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Remarks by Carolyn Clancy, M.D., Director of the Agency for Healthcare
Research and Quality
HIMSS Summit, Washington, DC, June 7, 2006
We actually kicked off the week here on Monday with a 2-day AHRQ conference on quality, safety, and health IT. I hope to make it abundantly clear today that we look to better quality care as the ultimate goal for health IT, and we believe health IT will help us achieve better quality in many different ways.
As you know, speakers often begin their remarks by quoting someone else. I'm going to start with three quotes, where some well-known folks allegedly tried their hand at predictions.
- In 1943, the chairman of IBM is quoted as saying: "I think there is a world market for maybe five computers."
- In 1977, the president of Digital Equipment is quoted as saying: "There is no reason for any individual to have a computer in their home."
- And in 1981, Bill Gates is quoted as saying: "640K ought to be enough for anybody."
Presumably that was not a reference to his income.
Now, one of those three quotes is acknowledged, one of them is disputed, and one is denied. Welcome to the world of evidence! Not to mention the world of predictions!
I'm going to do something that my agency's Evidence-Based Practice Centers would never do; and I'm going to draw some lessons from this apocrypha.
Lessons for Health IT
Lesson No. 1: "It's not the technology. It's how you use the technology."
Guess where we found all three of those quotes? It rhymes with "Flugle." Guess how fast they turned up? But, at the same time, we found the more accurate background about the quotes in just the same way.
So the simple power of the technology isn't enough. It's about using it right. In health care, this lesson is especially important. We can install the technology. We can even force the clinical staff to use it. But it won't deliver the results we want if it's not used right. And furthermore, using it "right" will often differ from one practice to another. We're talking about building technology into the culture of medical practice and into the micro-culture of each clinic, if we are to really derive the benefits.
So in the end, it's really about people. That's a thought we'll come back to.
Lesson No. 2: "Evidence is important."
Let me cite one piece of evidence that we really shouldn't forget. It's been some 40 years, nearly two generations, since AHRQ's predecessor agencies began funding something called health informatics, using giant computers with paper punch cards. They probably had less computing power than your cell phone, but the idea was already there: information technology had something to offer health care.
And for those of us who have been close to the subject, it's been nearly a full generation since it became clear that health care delivery and health care technology were a "marriage waiting to happen." It seemed obvious: IT could help clinicians deliver better care, if we could just get them together.
Since then, we've seen many attempts at health IT implementation that were launched—and that failed. Of course, there have been plenty of changes, and there's plenty of reason to believe that this, finally, is the moment for health IT. But let's also arm ourselves with this lesson and not repeat the history.
I don't really agree with those who say that health professionals are just laggards, and the health care sector is really no different than banks and airlines when it comes to information technology. The fact is, health care is different. And when we achieve broad-scale adoption of electronic health records, clinical decision support, and health information exchange in a secure environment where consumers and providers trust the integrity of the system, then we will truly have accomplished something new.
It will be hard work. And to help us do it right, we need all the good evidence we can get about the opportunities, the barriers, and the real-world experience of clinicians from sources like AHRQ's health IT grantees.
Lesson No. 3: "Evidence is important, but evidence isn't everything."
We also need vision. When Ken Olson, the president of Digital Equipment, said there was no place for computers in the home (yes, that's the quote that's acknowledged), he may have had plenty of evidence. But what did his evidence mean? He wanted it to mean that his company's position was safe. But what he needed was the vision to see what wasn't already there.
Evidence is there to remind us that doing is never as easy as imagining. But vision is there to tell us that the picture can change, and we can help change it.
And finally, Lesson No. 4: "Predictions are what?"
Literally, if we take the word apart, predictions are "speaking before we know what we're saying." Did the gentlemen we quoted predict that computers would save money? No doubt. Were they right? Sure. But what's more important is that computers changed the world, and we transformed ourselves around them.
Transformation of the System
And that's analogous to what we want for our health care system today: not just information technology because we can but information technology to power transformation in our health care system.
Let's look for a moment at what this "transformation" can be, and why health IT is essential to make it happen. This is the true potential for the work we're doing today. We all know about the costs of health care: $2 trillion today and climbing to $4 trillion by 2015. We're 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 measurement at the center of health care delivery. And at the same time, we're looking toward health consumer empowerment. We're raising our expectations of patient-centered care, and we're increasing 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 to Get There
How do we take a fractured system, keep up with scientific developments, and turn hundred 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 achieve good and measurable 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 has to 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.
- We need to make the patient's information available and up-to-date, when and where it's needed.
- We need to support our clinicians with usable and current information about safety and best practices.
- We need real-time measurement of safety and quality.
- And we need health IT systems to help us "grow" and harvest the evidence that can make health care more effective.
Three elements—all three of them interlinked and interdependent:
- Powered by health information technology.
The State of Transformation
Where do we stand now on these three elements?
First of all, quality measurement and quality reporting are now explicit goals of our health care policy. We want high-grade information about quality of care and provider performance. We want this information to be fair, accurate, and public. And we want it to be comparable, for use by consumers and payers, and, just as important, by providers themselves.
There's plenty of work ahead to achieve these goals. And we cannot truly achieve them until our system is health IT-based. But the "quality" ship is well-launched. And I'm happy that AHRQ is bringing decades of research and experience to this effort.
For the second element, evidence-based practice, we have a beginning foundation. For many health conditions, we have good evidence about what works best. In a few 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 questions. We need to develop new information in a timely way. And we need to produce results that are understandable and useable—for provider and consumers alike.
At AHRQ last year, we launched a new program—the Effective Health Care Program—to help reach those goals, by comparing 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?
- Under what circumstances?
This should help create a more transparent, stronger marketplace in health care. And again, we need health IT, both to disseminate the findings and to transform the process of gathering the evidence. And as for health IT itself, I think this first National Health IT Day, and your presence here today, tell the story.
The President has put health IT at the top of the health agenda.
Last month, Secretary Leavitt's American Health Information Community voted out its initial set of instructions for the development of standards to lay the base for nationwide health information exchange.
This summer, the Certification Commission will issue findings on its first set of vendor products.
At AHRQ, we're working with 22 States so far to review their differing landscapes on privacy and security. And in our Health IT initiative, we're supporting 122 grantees in 41 States, as well as statewide contracts for health information exchange in six States. These projects are designed to look at health IT in all kinds of settings, from the teaching hospitals to the rural clinic. And they're designed to show us the real impact of health IT systems in the clinic: the impact on quality of care, the impact on staff, the benefits for patients, and the return on investment.
As of this year, the lessons we learn are being made public, quickly, on the Web site of our National Resource Center for Health Information Technology.
What should we bear in mind as we work together to reach the health IT vision? Since the President announced his goal, we've generated wide public interest and important first steps toward adopting health IT. Maybe we should think of it as a period of "rational exuberance."
Now it's time for hard work, and results. So what should we be doing to keep up the momentum and steer toward the best results?
- First, we need to know (and we need to help the public know) that health IT is about quality. Increasingly, with health IT, we will be better able to identify quality, measure it, and reward it. Quality improvement needs to be a North Star in guiding us.
- Second, let's acknowledge that success is not inevitable. Just because health IT can work, and just because it should work, doesn't guarantee that we'll succeed in achieving health IT's full promise. I don't say that to be negative. But a false sense of inevitability could lead us to be less alert, less open to experience, less collegial, and less far-sighted than we need to be. We don't just want health IT; we want it with all the benefits it has to offer.
- Third, we need to be guided by real-life clinical and consumer experience. The Institute of Medicine talked about the chasm between the health care we have now and the health care we could have. We need to remember that the bridge from this side of the chasm, to the better side, is made of millions of individual actions, decisions, and encounters. To help build that bridge, health IT has to make sense for the individual hospital, clinician, and consumer.
People easily understand two legs of the health IT stool: the need for common standards and the challenge of financing. But the third leg, making health IT work in the medical culture and in the clinical micro-culture, is too often taken for granted. At the end of the day, the technology has to help deliver more effective care. And as we go forward, we need our clinicians and patients to help guide us in the directions that work best.
Let me say a word about trust. It's really at the heart of success for health IT. Whether we're looking at patients' confidence that their personal information will be secure, or whether we're looking at providers' willingness to take on a new, more open way of doing business and sharing information, trust is the key. It's built over time, and it's especially built face-to-face, in the community and in the clinic.
In addition, we need to build the base of medical evidence. And we need a health IT system that will expand that base of knowledge rapidly and disseminate its findings effectively.
Finally, we have to put the consumer at the center of this enterprise. We're not just talking about new capacities for providers. We're envisioning a new place for the patient on the health-care and health-maintenance team.
I wonder, in the years ahead, when we've truly achieved a health IT-based health care system, whether people will look back and call this the "Health-IT Revolution." I suspect not. I suspect it will be transparent—taken for granted. And that's fine.
I hope they'll see there was a biomedical revolution, where radically new and successful therapies became available. I hope they'll see there was a quality revolution, that helped us put effective treatments to work. And I hope they'll see there was a third revolution, where individuals were empowered with the information and the capacity to achieve high-quality health care and high-impact results. But I know they won't see any of those unless we succeed here first.
Current as of June 2006