Online Performance Appendix: Performance Detail, Health Information and Technology

Budget Estimates for Appropriations Committees, Fiscal Year 2011

As the Nation's lead research agency on health care quality, safety, efficiency, and effectiveness, AHRQ plays a critical role in the drive to adopt health information technology (health IT). Established in 2004, the purpose of the Health IT Portfolio at AHRQ is to develop and disseminate evidence and evidence-based tools to inform policy and practice on how Health IT can improve the quality of American health care. This portfolio serves numerous stakeholders, including health care organizations planning, implementing, and evaluating health IT, health services researchers, policymakers and other decisionmakers. The portfolio achieves these goals through funding research grants and contracts, synthesizing findings, and developing and disseminating findings and tools.

Research Grants

Conclusion of Transforming Healthcare Quality Through IT (THQIT) Grant Program
In 2004 and 2005 AHRQ initiated a $132 million grant program to assess the ability of primarily small and rural hospitals to plan, implement and demonstrate the value of health IT. 2009 represented the conclusion of this series of grants, the largest ever single investment in understanding barriers and drivers on how health IT can impact quality, and provides a unique and timely opportunity to leverage these lessons to inform today's national drive for adoption and meaningful use of health IT. While the program has posted project summaries, publications and final reports from each of the 100+ grantees in this program on the National Resource Center for Health IT (NRC) Web site (http://www.healthit.ahrq.gov), the program has begun to synthesize the lessons from individual projects to identify best practices and broader trends. In addition to developing a series of "Emerging Lessons Learned" papers (and posted on the NRC), in 2009 AHRQ awarded a contract to synthesize the findings from this grant program as a whole. The results are expected to be available beginning in December 2011.

Ongoing Ambulatory Safety and Quality (ASQ) Grant Program
The Ambulatory Safety and Quality (ASQ) program accentuates the role of health information technology (health IT) through awards in three areas: quality measurement, quality improvement, and patient-centered care through health IT. While most grant activities in the ASQ program are still in progress, the program has begun to develop emerging lessons learned based on a limited number of completed grants and insights gained from grant activities to date. A key subset of grants in this program with prime relevance to current national health IT initiatives is the program's EQM or Equalizing Quality Management, which seeks to identify and overcome barriers to quality reporting. All the ASQ non-competing grants that began in FY 2006 will end in FY 2010.

Health IT Program Announcements
In FY 2009, the Health IT portfolio developed three standing funding opportunities to address research to support the program's three strategic focus areas: the use of health IT to support patient-centered care and transitions in care; clinical decision support (CDS) and improved decisionmaking; and the effective use of electronic prescribing and medication management. The program awarded grants to support real world demonstration projects that evaluate facilitators and barriers associated with successful health IT implementation and use and ultimately improved health care outcomes, as well as grants to support short-term preparatory, pilot or feasibility studies that will inform larger scale real world health IT implementation and use or the conduct of more comprehensive health IT implementation research

Some recent achievements and research findings funded through Health IT grants include:

• AHRQ funded research showed significant cost savings can be achieved when formulary decision support (FDS) is available in e-prescribing applications. Clinicians using e-prescribing with FDS were significantly more likely to prescribe tier 1 medications, and the potential financial savings were substantial. Widespread use of e-prescribing systems with FDS could result in reduced spending on medications. (http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_3882_868892_0_0_18/Prescribing_Patterns_of_Preferred.pdf) Plugin Software Help.
• AHRQ funded researchers have developed a specialized health IT tool, called the "Smart Form," to facilitate documentation-based clinical decision support (CDS). The form, which is tied to electronic medical records, organizes clinical data in a disease-focused manner to help in decision making. It also highlights and requests coded information, such as height, weight, and smoking status. The form also is designed to fit into workflow before, after, and during the clinical visit where CDS systems should have the biggest impact on provider behavior. (http://www.ahrq.gov/research/jan09/0109RA3.htm).
• AHRQ funded researchers have also been studying patient use of secure messaging within a shared medical record, and found that use of secure messaging varied according to individual clinical, social and demographic characteristics. (http://healthit.ahrq.gov/portal/server.pt/gateway/PTARGS_0_3882_898612_0_0_18/09-0096.pdf) Plugin Software Help.

Other Grants
Other AHRQ grant programs support the mission of the health IT portfolio by convening conferences related to health IT, training future researchers, and conducting relevant research. Specifically, the health IT portfolio has funded conference grants, training grants, and a Center for Education and Research on Therapeutics (CERT). These projects are still ongoing, and when completed their results will be disseminated with other health IT-funded evidence.

Research Contracts

National Resource Center for Health IT (NRC) and NRC 2.0 Launch
The Health IT portfolio disseminates its products and delivers technical assistance through its online National Resource Center for Health IT (NRC—available at http://www.healthit.ahrq.gov), Web conferences, and direct participation in select meetings, workgroups and journals. Usage of the NRC Web site, both by the program's intended audiences and by fellow federal entities focused on health IT has continued to grow.

In anticipation of the continued growth of the NRC and the conclusion of the initial 5-year contract for the NRC, in 2009 AHRQ re-competed and awarded a series of Master Task Order Contracts to support the next generation of the NRC as well as an initial set of fifteen tasks to support core NRC operations and program research activities. Some key AHRQ program tasks awarded under the NRC in 2009 include:

• Operation of the NRC web, national webinar and technical assistance infrastructure.
• Synthesis of findings form 132 THQIT grantees and six state and regional health information exchange (HIE) demonstrations.
• Support for the use of health IT in the Patient Centered Medical Home, a promising model of care that aims to lower costs and improve quality by reorganizing the way primary care practices deliver care.
• Marketing and dissemination strategy and support.

Activities to Inform Other AHRQ Portfolios and Support Agency Goals
The AHRQ Health IT program continues to collaborate and inform other AHRQ programs in support of Agency goals. Some key activities by the Health IT program to inform and support other AHRQ portfolios include:

• Providing technical assistance to the AHRQ Comparative Effectiveness Program to develop and refine ARRA-funded registry contracts
• Design and implementation of the Patient Safety Organization national reporting system.
• Work with the Agency's Center for Delivery and Organization of Markets in support of measure development activities.
• Work with the Prevention and Care Management Portfolio in support of efforts to establish a research agenda and federal collaborative efforts around the Patient Centered Medical Home (PCMH)

In cooperation with the Agency's Long Term Care (LTC) program, AHRQ is establishing a specialized research center to support enhancing care management and transition in care for the elderly. This project will fund a consortium to conduct multiple, inter-related projects that are focused on the role of communications and health information technologies in self-management and transitions in community-based care and services.

Activities to Inform National Health IT Initiatives and Overcome Barriers
Public and private entities continue to leverage AHRQ's research products, researchers and insight to inform legislation, plan operations, and develop evaluation plans. AHRQ Health IT portfolio-funded researchers staff many of the key roles in the newly-formed Health IT Policy and Standards Federal Advisory Committees. AHRQ helped organize and participated in the April 2009 National Committee on Vital and Health Statistics (NCVHS) hearing that ONC and CMS held to help define "meaningful use" and the subsequent NCVHS hearing on "meaningful measures". AHRQ continues to provide insight into best practices, evidence and evidence-based tools to inform and support public and private decision-makers, implementers, and researchers.

Also in 2009, the program leveraged its unique connection to AHRQ's other portfolios and centers and the nation's health IT research community as a rapid way to gather and deliver insight (via concise issue briefs) on key health IT issues to ONC and other program customers. The program held a series of "grantee open forums" (moderated listening sessions) with small (fewer than 10) numbers of program grantees on topics including: the feasibility and design of proposed meaningful use reporting requirements, meaningful use consumer engagement requirements, medication management and patient recruitment.

Poor usability and information design in electronic health record (EHR) systems remain a barrier to their adoption and meaningful use. AHRQ commissioned the creation and dissemination of two reports that synthesize the existing research and evidence in this area to guide the development of an objective EHR usability evaluation process and recommend policies to improve the usability and safety of EHR systems. Based on these recommendations, AHRQ awarded a follow-on contract to evaluate certified EHR vendor usability processes and practices and is driving coordination of AHRQ-funded EHR usability activities with NIST and ONC.

Clinical decision support (CDS) represents a key component of EHR systems to improve healthcare quality. In 2008, the program awarded $5 million for two new contracts to advance the understanding of how best to incorporate CDS into health care delivery. While these projects are not yet complete, in 2009 AHRQ published and disseminated important white papers that assess the state of the field in CDS and provide insight on how to incorporate CDS into practice workflow. In addition, the program funded free public access to online access to the first chapter of "Improving Medication Use and Outcomes with Clinical Decision Support: A Step-by-Step Guide" to assist implementers of clinical decision support (CDS) tools, hosted a town hall meeting on CDS, and produced a series of podcasts on the topic. Finally, the program awarded a contract to develop and disseminate specifications for common clinical decision support rules, a project which healthcare organizations can directly use to support the Health Information Technology for Economic and Clinical Health (HITECH) Act requirements in this area.

Some recent activities related to quality measure reporting include:

• An AHRQ-funded report from the National Quality Forum advanced quality measurement using health IT by identifying standard codesets for all NQF-Endorsed quality measures and proposed a draft quality data set that could be adopted by health IT vendors.
• Mapping the AHRQ-funded U.S. Health Information Knowledgebase (USHIK), a metadata registry of health information data element definitions, values and information models that enables browsing, comparison, synchronization and harmonization within a uniform query and interface environment, to HITSP (Health IT Standards Panel) use cases, a key enabler for standardized electronic reporting.
• The program supported the National Committee on Vital and Health Statistics, an HHS advisory committee, in their recent hearings on meaningful use of health IT. Agency staff and AHRQ funded researchers organized the hearing and presented testimony on ways to improve the capacity and effectiveness of using health IT to measure and improve healthcare quality.

Driving establishment and sustainability of health information exchange (HIE) activities represents a significant goal of national health IT efforts and an area of ongoing support for the AHRQ health IT portfolio. In FY 2009, the program continued its support of six state and regional demonstrations of HIE, convening two in-person meetings for participants to share best practices and inform recommendations for future activities in this area. In addition, the program published "Liability Coverage for Regional Health Information Organizations" based on lessons from its supported activities.

Other recent achievements and research findings funded through contracts related to Health IT include:

• Publication and dissemination of a high quality evidence report on The Impact of Consumer Health Informatics Applications. This report identifies significant evidence that consumer health informatics applications, electronic tools that are designed to interact directly with consumers and provide or use individualized (personal) information, impact health outcomes (http://www.ahrq.gov/clinic/tp/chiapptp.htm).
• Publication and dissemination of the program's first ever Annual Report of Portfolio Funded Projects. This report provides both an overview of all of the AHRQ health IT program's funded projects for CY2008 and detailed performance assessments for each activity. (http://healthit.ahrq.gov/portal/server.pt?open=512&objID=654&&PageID=16758&mode=2).
• Publication and dissemination of a report and two associated journal articles on health IT functionality to support proactive, prevention-focused primary care.
• AHRQ co-funded the very timely and widely cited, "Stimulating Health IT" edition of Health Affairs (March/April 2009), which detailed the most up to date research and commentary on health IT just as the ARRA was passed. It has subsequently been an invaluable resource for those responsible for implementing and overseeing the health IT provisions of ARRA. AHRQ staff and AHRQ-funded researchers contributed much of the content of the issue through selection by peer review. (http://content.healthaffairs.org/content/vol28/issue2/index.dtl).
• AHRQ conducted groundbreaking consumer focus groups across the Nation to better understand individuals' perspectives and needs about their health information. This information is sorely needed to understand how the nation can best use health IT to improve health care quality for individuals.

Overall Performance Goals and Measures

The Health IT program at AHRQ set several ambitious performance measures in 2004, and has seen steady progress on all of the measures. (Please go to AHRQ's Online Performance Appendix (available at http://www.ahrq.gov/about/cj2011/cj11opa.htm) for measures the portfolio will be retiring in FY 2011.)The changing health IT landscape defined by the HITECH provisions of the Recovery Act and changing research needs of its customers require that the program evaluate its measurement strategy, retire measures that no longer make sense, and adopt new measures in support of these broader initiatives. As a result, the program has retired its historical performance measures and embarked on efforts to define appropriate measures and data sources. The program has established a project with experts in the field of performance measurement to develop a logic model and associated measures. In addition, the program has extended a project, begun in 2007, to identify data sources for potential performance measures and initiated a strategic planning process to refine its mission and goals to align with the goals of the agency and broader national health IT initiatives.

Program Assessments

The Health IT portfolio underwent a program assessment in 2008. As a result of the program assessment, the Health IT program has embarked on a plan to address issues raised by the assessment. Some recent key improvement activities include the development of efficiency and long-term outcome measures, gaining feedback on how to improve its Web site by conducting focus groups of program stakeholders and summarizing the results, developing multiple "how-to guides" for the NRC Web site (www.healthit.ahrq.gov), and developing and posting its first ever publicly available report on the aggregate and individual performance of its grantees and other funded projects. (http://healthit.ahrq.gov/portal/server.pt?open=512&objID=654&&PageID=16758&mode=2).

The program has also begun to collect data on its two new performance measures. Delays in the availability of FY2007 NAMCS data and identification of inconsistencies within the data set have slowed the program's ability to establish targets and baseline its long-term outcome measure associated with the use of clinical decision support and improved adherence to anti-platelet therapy. The program received a preliminary analysis of 2007 NAMCS data on 9/30/09 that revealed irregularities in the data set (e.g. 16% of practices reporting that they did not have an EMR reported having notes capability in their EMR). In addition, analysis of 2005, 2006 and 2007 NAMCS data for trending reveals that values vary widely depending upon the parameters of data run specifications (e.g. weighting, inclusion / exclusion factors, etc.). The program is working to resolve the data issues.

The program is using the experience gained from developing its first ever Annual Report of Portfolio Funded Projects to inform establishment of a baseline for its approved efficiency measure associated with the per grantee cost of developing and posting grantee performance summary reports on the NRC. The program has provided guidance of $6,023 per grantee as a baseline for this measure and will work to establish an actual baseline. In addition, the program has released a task through the NRC for 2010 to develop an Annual Report of Portfolio Funded Projects for calendar year 2009.

Performance Trends: The Health IT portfolio at AHRQ set several ambitious performance measures in 2004, and has seen steady progress on all of the measures. Please see AHRQ's Online Performance Appendix (available at http://www.ahrq.gov/about/cj2011/cj11opa.htm) for measures the portfolio will be retiring in FY 2011. The changing health IT landscape defined by the HITECH provisions of ARRA and changing research needs of its customers requires that the program evaluate its measurement strategy, retire measures that no longer make sense, and adopt new measures in support of these broader initiatives. As a result, the program has retired its historical performance measures and embarked on efforts to define appropriate measures and data sources. The program has established a project with experts in the field of performance measurement to develop a logic model and associated measures. In addition, the program has extended a project, begun in 2007, to identify data sources for potential performance measures.

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