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Health Care IT: The Foundation for Improving Care

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Remarks for HIMSS 2006 Conference by Carolyn Clancy, M.D.

As delivered by Scott Young, M.D.

February 13, 2006, San Diego, CA

Thank you, Joe [Joe Pleasant, Jr., CIO, Premiere Inc.], for the kind words, and thank you for the opportunity to speak here today at the annual conference of the Healthcare Information and Management Systems Society [HIMSS].

It's great to see so many familiar faces, meet so many new people, and see the tremendous enthusiasm everyone has as we work towards one of the most ambitious and essential goals of our time: the transformation of American health care through information technology.

This week, HIMSS has brought together many of the best minds and most dedicated organizations in this field. And we need nothing less. Because we are facing a health care system that can only be described as increasingly broken. For all its outstanding features, our system is not delivering what it can and should deliver. And this is not about abstractions. It's about lives saved and lives lost.

Our health care system doesn't deliver the quality of care that it could. It doesn't protect patients from error in the way that it should. It doesn't coordinate care in the patient-centric way that we need. And it doesn't spend its dollars as effectively as it must.

Health IT is not the answer to every problem in our health care system. But at the same time, health IT is truly the fulcrum for change that can make the transformation of our system possible. In particular—when we are clear that health IT, quality of care and health care effectiveness can act together as a single force, then we will have the formula for a transformed system.

So this conference is about information exchange, and plan-making, and idea-sharing. But it's also more than that. It's about a mission that we share. It's a mission that is vital to our patients, our providers and our nation. Even as we dive deeper into details and mechanics, we need to remember the urgency and the crucial importance of what we're doing here.

This is also an opportunity for all of us, and especially for Agency for Healthcare Research and Quality and others in the public sector, to recognize how much we are partners with HIMSS and its members in this health IT enterprise: "partners-in-learning" and "partners-in-action." At my agency, this is more than just a metaphor. In every one of the health IT projects that we're funding throughout the country, some member of HIMSS is there—providing the hardware, or the software, or other expertise. In a fundamental way, our job at AHRQ is very much like yours. We want to know what works, and how it can be made to work best.

We're a small agency with a big mission—to improve the quality, safety, effectiveness and efficiency of health care for all Americans.  And our Health IT Initiative touches each of these areas. Our initiative totals $166 million for projects across the nation. A significant portion of this support is backing studies to help small and rural hospitals and practices benefit from health IT. We also want to help patients and providers on the wrong side of the digital divide—members of racial, ethnic and socioeconomic minority groups—to obtain access to electronic health records, e-prescriptions, telemedicine, and other applications. Health IT isn't just for big health plans. It can also help us overcome the disparities in health care that have plagued our nation so persistently.

Any way you look at it, making the transition from paper to paperless is one of the most profound changes the health care industry has ever made. More research is being done now than ever before on health IT related topics.   Every day, our evidence base is getting stronger. And we're going to need to leverage every bit of this knowledge to keep building momentum for health IT. The truth is—IT may be the super-highway of the future for health care. But we're still very much in the construction zone.

Last month, a study by the California Healthcare Foundation reported that only 15 percent of physicians are writing E-prescriptions.

Another study last month from Harvard estimated that just 20 percent of integrated delivery networks and 12 percent of standalone hospitals have inpatient electronic health records. Even fewer have computerized physician order entry systems.

For a variety of reasons that we're all too familiar with—cost, complexity, organizational inertia—we're on a plateau, and if we're going to reach broad levels of acceptance, we've got a lot of questions to answer. The situation reminds me of an observation by that noted American philosopher and baseball player, Yogi Berra, who observed that, "If people don't want to come out to the ballpark, how are you going to stop them?"

How are we going to get more of our doctors and hospitals to come out to the health IT ballpark?  And how are we going to do it in the current environment of fiscal austerity, and despite the broad range of health care initiatives competing for the same scarce dollars? That's the first of three challenges I put before you this morning.

We're all familiar with the estimate last August that a national health information network could require $156 billion in capital investment over five years, and $48 billion in annual operating costs.  True—that investment would yield better efficiency, better quality of care, and system-wide savings. But it's still a big down payment.

Equally important is the reality facing providers as they make their individual decisions on adopting health IT. They need more than rough estimates and good intentions. They need evidence that practices like theirs can achieve real efficiencies and serve their patients better. And when they make that investment, they need to know that they will share in the new value that they're helping to create.

AHRQ's Health IT Initiative is precisely about providing the evidence and the experience that our providers need. The projects we're supporting are helping us learn what works best in adopting health IT—and at the same time, these projects will provide new, rigorous findings about the value added.

But at the same time that we add value, we also need to be sure we can share its rewards. At AHRQ, we're working with CMS [the Centers for Medicare & Medicaid Services] and others to examine the potential for "Pay for Performance" (P4P) approaches. P4P is simple in concept—and complicated in practice. It needs to recognize and reward good quality care, it needs accurate clinical measures and evidence-based goals, and it needs to fit with the realities of medical practice.  All of these are areas we're working on. And I'm glad to see "Pay for Performance" on the agenda at this conference.

Whatever form our "value sharing" may ultimately take, a key principle must be that quality measurement and provider payment become linked. Whatever tools we develop to share the costs of health IT investment, we need to be sure that quality measurement and quality rewards are in the picture. With them, we'll realize the true value that health IT can bring. Without them, we'll miss the chance to enlist IT to transform health care.

And now I'd like to put before you a second major challenge we need to address if we're going to see rapid expansion of health IT, and that's the issue of the privacy and security of patient records. Time and time again, we've seen that in any public survey about electronic health records, consumers always put privacy at the top of the list when it comes to concerns about the migration to EHRs [Electronic Health Records].

Federal HIPAA [Health Insurance Portability and Accountability Act] regulations provide a uniform baseline for privacy and security practices. But the patchwork of state laws, as well as additional business practices, related to confidentiality and access to patient records makes the landscape here enormously complicated. It's going to require a productive dialog and partnership between medical and legal professionals, consumer advocates and policymakers to make progress in this area. AHRQ, working with the Office of the National Coordinator, is using our unique position in the research community to facilitate discussion, share knowledge, and help ensure that our emerging health IT infrastructure achieves an effective balance between access, portability and privacy.

We're supporting a nation-wide discussion on privacy and security of information that will examine the different privacy laws and business practices in up to 40 states. This work will make the legal landscape clear—but it will also do more.  We'll be looking at privacy and security practices at the enterprise level, in clinics and hospitals. We'll identify policies and practices that work best, and those that are problematic. More than that, we'll help to start and to inform the process as communities and regions look toward health information exchange.

This will complement the work of many other groups already developing strategies for communities facing the practical issues of building in privacy and security. AHRQ is active in many of these initiatives as well—and we're working with many HIMSS members—to promote the consistency and integration of all these efforts.

We need to ensure that patients are confident that their personal health information is safe and secure. If they don't, all our efforts will be wasted.

Just as with financial incentives,  I'm pleased that this year's HIMSS conference has several excellent programs on privacy and record security, and I look forward to the knowledge and insights gained at these discussions.

And that leads me to the third challenge we have to building momentum for health IT, the challenge of quickly and effectively sharing what we learn. Part of this problem is structural and related to the sheer size and diversity of the health care industry. But part of it is cultural. We need to make every effort we can to tear down organizational silos, and avoid the compartmentalization of knowledge. That's where organizations like HIMSS and conferences like this are so important, and we need to support these meetings of the minds. There is a tremendous amount of health IT knowledge out there, and we need to get it out there in the clinics, hospitals and other care settings where going digital can make a difference.

AHRQ puts a premium on sharing and disseminating knowledge about health IT and how it is being integrated into clinical practice. In our Health IT Initiative, we're supporting more than a hundred grants and contracts in 41 states. The program is a true cross-section. Some of our grantees are using health IT for the first time. Others are building on years of experience. In some, we're looking at what works best when health IT is first implemented. In others, we're measuring the value-added by various health IT applications. In all cases, we're looking at the use of health IT on the ground level, because the real goal is to learn what works best in actual clinical settings, so that we can help get health IT into practice rapidly.

Today, I'm happy to be able to announce a new phase in our health IT initiative.

An important element of the initiative has been the AHRQ National Resource Center for Health Information Technology. In the first year of the initiative, the Resource Center has functioned primarily as an internal resource for our grantees and contractors. It's provided technical assistance, and it began gathering "lessons learned" from the field.

Today, our Resource Center enters its second, and more important, phase. We are opening most aspects of the Center to the public, so that it can serve not only our AHRQ grantees, but all providers, and indeed all those interested in achieving health IT adoption. The new resources will include "Emerging Lessons from the Field", a "Knowledge Library" connecting to more than 5,000 information sources, an "Evaluation Toolkit" for those implementing HIT, as well as other resources pointing to current activities, funding opportunities, and more. It will include information ranging from using CPOE... to adoption of electronic health records... to building health information exchanges. It's located at the Resource Center Web site.

The goal is simple—to help health care providers and other stakeholders learn from each other's real-world experience, and to give them access to the best information available.

It's not an easy job, because as we all know, dealing with computers can be frustrating, especially when you're also trying to run a practice. Computers can be maddening contraptions. I was talking with a physician friend of mine the other day, and he put it pretty graphically. He said, "A computer once beat me at chess, but it was no match at kick boxing." We're trying to do everything we can to remove the kick-boxing option from the computer equation. That's why sharing our knowledge base is so important.

Adoption of health IT will be too slow, and too uneven, if providers have to learn and re-learn these lessons one by one. With the learning brought together in one place, we can help providers avoid problems and achieve the full potential when they make their move to health IT. By investing in the FULL vision of health IT, I am confident that we can achieve phenomenal benefits for patients, providers and payers alike. Just so long as it's about value—real value.

In the long run, the real value in health IT must come from improving the quality and effectiveness of care. How we realize that value, and how we share it, is just one part of this very long and complex journey we're taking. But in the end, if it's to pay off, this journey has to be about value. In health care, REAL value is about: better care... and better health. And these days, the appetite for REAL value in health care is growing very fast, and AHRQ is aligning everything we do to meet this need.

Our area is health services research. Our job is to understand how the health care system is working, and how it could work better. We have a broad portfolio of studies and surveys that carry out this mission. These resources will grow over time. Today, we have only the earliest lessons from our grantees and contractors. But we have chosen to put this structure in place now. We're not waiting for perfect information—we're making good information available, as we develop it.

Ultimately, our goal is not only to provide the findings of individual projects. We also aim to synthesize their experiences and develop new tools to help other providers as they step through the adoption of health IT. And that is crucial.

Implementing health IT is not just about adopting the technology. It's equally about the medical staffs that use the technology, and the settings they work in, and the work-flows they follow. It's about the support they need, as they serve their patients. It's not about their need for more computer time.

When a CPOE system deluges a doctor with warnings and demands, does she patiently click thru, while her patient waits? Or does she turn that function off? I think we know the answer.

But at the same time—When that doctor has a question she needs answered fast, she'll consult her IT system—if it's designed to respond to her need, and if she knows how to use it.

Health IT will not deliver on its promise, just because it's installed. It will not deliver value based merely on technical capacity. It will succeed, and deliver on its promise, when it's a useful tool for clinicians in serving their patients. Success for health IT means people and systems working productively together, for the patient. And that puts responsibility on both sides.

For product developers, it means user-friendly and mission-friendly systems. Developers are undoubtedly ahead of the literature in looking for good "people fit" for their products. From AHRQ's grantees, we hear many reports about vendors working with clinicians to make their products more useful.

On the other side is the clinician. One thing we learned early from our grantees is that health IT is not a "pop-out-of-the-box" technology. It requires real preparation for new ways of work. AHRQ and others can help provide guides. But the work of "re-engineering" must be done, clinic by clinic—even if the work-flow was seldom "engineered" in the first place.

With that in mind, we need to be realistic. Clinicians want evidence that these changes will produce real benefits. And that is another role for AHRQ's Health IT Initiative. Our initiative is not only gathering experience about new health IT implementation—it is also measuring the value-added by health IT in all kinds of clinical settings. We know the potential benefits are great—for reduced medical error, for higher efficiency, and for greater patient-centeredness. But many of these findings come from a few institutions that have dedicated substantial time and resources to these pioneering efforts.

Can a smaller clinic achieve these positive results, based on an affordable effort? AHRQ's initiative is designed to help identify the path and demonstrate the benefit for clinics of all kinds. It's important to achieve the benefits of health IT in all kinds of clinical settings—not just in our sophisticated teaching hospitals or big health plans.

When we hear ourselves asking these questions, and taking on these challenges, it's worth remembering how far and how fast we've traveled in a short time. Just two years ago, health IT was a new issue for most Americans. Many people were surprised to learn how little IT was used in the health care sector. A year ago, we were still identifying the potential benefits, and sorting out approaches. In the last year, Secretary Mike Leavitt established a systematic process for laying the groundwork for national use of health IT.

Today, our focus is increasingly turning to specific barriers and opportunities. This represents a rapid maturing. We are assembling the critical mass to get health IT in place, and derive the full benefits. 

As I see it, we're at work today building four different kinds of foundational structures in health IT: A technical structure... a trust structure... a learning structure... and a quality structure.

We're further along with some of these than others. But each of them is essential in order to realize the true potential benefits of health IT.

First, and most conspicuously, we're building a technical structure. Secretary Leavitt has made clear that information exchange is a prerequisite for achieving the benefits of health IT—and that means common standards. He's created the American Health Information Community to provide for leadership and consensus in achieving those standards.

This technical challenge is the one that's understood best by the public. And of all that we need to do, it's the furthest along. But it's only the beginning. Beyond the technical groundwork is the trust that must underlie the exchange of information. That means trust by patients that their health information is secure. It also means trust by providers and other users, and their belief that a system of open information will work successfully.

AHRQ is working on a number of fronts to help ensure that these trust foundations are strong. I talked earlier about our collaborative role in the area of ensuring patient confidentiality, but there's a lot more that we do. AHRQ's health IT initiative is also supporting the development of RHIOs—regional health information organizations. Our initiative includes contract support for six different statewide efforts. Beyond that, we're lending a hand to many other states and regions, as well.

The third foundation is the learning structure—this is the work I talked about earlier, to ensure that clinicians and computers work together successfully for the patient. AHRQ's expanded Resource Center will be one element to help learning happen, quickly and effectively.

The work of HIMSS and its members is just as important. Your representatives and your products are the "business end" of health IT. The service, and especially the followup, that you provide to your customers can be the "learning" that counts most.

Certification and product testing can be another part of this learning process. The Certification Commission is already developing standards that will help ensure that products can perform as needed. AHRQ is working with partners like Leapfrog on testing mechanisms to demonstrate that these systems are successfully performing their technical functions in the clinics where they're installed.

In particular, we've been supporting the Leapfrog group in developing a test that would demonstrate whether clinics and hospitals are successfully achieving the Leapfrog standard for detecting medication errors. This would be a test not merely of CPOE systems, but how well the systems work in actual implementation in a specific setting. This can help providers in measuring their own performance—and it could help in public measurement of this aspect of patient safety. Tomorrow at this conference, there will be a presentation of some early results.

But there's yet another level would be of great value. I'm talking about a kind of "continuum" of certification that starts with the product, but also extends to interaction with the clinical staff. In other words, what about developing not only testing tools to ensure the technical capability... but also simulation tools to let an IT solution prove itself in real situations, responding to the needs and practices of individual clinics? What about real interaction between the clinic and the IT system before the clinic switches the "on" button? Or even before the purchase is made?

We see too many situations where the clinic's practice and the computer design haven't matched, or where the clinic hasn't thought through how the applications will play out. Let's find those mis-matches, and work them out, before we bring the patient into the process.

And that brings us to the fourth structure, and our real goal: better quality and better patient safety. When we talk about quality, of course, we're talking about a larger movement that transcends health care today—to put quality first, and to use quality 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 base.
  • 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.

Everyone knows we look to health IT to improve quality by making the patient's information available.  We're also working to use health IT to bring about meaningful and fair quality measurement. But beyond that, we should be looking 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. And that means we need the strongest foundation possible, of evidence and results in health care: what really works, based on rigorous scientific investigation.

Last year, AHRQ launched a new program that will help build the foundation for better quality care. This is the Effective Health Care Program, which was authorized by 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. Our first report was issued in December. Our most recent, on breast cancer diagnostic tests, was issued just last Thursday. These reports will 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 our knowledge quickly, and strategically. And this 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.

Health IT will be important in disseminating what we know about best treatments. And at AHRQ, we're already working on plans for putting our expanded evidence into computer-friendly formats. Equally important for the long term: the more our health data exists in electronic forms, the more usable it will become as a source of safety and effectiveness information. We can use this information to learn about drug safety and treatment effectiveness—with much more rapid results, and much more thorough and timely followup.

To use health IT data this way, we need to ensure privacy and anonymity of data. And we need to plan for data designs that will help us retrieve information effectively. In the coming months, AHRQ will be joining other partners to undertake planning efforts in this direction.

These are the steps that can "close the circle" for health IT and quality of care.  Health data in electronic forms can both disseminate and collect the information to improve quality of care for our patient. Health IT... quality of care... evidence-based medicine.  This is an inter-linked triad that can transform health care delivery. And the time has come to do it.

It's been almost two years since the President announced his goals for electronic health records. In that time, we've had heightened discussion, broadened horizons, and real first steps in health IT. Now we're bringing that vision to the ground level. We're developing the common technical standards that an effective system will depend on. We're learning how to ensure the protections and the trust that patients and providers will need. We're recognizing that even the best IT solutions can only work when they're truly integrated with real-world clinical practice. And we're looking toward the new capacities that that an IT-based system will give us to improve quality of care.

That's a full menu. But it's also a picture of the real benefits we can work toward.

It's up to all of us, as individuals, as organizations, as Americans, to work together and share our ideas and enthusiasm, not only for the wiring of American health care, but to deliver the promise of health information technology for improving the health care quality, safety, efficiency and effectiveness of health care for all our citizens. Everything we do, large or small, will have an impact, and bring us closer to the day when we can all benefit from electronic medical records, E-prescriptions and all the other applications health IT has to offer.

I know we often hear speakers refer to Malcolm Gladwell's popular book, The Tipping Point. Let me quote just a few of his actual words:

"Look at the world around you.  It may seem like an immovable, implacable place. It is not. With the slightest push, in just the right place, it can be tipped. What must underlie successful epidemics of change, in the end, is a bedrock belief that change is possible, that people can radically transform their behavior or beliefs in the face of the right kind of impetus."

The marketplace of ideas and healthy competition is the right kind of impetus for transforming our health care system, and I look forward to working with all of you as we keep tipping the transformation to health IT in the right direction.

Thank you.

Current as of February 2006


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