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Remarks by Carolyn Clancy, M.D., Director of the Agency for Healthcare Research
and Quality (AHRQ)
World Healthcare Innovation and Technology Congress, Washington, DC, November 1, 2006
Introduced by Peter Robinson,
author, TV host, former White House speech writer for President Reagan
and then Vice President Bush, Hoover Institution Fellow.
Thank you very much, Peter. When
President Reagan said, "Mr. Gorbachev, tear down this wall!" nearly 20
years ago, it was one of the most inspiring passages of our time. I am
pleased to have the honor of being introduced this morning by the author
of that speech, and those famous words.
Great words can lead to great
deeds. We are beginning to see this more and more in health care as the
enthusiasm grows for working towards one of the most ambitious goals of
our time: the transformation of the American health care system through
Here in the United States, we
are fortunate to have the finest health care workers, nurses and physicians
in the world. Unfortunately, the health care system in which they practice
is not always the best that it can be. There is a lot of room for improvement
in just about every category of health care that can be measured. We are
making progress. But the pace is way too slow and, collectively, we need
to accelerate the pace of change.
Accelerating the pace of improvement
is a charge that the Agency for Healthcare Research and Quality, or AHRQ,
takes very seriously. Our mission is to improve the quality, safety, efficiency,
and effectiveness of health care for all Americans. We do this by supporting independent,
user-driven research that is designed to help people and organizations
at the Federal, State, and local levels make better decisions about health
care. And, it has become clear to us that, as the complexity of our health
care system continues to grow, providers must leverage information technology
to improve patient safety and health outcomes.
Computers have changed the world,
as we have been willing to adapt our habitual ways of doing things. We
send billions of E-mails daily. We have come to trust the technology enough
to pay our bills and monitor our 401Ks online. We shop online. That's the
level of trust we want people to have in health IT [health information technology].
The cost of health care is about
$2 trillion annually, which exceeds the gross domestic product
of Russia and accounts for about one-sixth of the U.S. economy. And it
is expected to double within the next 10 years—and we know that these
numbers are probably unsustainable.
But that's not the worst of it.
The worst is that we don't deliver $2 trillion worth of quality
care. It's probably not even close. I believe it was Ben Franklin who said,
"God heals and the doctor takes the fee." Quality was an issue even then.
With health information technology,
we have a phenomenal opportunity to improve the way we treat patients,
by giving health professionals real-time or near-real-time access to quality
and care-enhancing information.
In order for this to happen, there
must be a total commitment within the industry. We must begin to view health
IT more as an opportunity and less as a cost of doing business. Yes, I've
heard the comments. I've heard about the jokes. I know, for example, that
some people refer to Pay for Performance as Pay for Reporting.
I understand the reservations.
We all do. We also understand the need to address the uneven quality of
care, unjustifiably high rates of medical errors and unsustainable cost
No one understands this better
than Secretary Leavitt. He has been very visible and vocal in driving this
issue—talking about the need for a sense of urgency, imposing strict
deadlines and working hard to keep this from becoming an academic endeavor.
It's unfortunate that he couldn't
be here this morning to share his vision first hand. It would have been
great for you to hear him talk about a value-based health care system which
focuses on four cornerstones—quality standards, cost standards, interoperability
Everything begins with quality
and cost standards, because we're never going to get to a value-based health
system until we:
- Define what constitutes quality health care.
- Design systems to collect quality-of-care information.
- Pull together claims information so we can compare costs between specific doctors and hospitals.
We've been laying the foundation
for quality and cost standards for a long time, and we're starting to make
some real progress where theory meets reality, at the grassroots level
of our health care system.
At the 10,000-foot level, we know
for example that we can't get to Pay-for-Performance and true innovation
and value in health care without information technology. The work must
be—and is being—done at the ground level by people like you.
The Quality Work Group under the
American Health Information Community—or AHIC—initiative is in the
process of determining how health IT can provide the data needed for developing
quality measures that:
- Are useful to patients and others in the industry.
- Automate the measurement and reporting of a comprehensive current and future set of quality measures.
- Accelerate the use of clinical decision support that can improve performance on those quality measures.
- Make recommendations for how performance measures should align with the capabilities and limitations of health IT.
I am co-chair of this work group.
One of the initiatives we have taken on is an analysis of the business
case for quality. We found some excellent examples of the potential that
exists in automated quality reporting.
One involves the Indian Health
Service, which provides care for 1.6 million Native Americans and Alaskan
Indians in about 600 health care facilities. The service's Resource and
Patient Management System provides automated local, regional, and national
tracking of clinical performance on demand. Since 2002, this system has
resulted in cost savings of $57 million on chart review.
The Quality Work Group has several
additional priorities. Included on the list is automating data capture
and reporting, to support a core set of Ambulatory Care Quality Alliance
(AQA) clinician-focused quality measures and a core set of Hospital Quality
Alliance (HQA) inpatient quality measures.
The HQA effort has identified 21 quality measures within four subcategories.
They are Acute Myocardial Infarction, Heart Failure, Pneumonia, and Surgical
The AQA has endorsed a starter set of 26 standard performance measures
that are now being put in physician contracts and implemented around the
country. We expect that when completed, the knowledge we develop
through the AQA pilots will provide a comprehensive national framework
for performance measurement and public reporting.
A few weeks ago, I had the opportunity
to travel with Secretary Leavitt and visit the sites of the first six Ambulatory
Care Quality Alliance (AQA) Pilot Projects. They are in
San Francisco; Indianapolis; Phoenix; Madison; St. Paul; and Watertown, MA.
Through these projects, which
are being sponsored by AHRQ and the Centers for Medicare & Medicaid
Services (CMS), we're going to be able to combine public and private data
on physician practice for the first time.
We're testing the most effective
methods to provide consumers with meaningful information they can use to
make choices about which providers will best meet their needs. We're testing
different ways to pull together and report data on physician performance.
And, in addition to measuring the quality of care, we're going to identify
providers who deliver efficient care to patients while avoiding unnecessary
complications and cost.
We're also preparing to significantly expand the number of pilot sites,
because we know how important this information will be to setting the quality
and cost standards we need to define and measure value in health care.
We expect that, when completed, the knowledge we develop through the
AQA pilots will provide a comprehensive national framework for performance
measurement and public reporting. This framework can also serve as a foundation
for evidence-based reporting.
Information technology is much more than a means for collecting data
quickly and efficiently. One of its real value-generating capabilities
is in decision support—as a method for providing important health care
information for use in real time.
A good example of this is the brand new Electronic Preventive Services
Selector, or ePSS. This tool, which was created by AHRQ, is designed to
help clinicians in selecting the right preventive service for patients.
They can use it with computers or PDAs to generate custom real-time reports,
based on the latest recommendations from the U.S. Preventive Services Task
Force. You can view or download the tool at http://www.ePSS.ahrq.gov.
In addition, under the leadership of Secretary Leavitt, AHIC is making
advances in value-based care by working to accelerate the use of health
IT for consumer empowerment, chronic care, electronic health records, and
public health biosurveillance.
HHS [The Department of Health and Human Services] has also certified the first
round of ambulatory electronic health record products, and announced final
regulations needed to support physician adoption of e-prescribing and e-health
records technology. Electronic health records, computerized physician order
entry, e-prescribing, and other health IT applications have the potential
to transform the way health care is delivered in this country, and AHRQ
is deeply committed to helping providers adopt health IT in their everyday
We're seeing that health IT, when properly used and understood,
can help providers make better use of their
time and energy, by streamlining tasks such as:
- Sharing information through complex
Since 2004, no other Federal agency
has invested more money to understand and implement health IT at the provider
level than AHRQ. We are currently backing more than 125 projects
in 43 states with more than $166 million in grant and contract funding.
We will soon announce that we will
be awarding up to $24 million to fund studies on using health IT to improve
patient safety and quality of care in ambulatory care settings. One of
the primary goals here is to gauge the effectiveness of electronic health
records systems [in settings] where the majority of health care occurs.
Earlier this year, we released a
report prepared by the RAND Corporation that surveyed the best available
evidence on how health IT improves quality. The evidence suggests that,
indeed, the quality of health care can be significantly improved, but this
improvement is primarily seen in large health care systems that develop
their own health IT systems and have substantial resources to commit to
their health IT efforts.
Nevertheless, the majority of physicians
still practice in small office settings. These providers stand to benefit
the most from e-health systems, but they don't have access to the resources
large hospitals and provider networks have. AHRQ places a heavy emphasis
on helping small practices serving inner city, small town, and rural populations
realize the promise of Health IT.
While other entities of the Federal
Government are backing public-private initiatives that tackle technical
issues such as interoperability and infrastructure, AHRQ is supporting
research designed to help individual clinicians.
We want to understand how health
IT impacts the culture of care, and how doctors, nurses and other providers
interface with these powerful new tools to enhance patient care.
Earlier this year, AHRQ launched
a new Web site—the National Resource Center on Health Information
Technology—that is now available to all providers who want to learn
from each other's real-world experiences. Our philosophy behind this Web-based
learning resource is simple: to learn as we go.
Rather than wait years for report
findings, we see the importance of capturing and sharing lessons learned
in real time to build a community of health IT users, and accelerate the
learning curve through a steadily increasing knowledge base.
Despite the widespread enthusiasm
for health IT, and the growing priority it has with the Government and
the health care industry, we still have a long way to go in the wiring
of the American health care system—which is still much less computerized
than other industries.
Beyond that, we have some distance
to make up between the number of health care professionals with access
to computerized health care systems and the number who are actually using
them. According to a study last month by the Institute for Health Policy,
about 1 in 4 doctors use some form of electronic health record, and
only 1 in 10 use them as part of an integrated quality improvement system.
I was a patient at a local hospital
(which will remain nameless) about 3 years ago. When I was wheeled
to the operating room, they placed the paper orders on my bed. While this
traditionally has been standard operating procedure, I was somewhat surprised
because I knew the hospital had a state-of-the-art IT system. I asked and
was told that the system was too slow for the doctors.
Instead of using the system, the
doctors continued to use paper and the nursing staff had to enter the data
from the paper documents into the system, effectively eroding any potential
value in the technology at the outset.
Doctors see patients one at a time,
and IT offers the potential for significant enhancements in this process,
in terms of being able to look at patterns of care. It's the equivalent
of what airplanes did for making maps.
But, the reality is, it's a huge
cultural change. It requires a commitment to achieving and sustaining an
evolution in the culture that is likely to change the way many facilities
How powerful is culture? I recently
heard a maxim that states, "When it comes to changing an organization,
culture eats strategy's lunch every time." Even the best plans made by
the smartest experts are no more than academic exercises without the support
of everyone involved.
Without the buy-in of management
and the workforce, an organization runs the risk of being left with a hefty
software and implementation bill for a product that gets little use and,
therefore, creates little or no return on investment. Next comes the blame
Of course, this kind of a scenario
is not unique to the health care industry. The information highway is littered
with stories of projects gone bad and money wasted. Fortunately, these
stories don't happen as often as they did 5 or 10 years ago, when software
companies operated under the "build it and they will come" strategic
Health IT is gaining momentum at
a time when people understand the value and importance of putting software
developers in the same room with health care professionals to develop products
that are based on need. And it doesn't hurt to have people on staff who
are "bilingual," or fluent in the languages of health care and information
Today there are about 200 companies
producing electronic health record technology alone, and a number of the
big players are hovering, trying to anticipate the coming of the tipping
point in the uptake of health IT.
Performance improvement strategies
from other industries are also making their way into the health care arena.
Until just a few years ago, it would be unheard of in health care circles
to be talking about things like Six Sigma and the Toyota Production System,
but we're opening up to a lot of externally originated concepts, and some
of these ideas are gaining traction.
The idea that's really raising eyebrows,
not to mention excitement and even anxiety in many health circles, has
taken its place as the fourth cornerstone of value-based health care—incentive-based
performance improvement, or pay for performance.
At the beginning of this decade,
only a handful of health care organizations had any experience with pay
for performance—or P4P—and there was almost no evidence, other than
anecdotal, to determine if rewards and recognition could drive quality
improvement in areas where other initiatives had failed.
There is now one area where we have
an impressive amount of evidence, and that is the impressive rate of growth
we're seeing across the country with incentive-based programs. At
last count, there were well over 100 P4P programs in the United States,
covering over 53 million Americans. Expectations are that over 85
million Americans will be covered by P4P programs by 2008.
At this relatively early stage of
P4P's development, collaboration with providers and purchasers is an important
role for AHRQ. But as P4P gains momentum, it's also likely that AHRQ
will become one of the major participants in writing the rules of the road
Today, AHRQ-sponsored research provides
essential data about quality and cost performance benchmarks from the consumer's
point of view. This is especially the case with our ongoing Consumer Assessment
of Health Care Providers and Systems, or CAHPS®, where consumers can rate
their health care experiences.
The Institute of Medicine's P4P report
from last year also identifies AHRQ as one of the key organizations that
will help determine a common set of performance measures for P4P evaluations.
Before I finish, there is another
"e" opportunity I would like to talk about. We have touched on
achieving value in quality and cost standards, interoperability and incentives.
The health IT work that is being done—e-prescribing, e-health records,
and e-reporting—is truly groundbreaking, but there is another "e" opportunity
that we cannot afford to ignore. That "e" stands for evidence,
as in evidence-based medicine.
As the wiring of America's health
care system continues, we need to find ways to integrate the principles
and practice of evidence-based medicine across the full spectrum of care,
particularly in areas including clinical decision support systems, payment
systems, care coordination systems, and patient-provider communication
We need to hard-wire the emerging
value-based health care system to make the right thing to do the easy thing
to do. That means:
- Designing and building a system
that can take advantage of the mountains of evidence we have available
right now to help doctors and patients make informed decisions about:
- Costs and benefits.
- Designing a system that can deliver
accurate, up-to-date information at the point-of-care on the comparative
effectiveness of treatments.
- Having a system that can deliver
critical, time-sensitive information, such as FDA [Food and Drug Administration] drug warnings, to practitioners
- Having a system in place that
can address issues such as the growing practice of physicians prescribing
medication for off-label uses without having much evidence for these
off-label treatments. According to an AHRQ-supported study, one
in five of all prescriptions are written for nonapproved uses, and 75
percent of the time, there is little or no proof that the prescription
drug will work.
Health IT could serve as the repository
for building an evidence base to support for prescribing off-label drugs.
This could be of particular importance as investments in biomedical science
bring new diagnostic and therapeutic options. This expanded array of choices
for treating hypertension, heart failure, HIV and other chronic illnesses,
and innovations in diagnostic evaluation and prediction, bring us closer
to our vision of personalized health care than ever before.
These growing opportunities challenge
clinicians, payers and health care organizations to determine which innovations
represent added value, which offer minimal enhancements, and which fail
to reach their potential.
Health IT could provide the means
to developing better evidence about the benefits, risks, and costs of these
There are any number of value-added
activities that can be driven by health IT.
Another one that comes to mind is
registries. There is one run out of the University of Pittsburgh that tracks
people who have lost weight and kept it off. The participants are contacted
on a regular basis, and periodic progress reports are developed similar
to one that appeared in the New England Journal of Medicine a few
With an effective IT system, organizations
can develop and track multiple registries from one single, integrated database.
We have a draft guide to patient
registries that is moving through the process. The comment period ends
November 27th. Anyone who is interested in reviewing the guide
at this stage should visit our Web site at http://www.effectivehealthcare.ahrq.gov and go to the Spotlight section of the
Effective Health Care main page.
We don't have the luxury of building
an interoperable Health IT system from scratch. We have to build
on what we have, but when you look around, the infrastructure we have in
place is considerable.
It may be that today, the penetration
of clinical health IT systems is only 15 percent. But on the other
side of the office, more than 90 percent of all health care settings have
electronic billing systems, and most medical laboratories and pharmacies
have fully computerized operations.
So, in the end, it's really about
people. It is not the technology; it's how you use the technology. Technology
will not deliver the results we want unless it is used correctly. And,
using it correctly will often differ from one practice to another.
That means everyone in this room
can help to fix this problem. We all need to dedicate ourselves to tearing
down some of the walls that exist within the health care system to build
the infrastructure and relationships necessary to create a transparent,
value-based health care system: a system which delivers high-quality, safe,
efficient, and effective health care for all Americans.
The challenge is great, but the payoff
in lives saved, not to mention real-time information exchange and reduced
administrative burdens, will be enormous.
Current as of November 2006