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Health Information Technology, Quality of Care, and Evidence-based Medicine: An Interlinked Triad

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

Annual Symposium, American Medical Informatics Association (AMIA), Washington, D.C., October 25, 2005

Momentum for Health IT
The Coming Revolution
Quality and Health IT
Effective Health Care
What's Next


Thank you for inviting me to share this time with you. It's flattering to be considered a close enough cousin to AMIA to be included in your "State of the Association" session.

We have a lot of history in common.

It's been nearly the space of two generations since AHRQ's predecessor agencies began funding something called health informatics—using giant computers with paper punch cards that probably had less computing power than your cell phone. Today, AHRQ and AMIA's members are seeing pay-back from those early and ongoing investments.

And for those of us who have been close to the subject, I would say it's been nearly a full generation since it became clear to all of us that our health care system and our information technology [IT] were a "marriage waiting to happen." No profession or sector has greater need for 21st-century information power. Yet so much health information remains stuck in 19th-century models.

So health care and IT should be "a match made in heaven." But it's going on 20 years now—and even for heavenly engagements, 20 years is a long time. Try to imagine Ben Afleck and J-Lo prolonging their famous engagement on the cover of People Magazine for two decades. It might be perversely interesting—but not very results-oriented.

It's as clear as it can be that our health care system needs what information technology has to offer. So, after all these years—with a few big successes, and a few jarring failures —has the time actually, finally arrived for information technology in our health care system?

The answer has to be "yes." More to the point—we have to make it "yes."

Has anything changed to make that possible?

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Momentum for Health IT

Well, for one thing, it's not every day that the President takes up your cause and puts it near the top of the national agenda.  But it's happened to health IT. The President has changed public awareness and created a new sense of urgency. That is playing out in hundreds of studies and articles, and thousands of projects, that would have been under the horizon or non-existent. And that has raised the possibility of progress to a new level.

[HHS] Secretary Leavitt has taken on the challenge with vigor, and order, and depth. As you know, he's created an "American Health Information Community" (the AHIC) to bring together stakeholders to agree on technical and other standards. He's personally leading that effort.

Four contracts under the Office of the National Director for Health IT will help lay the groundwork for interoperability. AHRQ is administering one of these, looking at the different State-level legal issues and business practices that could impact health information exchange. And AHRQ's own health IT initiative now includes $166 million in grants and contracts to help advance health IT—and learn quickly from our experience.

Let me say a few words about AHRQ's initiative. This program is a true cross-section. Some of our grantees are using health IT for the first time. Others are building on their experience, to help us all move forward. It's an ambitious program, with more than a hundred grants and contracts, in 43 States.

One important goal of this program is to bring health IT to settings where it's new. More than half our grants are in rural areas and underserved communities, where we can help introduce these technologies. More than that, we want to learn how health IT works in real-world clinical settings. Because the fact is this: we need to prepare the human side, just as we need to prepare the technical side, for health IT. Along with 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 preview of the benefits and the challenges. That's the heart of AHRQ's health IT initiative: a "real-world laboratory," looking at health IT in real clinical settings, and delivering findings based on day-to-day experience. That kind of real-world information, drawn from experience, can help clear the path for those who will follow.

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The Coming Revolution

Health IT promises to be transforming. But transformation means fundamental change. When we talk about "re-engineering" health care settings that were never really "engineered" to begin with, we're talking about a lot of learning: valuable learning, but lots of it. One of our grantees has figured that, for the provider, transition to health IT is "one part technology, and two parts culture and work process change."

In the movies, they can whisper: "If you build it, they will come." But in health IT reality, merely "building it" is not enough. Providers need to be ready for the adjustments, and convinced of the ultimate benefits.

AHRQ's initiative is designed to help with that learning. A key element of the initiative is AHRQ's National Resource Center for HIT. This Center and its Web portal have served this year as a source for our grantees, answering questions, sharing experiences, and beginning to pool results.

In recent months, we've begun expanding access to the Resource Center site, even as we continue building it. Next year, we plan to make the Resource Center publicly available—open to everyone who can benefit from the experiences of our grantees and others—anyone from large health systems to solo-practice physicians. This will leverage our learning and our investment, and help us move quickly toward an IT-based health care system.

At the same time, we need to be sure we're aiming squarely at the true goal: better quality and better safety for the patient. AHRQ's initiative is designed to support, and measure, health IT's capacity to deliver better quality care.

It's also important to understand that this is part of a larger movement—maybe even a revolution... certainly an opportunity—to put quality first, and to use it 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.

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Quality and Health IT

Everyone knows we look to health IT to improve quality by making the patient's information available. But we also look 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.

Over the past 10 years, Americans have learned how often our health care system falls short in delivering that basic result. In particular, reports issued by the Institute of Medicine have made clear how far we are from the kind of quality care that should be possible.

The IOM [Institute of Medicine] reports pointed to health IT as a central part of the solution. At the same time, if we're to avoid injuring our patients—and succeed in giving them the right treatments—and spend our dollars effectively—then we need the best information we can get about which treatments really work, and for whom. In a word, we need the strongest foundation possible, of evidence and results in health care.

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Effective Health Care

Over the past 30 years, AHRQ and its predecessor agencies supported much of the research that stood behind the IOM reports. This year, AHRQ has launched a new program that will help build the foundation for better quality care. This is the Effective Health Care Program, created under Section 1013 of 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. In the first round, our topics are geared especially toward Medicare. Next year, we'll begin a second round, including priority areas for Medicaid and the State Children's Health Insurance Program. Our evidence-based centers are already carrying out the first round of work, and we expect their first reports to be released soon. They'll 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 quickly, and strategically. Learning what the evidence shows today is the correct first step—but developing the capacity to move that knowledge forward, where it's most needed, is an important new step. It means a clearer focus on our knowledge gaps. And the 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. We'll communicate results in a variety of formats, to serve different audiences, and our test will be usability. The new center will guide this work of "translating" results. It will also carry out its own program of research in communications science. And it will build a new foundation for developing decision aid tools, aimed especially at helping consumers get the results they want. 

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What's Next

Health IT... quality of care... evidence-based medicine.   This is an interlinked triad that can transform health care delivery. And the time has come to do it.

It's been many years since the potential of health IT became clear, and little of that potential has been realized so far. Yet it's also a time when the problems in our health care system beg for solutions that depend on health IT, and a time when the Nation's leadership has embraced the concept and established a goal.

Since the President announced his goal, we've had more than a year of heightened discussion, broadened horizons, and real first steps in health IT. Maybe we should call it a period of "rational exuberance." But when "exuberance" tapers, and "rational" is still left, what should we do next? If this is the moment we knew was coming, when the work gets longer and the questions get harder, what should we be doing to keep up the momentum and steer it toward real results?

First, it needs to remain clear that health IT is about quality. Health IT is not an end in itself, but a means to better quality, safety and effectiveness. Increasingly (and with the help of IT), we can identify quality, measure it, and reward it. Quality improvement needs to remain a North Star in guiding our health IT endeavors.

Second, let's acknowledge that success is not inevitable. Just because health IT can work, and just because it should work, doesn't guarantee that it will actually fulfill its promise. I don't say this to be negative. But a false aura of inevitability could lead us to be less alert, less open to experience, less collegial, and less far-sighted, than we need to be. We need to remember that the pitfalls are still there, if we're to have the staying power to overcome them.

Third, we need to keep up the energy by keeping the big perspective in mind. There are rosier scenarios, and there are greyer scenarios, but we all know our health care system could be much better than it is today. That vision is an energy source that we need to keep tapping.

Fourth, we need to be guided by real-life clinical and consumer experience with health IT. The Institute of Medicine talked about the chasm between the health care we have now and the health care we could have. We need to remember that the bridge from this side of the chasm, to the better side, is made of millions of individual actions, decisions and encounters. To help build that bridge, health IT has to make sense for the individual hospital, the individual clinician, and the individual consumer.

People easily understand two of the legs of the health IT stool—the need for common standards, and the challenge of financing. But the third leg is equally important, and too often taken for granted. At the end of the day, the technology has to be helpful and usable in delivering health care. And as we go forward, we need our clinicians and patients to help guide us in the directions that work best.

Fifth, we need to build the evidence base—and we need a health IT system that will expand that base exponentially. Our new Effective Health Care Program is an important step, but health IT can help us deliver much more. It seems obvious, but it needs to be said: When we confront a health condition, we need to know all we can about which treatments work best.

Finally, we have to put the consumer at the center of this enterprise. We all say that—we all believe it. But I think we have to admit candidly that we don't know exactly how to do it. So far, we're having difficulty even defining what a consumer-faced Personal Health Record should be. We'd probably know "patient-centered care" if we saw it—but that's not the same as knowing how to achieve it. Rather than theorizing, we may get further if we just stipulate that the consumers themselves could be the experts here—and ensure, case by case, that they have a real voice in the process and a seat at the table.

I said earlier that I hoped we're in a "quality revolution." Actually, it's my hope that we may be in three health care revolutions at once:

  • A biomedical revolution, where radically new and successful therapies become available.
  • A quality revolution, to help us put effective treatments to work.
  • And a third revolution, where individuals are empowered with the information and the capacity they need to achieve high-quality health care and high-quality health results.

That's where we should be headed. And this time, let's get past the starting blocks.

Twenty years is a long time for an engagement. It's too soon to declare success. But it's too late for an annulment.

It's up to us to make this match happen.

Current as of October 2005


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