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Town Hall Meeting at the AHRQ 2007 Annual Meeting
September 27, 2007
Well, thanks to a terrific
panel, and now we're going to move to the part where you get to ask questions.
I should have told all of you, the panel knows this, that we're actually taping
these sessions for the people who wanted to register for this conference and we
had to tell them, "Not this year, but stay tuned for our next AHRQ-a-palooza." So
we have microphones throughout the room, and we will be asking you to identify
yourselves. So, any of the panelists are open to questions.
While you're gathering your
thoughts, let me just comment on a few things I heard. First, Dan, I do have to
say, you probably give the most quotable comments here, "tweaking ourselves to
glory" and "gloriously mediocre." I think those are phrases I'll use with full
attribution, of course. I think we heard some very important themes about the
power of collaboration, about the power of transparency in information, about
the power of activation, and also about how challenging that is. I think all of
us recognize that activated consumers and patients can be a very powerful game
changer, but actually getting people over that hurdle and getting information
that is accessible and understandable to them is tricky. And we heard a lot,
particularly from Tom, about the power of shared learning. I think we've also
heard from these five people about their capacity to just say, "Well there
isn't a path, but we're just going to make one." And I think that that is an
experience that many of us are going to have to share, and I think that our
next big transition is going to be try to figure out how do we hard wire some
of this, so Jeff, I'm deeply impressed with the Virginia initiative, but at the
same time, it feels like something that was done outside of our usual
structures, and the question is, "How does that become sort of a cost of
business, ultimately?" Because this is the business that we're in.
I see a couple of people
standing up, so I'm going to turn to the microphone here. If you could just
Hello, I'm Barbara Fahmy. I'm with
the Division of Worker's Compensation in Colorado. And, I have to tiptoe here a
little bit. I have a suggestion for the speaker from the Marriott... I'm sorry
I didn't get your name. [Dr. Clancy: Jill Berger.] I'm sorry? [Dr. Clancy: Jill Berger.] My
suggestion is that when you hire on new employees, try to think of each
employee as a potential patient and at employee orientations, when people are
very enthusiastic about their jobs and very alert and everything like that,
bring forth some simple preventive measures for their own care, so they can
take ownership into their own care. For example, things like the dangers of
overdosing on over-the-counter medication. When you go to the doctor or nurse,
it's okay to have a list of questions and have those questions answered.
Hands-on training of proper lifting and demonstrating the ability to lift
properly. That's probably big for those who work at hotels. And not just where
to go if you get hurt on the job, but what should you do? What does an incident
report look like? What kinds of things should I be reporting? What time did
this injury occur, etc.? So, it might be a good way to attack it at the
beginning before it occurs. So, that's my suggestion.
Great suggestion, thanks.
Hello, I'm Ann Barber from
Providence Hospital. Thank you for your comments about transparency, and can
you give us some guidance on how to take the first steps? For instance,
there's an Asian concept of saving face, and I struggle with how do you protect
individual egos from feeling hurt, and how do you still help everybody
understand the benefits of transparency? Thank you.
It's a great question, and I
think that to talk about some constituency groups. When we took this
initiative in both settings in which I worked, we took this to the medical
staff. The first thing that we made clear was that there was no individual
reporting associated with this, that health care is a team sport. It's a
combination of physician clinical competence and hardwired processes and the
capital and the technologies that the facilities bring together, and so forth.
So, we started off saying this was going to be a collective report. There was
going to be no individual-level reporting. What's interesting about that is
that, as we started to work through the report, the demand for individual-level
information was overwhelming. And in fact, to be quite honest, while in
neither situation have we had to add a lot of FTEs as we built the report, what
we've had to add is data capacity to be able to meet the demand of nursing
units, physicians, physician groups asking for their own personal data, so that
they can look and see how fit into this milieu—how they can contribute to the
overall improvement and performance. So, I think the first thing was that we
made it clear it was a collective effort, number one. So there's really no "blaming"
The other piece of it, was to
make sure that we understood that we weren't singling out the organization for
any sort of particular or specific level of performance in the get-go.
Everything we did had to be a comparative indicator. So, I mean, I can tell
you that getting over the face-saving piece—getting over the initial fear of
this—it's pretty easy when you sit down and look at the fact that you're, you
know, AHRQ patient safety indicator #13 on postoperative sepsis that your rate
was four times the national average. People don't feel very good about that,
but there's also a dramatic move very quickly to improving that indicator. So,
I think the big take-away on that is make it a collective initiative. Don't
make it an individual-level initiative.
Over here on this
Hi, I'm Joe Carter from Vanguard
in Boston. I'm sorry to keep peppering Dr. Varga with questions here, but that
aspect of experiencing other organizational unintended consequences that came
out of doing this kind of transparency—have you found other things outside from
analytic requirements in terms of either gaming or anything else that's
starting to happen from that kind of transparency? And then second, have you
moved it along to high excellence incentives around performance at individual
Sure, I'll take both of
them. I think we have all seen in the public reporting arena the issues around
unintended consequences and, you know, as we're looking at the core measures
now, we're looking at, you know, the antibiotics for pneumonia and the timing
for that, and so forth, but... one of the reasons, I think, to be quite
honest that we made the big report, was, not to say it again, but it prevents
you from trying to tweak yourself to a higher-level performance. You actually
had to deal with the big indicators. And I think that what we ultimately found
with that is that you have to develop a certain dexterity, looking at this big
indicator set and finding out how these things map back and where you can get
the ultimate leverage around that. And I think that that drives it far more
down to the process level as opposed to the indicator level. So the big report,
I think, helped us avoid that. Relative to getting to individual incentives, I
was talking with Jeff before the session.we had a catastrophe in St. Louis around
cardiovascular surgery, and a couple of the big groups blew up, so we had to "employ"
our cardiovascular surgeons to keep the program together. It's about a 1,000
heart program a year, but we've got 50 percent of the compensation of this
cardiac surgery group based entirely on their performance against the STS
database, and how they performed internally. To be quite honest with you, we
really didn't have a lot of pushback on that. I think there's a lot of comfort
around that database, and the folks are good with it. I think we're going to
see an incredible improvement in our cardiovascular surgery program there, but
yeah, I think you can start to push that down pretty quickly.
Thank you. My name is Perry Cohen
and I'm with the Parkinson Pipeline Project, which is a patient-advocacy
organization, grassroots. I'm also a participant on the working group for
evidence-based health care, which is a coalition of 45 patient organizations
that are interested in getting involved with health services research and some
of the things you're talking about. I thank Carolyn for all her support for the
patient perspective and, of course, patients are critical for developing the
clinical research as participants in research. But we're more than rats, and
so we want to be at the table when the policies and decisions are made also. My
question has to do with the use of information technology for self-help and
patient empowerment, and one of the speakers was from Medicaid, and he
mentioned the challenging population. I want to ask him if he felt that this
population would be ready or how he might like to address the issue of
information technology support for this population considering they might not
have computers or Internet access or some things that those of us who have
become empowered through the Internet enjoy. Thank you.
Well, talking about
information technology as it applies to members is certainly a difficult
situation and challenging in the Medicaid population. When we first began our
first disease management program, which was asthma, we identified approximately
2,500 members, which we thought were our greatest risk, were having
hospitalization or E.D. visits, and of that 2,500, unfortunately, we were only
able to reach about 300 because of availability of telephones for our
population, not necessarily Internet. We tried writing them, and we wrote
1,000 letters, and we got 18 responses, so communication's a very, very
difficult, challenging situation for us. The Internet—we have developed, at
the Medicaid office, a Medicaid electronic record system where we've made
information available to providers. Currently, it's not available to members,
but that would be one of the next steps that we'd like to pursue.
Did you actually mention
something about behavioral health issues?
Well, our behavioral health
provider is a carve-out from the Medicaid program, and we have access to
encounter information, but not necessarily any kind of behavioral health
utilization information. In our particular population of membership, I don't
see information technology from the patient or member's perspective being an
important issue at this time.
I think I would just add one
thing to that, based on some of the work that we have funded for people with
selected illnesses where they need information and when they're under a lot of
active treatment. We have certainly funded a lot of centers that have included
and enrolled folks very similar to your population; people who didn't have
their own computers, people who often didn't have phones and so forth. But if
you're being actively treated for HIV, for example, you've got some incentive
to be part of this and so, in an isolated project-specific basis that seems to
work. I think we're going to need to make a distinction between that kind of
approach where we know that at least under some circumstances it can work and a
scaleable approach that gets everyone actually recognizing that being informed
about your care is part of what it's about.
One of the things we have
tried to do is, our Department of Public Health has a presence in 98 or 99
counties in Iowa, and they also have Internet access. We were trying to develop
a health-risk assessment tool for our entire population, and the strategy was
to involve the Public Health Regional Offices and bring patients to the Public
Health to give them access to the Internet and the information.
Thank you. One more
Hi. I'm Maureen Street, and I'm a
medical director in Community Health Center in Michigan, and I have a question
for Dr. Kline. Can you comment on the impact that the Medicaid HMOs, in
particular the for-profit Medicaid HMOs, have on your ability to do case management?
Sure. HMOs in the State of
Iowa does not have a large presence. A few years ago, we had three managed
care organizations that provided services to the Medicaid population, and it
was a total of about maybe 15,000 members. Currently, we have one with about
5,000 members. Again, it's a situation of collaboration. I know the medical director
for the Medicaid managed care very well, and when we've instituted our disease management
program, we included many of the elements that they had in their disease management
program, so it would not be different, and the Medicaid population would be
getting consistent care. Unfortunately or fortunately, except for our primary care
case management program, managed care doesn't have a big issue in Iowa.
Well, I'm sure that all of
you share my sense of inspiration and hoping to run and to catch up with some
of the efforts that we've heard here. So I hope you'll join me in thanking the
panel for a terrific conference.
Current as of July 2008