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Health Information Technology and Health Care Transformation


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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 health outcomes.

That's 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.

We 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.

So 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 providers. 

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.

How 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?

First, 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.

Furthermore, 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.

That 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.

Health 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.

And 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.

Perhaps 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. 

And 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.  

So those are a few of the highlights of the quality potential.  And this kind of quality translates into more cost-effective care.

But 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.

So 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?

The 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?

For 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 IT applications.
  • 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 to prepare.

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 to answer.

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 them?"

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 to create.

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) approaches.  

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.

And 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.  

We 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 spend.

The 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 better care.

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 approach:

First—The 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.  

Second—To 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 works.

Finally—To 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 and interdependent. 

"Quality-centered... evidence-based... and powered by information technology."

Where do we stand now on these three elements?

Quality Centered

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 more. 

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 Act, and 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.

HIT "Structures"

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.

  1. A technical structure:  To develop the common standards we need.
  2. A quality structure:  Using health IT to support quality care and measure the results. 
  3. A learning structure:  To help health care providers adopt, and adapt, to health IT.
  4. A 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.

I want 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.

That's why the work you're doing is so important.

The 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.

We're 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.

Our opportunities are truly great.  And health IT is the indispensable tool for bringing them about.

Thank 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

 

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