Transcript Tie in HIT developments to improved quality and safety of

Agency for Healthcare Research and Quality
Advancing Excellence in Health Care • www.ahrq.gov
Advancing Excellence in
Health Care
Carolyn M. Clancy, MD
Director
January 21, 2005
Advancing
Excellence
in Health
Care
Case Presentation - 1
 Paul, a 54 yo patient with diabetes and
hypertension visits a primary care clinician for
abdominal pain of 2-3 days duration.
 Prior to his visit, he and his pc team leader
have reviewed his symptoms and history by email, and have examined possible causes by
going to the PC Navigator, a system that has
been developed to improve diagnosis and
management of patients with undifferentiated
symptoms.
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Case Presentation - 2
 Paul’s pc team has also reviewed Paul’s
recent entries to the jointly held
electronic medical record.
 A diabetic for 10 years, Paul manages
his condition with diet and exercise, after
several bumpy years on insulin. His
self-management is supplemented by email consultations prn.
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Case Presentation - 3
 When Paul and his clinician meet -- at
his convenience -- they discuss his
options and agree on a diagnostic test,
after reviewing possible outcomes of the
test and options. The test is scheduled
for that day.
 Before leaving the practice, Paul leads a
group visit at which there are several
medical students -- required to attend to
learn from patients about chronic illness
management.
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Case Presentation - 4
 The patients in the group visit provide
feedback to the students about how they
can enhance patients’ skills in self
management.
 Paul then gets his diagnostic test, and
before the end of the day his primary
care clinician has e-mailed the results
and suggested next steps.
Advancing
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Overview
 About AHRQ: The Evidence Agency
 Health Care 2005: Current Context
 Recent Findings and Directions
 Future Challenges
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Mission Statement: AHRQ
The mission of the Agency for
Healthcare Research and Quality
is to improve the quality, safety,
efficiency, and effectiveness of
health care for all Americans.
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Advancing
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AHRQ RESEARCH FOCUS:
HOW IT DIFFERS
 Patient-centered, not disease-specific
 Dual Focus -- Services + Delivery
Systems Effectiveness research focuses
on actual daily practice, not ideal
situations (“efficacy”)
 AHRQ mission includes production and
use of evidence-based information
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Ten Roles of Government
in Health Care Quality
 Purchase health




care
Provide health care
Assure access for
vulnerable
populations
Monitor health care
quality
Regulate health
care markets
 Inform health care
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


decision- makers
Support acquisition of
new knowledge
Support development of
health technologies and
practices
Develop the health care
workforce
Convene stakeholders
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Excellence
in Health
Care
Overview
 About AHRQ: The Evidence Agency
 Health Care 2005: Current Context
 Recent Findings and Directions
 Future Challenges
Advancing
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in Health
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Driving Forces
 Rising health care expenditures
 Aging and increasingly diverse
population
 Consumerism
 Biomedical advances: public and
professional expectations
 Growing influence of purchasers
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Current Environment
 Unprecedented opportunities and
innovations
 Rising health care costs
 Consumer and purchaser demand for
value
 Limited information on performance – and
how to improve
 Numerous initiatives to address one piece
of the puzzle
Public Perceptions
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Percent who say they are dissatisfied
with the quality of health care in this
country…
2004
2000*
Has the quality of health care in this
country…
Gotten
worse
Stayed
about the
same
55%
40%
44%
38%
4%
17%
Don’t
Know
Gotten
better
* Gallup Poll conducted September 11-13, 2000 with 1,008 U.S. adults.
Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’
Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).
Personal Experience
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Have you
Care
been personally involved
in a situation where a preventable
medical error was made in your own
medical care or that of a family
member?
No
65%
34%
Did the error have serious health
consequences, minor health
consequences, or no health
consequences at all?
21%
Serious health
consequences
10%
Minor health
consequences
Yes
3%
1% Don’t
Know
No health
consequences
Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’
Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).
Role Of IT In Reducing Medical Errors
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Percent who say…
The coordination among the
different health professionals
that they see is a problem
69%
Have you or a family member ever
created your own set of medical
records to ensure that you and all
of your health care providers have
all of your medical information?
Yes
They have seen a health care
professional and noticed that
they did not have all of their
medical information
They had to wait or come back
for another appointment
because the provider did not
have all their medical
information
48%
32%
1%
32%
Don’t
know
67%
No
Source: Kaiser Family Foundation / Agency for Healthcare Research and Quality / Harvard School of Public Health National Survey on Consumers’
Experiences with Patient Safety and Quality Information, November 2004 (Conducted July 7 – September 5, 2005).
Pace of Change Varies
Across Care Settings
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Median percent change
Median change in performance by setting, 2003 NHQR vs 2004 NHQR
20.0%
18.0%
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
17.7%
5.4%
3.0%
1.4%
Hospital care
Ambulatory
care
Home health
care
Nursing home
care
Setting
(24 measures)
(49 measures)
(12 measures)
(3 measures)
 Of 98 measures
with trend data,
88 can be
mapped to care
settings
 Some
improvement
seen in all
settings
 However,
change in
performance
varies across
settings
Major Opportunities for
Improvement
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Percentage of patients
Quality of Pneumonia Treatment for Elderly, 2002
100
90
80
70
60
50
40
30
20
10
0
 81% of Medicare
81
63.1
67.9
29.6
Received 1st
Received
Have blood
Received all
dose of
recommended
cultures
recommended
antibiotic within
antibiotics
collected before
treatment
4 hours of
consistent with antibiotics are
regimens
hospital arrival
current
administered
guidelines
Measure
Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program,
2002.
pneumonia
patients get blood
cultures before
antibiotics
 68% get the right
antibiotics
 63% get their first
antibiotic in a
timely manner
 Yet, only 30% get
all of three
recommended
interventions
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The proportion of adults with diabetes
who received all five recommended
diabetic services (MEPS, 2000-2001)
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40%
30%
2000
2001
20%
10%
or
N
ea
M
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id
oo
dl
e
r
In
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m
ig
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e
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is
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W
hi
-H
is
pa
ni
c
B
la
ck
N
on
W
hi
te
0%
Advancing
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Care
HHS: Recent Developments
 Nursing Home Initiative
 Home Health Care Initiative*
 AHA-JCAHO-VHA …. Hospital reporting
initiative*
 Patient experience in hospitals*
 Bar coding
 IT standards (*)
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Patient Safety: Achieving A New
Standard For Care
“Americans should be able to count on
receiving health care that is
safe……..This requires, first, a
commitment by all stakeholders to a
culture of safety, and, second, improved
information systems.”
Institute of Medicine, 2003
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Issues
 Will public reporting 
improvements?
 Paying for quality – YES, but
HOW??
 Pay for quality – OR use of HIT?
 How to align measurement and
improvement efforts?
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Overview
 About AHRQ: The Evidence Agency
 Health Care 2005: Current Context
 Recent Findings and Directions
 Future Challenges
AHRQ Research Study: Identifying
Successful Hospital Quality Improvements
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 Major finding: Hospitals that were more
likely to prescribe beta-blockers shared
similar characteristics:
–
–
–
–
Solid support from their hospital administration
Strong physician leadership
Shared goals of improving medical practice
Effective way of monitoring progress
 Conducted by Yale University School of
Medicine
E Bradley, E Holmboe, J Mattera, et al., A Qualitative Study
of
Increasing B-Blocker Use After Myocardial Infarction, Journal
of
Advancing
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AHRQ Research Study: Sleep
Deprivation and Safety
 Major Finding: Serious medical errors fell
significantly when medical interns’ work
schedule was reduced from 30-hour-in-a-row
shifts and when continuous work schedules
were limited to 16 hours
36% more serious
medical errors
21% more serious
medication errors
CP Landrigan, JM Rothschild, J W Cronin, et al., Effective of reducing interns’ work
hours on serious medical errors in intensive care units, NEJM, October 28, 2004
AHRQ Research Study: Outpatient
Prescription Drug-Related Injuries in Elderly
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 Major Finding: Outpatient Medicare
patients suffered as many as 1.9 million
drug-related injuries a year due to
medical error or adverse drug events
(ADE) not caused by errors
 Why did preventable ADEs occur?
– 58% prescribing medications
– 61% monitoring medications
– 20% patients adhering to medication
instructions
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HIT + Systems approach
Can Make a Difference
Proportions of patients receiving the appropriate discharge
prescriptions
 Intermountain
Health Care QI
effort on CVD
 Results:
– 90%
prescription
rates
– 27% decrease
in unadjusted
absolute death
rates
Lappe JM et. al., Ann Intern Med 2004;141:446-453
Advancing
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Hospital Survey on Patient
Safety Culture
 New tool helps hospitals and
health systems evaluate
employee attitudes about patient
safety in their facilities or within
specific units
 Includes survey guide, survey,
and feedback report template to
customize reports
 AHRQ partnership with Premier,
Inc., Department of Defense, and
American Hospital Association
 www.ahrq.gov/qual/hospcult
ure/ or e-mail to
[email protected]
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Key Implementation Activities –
QualityTools
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National Health Plan Learning Collaborative
to Reduce Disparities and Improve Quality
 Public/private partnership to reduce
disparities in health care for people with
diabetes and other conditions
 Over next 3 years, collaborative will test
ways to improve collection and analysis
of data on race and ethnicity and match
data to existing quality measures to
close gap in care
 Sponsored by nine of Nation’s largest
health insurance plans, and other
organizations
Advancing
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Care
Overview
 About AHRQ: The Evidence Agency
 Health Care 2005: Current Context
 Recent Findings and Directions
 Future Challenges
Advancing
Excellence
in Health
Care
The Future Delivery System:
Baseline Assumptions
 Today’s students will encounter a

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dramatically different health care system
Basic premise of health insurance is
evolving
System fragmentation will increase
Consumer-directed options will increase
 increased price sensitivity and need
for information
“Disruptive challenges” (BT, SARS, ???)
a daily reality: the “new normal”
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What We Have Learned
 Knowing the right thing to do is NOT =

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

doing it!
Improvement must be based on science
Patients as participants are far more
effective than patients as ‘recipients’
Sutton’s Law: improving chronic illness
care is essential
Safety in health care delivery is critical
Findings: Debunked
Assumption
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Question
Hypothesi
s
Study
Publication
s
Changes in
practice
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A Flawed Model
 Receptor sites are “assumed”
 Decisionmaking is not-linear:
evidence is only part of the
“solution”
 Broad dissemination  modest
effects
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Improving Quality and Safety
“We need to make the right thing
the easy thing…”
Mark Chassin, MD
October 12, 2000
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Advancing
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If HIT is Such a Great Idea …..
 Generalizability of promising findings
open to question
 Even successful hospitals use
multiple vendors – and have internal
interoperability challenges
 Implementation is “challenging”
 Physicians are independent
contractors
FY04: Transforming Healthcare
Quality through IT
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 Planning : up to $7M
– assist healthcare systems and their partners
in planning for activities that will lead to
successful HIT implementation
 Implementation : up to $24M
– support organizational and community-wide
implementation and diffusion of HIT
 Value : up to $10M
– assess the value derived from the adoption,
diffusion, and utilization of HIT
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State and Regional
Demonstrations in Health IT
 Identify and support statewide data sharing

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and interoperability activities on a discrete
state or regional level.
Approximately 5 states
$25M over 5 years
“Test Beds” to produce demonstrable
improvements
Improvements must be sustainable beyond
end of contract and applicable to other states
or regions
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Critical Challenges
 Common data elements and
definitions; build capacity to make
improvements
 Linking implementation to requisite
clinical transformation
 Avoiding the “NIH” syndrome
 Aligning incentives and rewarding
success
 Making it easy
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Contemporary Challenges
 Scientific basis for safe and
appropriate use of diagnostic,
therapeutic and preventive
interventions -- from and to the point
of care
 Quality improvement as science
 Translating promising educational
models into large-scale
improvements in care and outcomes
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What is Section 1013?
 To improve the quality, effectiveness and efficiency of
health care delivered through Medicare, Medicaid and
the S-CHIP programs
 $50 million is authorized in Fiscal Year 2004 for the
Agency for Healthcare Research and Quality (AHRQ)
to conduct and support research with a focus on
outcomes, comparative clinical effectiveness and
appropriateness of health care items and services
(including pharmaceutical drugs), including strategies
for how these items and services are organized,
managed and delivered
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What is Section 1013?
 By June 2004, the Secretary shall
establish an initial list of research
priorities (including those related to
prescription drugs)
 Priorities may include health care items
and services which impose a high cost
on Medicare, Medicaid or S-CHIP,
including those that may be
underutilized or over utilized
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SHARED DECISION MAKING:
DECISIONS AND OUTCOMES
Patient
Alternative 1
Alternative 2
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PREQUISITES FOR
CHANGE
 Integrating strategy to make existing
information accessible with requisite
data collection
 Expected differences in patient
experiences (e.g., disparities associated
with race, ethnicity and SES)
 How to present information in usable
formats (different versions of “the
answers” will be more effective for
different audiences)
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Focus: Research and Policy
 Describing problems – policy window
 Developing and testing solutions to
problems
 Evaluating solutions
 Interaction with stakeholders and
decision makers is not optional
Supply-Side Research
Paradigm
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Research world:
User world:
• Questions
• Hypothesis
• Study
• Many needs
• Beliefs & interests
• Decision processes
Publication
34
c2
The winding road
to a receptor site
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Demand/Supply Side Model
Research world:
User world:
• Questions
• Hypothesis
• Study
• Many needs
• Beliefs & interests
• Decision processes
34
c2
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Approaching Knowledge Gaps
≠
 Not always head to head
 Need to be creative
 Explore new methodologies
 Examine existing or forthcoming data sources
 Reserve most expensive approaches for the
most important and controversial questions
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Essential Issues to be Addressed
 Ethics and Quality Improvement: (when is it
research?
 Identification of subgroups most likely to benefit
 Identifying critical intervention points (“teachable
moments”)
 Conceptual blueprint for practical clinical trials
 Integration of disease management with clinical
decision support – “knowledge engineering”
 Patient engagement (including the precontemplative)
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Questions in Search of Answers
 Linking knowledge development to
policy levers (e.g., payment;
regulation): role of ‘demonstrations’
 When is “good enough”?
 Vocabulary and pathways for
translation of knowledge-based
interventions under-developed
 Concurrent -- or sequential -evaluation and translation?
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“It is not enough just to develop
new insights into the fundamental
nature of disease and its prevention.
It is not enough to test that
fundamental knowledge in rigorously
controlled clinical trials. We must
also improve the distribution of that
knowledge so that it reaches
everyone in the world -- so that
everyone will benefit from it.”
Robert H. Brook, M.D., Sc.D., remarks to
Research! America, March 20, 2001