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AHRQ's Health IT Initiative: A "Real-World" Laboratory

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Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ)

Connecting for Health Conference, Washington DC, May 26, 2005

This year promises to be another landmark for health information technology [IT] in America. I'm sure that you'll agree with me that the leadership for health IT at the Department of Health and Human Services has only continued to grow in strength under Secretary Mike Leavitt.

The Secretary has made it clear that health IT is among his very highest priorities. He sees an important role for government. But more important, he sees the urgent need for active, good-faith collaboration among all of us. Without real collaboration, now, the opportunities are in jeopardy—and the costs can only rise.

As you know, the Secretary's near-term goals for health IT are:

  • Conveying a clear vision of the benefits.
  • Bringing about a collaboration to set standards.
  • Realizing near-term benefits, like E-prescribing, quickly.

AHRQ's health IT initiative offers support for each of these—we are investing $139 million in more than 100 projects in 40 States.

These projects are supporting immediate improvements and benefits for patients and providers.

Together with the "Connecting for Health" communities, they're helping us learn how to create and manage networks for health information exchange. Th are bringing health IT to rural areas.

And they'll generate tested lessons that will help us use health IT in the most effective way—to improve patient safety, develop user-friendly products, measure cost-effectiveness, and build a reliable business case.

We'll share these lessons through AHRQ's new National Resource Center for Health IT. The National Resource Center will help inform all of us—but it will be especially helpful to providers as they adopt health IT systems.

Secretary Leavitt's first emphasis is standards. This is the foundation we need in order to exchange health information widely, efficiently, securely, and with patient privacy protection.

One important element will be a common clinical vocabulary—a single name for a single condition or procedure, no matter who is the patient, the provider or the payer. "About time," we might say. But it's no simple task. AHRQ's on-going work with the National Library of Medicine will be helpful in developing this much-needed common vocabulary.

AHRQ is also working with the National Coordinator for health IT, other agencies and private sector groups to address important issues of trust—especially the privacy and security of personal health information. It's a priority for AHRQ to help build security and privacy into health information systems—and show patients and consumers how electronic health records may be more secure than existing systems. Of course, the legal environment for a nationwide network will include State and local statutes, not just Federal law. So we need to learn now about this legal terrain.

Of course, the long-range goal is the President's vision: electronic health records for Americans, to be available whenever and wherever the patient allows within, now, 9 years.

It's actually been a year and a month since President Bush laid out his goal. The clock is ticking. And there's much to be done—not only on the technical side, but on the human side—or rather, in that zone where the two meet.

In addition to the standards that will make health IT interoperable, we need a health care sector that's ready to make health IT work.

We need user-friendly products—and we need willing, prepared users.

We need health professionals who will take the plunge. And we owe them an accurate picture of the benefits—and our shared experience to help smooth the transition.

This is the heart of AHRQ's health IT initiative. I've called it a real-world laboratory, because it looks at health IT in real clinical settings, and delivers findings based on day-to-day experience.

In a word, our initiative is asking:

  • "How do health IT systems perform when they actually move into the working environment? And how does that environment react?
  • "How well do these systems support the work that needs to be done? And how effectively do they serve the workers?
  • "How much do they enhance patient care? How much do they enhance patient safety? And how can they be improved?"

Anyone who's ever had to "get acquainted" with a new software, knows that these are very real questions. New encounters with a computer system can be like bronco-riding at the rodeo—it's unclear who is breaking-in whom. At the same time, when the "get-acquainted" period is over, we often ask ourselves: "How did we ever get by without it?"

Some of our projects deal with specific health IT applications. We ask: "Does a particular system interface easily with physicians and nurses? Or is the information confusing or frustrating?"

We need to know the answers—not in order to condemn any product, or undermine health IT—but to test, improve and learn what works, and how to customize.

I've heard that some tech companies spend 25 percent of their Research and Development budgets trying to cause failures in their products, so they can fix them in advance. In the AHRQ grants, we don't actually pay our clinicians to try and break these systems. (Although the vendors probably figure clinicians do that for free.) But we want to know how health IT systems conform with the real needs of clinics and hospitals, how well they serve real medical staff, and how they perform under real stress.

We also ask: "Will the benefits of an application be cost-effective? And does it work in different settings—the nursing home, or the community clinic, as well as the hospital and physician's office?"

The AHRQ initiative is about the marriage of new health IT systems with the way work is done in health care today. Like any marriage, there's an impact on both parties. As one of our grantees puts it: "The technology will impact the facility, and the facility will impact the technology." The more we can foresee those impacts, and prepare for them, the better this marriage will be.

And even before any system is in place, we ask: "What are the challenges in simply planning an health IT application? What are the barriers? What are the providers' attitudes? And again, what works best to help make the transition smooth?"

Don't misunderstand—health IT will transform our health care system for the better.

But transformation means fundamental change. And fundamental change can be threatening—and disruptive. The more we understand about the process of change, the easier that change can be.

When we talk about "re-engineering" a health care system that was never really "engineered" to begin with, we're talking about new lessons and new procedures.

Our hope is to learn our lessons—and share them—and then move on to the next ones... instead of leaving providers on their own, to learn the same lessons, over and over.

The AHRQ initiative recognizes a reality: that our technical challenges are just one part of the health IT story. Changes in work flow, and indeed changes in the culture of the clinic, will be just as important. Another of our grantees figures that, for the provider, transition to health IT is "one part technology, and two parts culture and work process change."

We need to learn what this transition will really mean for providers—especially smaller practices. Today, some clinicians may actually have inflated fears about this change—because of what they don't know. The more we learn now, the more our providers can feel a sense of control and confidence.

At one recent meeting in Washington, a number of health professionals told us about their experiences in transitioning to E-based clinical systems. None of them said it was easy. But they all said it was worthwhile.

Now, these were the brave souls we call "early adopters." They knew when they started that they were pioneers. We can learn from the paths that they've taken—and the next traveler will be better-prepared.

  • By creating the standards that Secretary Leavitt has called for, health IT systems will be compatible, and investments can be made with greater confidence. That's a luxury our early adopters have not had.
  • Likewise: By systematically looking at this technology in use—learning from the challenges that others have faced, and the solutions they've tried—we can help make the transition smoother in the future. And at the same time, the AHRQ initiative will provide sound data about the costs and benefits.

AHRQ's initiative looks at a wide variety of health IT applications and experiences:

  • They range from very big projects, like an assessment of Kaiser's billion-dollar EHR [Electronic Health Record] investment... to very focused projects, like a medication safety initiative for elders on one part of the coast of Oregon.
  • They include projects confined within health systems... to activities that reach outside of traditional health care settings, like the project in Rochester, NY, that links health professionals with day care centers and elementary schools.
  • Some grantees already have considerable health IT experience... but our 38 planning grants focus especially on areas where health IT and health information exchange is completely new.
  • Our grants and contracts were awarded just last September. So we're a long way from the final results. Those results will measure specific outcomes, especially improvements in patient safety, and the costs and savings.
  • But in the mean time, we're hearing early reports that tell us something about the process of building and adopting health IT systems:
    • First lesson: As one of our planning grantees puts it—"health IT is not a pop-out-of-the-box technology." And I would add: it probably never will be, and possibly never should be.
      Health IT applications need to serve the needs of individual health care settings. These systems need to mesh with the purposes, and the processes, and the staff of each setting. That means the capacity to customize—in both large systems and small. I'm happy to say that our reports so far indicate that vendors recognize the importance of customizing. And of course, when they work with providers, they get valuable feedback for refining their products.
    • Second lesson: Getting the work environment ready for health IT is long, hard, valuable work. It means putting your workflow under the microscope, and standardizing it, often for the first time. The broader the participation by frontline staff, the better. That way, you draw on experience from every level—and this can lay the groundwork for better communication and a safer health care environment. It's a necessary and worthwhile effort—but it can take more than a year to accomplish, even before the technology arrives. One grantee says "motivation matters:" when clinicians know that quality and patient safety will improve, they're better able to sustain this kind of effort.
    • Third lesson: In some cases, a little seed money, or a little incentive, may go a very long way—especially if it's accompanied by technical help. One grantee saw facilities invest up to $500,000—stimulated by a $5,000 grant and access to help.
    • And fourth: As we look toward a health IT future, one of the most important underlying issues is trust—not only trust in the security and privacy of a system, but also trust among health care providers themselves. Today, some providers hesitate—not only because of the investment—but also because of what they may see as the risks of cooperation. Some of our planning grantees are trying innovative, personal approaches to build trust and participation by providers. In the end, of course, the benefits speak for themselves.

And we are indeed seeing successes:

  • The Utah Health Information Network is building on an already very broad system. It started with administrative data, then added clinical features, and now will support adoption of electronic medical records. This system has already knocked 80 percent off the cost of filing a claim, compared with paper.
  • In Indianapolis, an information exchange system is already widely in place. Indiana is building on the success of the local network to assemble a statewide infrastructure. And that system will include public health surveillance, to share emergency department data from hospitals around the State. This is the kind of system that needs to be in place to detect epidemics, including the possibility of bioterrorism.
  • In New York's mid-Hudson Valley, the Taconic IPA [Independent Practice Association] is building a network by focusing on a limited area, and helping smaller practitioners afford the costs—by providing the system through subscription, by arranging incentive payments from insurers, and by including extensive training and support.
  • The University of Tennessee is providing a tele-health system to help deliver cancer services for one of the nation's poorest areas. This provides access to follow-up treatment that simply would not be available to these patients without telemedicine.
  • Another project, involving nursing homes in several areas, showed how the value of health IT starts with redesigning work, even before systems are installed. The staff worked in teams to improve work processes—first on paper, and then migrating to health IT. One result was the elimination of up to seven different reporting forms. The new system also supported better quality care—pressure sores declined significantly among high risk residents. The number of facilities that now want to use this process has grown from 11 to almost 300.
  • In Portland, Maine, the Medical Center is making available a top quality radiology system for smaller hospitals and imaging centers that couldn't afford it on their own. The smaller centers get access to specialists, as well. And health IT-based record-keeping promises to work better, while costing less than a film-based system.

These are a few examples of success. There are hundreds more. But there need to be thousands more.

These successes tell us our health care system can be more efficient. Even better, they tell us that we really can improve the quality of our health care by freeing, and organizing, the information that today is paper-bound.

I don't want to end without talking about quality—because that's our real goal. The "T" in HIT gets the attention—but the "H" is what we're really after: better health and better health care.

Earlier this year, AHRQ released its second annual National Healthcare Quality Report. It showed some progress—but painfully slow in most areas.

We followed this report with a Quality Summit. And we learned from practitioners in the field that quality of care means informed and personalized care. health IT is crucial in giving us that combination:

  • In so many cases, we've learned what the best treatment practices are—yet at the front-line, we fail to carry them out. Health IT can help fill that knowledge gap, with clinical decision support, geared to the individual patient.
  • And to continue learning what works best, we need data—extensive, current data—and the power to analyze it. Health IT promises to transform our ability to collect that data, and learn what works best.

The quality approach depends on a new culture in health care. I think of it as candor, comparison, and cooperation. In other words:

  • Open information about the quality of the care that's delivered.
  • Good data for comparing quality levels among providers.
  • At the same time, cooperation to help make quality of care better for all our patients.

We should add to that list one more: computer power. Because health IT is really the pivotal tool that can make the rest possible.

This is our challenge. Let's work together to achieve the technical standards we need for sharing health information. Let's learn how to make health IT work in our real-world health care settings. And let's share what we learn.

Our opportunity is great. And our vision of the future of health care should be positive and hopeful.

There's hard work at hand. But how fortunate we are to be here to do it.

Current as of June 2005


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