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Health IT: Improving the Quality of Health Care

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Remarks by Carolyn Clancy, M.D., Director of the Agency for Healthcare Research and Quality

AHRQ Patient Safety and Health IT Conference, Washington, DC, June 5, 2006

Good morning. Welcome back to Washington—as John F. Kennedy called it, "city of northern charm and southern efficiency."

Maybe this is the right place, after all, for a conference on our health care system.

(Except that ... times must have changed ... and we have our "Marcs" here to prove it. Who could be more efficient than Tennessee's Mark Frisse? And who could be more charming than Indiana's Marc Overhage?)

Welcome, also, to our sixth national conference on Patient Safety—and our second combined conference on Patient Safety and Health IT. As I'll say again later, these two programs represent AHRQ's leading edge in helping to improve health care in our Nation. The issues before us in these two programs go to the heart of important reforms that are underway in our health care system. We need to understand that connection, and be responsive to the urgency it places on our work.

Finally—welcome to the first-ever "National Health IT Week." As I'm sure you know, more than 40 organizations have come together to sponsor a week-long focus on health information technology—looking at where we stand today, and how we can move toward realizing the benefits that we want to achieve from widespread adoption of health IT.

"Health IT Week" begins with this 2-day conference on the groundwork we're laying through AHRQ's initiatives. Later in the week, the annual HIMSS Summit will convene here. And Wednesday is "National Health IT" Day.

The First Word: Quality

Now, as fate would have it, I get to have the first word as Health IT Week begins. And I want that first word to be the right one.

So let me steal a page from a classic film that some of us are old enough to remember—"The Graduate."

And, as in that film, let me say just one word to you. That word is ... "quality."

What brings us here is the opportunity to improve the quality of health care in our Nation, and ultimately, the health status of our people. As the Institute of Medicine made clear, patient safety is at the very foundation of improved quality; it's the first of the Institute's six dimensions for a transformed health care system. And as we'll hear throughout this week, health information technology is the indispensable tool for achieving the elements of a transformed health care system. But let's keep our eyes on the prize: namely, quality health care—"the right treatment, for the right patient, at the right time."

That's where we want to be. And our other tasks will be in true alignment if we keep our quality goals in sight—defining them correctly, delivering them consistently, measuring them fairly, and rewarding them appropriately.

So that's my theme, not just for our conference today and tomorrow, but also for this "National Health IT Week." And I hope it will be yours. And, as long as I'm already appropriating the message for the week, let me take another step and suggest an alternative title for our own conference as well.

We've called this conference "Strengthening the Connections Between Patient Safety and Health IT." That's fine. Those connections are strong, and we need to keep nourishing them, with the goal of better care for the patient and making it easier for clinicians to do the right thing and make the right choices, in every encounter.

Vision and Evidence

But let me also suggest another theme that may be right for this moment: that is, "Strengthening the Connections—between the Vision and the Evidence."

What do I mean by that? In a word, I mean that we need both and that they need each other.

As we work together to improve our health care system, we need the kind of vision that provides direction and leadership. We need to see the potential, and we need to understand where each of us can contribute to change. Vision of that kind is the right starting point and the right rallying point. Without it, we'd have little reason to challenge ourselves or move forward. But visions also tend to be very big concepts. Sometimes, they may look closer than they really are, simpler than they really are, and sometimes even different than they really are.

Visions hold within them the big goals that we want to reach. But the most effective route to our big goals may not be the single, giant leap but rather a step-by-step journey: a journey of experience and change, a journey with surprises; and, if we undertake it with the rigor it deserves, a journey that gives us usable and predictive information—a journey of "evidence."

Now anyone in the AHRQ family will need very little convincing regarding the value of evidence. Looking closely at what we really know about health care delivery, and how we know it, is what AHRQ is all about. Of course, that doesn't always make AHRQ easy to understand—just look at the titles of some of our research! It also means that we're not always the most popular folks at the party. But I want to make the case that today, the evidence we're generating is more important than ever and that we have a special responsibility, not merely to find it, but to actively share and promote it. I think that's especially true for our health IT and patient safety programs.

In health care today, our Nation is facing enormous challenges—from access and coverage, to quality and safety and costs and value. At the same time, we also have some big visions for improving health care:

  • We envision electronic health records for all Americans and networks of health information exchange to make the records available when and where they're needed.
  • We envision systems of care and team approaches that openly identify patient safety problems and pool knowledge and experience to avoid medical errors.
  • We envision a continuously growing body of evidence-based knowledge about best medical practices, plus the decision support tools to make that information accessible.
  • We envision work models and technologies that not only put the patient at the center of care, but also bring the consumer onto the health care team.
  • And we envision payment systems that reward good quality care, not mere volume of care.

Together, these represent a sweeping vision for improving the foundations of our health care system—making it quality-centered, evidence-based, and IT-powered. Not only are they sweeping, but more important, I believe they represent goals that are widely shared throughout the health care sector and increasingly well understood on both sides of the political aisle.

As broad goals, they respond to our urgent need to get better value from our health care system. As "visions," they're compelling. But as tasks to be accomplished, they also represent many questions that need to be answered through experience.

Our job at AHRQ is to help answer those questions—not only through our own supported projects and research, but also through our sharing and partnerships with others. Hopefully, by targeting our efforts strategically, we can help develop the evidence as fast as possible—and help support providers and others in the actions and decisions they need to make.

My point is this: the evidence that you are developing in our Patient Safety and Health IT portfolios is critical. It goes to the heart of the "visions" and goals that are some of the major drivers in health care policy today. And at the same time, so much of what you're learning and experiencing is "ground-level" information that can help providers in a very direct and real-world way.

Sharing What We Learn

Far from being arcane or academically remote, the work you're doing is urgently needed. The experience you're garnering is truly in demand—perhaps even more than you realize. At this conference, we'll share what we're learning with one another. But an equally important part of our job is to find effective ways to share what we learn much more broadly.

In our Patient Safety program, we've developed information campaigns and survey tools, based on what we've learned about the conditions that lead to safer practices. Likewise, our patient safety Web sites, Patient Safety Net and WebM&M, provide effective ways to share widely and quickly as we expand our knowledge. WebM&M alone is receiving 28,000 visitors per month.

In the Health IT initiative, our Web-based National Resource Center for Health Information Technology was opened for public use this past February. This site is a source for basic information about Health IT adoption. But it's especially intended to be a lens on the experiences and lessons learned by our Health IT grantees and contractors.

I hope that during this conference, and in the months ahead, you'll help us think through how we can make our National Resource Center as effective and useful as possible:

  • How we can learn better and faster from your experiences and translate your lessons quickly for others.
  • How we can help providers make the most effective use of IT systems to improve patient safety and reduce medical errors.
  • And how our Resource Center can better serve you and your needs, as grantees and contractors.

AHRQ's Patient Safey and Health IT Programs

Before we begin the real work here, let's take a 30,000-foot look at where we've been and where we're headed in our Patient Safety and Health IT programs.

Since 2001, AHRQ has funded some 240 Patient Safety and Health IT projects, and awarded more than $400 million in grants and contracts for both programs. These efforts have been at the forefront of AHRQ's activities since the Institute of Medicine issued its ground-breaking report, "To Err Is Human," in 1999, and since President Bush named Health IT as a leading national health care goal in 2004. These issues have also been the Agency's leading edge, as we moved beyond our traditional ground in research and translation into new efforts and partnerships to put our findings into practice and actively help bring about improvements in the Nation's health care system.

The launch of our Health IT grants and statewide contracts in 2004 made AHRQ a leader in the effort to achieve electronic health records and health information exchange. In particular, AHRQ's efforts are helping to light the path and measure the benefits for the average practice and community hospital. These are the providers who deliver most of America's health care, yet their resources and technical expertise to adopt Health IT are spare. Helping show these providers how to make a successful transition to Health IT practice is a keystone in successfully adopting Health IT.

Last year, the enactment of the "Patient Safety Act" marked new territory for AHRQ. Under the legislation, we'll oversee the creation of new Patient Safety Organizations and a network of Patient Safety databases. Under contracts with health care entities, these PSOs will help providers identify and correct medical errors and threats to patient safety, and they'll ensure that the information given cannot be used against the provider in courts or in disciplinary proceedings. They'll provide the safe haven that is essential for learning where weak points lie and how to fix them. And they'll represent a new capacity for aggregating safety and quality information. The network of databases will help us measure where we stand and what progress we're making in improving safety and reducing error. This will be reliable information that simply has not been available before.

In both the Patient Safety and Health IT areas, we're moving from a "what" phase to a "how" phase. From the public's perspective, the Patient Safety issue exploded in 1999, with a palpable feeling of shock at the extent of medical error in our system. For Health IT, the public's interest was also focused suddenly and dramatically but at the other end of the spectrum. The potential benefits of Health IT, including the potential for reducing medical error, made for a 2-year debut that I've sometimes called a time of "rational exuberance."

Doing the Job

Now it's time for the hard work. We've defined the challenges and the opportunities. Now we need to take that journey, one step at a time, toward a safer, quality-centered health care system.

In Patient Safety, we've identified the most common danger areas. We've supported significant research into the problems of clinician fatigue and safety in intensive care. We've looked at the key factors in medication safety and adverse event reporting. And we've built a foundation of knowledge about communication and patient support.

We've also developed tools for hospitals to measure their own patient safety cultures. And we've built partnerships with JCAHO, the Institute for Healthcare Improvement (IHI), and others. We'll join IHI later this month when they announce the results of their 100,000 Lives Campaign.

Later this summer, we expect to publish our proposed regulations for Patient Safety Organizations. We're developing benchmarking measures based on the results that have been generated from our "Hospital Survey on Patient Safety Culture." And we're working with the Advertising Council to develop national public service announcements aimed at helping consumers recognize and insist on safe care.

In Health IT, we're supporting 122 grantees in 41 States, as well as statewide contracts for health information exchange in six States. These projects are designed to look at Health IT in all kinds of settings, from the teaching hospitals to the rural clinic. And they're designed to show us the real impact of Health IT systems in the clinic: the impact on quality of care, the impact on staff, the benefits for patients, and the return on investment.

Those of you who are running these programs are using a variety of systems to improve quality and safety: electronic records, clinical decision support, computerized physician/provider order entry (CPOE), and e-prescribing. I've already talked about the importance of proactively sharing what we learn in these projects. And that point is underlined by a recent study, supported by AHRQ and carried out by the RAND Corporation, one of our 13 Evidence-based Practice Centers.

We commissioned this report to make a thorough search of the literature and learn what has already been rigorously demonstrated about the costs and benefits of Health IT. Not another projection, but what do we really know, right now, about the effectiveness of Health IT systems?

RAND's findings had two sides: On the one hand, we can count it as "known" that Health IT systems are indeed capable of delivering on their promises of improved safety and quality. The report cited findings from Partners Health Care in Boston, which achieved an 86-percent reduction in serious medication errors from CPOE and e-prescribing. It also cited a 34-percent reduction in the use of redundant lab tests and a 21-percent increase in appropriate test ordering. Likewise, at the Regenstrief Institute, the report cited increases of 10 to 20 percent in the use of preventive services.

So, is the technology capable of delivering the safety and quality results we want? Yes, or at least, "yes" if you're the Partners system in Boston, or the Regenstrief Institute in Indiana, or the Department of Veterans Affairs, or Intermountain Health in Utah. Most of the results came from large, integrated organizations, where substantial time and resources had been devoted to putting "homegrown" systems in place.

And that leaves a question: How can we help achieve results like those in the kinds of settings where most Americans actually receive their health care? How can we help the average practitioner and the community hospital, with limited resources and technical knowledge, and relying on vendor-supplied systems, to achieve the kinds of dramatic improvements in care and safety that we know are possible?

AHRQ's Health IT Initiative

That's what our Health IT initiative is designed to do—and that's why I say to our grantees here how important it is that we share your experience, quickly and widely, as you learn.

As always, events are moving quickly in the Health IT field. Last month, Secretary Leavitt's American Health Information Community voted out its initial set of instructions for the development of standards to lay the base for nationwide health information exchange. This summer, the Certification Commission will issue findings on its first set of vendor products.

At AHRQ, we're working with 22 States so far to review their differing landscapes on privacy and security. Every day, it seems, the media bring us a new "can-you-top-this" story of breaches in electronic security and personal information. Health IT won't be accepted if we can't design information systems where personal data is safe. Our privacy and security policies need to be coherent and effective. And we want to use our review process to invigorate the privacy and security discussion at the community and State levels.

AHRQ is also working with the Centers for Medicare & Medicaid Services to review alternative standards for e-prescribing, especially to measure the impacts on patient safety and quality of care: How well can alternative approaches reduce adverse events and increase appropriate drug prescribing?

We've also supported the Leapfrog Group in developing a test to measure how well CPOE systems are performing in particular settings. This is a test not merely of a CPOE system, but how well that system is performing in a particular clinic or hospital. This could help providers in measuring their own performance, and it could be used for public reporting as well.

In the longer run, our object is a "continuum" of testing, so that we move beyond the simple certification of the product alone ("Can it do what it says it will do?") and extends to real interaction with clinical staff ("How does the system work in this particular clinic or hospital?"). Ultimately, we want to be able to simulate interactions between a system and a clinical staff and find any problems before the system goes online—or even before a purchase is made. Earlier this year, we invited proposals for simulation research of this kind, and we're reviewing those submissions now.

So those are some highlights. There's much more, and that's what this conference is all about.

Tools, Teamwork, and Trust

Strengthening the connections between quality, safety, and Health IT has never been more important. And I'm glad we're able to begin "Health IT Week" on that note.

The connections are really of three different kinds and three different levels of importance:

  • The first connecting point, of course, is Tools: the products and systems that can help providers do their jobs better and help consumers get the results they deserve. As we aim for higher quality care, we need to make our IT tools work FOR us, as well as WITH us.
  • The second connecting point is even more important: Teamwork. We know that better quality and safety depend on achieving a new level of cooperation and communication on the clinical staff. We talk about creating a new culture in our clinical settings—one that recognizes our limitations as individuals and our strengths when we pool our knowledge and act together. This is no less a need as we adopt Health IT. One of our grantees, Trinity Health, has said that IT adoption is "one part technology and two parts work flow and culture change." And that culture change is the same one we've identified for patient safety. Engineering our clinics for safety and quality and engineering them for Health IT depend on the same foundation of teamwork and inclusiveness.
  • Which brings us to connection number 3: Trust. Earlier this year, at the Connecting for Health conference in Washington, I talked about the importance of trust as the "invisible infrastructure" of health care. Whether it's the patient's trust that personal data will remain private, or the provider's trust in new ways of doing business in an e-connected world, or the clinician's trust in confidentiality when safety problems are reported, trust is the real foundation of any complex human endeavor and it's the essence of our calling in health care. The Hippocratic Oath remains with us today, not because it's about technique, but because it's about trust.

Another important component of trust is transparency. There are a number of efforts to provide information to patients so they can make informed decisions. CMS last week posted data on its Web site about 30 common hospital procedures, including what it pays and hospital volume. This is an important step in providing information to consumers; however, if they can't trust the data to be relevant and valid, the effort will be meaningless.

I hope that at this conference, we can affirm and strengthen our understanding of these connections. And then I hope we can go back to our communities and help bring about the steady building process that can give us the tools, the teamwork, and the trust that we'll need to achieve a better quality health care system.

Current as of June 2006


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