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Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ)
Second Health IT Summit, Washington, DC, September 9, 2005
The Quality Movement
HIT and Quality of Care
AHRQ's Effective Health Care Program
HIT and Effectiveness
If you are a person who often takes car trips with young children, or if you are a person who often attends Health IT (HIT) conferences, then there's a question you probably hear frequently:
"Are we there yet?"
"Are we at the store? Are we at Grandma's? Are we at the 'tipping point?' Are we at the break-even point? How much further? Can't we go faster?"
Of course, the truth is simple: with HIT, we can't get there fast enough.
The tragic situation in the Gulf Coast shows us many things. One of them is how important electronic health records and health information exchange could be in any national emergency. And on the individual level, what a difference it could make to have our own secure, interoperable personal health record in place, accessible via the Web, ready for any need. In the meantime, we should all consider developing an electronic personal health record for ourselves and our families, as part of our own emergency preparedness list—along with the flashlights and the reserve of water.
It's no wonder we feel the urgency. The benefits are so broad, and the steps to get there are so many, and so complex.
We need to keep that sense of urgency. But we also need to do the job right. Health IT needs to be a step forward, to help our patients and providers—not an add-on task for people who already have plenty to do.
As you know, Health and Human Services Secretary Leavitt has sorted out a priority list and a timetable for laying the technical groundwork and achieving common standards. At the same time, the private sector is moving fast to develop and improve products.
Simultaneously, at AHRQ, we're supporting a broad-ranging program to help health care providers build their capacity to use HIT, to support innovation, to measure the added value, and to give feedback about what works best in health IT.
Our goal is to help the people who will use this "health information highway"—and help ensure that the end-products will serve the real needs of providers and patients.
We're aiming to compress a generation of learning into a few years. And that's a challenge. Let me give just a couple of examples, from my agency's program:
- One of our grantees, Jewish Hospital Healthcare Services of Louisville, Kentucky, is using electronic tracking in its Emergency Departments. In its first months of operation, it brought about a re-engineering of patient flow—and the average patient time spent in the Emergency Department came down by more than 30 percent.
- They've also installed remote overnight monitoring for their Intensive Care Units. In July, on the very first night this system was turned on, it identified a patient in serious distress—and a doctor and nurse a half-mile away were able to help guide the on-site nurse through the patient's recovery. In the month that followed, the remote site physicians have intervened with some 400 orders during the night-time hours.
Does that mean better health outcomes? I think we can bet that it does. We may not have precise findings as yet. But as the hospital's Chief Information Officer (CIO) says: "Just try telling those patients and their families that this investment didn't pay off."
So the promise is real.
At the same time, we all know how much there is to be done. The President's goal of electronic health records for Americans is ambitious. And next week, we'll have new evidence of the "adoption gap" that David Brailer so often talks about.
A survey supported by AHRQ and carried out by the Medical Group Management Association, the largest of its kind so far looking at group practices, will show EHR adoption remains well below 20 percent among all group practices, with a significant gap between larger and smaller practices.
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The journey to health IT will be taken one provider at a time. And I want to talk today about how AHRQ's program will help those providers on their way.
But I also want to back up and give a broader view of this journey. Because, of course, it isn't merely about hardware and software. It's about quality. And it's part of a much larger movement—maybe even a revolution, certainly an opportunity—that's before us today. A movement to:
- Better identify quality health care.
- Better deliver quality health care.
- Actually save money, because quality care is cost-effective care.
In particular, I want to talk about a new program at AHRQ—the Effective Health Care Program—a dynamic new effort to learn systematically which treatments really work best, and put that knowledge into practice.
I want to suggest that, when we look across the spectrum, we're actually moving more coherently, and maybe even faster, than we give ourselves credit for.
As you've heard today, we're seeing the possibility of fundamental changes in our health care system:
- Efforts to align payment with quality.
- Efforts to build the quality knowledge base.
- The opportunity to turn wasted health care spending into productive spending.
So far, this is mostly potential. If indeed there is a "quality revolution" underway (as I hope there is), it needs nurturing. But first, the opportunities need to be seen and understood—including the central role for health IT.
All of this can help us see where we really are in the health IT journey.
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Let me say a few words about AHRQ's health IT initiative.
AHRQ's program is a true cross-section. Some of our grantees are using HIT for the first time. Others are building on their experience, to help us all move forward. It's an ambitious program, with more than a hundred grants and contracts, in 43 States, totaling $139 million, and impacting communities with populations totaling some 40 million Americans.
An important goal of our program is to bring health IT to settings where it's new. More than half our grants are in rural areas and underserved communities, where we can help introduce these technologies. In the first year of the program, many of these grants have supported planning processes.
- A Nebraska collation is making plans for connecting frontier providers of all kinds over a 14,000-square-mile area.
- Rural providers in Vermont are seeing how existing HIT software might be used to integrate systems that presently stand isolated.
- In Hawaii, a project is planning improved transitions in care to reduce medical errors, including those caused by linguistic or cultural barriers.
- And in both rural Louisiana and southern Mississippi, AHRQ has been helping facilities at different HIT stages to plan for a common infrastructure. These efforts are especially aimed at helping safety net facilities. The hurricane and its aftermath only make clearer how important all these efforts are.
This fall, more than a dozen of our planning grants will be converted to multi-year implementation projects, totaling more than $20 million in new investment. In each case, our grantees will use accessible technology approaches, aimed at specific improvements in the quality and safety of care.
And the lessons they learn will be valuable for others who follow.
The fact is this: 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.
We need user-friendly products—and we need willing, prepared users.
We need health professionals who will take the plunge. And we owe them an accurate preview of the benefits and the challenges.
That's the heart of AHRQ's health IT initiative: a "real-world laboratory," looking at health IT in real clinical settings, and delivering findings based on day-to-day experience.
That kind of real-world information, drawn from experience, can help clear the path for those who will follow. And that's important, because, even in the best of circumstances, the transition to health IT is a demanding task for providers.
The AHRQ initiative is about the marriage of health IT processes with the way work is done in health care today. Like any marriage, there will be adjustments on both sides. One of our grantees has figured that, for the provider, transition to health IT is "one part technology, and two parts culture and work process change."
So AHRQ's initiative asks:
- How do these systems perform when they move into the working environment? And how does that environment react?
- How well do they support the work that needs to be done? How effectively do they serve the staff?
- How much do they enhance patient care and safety? And how can they be improved?
Health IT promises to be transforming. But transformation means fundamental change. When we talk about "re-engineering" health care settings that were never really "engineered" to begin with, we're talking about a lot of learning: valuable learning, but lots of it.
In the movies, they can whisper: "If you build it, they will come." But in HIT reality, merely "building it" is not enough. Providers need to be ready for the adjustments, and convinced of the ultimate benefits. We need to do all we can to help our providers be prepared.
AHRQ's initiative is designed to help with that learning.
A key element of the initiative is AHRQ's National Resource Center for HIT
(http://healthit.ahrq.gov/). This Center and its Web portal have served this year as a source for our grantees, answering questions, sharing experiences, and beginning to pool results.
In recent months, we've begun expanding access to the Resource Center site, even as we continue building it. We're making it available to the Nation's network of community health centers and rural critical access hospitals, working with HHS' Health Resources and Services Administration. In the coming months, we'll also begin making it available to states as they undertake health information exchange projects.
Next year, we plan to make the Resource Center publicly available—open to everyone who can benefit from the experiences of our grantees and others—from large health systems to solo-practice physicians. This will leverage our learning and our investment and help us move quickly toward an HIT-based health care system.
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HIT and Quality of Care
At the same time, we need to be sure we're aiming squarely at the true goal: better safety and better quality of care for the patient. AHRQ's initiative is designed to support, and measure, HIT's capacity to deliver better quality care.
- In health IT, better quality starts with making patient information available, when and where it's needed. That gives clinicians the information they need to provide the right treatment, without delay. AHRQ's contracts in five States are helping build out information exchange systems, based on different models. And many of our grants are supporting new community-based exchange projects.
- Better quality also means providing information on the best treatment choices for patients. This can help ensure that physicians and nurses employ proven best practices. Grantees like the California Rural Indian Health Board are showing how treatment information can be brought to the bedside in multiple locations. And in the Kaiser system, where a multi-billion dollar investment has been made in HIT, we're assessing the impact of that system on quality, safety, and resource use.
- Better quality means preventing medical errors—and that's a predominant theme in AHRQ's initiative. Duke University is building and assessing a computerized system for early detection of adverse drug events. And a project in northern Michigan is integrating bar-coding and other features into an existing IT network.
- Better quality also means coordinating the patient's care, especially by giving different providers access to the same, accurate and current information. This is especially important for managing chronic conditions like diabetes. A grantee at the University of Illinois at Chicago is looking at shared information to lower the risks when patients are handed off from one provider to another. And a grantee in rural Oregon is creating a system to break down "silos" of information among different providers serving elderly patients.
- Better quality can come from extending medical resources and expertise—especially for underserved areas. For example, the University of Tennessee is developing a tele-health system to deliver cancer services in one of the nation's poorest areas. This provides access to followup treatment that simply would not be available without telemedicine.
- Measuring performance is another key to better quality—and health IT systems will be critical for comparing providers and spurring improvement. At Brigham and Women's Hospital in Boston, an AHRQ grant is supporting a new approach that links the "front" and "back" ends of patient care. On the "front end," they're using a decision support tool to assist in providing treatment—and at the same time, they're developing an individualized feedback system—a "dashboard"—to show physicians how they're doing.
- And finally, patient involvement. For most of us, it's an article of faith that patient involvement and patient empowerment are crucial for quality of care. Health IT can help in many ways—and we need to know which approaches will work best. At Case Western Reserve University in Cleveland, for example, researchers will look at outcomes for 13,000 diabetics in 22 primary care practices. They'll compare a "patient empowerment" approach, using a Web-based portal and decision support—with a more traditional disease management approach, using office-based electronic records.
Those are just a few examples. Our initiative is supporting 108 grants and contracts. Each is looking at a technological approach, its impact on providers—and most important—the results for patients.
Reliable, high quality of care is the ultimate goal. It's the core mission at AHRQ. And as I suggested earlier, we're moving toward better quality on many fronts.
We heard this morning about a variety of activities underway at the Centers for Medicare & Medicaid Services (CMS). At AHRQ, we're happy to be collaborating with many of those projects. In particular, we're joining CMS in a $7 million pilot project to ensure that new e-prescribing standards for Medicare will work as intended, and improve patient safety. For many physicians, e-prescribing may be the entry point to health IT. We need to get it right.
Another significant quality of care activity for AHRQ is our National Healthcare Quality and Disparities Reports. These annual reports help us see how well the Nation is doing in putting proven treatments into practice. So far, our performance has been lukewarm at best. In last year's Quality report, we saw overall improvement—but only at a rate of less than 3 percent.
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AHRQ's Effective Health Care Program
We all look to HIT to help improve quality, not only by making the patient's information available, but also by making the best treatment information easily available, as well.
So let me go one layer deeper in AHRQ's quality-of-care programs, and describe our new effectiveness research program. It, too, is part of the health IT universe.
Quality of care is about personalized care; it's about avoiding errors in care; but most fundamentally, it's about delivering the right care, at the right time to meet the patient's needs. In the past 10 years, Americans have learned how often our health care system falls short in delivering that basic result.
First, in the report "To Err is Human," the Institute of Medicine (IOM) made clear the extent of the problem we have with medical errors. Later, in its "Quality Chasm" report, the IOM described how far we are from the kind of quality care that should be possible.
These reports shocked Americans. But they've also motivated us. If as many as 98,000 patients are injured by their medical care each year—if only slightly more than half of patients are getting the recommended care they need when they encounter the health care system—if 30 percent or more of our health care dollars are spent on procedures that are incorrect, duplicative, or even harmful—then the need for improvement is truly imperative.
At the same time, if we're to avoid injuring our patients—and succeed in giving them the right treatments—and spend our dollars effectively—then we need the best information we can get about which treatments really work, and for whom. We need the strongest foundation possible, of evidence and results in health care.
Over the past 30 years, AHRQ and its predecessor agencies supported much of the research that stood behind the IOM reports. This year, AHRQ is launching a new program that will help build the foundation for better quality care. This is the Effective Health Care Program, created under Section 1013 of the Medicare Modernization Act.
The idea of effectiveness research is not new. At AHRQ, we've supported a network of Evidence-based Practice Centers (http://www.ahrq.gov/research/findings/evidence-based-reports/centers/index.html) since 1997. They determine, condition by condition, what procedures and drugs have been shown to work effectively, and which ones are more effective than others. They assess the reliability of the evidence. In short, they help us understand what we really do know, and what we don't know, about the best treatments for specific conditions.
In creating the Effective Health Care Program, Congress recognized the impact that effectiveness research can make for quality. At the same time, the law calls on AHRQ to make these findings useful and understandable for everyone, including consumers.
To achieve those ends, we're creating a three-part structure:
- First, our existing evidence-based centers will form a strong central core. They'll examine the questions that are identified as being our most pressing effectiveness issues. "What treatments work best for a specific condition?" "Which drugs are effective, and with what risks?" In the first round, our topics are geared especially toward Medicare. Next year, we'll begin a second round, including priority areas for Medicaid and the State Children's Health Insurance Program. Our evidence-based centers are already carrying out the first round of work, and we expect their first reports to be released this fall. They'll tell us what's known about specific topics in 10 priority areas. Equally important, they'll help identify what's not known—where additional research is needed.
- And that's where a new element comes into play, because the second part of AHRQ's program will be a new network, called "DEcIDE," which is especially created to perform rapid research where specific additional information is needed. This capacity for targeted followup is an important new feature. It will help us build quickly, and strategically. Learning what the evidence shows today is the correct first step—but developing the capacity to move that knowledge forward, where it's most needed, is an important new step. It means a clearer focus on our knowledge gaps. And the new network is designed to take advantage of the greatly expanded data that's now available from health plans and others.
- Equally important is the third element of this program: a new Center, focused specifically on communicating results. Congress made clear: it's not enough to produce the evidence, if we fail to make our findings as usable as possible. That means clear, understandable language for consumers, as well as detail and precision for payers and others. We'll communicate results in a variety of formats, to serve different audiences, and our test will be usability. The new center will guide this work of "translating" results. It will also carry out a own program of research into communications science. To move evidence into practice, we need to know much more about how to make our findings useful.
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HIT and Effectiveness
This month, we'll be launching both the DEcIDE network and the communications science center. Their work will start immediately. And the connection to HIT is strong:
- First, of course, HIT will be the most important mechanism for conveying our findings.
- Second, and even more important: as more health care data come to exist in digital form, our ability to perform effectiveness research will grow exponentially. We are literally surrounded by information that could help us understand what works, and what doesn't, for whom, and with which risks. We can tailor our therapies more and more precisely to each individual patient, but only if the data are accessible. As more health information becomes digital, our ability to reach that information, and synthesize it, will grow.
And that brings us to the most fundamental question of all: not technology, not incentive, not even capacity, but trust.
For example, in our new Effective Health Care Program, there needs to be trust throughout the health care sector that our findings are sound and impartial, and truly about medical effectiveness, not costs. We'll seldom have all the answers we want. Patients, providers, and payers will always have to make judgments in cases where more evidence is still needed. They'll need to feel confidence that, where the evidence does exist, the foundation is strong and fair.
And for the whole HIT enterprise, as has been said so many times, trust in the privacy and security of individual health records is absolutely mandatory. In HIT, we need to build systems that are, quite simply, safer than the ones we read about in the news today. They need to be technically strong, they need to be operationally secure, and we need to be sensitive and responsive to the concerns that patients and providers will have.
One starting point is the effort we'll soon launch to review the business practices and state laws that impact health care privacy. And even as that review is carried out, AHRQ will be working with our partners to understand the challenge in depth. We need an active interface between the concerns that stand in the way of trust, and the steps that are taken to ensure privacy and security.
Where trust is concerned, I suspect we end where we began: with the relationship of the patient and the provider. If health IT comes between patient and provider, if it makes encounters more difficult and less personal, then no amount of privacy protection may bring about the trust we need. But if health IT makes
the patient-provider relationship stronger and more productive—if it enables the provider to focus better on the individual, and indeed on the complete health picture for the individual—if health IT becomes part of a new vocabulary for better patient-provider communication—then we're a long way toward the goal. Technology is the servant—and that's the way to keep it.
I said earlier that I hoped we're in a "quality revolution." Actually, it's my hope that we may be in three health care revolutions at once:
- A biomedical revolution, where radically new and successful therapies become available.
- A quality revolution, to help us put effective treatments to work.
- A third revolution, where individuals are empowered with the information and the capacity they need to achieve high-quality health care and high-quality health results.
That's where we should be headed. And, to borrow from Secretary Leavitt: health IT is the "big gear" that can enable these changes.
Quality is the right answer to the problems of waste and error in our health care system. We can't afford anything less. And all around us are signs that we're learning to use quality as a long lever for change.
Today, with the tragedy of Katrina constantly in our consciousness, we know how important it is to have strong systems in place. We also know that those systems take time and vision to build.
The urgency, and the promise, of health information technology are no different.
The better we build today—the better we share the goals, and work together toward them—the better we prepare the women and men of our health care sector—then the stronger we'll be in every health care area—and the better quality and value we'll deliver to our patients.
Current as of September 2005