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Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ)
2005 Annual Patient Safety and Health IT Conference—Making the Health Care System Safer Through Implementation and Innovation, Washington, DC, June 8, 2005
I'd like to welcome everyone back to our first-ever combined conference for patient safety and health information technology [health IT]. We have a very impressive line-up today. I'd like to thank Congresswoman Nancy Johnson for addressing us this morning. We're especially honored to welcome Secretary Mike Leavitt who will be speaking to us in a few minutes.
As many of you have heard, Secretary Leavitt announced on Monday a new entity called the American Health Information Community for requests for proposals that will advance efforts to reach President Bush's call for most Americans
to have electronic health records within ten years.
There are many familiar faces here, especially our partners who have done so much already toward a culture of safety in health care. I'm happy to welcome many newcomers—especially our health IT grantees. You have big shoes to fill, and I know you'll succeed.
We have a lot to learn from each other. And we have a common goal: quality health care for America.
For AHRQ, quality of care is really the end-point of everything we do. We want to bring all of our activities, and all of our partners, together under one banner for safety and quality. And of course, we want to harness the emerging—and enormous—power of health IT.
So many different factors impact on quality. And today, we're trying such an array of approaches that are new to health care—quality comparisons for consumers, new payment methods to reward performance, and of course the revolution of health IT.
It might seem easier if we had a map to guide us. But that's not really how it's done.
It's like the story of the two children standing on a street corner in Manhattan. They're all dressed up... they've got their tickets in their hands. But they're lost. They see an old man coming down the street—big black overcoat, tousled gray hair, and carrying a violin case. They run up to him and say: "Sir, Sir, can you tell us how to get to Carnegie Hall?" And he fixes them with a hard stare, and says: "Practice! Practice!"
That's how we'll get to quality and safety: practice, innovate, assess, readjust, and practice some more. We need to feel the urgency. We need to be tireless. We need to keep up the pressure. And as we learn what works, we need to draw maps to help others.
Our job at this conference is to summon all the force and all the best ideas we can muster to improve quality and safety in health care, including new roles for health IT: Because it is simply not acceptable that millions of Americans are injured, and tens of thousands die every year, from medical errors that don't have to happen. Not necessary. Not acceptable.
Yes, "to err is human." But to prevent would be divine. And we can do it.
I'd like to talk for a minute about the road that brought us here. To me, this combined conference is a milestone. For AHRQ, and our predecessor agencies, we've come to the culmination of one period in our history—and we're beginning a new one.
We can look back more than a generation to the studies that showed glaring variations in the treatments that Americans receive for identical medical conditions. It seemed the treatment you got depended mostly on where you were treated. We used to call this "ZIP Code medicine" or say that "geography was destiny."
And that didn't make sense. These findings begged the question: "Couldn't we determine scientifically which practices actually work best? And shouldn't that be the care we deliver?" These studies set us on the path to find answers—and create a body of evidence-based practice. It's been a generation in the making.
This was slow work, at first. We developed new tools and methods for mining health care data, and making sense of it. This work wasn't widely understood, and it wasn't always welcome. But it became a core mission as we developed into an agency of the Public Health Service.
Today, looking forward, we see a new prospect. A foundation of evidence-based practice is in place. We're looking ahead to an electronically linked health care system that can deliver better care, more consistently. We also see its potential to give data back, to help us learn more, and faster, about what works, and in what circumstances, and for whom. Let me just say, for a health services researcher, this may be more excitement than we should be allowed. We're looking at vast new potential for delivering the right care, at the right time, to the right patient.
At the same time, these potentials are now better understood and supported—by policymakers, by the health care community, and by a growing public.
There's a reason for that. In 1999, there was a sharp turning point that truly "changed the conversation." It was, if course, the Institute of Medicine (IOM) report with the gentle, self-evident title, To Err is Human. It changed the way the public sees the health care community, and the way the health care community sees itself. (And, I have to say—AHRQ takes great pride in the support that our predecessor agencies gave to Dr. Lucian Leape and others to develop the seminal findings that informed the IOM report.)
As we all know, that report declared the scale of medical error to be much greater than most people realized. And, it began a change in Americans' fundamental perceptions about the safety, and overall quality, of their health care. Safety and quality care were no longer something to be taken for granted. Nor did they have to be accepted, whether good or bad, as the best that could be done. They could be measured, they could be improved, and the tools to do the job should be developed.
This is the sea-change that's taken place in the years since 1999. Americans today know much more about quality and safety in health care. Their expectations have been raised. They're looking for dramatic reductions in medical errors. They expect health information technologies to help.
And they are on target.
Today, the mission we share is not only better-understood—it's become an imperative. And the national priority given to health IT gives us even greater opportunity to make new progress.
It's been 5 years since the IOM report. How are we doing?
I think it's clear that we've had significant accomplishments. But it's also clear that we're a long way from the ambitious goals that the IOM laid out.
Certainly, awareness is much higher. Hospitals realize that safety issues don't "take care of themselves" just because of the good intentions of the staff. The IOM report made clear that improvements in patient safety mean addressing the systems that can help protect safety. As my predecessor, John Eisenberg, used to say, "improving patient safety is a team sport."
Many hospitals have made concerted efforts to find weaknesses, and fix them. Still more need to undertake this work.
We've helped with our evidence report, Making Health Care Safer. It highlighted 73 proven patient safety practices—and especially 11 practices that were not being used routinely in the Nation's hospitals and nursing homes.
Working with AHRQ, the National Quality Forum also identified 30 key "Safe Practices." And new requirements by the Joint Commission on Accreditation of Healthcare Organizations have had an important impact in requiring basic safety measures.
In recent months, the work of the Institute for Healthcare Improvement has begun to show how effectively hospitals can reduce infections.
But at the same time, we have to be candid: None of us believes we've achieved the 50-percent reduction that the IOM aimed for.
It's time to rededicate ourselves. The plain fact is that we're wasting money, and injuring patients, giving less-than-good care when we have the means and the knowledge to do better.
One of our most important challenges remains the need for better tools to identify errors and measure safety trends. Errors are naturally difficult to find. We need to be inventive, and persistent, in finding data tools to help us.
Even more important—we need to encourage reporting of adverse events and near misses by doctors and nurses. AHRQ has supported the development of anonymous reporting tools, and these tools are available to hospitals. In addition, on our Web M&M site, we share new cases each month, along with expert commentaries, pointing to problem areas and solutions. But the fact remains: Even though reporting is crucial to a robust patient safety culture, difficult issues still surround it, and they haven't been resolved.
As the IOM said, errors are actually a form of information about a system, if they're reported. They identify problems that otherwise might never surface. It's true that we can make progress in building teamwork and improving systems, even without routine reporting. But until we develop a widespread reporting culture, where openness is the rule and health care professionals feel safe in sharing, we will not make the fundamental breakthroughs in patient safety that the IOM envisioned.
In other areas, we've made important progress:
We've taken steps to provide patient safety training—especially through the Patient Safety Improvement Corps. Representatives from around the country take home lessons from this training, to help hospitals identify problems and develop effective, long-term interventions.
In cooperation with the Food and Drug Administration (FDA), we also support the CERTs program—Centers for Education and Research on Therapeutics—to help uncover safety problems with drugs and medical devices once they're on the market. The CERTs have identified risks involving frequently prescribed medications, like the potential hazards associated with erythromycin interactions with certain other medications. This information should now be part of standard medication safety practice in our clinics.
Widespread adoption of effective health information technology will help identify similar adverse interactions faster and disseminate information faster to providers and the public.
And since 2001, AHRQ has funded more than 100 patient safety projects, especially research on medication safety, communication with patients, intensive care issues, and fatigue among hospital staff.
Last year, we launched a Hospital Survey on Patient Safety Culture, to help hospitals evaluate where they stand on the pathway to creating a culture of safety among their employees. I would like to acknowledge our partners in this effort—Premier, Inc., and the American Hospital Association for their enthusiastic support and adoption of this tool.
We are continuing to refine our Patient Safety Indicators (PSIs). I am especially proud that the Department of Defense uses the PSIs to improve safety in its facilities.
We've also launched the Patient Safety Net Web site, a new comprehensive resource of patient safety information.
I am also very proud that the research we have funded is beginning to have an impact.
Based on an AHRQ-funded study on preventing falls in nursing homes, Emory University designed a Falls Management Program. Early findings show that implementing this program reduces injury-causing falls by 45 percent. As a result, Beverly Corporation, a for-profit chain of about 350 nursing homes, is adapting the Falls Management Program materials for use in their nursing homes. Beverly will begin implementing this program this year.
Today, we're announcing the award of another $8 million to fund 15 new projects, aimed at implementing proven approaches. Over half of these projects focus on preventing medication errors, our most important target area. These approaches are designed for sharing. With these projects, we'll generate toolkits to be available to all providers.
Looking ahead, we have some specific challenges in patient safety:
- We've focused on hospitals so far—but we also need to know what's happening in other health care settings.
- We also need to redouble our efforts to take what we've learned and use it in practice. And we need to make information readily accessible and usable.
- It's important to encourage physicians and nurses to talk with patients when errors do occur. Patients deserve to know, and they want a sense that something is being done to prevent the error from happening again and affecting others. Candor and trust are two of the most important pillars of a safe health care culture. Along with error reporting, openness with patients is crucial.
I would like to commend the State of Illinois for passing the first "I'm Sorry" law which protects clinicians who apologize. Patients deserve to know what happened, receive an apology, and be assured that steps are being taken so the error doesn't occur again.
And we need to work with other stakeholders to set achievable goals, and ensure that we're "rowing together" toward common ends.
Finally, of course, we need to put information technology to full use in the service of safety and quality.
In its followup report in 2003, the IOM said: "Americans should be able to count on receiving health care that is safe. This requires, first,a commitment by all stakeholders to a culture of safety, and, second, improved information systems. "
As you know, President Bush and Secretary Leavitt have identified health IT as one of our top priorities. The President has called for electronic health records for Americans within10 years. And Secretary Leavitt is pushing hard to build the foundation and create the standards that will make health information exchange work. When Secretary Leavitt announced his vision for health information technology, his passion and enthusiasm garnered him a standing ovation.
Information technology has been recognized, from the start, as an important part of our patient safety agenda. Inadequate information is so often a root cause of medical errors. And by contrast, information systems that not only make patient information available, but also support decisionmaking—like "smart" drug-ordering systems—can make a big impact for safety.
AHRQ recognized this connection in its CLIPs grant program as early as 2001. These grants looked at technologies like hand-held devices to help avoid adverse drug reactions. They've helped prove the value of these technologies in the clinic. They've also helped us understand some of the factors that make the devices more useful for physicians.
These were a good start. But today's vision of health IT, and the contribution it can make to safety and quality of care, is even deeper and more far-reaching:
- When health information can be exchanged, securely and privately, so that a patient's health record is always available and always current.
- When computer ordering of drugs means, not just enhanced efficiency, but also sophisticated decision support to help avoid errors.
- And when "smart" systems like that can link to the patient's electronic record—and "read" it—and then alert the doctor to specific patient needs or problems.
- Then, a new level of health IT-supported quality and safety will have been achieved. This will mean that studies like the one which showed the dangers of interactions between erythromycin and other drugs won't be news because the dangers will be identified and relayed before harm is caused.
AHRQ's new health IT initiative is designed to prove applications like these—while at the same time we provide special help in rural and underserved areas. Our initiative is an important part of the government's overall drive to get health IT in place. At the same time, it looks specifically at how health IT can contribute to quality of care.
You'll hear from Secretary Leavitt in a few minutes, about his plans for the groundwork that must be completed to make health information exchange a reality. But let me talk briefly about the special nature of AHRQ's health IT initiative. Because we're not only helping the Secretary lay the technical foundation... and helping provide health IT where it might otherwise be long in coming... we're also looking ahead to the way IT will actually work in the clinic... and the steps that will help clinicians make the most of it, for themselves and their patients.
We want to help build the health IT network as fast as the job can be done. We also want to help ensure that, when a provider gets health IT capacity, it will work at its best. This means looking not only at the technical side, but at the human side of health IT. The AHRQ initiative is about the marriage of new health IT systems with the way work is done in health care today. Like any marriage, there's an impact on both parties. The more we can foresee those impacts, and prepare for them, the better.
To make the most of health IT, we're going to need user-friendly products—and we're going to need willing, prepared users. We're going to need providers who understand the benefits. But, just as much, we'll need to understand the challenges that clinicians will face.
Adopting health IT will indeed make new demands. One of our grantees figures that, for the provider, transition to health IT is "one part technical, and two parts culture and work process change." This will be hard work. But at the same time, it's an opportunity to design new and better workflows—and review work patterns that may never really have been examined. It's an opportunity to build in better efficiency, and an opportunity to build in more safety.
I know those of you who are health IT grantees have only begun work on your projects. But we're already learning from you.
You're telling us how important customization is. As one grantee put it, "health IT is not a pop-out-of-the-box technology." And I would add: it probably never will be—or should be. Health IT applications need to serve the needs of individual health care settings. That means the capacity to customize—in both large systems and small. The technology should be serving the clinician and the patient—not the other way around.
The real message here is that when health IT is introduced, it changes all the dynamics, and we need to be ready with a dynamic response. That's part of preparing for health IT, but it also means providing real, ongoing support. At one of the breakout sessions, it was suggested that we create "rapid response" health IT teams. As was noted at this session, the clinical staff needs to be able to get improvements made when they're needed, and the response by the IT team needs to be fast and effective.
And you're telling us about the process of converting to health IT. If it's done right, you tell us, it's long, hard, valuable work. It means engineering office processes that may never have been thought through. And it means getting the whole organization involved. That way, you draw experience from every level—and you lay the groundwork for better communication and a safer health care environment.
This is an important potential intersection between patient safety and health IT. It's an opportunity we shouldn't miss. Because when a clinic and its workflow are re-examined and re-adjusted for health IT, they can be renewed for safety as well.
The important fact is that, whether we're talking about patient safety or health IT, in the end we're really talking about people—the women and men in health care—and the systems they work in. If adopting health IT provides the opportunity to build a technology "dream team," let's take that opportunity to build a safety "dream team," too.
Practice... innovate... assess... readjust... practice some more... and share.
We may have only a few "maps" and tools now—but our health IT initiative will provide many more. And that's why a crucial part of our initiative is the AHRQ National Resource Center on health IT.
The Resource Center has already been at work supporting our grantees and contractors. It serves as a clearinghouse of information. And as we learn more, it will make our findings available to everyone.
We want to provide useful, practical information that providers can put to work. And we want health IT to contribute everything it can to the ultimate goal: high quality care.
Let me close with a formula... a formula for health care improvement. It's not a formula that makes our job any easier. But maybe it can help make the end-point clear.
It has four elements:
- Element One—"Connect health records." This is the President's goal—electronic health records, secure, private, and (subject to the patient's authorization), always available, always current.
- Element Two—"Build smart systems." This means computer systems that help the physician and nurse make the right decisions. It means making evidence-based information easily available: Not overwhelming providers with excessive alerts, but processing more information, and faster, than the human brain could do. When these smart systems can interact with the patient record, and offer patient-specific advice, then health IT will become something more than a tool. It will become part of the health care team.
- Element Three—"Put the patient at the center of care."
- Element Four—"Put prevention at the center of treatment."
I left out some of the details, but I think is where we're headed.
We have a huge opportunity. No matter how much we hear about the problems and the challenges, our vision of the future of health care should be positive and hopeful.
We're talking about a generation's worth of work, but we don't have a generation in which to do it. This is the moment we need to act, and I urge you to reinvigorate your efforts.
Tomorrow, I am testifying before the Health Subcommittee of the House Energy and Commerce. They will ask about our progress, and I will proudly list your achievements. They will also ask about what still needs to be done, and I will tell them that you are taking up the challenge to ensure the citizens of this nation
have the highest quality, safest health care system.
There's hard work at hand, but how fortunate we are to be here to do it.
Current as of June 2005