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by Carolyn Clancy, M.D., Director of the Agency for Healthcare Research
and Quality (AHRQ)
Symposium, American Medical Informatics Association (AMIA), Washington, D.C., October
Momentum for Health IT
The Coming Revolution
Quality and Health IT
Effective Health Care
Thank you for inviting me to share
this time with you. It's flattering to be considered a close
enough cousin to AMIA to be included in your "State of the Association"
We have a lot of history in common.
It's been nearly the space of two generations
since AHRQ's predecessor agencies began funding something called health
informatics—using giant computers with paper punch cards that probably
had less computing power than your cell phone. Today, AHRQ
and AMIA's members are seeing pay-back from those early and ongoing investments.
And for those of us who have been
close to the subject, I would say it's been nearly a full generation since
it became clear to all of us that our health care system and our information
technology [IT] were a "marriage waiting to happen." No profession
or sector has greater need for 21st-century information power. Yet
so much health information remains stuck in 19th-century models.
So health care and IT should be "a
match made in heaven." But it's going on 20 years now—and even for heavenly
engagements, 20 years is a long time. Try to imagine Ben
Afleck and J-Lo prolonging their famous engagement on the cover of People
Magazine for two decades. It might be perversely interesting—but not very results-oriented.
It's as clear as it can be that our
health care system needs what information technology has to offer. So,
after all these years—with a few big successes, and a few jarring failures
—has the time actually, finally arrived for information technology in
our health care system?
The answer has to be "yes." More
to the point—we have to make it "yes."
Has anything changed to make that
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Momentum for Health IT
Well, for one thing, it's not every
day that the President takes up your cause and puts it near the top of
the national agenda. But it's happened to health IT. The
President has changed public awareness and created a new sense of urgency. That
is playing out in hundreds of studies and articles, and thousands of projects,
that would have been under the horizon or non-existent. And
that has raised the possibility of progress to a new level.
[HHS] Secretary Leavitt has taken on the
challenge with vigor, and order, and depth. As you know,
he's created an "American Health Information Community" (the AHIC) to bring
together stakeholders to agree on technical and other standards. He's
personally leading that effort.
Four contracts under the Office of
the National Director for Health IT will help lay the groundwork for interoperability. AHRQ
is administering one of these, looking at the different State-level legal
issues and business practices that could impact health information exchange. And AHRQ's own health IT initiative
now includes $166 million in grants and contracts to help advance health
IT—and learn quickly from our experience.
Let me say a few words about AHRQ's
initiative. This program is a true cross-section.
Some of our grantees are using health IT 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.
One important goal of this 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. More than that, we want to learn
how health IT works in real-world clinical settings. Because 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.
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The Coming Revolution
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. 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
In the movies, they can whisper: "If
you build it, they will come." But in health IT reality, merely "building
it" is not enough. Providers need to be ready for the adjustments,
and convinced of the ultimate benefits.
AHRQ's initiative is designed to
help with that learning. A key element of the initiative is
AHRQ's National Resource Center for HIT. 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. 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—anyone from large health systems to solo-practice
physicians. This will leverage our learning and our investment, and help
us move quickly toward an IT-based health care system.
At the same time, we need to be sure
we're aiming squarely at the true goal: better quality and better safety
for the patient. AHRQ's initiative is designed to support, and measure,
health IT's capacity to deliver better quality care.
It's also important to understand
that this is part of a larger movement—maybe even a revolution... certainly
an opportunity—to put quality first, and to use it as a long lever for
change in our health care system. It's a movement to better identify quality... better deliver quality... and actually
save money, because quality care is cost-effective care.
We're seeing the possibility of fundamental
changes in our health care system, with:
- Efforts to align payment with quality.
- Efforts to build the quality knowledge
- And 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.
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Quality and Health IT
Everyone knows we look to health
IT to improve quality by making the patient's information available. But we also look to health IT to
make the best treatment information available. And
that means knowing more about which treatments work best. So let me go one layer deeper in
AHRQ's quality-of-care programs, and describe our new effectiveness research
program. I see it as another 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.
Over the past 10 years, Americans
have learned how often our health care system falls short in delivering
that basic result. In particular, reports issued by the Institute
of Medicine have made clear how far we are from the kind of quality care
that should be possible.
The IOM [Institute of Medicine] reports pointed to health
IT as a central part of the solution. 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. In a word, we need the strongest
foundation possible, of evidence and results in health care.
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Effective 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 has launched 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 since 1997. They determine, condition by condition, what procedures
and drugs have been shown to work effectively 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've created
our Effective Health Care Program with 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. Most important,
they'll compare treatments, including drugs, to see what works best.
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 soon. 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 its own program of research in communications science. And
it will build a new foundation for developing decision aid tools, aimed
especially at helping consumers get the results they want.
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Health IT... quality of care... evidence-based
medicine. This is an interlinked triad that
can transform health care delivery. And the time has come
to do it.
It's been many years since the potential
of health IT became clear, and little of that potential has been realized
so far. Yet it's also a time when the problems in our health
care system beg for solutions that depend on health IT, and a time when
the Nation's leadership has embraced the concept and established a goal.
Since the President announced his
goal, we've had more than a year of heightened discussion, broadened horizons,
and real first steps in health IT. Maybe we should call it a period
of "rational exuberance." But when "exuberance" tapers,
and "rational" is still left, what should we do next? If
this is the moment we knew was coming, when the work gets longer and the
questions get harder, what should we be doing to keep up the momentum and
steer it toward real results?
First, it needs to remain clear that
health IT is about quality. Health IT is not an end in itself,
but a means to better quality, safety and effectiveness. Increasingly
(and with the help of IT), we can identify quality, measure it, and reward
it. Quality improvement needs to remain a North Star in guiding
our health IT endeavors.
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 it will
actually fulfill its promise. I don't say this to be negative. But
a false aura 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
need to remember that the pitfalls are still there, if we're to have the
staying power to overcome them.
Third, we need to keep up the energy
by keeping the big perspective in mind. There are rosier
scenarios, and there are greyer scenarios, but we all know our health care
system could be much better than it is today. That vision is an energy
source that we need to keep tapping.
Fourth, we need to be guided by real-life
clinical and consumer experience with health IT. 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, the individual clinician, and the individual consumer.
People easily understand two of the
legs of the health IT stool—the need for common standards, and the challenge
of financing. But the third leg is equally important, and
too often taken for granted. At the end of the day, the technology
has to be helpful and usable in delivering health care. And
as we go forward, we need our clinicians and patients to help guide us
in the directions that work best.
Fifth, we need to build the evidence
base—and we need a health IT system that will expand that base exponentially. Our
new Effective Health Care Program is an important step, but health IT can
help us deliver much more. It seems obvious, but it needs
to be said: When we confront a health condition, we need
to know all we can about which treatments work best.
Finally, we have to put the consumer
at the center of this enterprise. We all say that—we all
believe it. But I think we have to admit candidly that we
don't know exactly how to do it. So far, we're having difficulty
even defining what a consumer-faced Personal Health Record should be. We'd
probably know "patient-centered care" if we saw it—but that's not the
same as knowing how to achieve it. Rather than theorizing,
we may get further if we just stipulate that the consumers themselves could
be the experts here—and ensure, case by case, that they have a real voice
in the process and a seat at the table.
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.
- And 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
this time, let's get past the starting blocks.
is a long time for an engagement. It's too soon to declare
success. But it's too late for an annulment.
to us to make this match happen.
Current as of October 2005