Expert Panel Meeting: Health Information Technology
On July 23-24, 2003, the Agency for Healthcare Research and Quality (AHRQ) held an expert panel meeting to provide guidance on its new health information technology (Health IT) initiative. AHRQ is focusing on implementing and evaluating proven technologies in small and rural communities and advancing the field of Health IT by supporting the implementation and evaluation of innovative technologies in diverse health care settings.
Working Group Presentations and Discussion
Health IT in Rural and Small Community Hospitals
Health IT Adoption and Impact on Patient Safety
Evaluation Process—Rural and Small Community
Evaluation Process—Patient Safety and Quality
Health IT Incentives and Financing Vehicles in Rural and Small Community Hospitals
Health IT Incentives and Financing Vehicles in Outpatient Settings
Review of Working Group Outcomes and Recommendations
One of AHRQ's priority goals is to promote the adoption of health information technology (Health IT) that produces safer, higher quality, and more efficient delivery of health care. This expert meeting had these purposes:
- Develop actionable recommendations for AHRQ to use in the design and implementation of its Health IT initiative that will make the most substantial, sustainable, and measurable impact on improving patient safety and quality of care in 2-5 years.
- Develop new funding strategies that address barriers to Health IT adoption and provide solutions to help overcome these barriers.
- Identify long-term opportunities that build on the Agency's Health IT investment to promote the adoption of Health IT that will result in safer, higher quality, and more efficient delivery of health care.
Senior AHRQ staff represented by Helen Burstin, M.D., Director of AHRQ's Center for Primary Care, Prevention, and Clinical Partnerships, asked participants to consider AHRQ's role, especially in Federal and public-private partnerships to advance Health IT. The Agency has done much Health IT work over the years, including developing, evaluating, and disseminating technologies in diverse clinical settings. It continues to advance the building of an evidence base for Health IT and emphasizes:
- Electronic medical records (EMRs).
- Clinical decision support.
- Electronic prescribing.
- Hand-held devices.
- Consumer uses of the Internet to improve safety and quality.
President Bush's AHRQ budget request for Fiscal Year (FY) 2004 included $84 million for patient safety, $50 million of which was earmarked for Health IT programs. The budget initiative contains two areas of focus:
- Implementing and evaluating proven technologies in small and rural communities.
- Advancing the field of Health IT by supporting the implementation and evaluation of innovative technologies in diverse health care settings.
AHRQ seeks to support activities that can demonstrate the effect of Health IT on important outcomes relating to safety, quality, effectiveness, and efficiency and that have the potential for long-term sustainability. Further, the Agency is interested in initiatives to identify and overcome barriers to Health IT implementation and adoption.
AHRQ convened this expert panel meeting to obtain guidance from a diverse array of potential partners and stakeholders, including:
- Members of AHRQ's National Advisory Council.
- Representatives from Federal agencies.
- Experts in Health IT, patient safety, and rural health care.
- Individuals from the front line of health care (e.g., rural providers, community health center clinicians, and rural clinic directors).
The participants formed working groups and focused on six topics. A summary of each discussion follows.
General Comments: Rural systems need expertise aimed at Health IT readiness in technological, operational, and clinical areas. To facilitate interconnectivity among rural providers, AHRQ should consider developing partnerships with health care organizations in rural areas. It was noted that quality indicators in rural areas often differ from those noted in other geographic regions. One aim is to define and measure those differences.
Two general themes emerged from the discussion:
- Bringing people together.
- Providing technical assistance.
To achieve those goals, the working group members recommended that the following activities be considered:
- Support demonstration projects that involve Health IT implementation and will lead to the creation of learning networks comprised of providers from various types of rural health care organizations.
- Create learning communities that span geography; collect and analyze the outcomes associated with participation.
- Once factors that facilitate learning communities and Health IT implementation have been identified, engage CMS and other purchasers to define an appropriate reimbursement strategy.
- Incorporate evidence-based primary care guidelines with rural relevance into technological templates. Clinicians are likely to accept clinical guidelines offered by the Federal Government at no cost.
- Support local capacity development for Health IT, including barrier analysis, education and other activities.
- Provide sustained technical assistance.
General Comments: AHRQ should participate in defining what an Health IT functional system would look like (i.e., what would be a desirable "end-state"). The Agency could support an environment for research and demonstrations. Because of the complexity of many health care delivery systems, AHRQ should consider demonstration activities that are both long and short-term in nature.
There should be further elaboration of standards, with a process to develop minimum standards in 2-5 years. We need a framework for system interoperability, including reference information, key data elements, controlled medical terminology, and executable knowledge. AHRQ should also focus on making clinical information useful at the point of care to provide decision support. Both public and private efforts will be important for success.
There is a question of how to engage, recruit, and train individuals with the right level of expertise. The Institute for Healthcare Improvement (IHI) has a proven model for assembling diverse individuals around a central issue, providing them with technical support, and achieving breakthrough results. AHRQ should consider developing some IHI-like initiatives to help organizations cross the boundaries toward Health IT implementation and utilization activities.
Malpractice risk and insurance cost may affect behaviors of both providers and health care systems. AHRQ should consider supporting initiatives to determine how adoption of Health IT can mitigate medical risks and therefore provide an incentive using Health IT. Providers, payers, and policymakers are keenly interested in the business case for Health IT. What is the value of Health IT in health care, including direct and indirect benefits? AHRQ should consider supporting projects that will help delineate the value of Health IT and can inform stakeholders about the business case for using Health IT. Activities supported under this topic area should be broad based and encompass a wide scope of activities.
AHRQ should consider developing opportunities for informatics training (e.g., a fellowship programs in informatics) to develop leaders and build future capacity. AHRQ will soon begin the Patient Safety Improvement Corps Program. This 6-month training program is designed to build capacity in the field of patient safety. Perhaps a similar program for Health IT training and dissemination would be useful.
In the area of evaluation, categories for consideration include scope of the project, goals and critical success factors, and technical assistance. Potential roles for AHRQ include cataloging and promulgating best practices. As it defines effective practices and technologies, AHRQ should work with the Centers for Medicare & Medicaid (CMS) to better define reimbursement strategies and align incentives for Health IT implementation.
One idea centered on the provision of community grants to support personal digital assistant (PDA) systems for decision support. The Agency should consider rural health care sites that are currently receiving funding (e.g., from the Health Resources and Services Administration [HRSA]) as good places to start the rural Health IT initiative and eventually include additional sites. AHRQ should assess the readiness of communities and hospitals to take part in Health IT initiatives. Early investment in the planning stages should include community integration and developing goals and outcomes.
The initiative should include:
- Developing toolkits.
- Leveraging known tools.
- Developing capacity.
- Disseminating best practices.
Tools should include software (and its instructions), tools for planning, and tools for conveners who provide technical assistance. Goals include standard definitions and processes for documenting improvement, tools and approaches to determine Health IT readiness, and a process for ensuring good data.
Projects should develop a conceptual framework, definitions, and dimensions of benefits and costs across various stakeholders. Success could be defined as having an influence on stakeholders and their adoption of the framework. AHRQ should consider evaluation of what is currently in place-in terms of costs and benefits-and determine the roles of implementation and operational issues. Measures must span the programs and projects' effects on investment decisionmaking behavior and the rate of adoption.
AHRQ should play a role in defining minimal clinical data sets for quality and safety improvement. We need to operationalize data measurement elements and translate them into terminology that can be incorporated into EHRs. This requires collaboration with industry and those who set standards. A national repository for clinical knowledge that contains free clinical information in a codified executable manner is publicly available. It can be incorporated into an institutions' clinical information systems as point-of-care decision-support tools and would be of great benefit to providers and other stakeholders.
Perverse financial incentives, the cost of doing business, patient safety metrics, and cultural factors can work against safety initiatives. AHRQ needs to quantify the benefits of participation in Health IT initiatives to the public, providers, and payers. It can act as a catalyst in rural areas by providing incentives to doctors and organizations and by helping to overcome these barriers. AHRQ can also foster the development of collaborative partnerships involving local or regional entities that will lead to data sharing across institutions and which result in more long-term sustainability than individual projects.
In rural health care, data collection suffers from deficits in infrastructure. AHRQ should prioritize quality improvement areas, providing direction with flexibility. AHRQ should collaborate with HRSA's Bureau of Primary Health Care to help clinics advance Health IT and build sustainability.
AHRQ should consider supporting a systematic study of programs that have successfully implemented Health IT. These lessons could then be incorporated into long-term strategic planning processes and future Health IT implementation activities.
A specific challenge is the development of appropriate criteria for future funding of diverse health care settings. Rural sites have tremendous variation in resources, personnel, patient populations, capacities, and skills. Different initiatives should have the capability of being tailored to the different regions, organizations, and personnel involved.
AHRQ needs to identify designated test environments, to research economic issues, and to determine the willingness to pay for different levels of Health IT. In particular, the Agency should support environments that stimulate breakthrough research and innovation.
The Agency should consider programs similar to agricultural extensions for patient safety and Health IT. This could help leverage other efforts by quality improvement organizations and other resources and help hospitals and other providers through local technical support centers.
One important and explicit goal is not only adoption of Health IT but adoption of Health IT to enable improvement in performance. Measures at the beginning of the initiative could include the degree of automation and the number of systems integrated compared with current "silo" systems. Further measures of milestones across the life of the project could be incorporated to indicate the penetration of integrated medical information. Other identified Federal funders of rural and small community telecommunication activities include the Federal Communications Commission and HRSA.
The meeting participants provided a wealth of recommendations, including:
- Provide rural hospitals and clinics with more computers and access to the Internet.
- Develop electronic health records that are easy and intuitive to use.
- Ensure that clinical personnel have the needed and necessary functions in future EMRs.
- Create better software and algorithms for providers' palm and handheld devices.
- Create flexibility and scalability to address hospitals' and providers' various Health IT needs.
- Research, define and communicate to the public the degree to which current health care dollars, lost lives, and complications result from the delay in Health IT adoption and diffusion.
- Integrate legacy systems with interoperable electronic health records.
- Create a forum in which end-users could express needs and constraints about technologies and broader issues.
- Have users (physicians) drive the development of technology and act as integration and adoption leaders.
- Develop a model for regional collaborations, with input from patients, payers and providers.
- Study all current and emerging initiatives supported by AHRQ in the areas of quality, safety, and Health IT to assess their applicability to rural areas.
- Study workflow effects and costs/benefits as providers introduce Health IT.
- Merge the clinical and public health systems to facilitate Health IT.
- Support implementation or demonstration projects that address barriers to adoption of Health IT.
- Study successful models that utilize data standards to share information. Study successful business and economic models. Promote the deployment of data standards.
- Demonstrate utilization of Health IT in the mitigation of risk.
- Study the barriers to the free-flow and exchange of clinical information.
- Promote a disciplined, systematic way to consider challenges in the field and the elements of success.
- Provide no-cost Health IT assessment tools to providers.
Dr. Burstin gave a final list of action-oriented themes from the discussion:
- Engage multiple groups (including the community).
- Address financial incentives, workflow, and provider behavior.
- Evaluate demonstration projects and current initiatives (Federal, private).
- Place information in the public domain (no-cost and free-flowing).
- Create a business case for Health IT.
- Educate the public, providers, and policymakers about the value of Health IT.
- Study Health IT effects on workflow.
- Develop data standards to promote interoperability.
- Bring groups together (not only doctors and hospitals).
- Link/encourage collaboration among private sector, Federal agencies, and the public health system.
- Provide technical assistance to collaboratives and providers to build capacity within communities.
- Make investments for planning grants and activities.
- Encourage physician champions.
- Examine incentives.
- Develop economic quality-oriented solutions (beginning at the low end for Health IT diffusion).
- Define small and rural communities and their segments.
- Monitor rural quality indicators.
- Encourage regional and community collaborations.
- Examine multiple sites of care.
- Develop an overall framework to assess the value of specific Health IT features.
- Evaluate emerging technologies, including the integration of administrative and clinical systems.
- Study and promulgate best practices specific to rural communities.
AHRQ will use information from this meeting to help guide its FY 2004 Health IT initiatives to promote the adoption of Health IT and evaluate its impact on patient safety, quality of care, effectiveness, and efficiency. AHRQ views collaborations between Federal partners, health care provider organizations, local and regional communities, patients, and vendors as integral to success of Health IT implementation. AHRQ is also interested in the impact of Health IT on important outcomes, long-term sustainability, standards, interoperability, and priority conditions and populations.
Dr. Burstin encouraged the participants to forward additional comments or recommendations to Dr. Scott Young or Dr. Eduardo Ortiz at AHRQ.
Gerald J. Ackerman, M.S.
Kim Bateman, M.D.
Stephen Blattner, M.D., M.B.A.
Marcia K. Brand, Ph.D.
Sharon Ericson, M.A.
Barbara B. Frink, Ph.D., R.N.
Brent C. James, M.D., M.Stat.
Robert M. Kolodner, M.D.
Mark Leavitt, M.D., Ph.D.
John W. Loonsk, M.D.
Janet M. Marchibroda, M.B.A.
Blackford Middleton, M.D., M.P.H.
Arnold Milstein, M.D., M.P.H.
Ravi Nemana, M.B.A.
J. Marc Overhage, M.D., Ph.D.
Cathy Pfaff, R.N.
William Rollow, M.D., M.P.H.
Margaret Sabin, M.H.S.A.
Cary Sennett, M.D., Ph.D.
Paul Tang, M.D., M.S.
Anne E. Trontell, M.D., M.P.H.
William C. Vanderwagen, M.D.
Mary K. Wakefield, Ph.D., R.N.
William Yasnoff, M.D., Ph.D.
AHRQ Staff Present
Henry Barry, M.D.
James B. Battles, Ph.D.
Helen Burstin, M.D., M.P.H.
Carolyn M. Clancy, M.D.
Carole D. Dillard, M.A.
J. Michael Fitzmaurice, Ph.D.
Michael Harrison, Ph.D.
Marge Keyes, M.S.
Eduardo Ortiz, M.D., M.P.H.
Irene A. Ritzmann
Daniel Stryer, M.D.
Scott Young, M.D.
Roselie A. Bright, Sc.D.
Theresa Cullen, M.D., M.S.
Lisa Dolan-Branton, R.N.
Carol B. Haberman, M.S., M.P.A.
Sherrie Hans, Ph.D.
Tom Morris, M.P.A.
Frances M. Murphy, M.D., M.P.H.
Dena S. Puskin, Sc.D.
Syed Tirimizi, M.D