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Carolyn M. Clancy, M.D., Director, AHRQ
Testimony before the Committee on Government Reform, Subcommittee on the Federal Workforce and Agency Organization, U.S. House of Representatives, July 27, 2005
The Importance of Health IT
AHRQ's Current Health IT Activities
National Resource Center for Health IT
Working in Partnership
Porter, I am delighted to join Dr. Brailer in outlining the ways in which the
Department of Health and Human Services (HHS) is advancing the adoption,
implementation, and effective use of health information technology (IT).
the President's goal of widespread use of interoperable electronic health
records requires us to address a number of complex and technical issues, many
of which are not specific to the health system. My testimony will focus on how
the activities of the Agency for Healthcare Research and Quality (AHRQ)
complement the Department's other efforts by harnessing the power of IT to
improve the effectiveness, efficiency, quality, and safety of health care.
work with the Secretary and Dr. Brailer to ensure that the fundamental IT
infrastructure is in place, we are critically examining how these IT tools can
be used in real-world health care settings to make care better. This is
because patients and payers are not interested in health information technology
in and of itself. They are interested in
what it can do to improve quality, effectiveness, safety and cost. In other words, how do we do health IT right? How do we assure that the investment gets us—patients, caregivers, providers, payers and others—what we want? What measures, methods, and best practices
can be identified and used? In addition,
how do we take lessons learned about what works—and what does not—and disseminate
that knowledge so that the right medical practice, technology and information
practices get adopted more quickly? In
many ways, this aspect of the health care industry is in its infancy.
AHRQ exists to serve the American health care
system and Federal health care programs by assuring that cutting edge knowledge
is available when and where it is needed.
We are happy to share with you what we are doing in this area how our
work can be of assistance to the Office of Personnel Management (OPM) and
Federal Employee Health Benefits Program (FEHBP) as well as other Federal
health care programs.
health care providers, the need to address specific local threats to the safety
and quality of patient care is immediate; an increasing number of practitioners
and organizations have made or will soon make investments in health IT. AHRQ's
investments support evaluation of the impact of selected health IT applications
on quality and safety, with a strong emphasis on the needs of caregivers in
rural and underserved populations. That is why we have made awards to local and
regional organizations that affect the care received by more than 40 million
Americans. Leaders in health care recognize that improvement requires both
incentives and the capacity to respond to those incentives. Our focus is on
building the capacity within health care settings—large and small, urban and
frontier—for the effective use of health IT, and disseminating findings
rapidly. The benefits of health IT need to begin now for as many Americans as
possible. The results of these investments represent tangible benefits that
will be accelerated as the private-public collaboration to facilitate a
nationwide information infrastructure develops.
also addressing a critical stumbling block to the widespread adoption of health
IT, the human dimension of the use of IT, which focuses on the intersection
between IT and the health care providers who need to use it. Unlike the
baseball field in the movie Field of
Dreams, we have dramatic examples of the building of health IT systems,
whose designers found physicians neither came nor played. Unless we address
these issues as well as technical ones, we risk falling far short of a safer,
higher quality health care system.
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The Importance of Health IT
look at the challenges facing our health care system in the years and decades
ahead, there is no job more important than getting health IT into place, and
getting it right. As the Institute of Medicine noted in its second report on
patient safety, 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. While transformation of our
heath care system—with higher quality, patient-centric and cost-effective care—will
not happen simply as a result of health IT, it is difficult to think how
transformation could possibly take place without the capacities it brings. We
have a fundamental problem of fractured health care delivery that results in
needless waste of resources. Health IT can bind this system together, even as
it preserves its diversity.
for a moment about what is happening in health care settings around the
country. Millions of decisions are being made about people's lives without the
right information in hand:
- Is chemotherapy alone the best treatment for a
patient with breast cancer, or should she be treated with radiation and
- Which of our young athletes should be screened and
with what type of diagnostic test for heart abnormalities, as a front-page
story in the Wall Street Journal
asked last month?
- How does a person with diabetes, high blood
pressure, and obesity manage all the different demands of their
and consumers struggle with even more basic decisions:
- Which provider to see?
- When to seek care?
- Which treatment option is best for their needs?
these decisions are difficult even in the most ideal circumstances, when there
is sufficient time to assess good, reliable information. But as we all know,
these decisions frequently must be made at times and places where information
is not available, and time is of the essence. The power of IT can help us to
regularly assess quality and outcomes while bringing us reliable data that can
be accessed at the point-of-care.
nearly three decades, AHRQ has funded the basic science of health IT,
development and testing of tools to facilitate its use, and supported the work
of innovators. Many of the leading systems of our Nation were created on the
backbone of AHRQ and National Library of Medicine (NLM) grants over the last
three decades. The most prominent examples are Intermountain Healthcare in Utah and the Regenstrief system in Indiana, which are now models for the effective
use of health IT. The task we have now embarked upon is to move that knowledge
and experience into the health care system more broadly and to support targeted
research to fill the gaps in our knowledge base that are critical to widespread
diffusion of health IT. Successful implementation of health IT in turn provides
the best possible platform for delivering scientific evidence to clinicians and
patients when decisions are made.
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AHRQ's Current Health IT Activities
2004 AHRQ awarded 108 grants and contracts to address a number of those gaps in
our knowledge and to advance the use of health IT. Reflecting a commitment of
$139 million over five years, these awards were truly nationwide in scope. They
spanned 43 States, with over half of the projects based in rural and small
hospitals and clinics. In combination, the communities where AHRQ health IT
grants or contracts were awarded include more than 40 million Americans. Select
for more information.
research portfolio is making significant advances in meeting three objectives:
- Reducing medical errors.
- Improving the quality of patient care.
- Reducing the cost of health care.
Reducing Medical Errors
errors are a grave threat to patient safety and one of the greatest
opportunities for reducing medical errors. The potential value of health IT
here seems intuitively obvious:
handwriting and other communication errors.
cross-checks for errors in medication strength.
of interactions with other medications or other adverse events reflecting the patient's
overall medical condition.
projects span the spectrum from prevention to detection and prompt treatment of
medication errors, and identify the most effective ways to use health IT to
achieve each of these goals.
especially patients with chronic illnesses, can play an important role in
preventing medication errors. Some of our projects are developing
Internet-based portals to enable patients to manage their own care, including
medications. In the course of deploying this technology, we are learning
valuable lessons about how patients want to participate. Patients are very
enthusiastic about documenting their medications, giving their clinicians new
insights about medication compliance as well as other supplements the patients
may be taking on their own initiative. An unexpected side benefit from the move
to an Internet-based system was that the children of elderly patients who are
living in a different State were able to assist in their parents' care in a new
and engaged manner, when parents authorized access by their children.
that medication errors can still occur even when health care providers are
vigilant, a team at Duke University is attempting to minimize the potential
for serious patient harm. They are testing a monitoring system for hospital
patients that will detect the onset of an adverse drug effect, immediately
alert the hospital staff, and suggest the most appropriate intervention. AHRQ
is also funding systems for the voluntary reporting of errors.
Improving the Quality
linkage between health IT and improving the quality of care occurs on multiple
levels. We know that we cannot improve the quality of care unless we can
measure performance. But monitoring and reporting the quality of care is
time-consuming, inaccurate, and incomplete without IT systems. A challenge
shared by AHRQ and the Centers for Medicare & Medicaid Services (CMS) is
how to best translate measures of quality into computable, automated quality
reporting systems in settings such as hospitals and physician offices.
maturation of IT for use in daily practice comes at a time when the burden of
good health care delivery is rising. Many patients obtain care from multiple
providers and experience the effects of poor coordination of information and
care. Indeed, 69 percent of Americans report that poor coordination among their
providers is a serious problem for them, and 32 percent report that they or a
family member have created their own medical record to assure that all health
care professionals they see have accurate, current information about their
health issues. Health IT can reduce this burden by facilitating the transfer of
information among providers customizing knowledge for the patient, and
facilitating communication between providers.
funded cutting-edge research into how to translate medical knowledge into
specific information, tailored to the patient at hand and immediately available
to the clinician when decisions are being made. These include alerts about
inappropriate therapies, reminders about preventive care, and assistance in
automatically doing the right thing. Health IT has the potential to rapidly
disseminate knowledge previously available only to in large urban academic
example, an AHRQ project in Boston brings cutting edge diagnostics to
emergency medical services helping caregivers identify heart attack victims
even before they reach the emergency room. At least two manufacturers have now
incorporated this decision support system into EKG machines. By helping
emergency medical service teams and emergency room physicians better determine
when a patient with chest pains actually has suffered from, and may still be
vulnerable to, a heart attack, quality of care will be greatly enhanced. Those
who truly need care will receive it and those who may be suffering from less
serious problems, like indigestion, will be spared the risks, worries, and
costs that accompany unnecessary hospitalizations.
research has made clear the importance of system issues such as organizational
culture and workflow. Our investments evaluate specific strategies to close the
gap between the potential of health IT to improve care quality and the less
promising reality experienced by many providers due to suboptimal product
design or challenges in integrating health IT with the work of clinicians.
For example, we are funding studies of
technology integration, using time-motion studies, culture surveys, and
observational techniques to understand why technologies are accepted or
sabotaged by the clinical users. But we don't stop there.
AHRQ funds research projects to explore
how the technology can adapt in intelligent ways to clinician needs. We have a
suite of projects with Partners Healthcare System in Boston to develop "SmartForms" for various settings—smart because they
anticipate the physicians' needs for information based on the patient, and
automatically assist the physician in pulling together the various action plans
necessary to execute the right care plan. An
additional benefit of this project is the ability to report back to the
physician—immediately and individually—their performance on clinical
quality relative to their peers. By giving immediate feedback to
caregivers, we raise their awareness of how their decisions impact the
quality of care patients receive.
the breadth of our current portfolio has been instrumental in enabling AHRQ to
take health IT into settings where traditionally there has been
underinvestment. These include nursing homes and pharmacies, waiting rooms and
schools and homes, to parents and caregivers, to rural and small settings, to
the blind and chronically ill, and to those recovering from serious acute
events. Each of these new frontiers requires the discovery of the unique needs
of the targeted population, growing new partnerships, and creatively
transferring knowledge about lessons learned.
Cost of Care
potential for increased efficiency, including cost savings from systematic use
of health IT, includes avoidable expenditures in the administrative and
financial aspects of health care institutions, the improved efficiencies in
workflow, improved physician decision making (especially when decision support
systems provide immediate access to information on comparative effectiveness
and cost effectiveness), and in the reduced need for additional patient care
that medical errors often entail.
are also significant financial and non-financial costs to patients that can be
reduced through the introduction of health IT: the potential for bringing
health care to the patient's location (which can be a serious issue for those
isolated geographically, or receiving care at home or in nursing homes),
removing the inconvenience, expense, and increased risk of harm associated with
inpatient admission, reducing or eliminating the need to return to a tertiary
care hospital for follow-up consultations, and the potential for patients to
substitute E-mail or other Web-based consultations in place of office visits
with their physicians. One-third of Americans surveyed reported that they
needed to return for a repeat visit because their clinical information was not
consumers are a critical resource in improving the value of health care
services. To that end, we are also
taking steps to provide health care consumers with the tools they need to shop
for the best quality care. Under the
Medicare Modernization Act's (MMA) Section 1013, AHRQ is working with other
Federal agencies to establish a program to evaluate the comparative
effectiveness of products and procedures.
The results of those evaluations will be made available to the Medicare
and Medicaid programs, as well as to other Federal programs and the general
public. When individual providers,
health plans, and others help make the results available to consumers through
personal links to consumers' health information and medical records, it can be
a powerful tool for achieving both quality and value in health care.
prior investments provide evidence of the potential for savings in selected
care settings, and work in progress will demonstrate the value obtained from
investments in health IT in a broad array of settings. Over the last decade
work by one of our grantees demonstrated that computerized reminders can reduce
the cost of tests ordered for hospitalized patients by approximately 10
example is the Utah Health Information Network (UHIN), developed a decade ago
by then-Governor Leavitt, which demonstrated the potential for savings in
administrative and billing costs through the use of health IT. By creating a
single way to submit bills, UHIN both reduced costs and reduced the
administrative burden of re-entering the same data for different payers. AHRQ
now is working with UHIN to add clinical data to their statewide system to
enhance its potential to improve the quality and safety of patient care as
funding other statewide regional health information exchange projects in Indiana, Rhode Island, Colorado, and Tennessee. The Indiana project, led by the Regenstrief Institute, a national health IT leader, is
another example of the power for IT to directly impact care. The impetus for
this statewide initiative was the rationale that health care information should
be reliably available for patients seen in Emergency Departments regardless of
where they usually get care. When current data are available, redundant testing
can be avoided, and the right care can be delivered more rapidly. In an effort
to more definitively identify the cost savings of health IT, we are
concurrently funding an evaluation of the value of that exchange, not only in
the hospital system but also throughout the State's primary care and specialty
clinics. This well-designed evaluation will provide the Nation with clear
evidence of whether the actual savings are as significant as many hope. This
will provide crucial evidence for those seeking to make a business case for
addition, the results will be incorporated into a simulation model developed by
the Center for IT Leadership, letting real-world numbers improve the best
estimates of IT thought leaders. AHRQ-sponsored research will also help to
demonstrate the costs and benefits of the statewide electronic prescribing
roll-out in Massachusetts, undertaken by a consortium that includes Blue
Cross Blue Shield. AHRQ researchers will have access to claims and utilization
data for over 1000 prescribers, translating to approximately 480,000
prescriptions over the course of the year.
The results of
AHRQ's current research will also inform America about the wide-ranging effects of the large investments
in health IT by integrated delivery systems. One evaluation project studies the
effects of Kaiser's $3 billion investment in electronic medical records for
ambulatory physician practices on patient outcomes and resource utilization. As
a result of our funding, the evaluation findings regarding these major
investments will be available to the public. This will accelerate adoption by
enabling health care institutions to learn from the early adopters.
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National Resource Center for Health IT
Chairman, I cannot over-emphasize how essential technical assistance is to the
successful adoption and implementation of health IT. To assure that as many
Americans as possible benefit from our research, we are committed to exporting
lessons learned from current demonstrations rapidly and widely. We have been
inundated with requests for help from payers, providers and health care systems
attempting to adopt health IT. In response, we have created a National Resource Center for Health IT,
the largest single commitment to technical assistance in AHRQ's history.
Resource Center leverages our investments in health IT by offering help where
it is needed—real world clinical settings that may feel ill equipped to meet
the implementation challenge—facilitating expert and peer-to-peer collaborative
learning and fostering the growth of online communities who are planning,
implementing, and researching health IT. Our initial needs assessment led to
the development of a series of educational teleconferences on critical topics
for health IT implementers:
- How to comply with rules and regulations.
- How to design workflow, how to evaluate
- How to tackle clinical decision support systems.
we convened a highly successful, weeklong meeting attended by over 700 doctors,
nurses, pharmacists, and IT professionals to share practical knowledge about
health IT, and linked it closely with the goals for patient safety. As one of
our grantees from Kentucky said, "this meeting brought real life case study experience to so
many of the issues facing us today."
also used the Resource Center to assist States that are initiating
statewide clinical data sharing. We have convened small, round-table working
meetings of experts to share detailed expertise with States that are starting
the process of determining the governance and technical architecture of their
data-sharing organizations. The first of these was in Tampa, at the invitation of the Florida Governor's
Health Information Infrastructure Advisory Board; we have planned expert
roundtables in New York, Wyoming, and Montana, with further assistance to Delaware, Maryland, and Georgia. In these roundtables, AHRQ has been
fortunate to draw upon the expertise of our State contractors who are
intimately involved with this work in their own States, as well as consultants
from our Resource Center.
The Resource Center provides a Web portal with critical
infrastructure for convening practitioners, encouraging collaboration, and
disseminating best practices. The portal gathers communities of practice with
similar interests and concerns to share and learn. While it was initially only
open to AHRQ grantees, we are opening this rich resource to other Federal
grantees. We recently announced AHRQ will support a special portal for the
Nation's community health centers as they adopt health IT, with plans to expand
to providers involved in the Medicare initiative to assist with the changes to
clinical practice resulting from health IT in physician offices, known as
DOQ-IT, and to providers in the Indian Health Service (IHS). In recognition of
the widespread interest in rapid turnaround of health IT knowledge, the Resource Center will be expanding its practical,
educational teleconferences to any organization, and providing in-depth
"learning collaborative" curricula for a smaller subset of interested
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Working in Partnership
advance health IT, AHRQ is working closely with public and private
organizations, such as the National Governors Association (NGA), eHealth
Initiative, Markle Foundation, Connecting for Health, and America's Health Insurance Plans to promote the
development of solutions for many of the challenges I have described. With the
NGA, we will be participating in developing and providing leadership resources
for State officials on investing in health IT and health care quality
IT can accelerate improvements in safety and quality if there are clear
objectives. Working closely with leading medical professional organizations
(American Medical Association, American Academy of Family Physicians, and American College of Physicians), America's Health Insurance Plans, payers,
consumers and other stakeholders, AHRQ's leadership has been essential for
prioritizing goals for improving physician performance in ambulatory care. The
results of this collaboration, known as the Ambulatory care Quality Alliance
(AQA) will be adopted broadly in early 2006 in the private sector as well as by
CMS. The AQA is now developing strategies to collect and report the requisite
data, including the use of health IT when feasible. Improvements in care will
start now and can be accelerated by efforts to establish a nationwide
information infrastructure led by Secretary Leavitt.
working with the Leapfrog Group, an organization of leading employers, to
develop an evaluation tool that allows hospitals and physicians to ensure that
their computerized physician order entry (CPOE) systems and electronic
prescribing are effectively reducing medical errors. These tools will be
available by the end of the year. AHRQ is also providing support to the Medical
Group Management Association (MGMA) Center for Research to understand the level
of adoption of electronic health records and other new technologies in medical
groups and the issues associated with their successful implementation. By
documenting barriers encountered in adopting these technologies and mechanisms,
we will know better how to target our research to overcome these barriers.
collaborating with other Federal agencies to align our health IT efforts. With
CMS, we are active participants in the design and evaluation of health IT
projects that support research and evaluation of pay-for-performance,
electronic prescribing, and the implementation of the MMA. With the IHS, we
have supported enhancements to their electronic health record, and, incidentally,
that system has been chosen by the National Aeronautics and Space
Administration to be its electronic health record. In all of our efforts, AHRQ
maintains close relationships with other agencies, in order to maximize the
Federal investment of health IT dollars. We maintain these relationships, in
part, through working with the Federal Health Architecture (FHA)/Consolidated
Health Informatics (CHI) Initiative in the Office of the National Coordinator
for Health Information Technology. The FHA has been tasked to provide an
architecture, or framework, to guide Federal health IT investments, and to
foster interoperability through the selection and adoption of health data
standards, including privacy and security standards.
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I would like to conclude by offering a few brief observations based upon our
work in health IT.
health IT alone cannot provide the improvements needed in our health care
system. These improvements will depend upon the integration of high quality
health IT into the very fabric of care by incorporating systems into our
individual clinical practices, hospitals, and other settings.
for most health care settings, health IT is not likely to afford an
"out-of-the-box" solution. Effective use of health IT begins with a
careful examination of the health care setting and then uses the power of IT to
enhance its effectiveness and efficiency.
the development of a health IT infrastructure will be a critical element in our
Nation's effort to accelerate the pace of innovation and the speed with which
patients will benefit from new medical breakthroughs. The inherent delays in
our current system for assessing the effectiveness of new drugs, devices, and
procedures will decrease dramatically with widespread use of health IT and
advance our common goal of evidence-based medicine.
to accelerate the pace of health IT adoption and implementation, we need to
facilitate the sharing of both knowledge and experience through additional
opportunities for voluntary peer-to-peer learning. Given the level of economic
investment that is required, providers are understandably worried that a
mistake in judgment could prove financially catastrophic.
health IT can be an effective tool to assure safety, improve quality, and
increase the efficiency of our health care system. This vision can only be
realized if we have the means to develop to implement the programs that
purchaser, providers and health care consumers want and need. One essential attribute will be the
development of key capacities by public and private partners. AHRQ and its National Resource Center for Health IT are looking forward to
working with OPM to develop these capacities.
Current as of July 2005