support quality care and measure
learning structure: To help health care providers adopt, and adapt, to
trust structure: Trust among patients that their health information
will be secure—and, equally, trust by providers that this new way of
doing business will work successfully.
to leave you with the thought that this trust structure is the real bedrock
on which we must build health IT in America.
However elegant our technology, trust is still the
foundation of any complex human organization—and it's the essence of
our calling in health care.
why the work you're doing is so important.
common goals and understandings that make a system work need to be forged
in settings like this. And if the foundation that you build is strong,
the opportunities will just keep growing.
here to put health IT to work. But more than that, we're here to build
trust—and ultimately, to transform our health care system.
opportunities are truly great. And health IT is the indispensable tool
for bringing them about.
you again for inviting me to take part. What we really need in health
care is a rare combination of hard-headed realism and long-term vision. I
hope we can keep looking to Connecticut for that mix.
Current as of March 2006