Performance Detail

Performance Budget Submission for Congressional Justification

This statement summarizes budget information submitted to Congress by the Agency for Healthcare Research and Quality (AHRQ).

Performance Detail

Detail of Performance Analysis (Tables)

Given the uncertainty of final FY 2007 appropriation levels at the time the Agency for Healthcare Research and Quality (AHRQ) developed the performance targets for the FY 2008 Congressional Justification, the FY 2007 targets were not modified to reflect differences between the President's Budget and the Continuing Resolution funding levels. Enacted funding may require modifications of the FY 2007 performance targets. Performance measures that may be affected significantly are footnoted throughout the Performance Detail section.

Quality/Safety of Patient Care

Long-term Goal: By 2010, prevent, mitigate and decrease the number of medical errors, patient safety risks and hazards, and quality gaps associated with health care and their harmful impact on patients.

MeasureFYTargetResult
Identify the Threats

By 2010, patient safety event reporting will be standard practice in 90% of hospitals nationwide.

Outcome
2008Identify emerging patient safety threats through analysis of data submitted by Patient Safety Organizations (PSOs) to Network of Patient Safety Databases (NPSD).Dec-08
Monitor/report on changes in patient safety/quality through continued production/use of National Healthcare Quality Report (NHQR), National Healthcare Disparities Report (NHDR), and Patient Safety Indicators (PSIs)Dec-08
Conduct 5 or more ambulatory care patient safety risk assessmentsDec-08
Identify broad-based organizational issues compromising patient safety through analysis of Survey on Patient Safety (SOPS) benchmarking data (e.g., ambulatory, acute, long-term care)Dec-08
2007Initiate NPSD to identify emerging patient safety threatsDec-07
 Continue use of NHQR, NHDR, PSIs to monitor and report on changes in patient safety/qualityDec-07
2006Use NHQR, NHDR, PSIs to monitor changes in patient safety/quality2006 NHQR
2006 NHDR
2005Continue support for data standards and taxonomy development for improved patient safety event reporting, data integration/usabilityData standards development is on-going:
Supported National Quality Forum (NQF) taxonomy consensus building. Taxonomy approved 2005
 Redesign Patient Safety Incident Report System (PSIRS) database system to produce NPSD which includes data specifications, standardized taxonomyDec-06
 2004Develop a data warehouse and vocabulary server to process patient safety event dataCompleted
2003Develop reporting mechanism and data structure through the National Patient Safety NetworkCompleted
Educate, Disseminate, and Implement to Enhance Patient Safety/Quality

By 2010, successfully deploy practices such that medical errors are reduced nationwide.

Outcome
2008Conclude evaluation of simulation tools/technology and their impact on patient safetyDec-08
Analyze NPSD data to identify reported successful interventions resulting in improved patient safetyDec-08
Develop and deploy patient safety and quality measures in ambulatory care and across high-risk transitions in careDec-08
Evaluate and improve the safe delivery of care during transitions to and from ambulatory care and in provider-patient communications in ambulatory careDec-08
200750 participants in the Patient Safety Improvement Corps (PSIC) train-the-trainer program will initiate local patient safety training activitiesDec-07
Hold annual patient safety/healthcare information technology conferenceDec-07
2006Implement and evaluate best practice use of NHQR-DR Asthma Quality Improvement Resource Guide and Workbook for State Leaders in 2 to 5 statesDec-06
Michigan
Arizona
New Jersey
20055 health care organizations/units of state/local governments will evaluate the impact of their patient safety best practices interventions.Completed:
17 grant awards made for implementing patient safety improvement practices
2005Implement and evaluate best practice use of NHQR-DR Diabetes Quality Improvement Resource Guide and Workbook for State Leaders in 2-5 states.Completed:
Diabetes workbook has been developed and 2 states (Delaware and Vermont) are engaged in using it and setting an action agenda
 20046 health facilities or regional initiatives to implement interventions and service models on patient safety improvement will be in placeCompleted
2003Awards to be made to at least 6 facilities or initiativesCompleted
6 awards made
Educate, Disseminate, and Implement to Enhance Patient Safety/Quality

By 2010, successfully deploy practices such that medical errors are reduced nationwide.

Outcome
2008Disseminate findings of evaluation of simulation tools/technology's impact on patient safetyDec-08
Issue alerts of findings from analysis of the NPSD as needed.Dec-08
Disseminate interventions used to improve patient safety as reported to the NPSDDec-08
Train (through the 4th PSIC program) representatives from at least 15 major or critical access health care organizations/QIOsDec-08
Complete patient safety improvement projects (done by at least 60 members of the current PSIC program)Dec-08
Conduct local patient safety training (done by at least 50 members of previous/current PSIC program)Dec-08
Hold annual patient safety/healthcare information technology conferenceDec-08
200750 participants in the PSIC train-the-trainer program will initiate local patient safety training activitiesDec-07
Hold annual patient safety/healthcare information technology conferenceDec-07
200615 additional states/major health care systems will have on-site patient safety experts trained through the PSIC programCompleted:
16 States and 19 hospitals/health care systems participated in the PSIC
200515 additional states/major health care systems will have on-site patient safety experts trained through the PSIC programCompleted:
19 States and 35 hospitals/health care systems participated in the PSIC
200410 states/major health care systems will have on-site patient safety experts trained through the PSIC programCompleted:
15 states
13 hospitals-health care systems
5 health care organizations or units of state/local government will implement evidence-based proven safe practicesCompleted:
7 organizations received grants to implement evidence-based safe practices
Develop 4 NHQR-DR Knowledge Packs on Quality for priority populations and care settingsCompleted:
Knowledge Packs were replaced by reports on gender, children, and inpatient care
Conduct annual patient safety conference transferring research findings, products, and tools to usersCompleted:
Annual Patient Safety conference held
Sep. 26-28, 2004
2003Established PSIC training program.Completed
Award to 5 health care organizations or units of state/local government grants to implement evidence-based proven safety practicesCompleted
Maintain vigilance

By 2010, deploy and use measures of safety and quality for improvement in various care settings

Outcome
2008Maintain and use NPSD, NHQR, NHDR, and PSIs to monitor changes in patient/safety qualityDec-08
Use SOPS benchmarking database to monitor organizational culture's impact on patient safetyDec-08
Use NPSD to monitor patient safetyDec-08
2007Initiate NPSDDec-07
Deliver fifth NHQR-DRDec-07
Use NPSD, NHQR, NHDR, PSIs to monitor changes in patient/safety qualityDec-07
2006Deliver fourth NHQR-DR and continue use of NHQR, NHDR, PSIs to monitor changes in patient safety/qualityCompleted
4th Annual NHQR/DR
2005Develop measures of patient safety culture (ambulatory and longer term care)Dec-06
Contract award in FY 2005
2004Develop measures of patient safety culture (hospital-based)Completed
2003N/A1N/A1
Cost reductions associated with reductions in hospitalizations with infections due to medical care.

Efficiency measure

Baseline: 2003—$4,437.28 per capita
20082% reductionSep-11
20072% reductionSep-10
20062% reductionSep-09
2005N/A2N/A2
2004N/A2N/A2
2003Baseline$4,437.28 per capita

Data Source: Patient Safety Resource Coordinating Center (PSRCC) databases; NHQR/DR database.

Data Validation: Spreadsheets are created and maintained for accepted applications to the program.

Cross Reference: SG-1/5; HP2010-1/17/23; 500-Day Plan—Transform the Healthcare System.

1. New measure beginning FY 2004 for PARTed program
2. New efficiency measure—FY 2006

The long-term goal is to improve quality and safety by preventing, mitigating, and decreasing the number of quality gaps, errors, risks, and hazards associated with healthcare by 2010. With passage of the Patient Safety and Quality Improvement Act of 2005, the capacity to identify and monitor threats to patient safety and to identify interventions that prevent or mitigate medical errors and patient harm is greatly increased.

The Act and its resulting data supplement ongoing efforts reflected in the NHQR/DR reports where quality and safety are monitored annually on a national basis. The new databases resulting from the Act informs and helps target the research agenda used to create new knowledge about medical error, identify the need for specific interventions, support their development and testing, and disseminate the knowledge and those interventions deemed effective in improving patient safety.

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Health Information Technology

Long-term Goal: Most Americans will have access to and utilize a Personal Electronic Health Record by 2014.

MeasureFYTargetResult
By 2012, increase the number of ambulatory clinicians using electronic prescribing to over 50%.1

Baseline 2006: 12%

—Hospitals using Computerized Physician Order Entry (CPOE) by 10%. (Retired measure that has exceeded its target.)

Outcome
2008Increase to 20%Dec-08
2007Increase to 15%Dec-07
2006Provider utilization of CPOE increased to 15%Completed: 21.9% of physician practices use e-prescribing2
200510% of hospitals using CPOECompleted:
25% increase in the utilization of CPOE systems3
10% of providers using CPOECompleted:
14% of all medical group practices utilize a CPOE3
2004N/A3N/A4
2003N/A3N/A4
By 2008, in hospitals funded for CPOE, maintain a lowered medication error rate.

Outcome
2008Decrease preventable ADE's by 15%Dec-08
2007Decrease preventable Adverse Drug Events (ADEs) by 10%Dec-07
2006Increase rate of detection by 75%Duke hospital implementation completed early; extending work to ambulatory clinics.
Funded eRx pilot at Brigham & Women's which focuses on ambulatory ADEs
2005Increase the rate of detection by 50%Funded implementation study
2004N/A4N/A4
2003N/A4N/A4
By 2014, most Americans will have access to and utilize a Personal Electronic Health Record (PHR).

Outcome
2008AHRQ will develop a tool to assess consumer perspectives on the use of personal electronic health recordsDec-08
2007AHRQ will partner with one major Department of Health & Human Services (HHS) Operating Division to expand the capabilities of the Electronic Health Record (EHR)Dec-07
2006AHRQ will partner with one major HHS Operating Division to expand the capabilities of the Electronic Health RecordCompleted: American Health Information Community (AHIC) Workgroup May 2006 recommendation to partner with Centers for Medicare & Medicaid Services (CMS) on PHR technology
The core capabilities and function of the Personal Health Record will be delineatedCompleted: AHIC Consumer Empowerment Workgroup 2006
2005Complete at least two phased EHR improvements that could facilitate transferability to other public/private providers

Completed:
Phased improvement of Indian Health Service (HIS) EHR.
Discussions with the Indian Health Service (IHS) and National Aeronautics and Space Administration (NASA) Health Information Technology (IT)

Summit; FY 2006 Grant program regarding the utilization of PHR by patients and providersCompleted:
Summit held in partnership with the Markle Foundation and the Robert Wood Johnson Foundation
2004N/A4N/A4
2003N/A4N/A4
By 2006, Engineered Clinical Knowledge will be routinely available to users of EHRs.

Output
2008AHRQ will develop a tool to assess consumer perspectives on the use of personal electronic health recordsDec-08
2007Standards development organizations will be in the early development of tools enabling engineered clinical knowledge transferDec-07
2006Standards development and adoption with regard to Engineered Clinical Knowledge will be underway.Initiated standards development and adoption
2005Convene at least one National summit exploring public private partnerships with regard to Clinical Knowledge Engineering; Proceedings will be widely disseminated to affected stakeholders

Completed:
Expert meeting convened with National Coordinator for Health IT and American Medical Informatics Association (AMIA)

2004N/A4N/A4
2003N/A4N/A4

Data Source: Hospital CPOE usage as documented by the annual Healthcare Information and Management Systems Society (HIMSS) survey; Detection of ADEs noted in recent published articles (JAMA, Archives of Internal Medicine); Medical Group Management Association (MGMA) survey of health IT uptake in physician offices; Leapfrog annual survey; Center for Studying Health System Change (HSC), Community Tracking Study (CTS).

Data Validation: Data obtained regarding ADE detection published in peer reviewed journals. HIMSS data verified by other smaller efforts. E-prescribing data validated by other surveys.

Cross Reference: SG-1/5; HP2010-11/23; 500-Day Plan—Transform the Healthcare System.

1. Modified e-prescribing measure reflecting current Health IT research that supports AHRQ's ambulatory care efforts.
2. Data obtained from 2005 KLAS Enterprises survey.
3. Gans, David, Kralewski, John, et al. Medical Groups' Adoption of Electronic Health Records and Information Systems. Health Affairs 24:5 September/October 2005.
4. New measure—FY 2005.

Achieving AHRQ's long-term Health IT goal—assuring most Americans access to and utilization of personal electronic health records by 2014—will require evidence-based information and the cooperation of both public and private stakeholders. Core elements including health IT planning and implementation challenges, potential improvements in care, financial impact, privacy and security issues and essential EHR/PHR capabilities are currently being explored and better defined by the AHRQ Health IT portfolio.

Health information technologies such as CPOE and EHR have been shown to improve the delivery and quality of care. AHRQ's projects continue to demonstrate and monitor the benefits of health IT adoption. AHRQ research builds the evidence base for the technologies that are most effective, and the impact health IT has on quality and patient outcomes. For example, AHRQ's current projects show that computerized decision support improves physician adherence to high quality clinical practice guidelines, and are collecting data to demonstrate how this improves population health in the long term.

Many current cost-benefit models of health IT rely on expert opinion and simulation models. AHRQ's projects are generating real-world data to test quality and financial assumptions. A solid evidence base for health IT informs practitioners about which technologies to choose, how best to implement them, how well they work, and how the technologies should develop. Additional projects are investigating other critical issues such as privacy and security of health data, workflow implementation challenges and the impact of electronic prescribing.

AHRQ has funded more that 100 research, demonstration and implementation projects that address the specific challenges facing the myriad of stakeholders either actively utilizing or contemplating health IT activities. Many of these projects will be nearing completion by 2007 with interim results and lessons learned being harvested and disseminated broadly by AHRQ's National Resource Center for Health IT. Specifics include:

CPOE Utilization and Impact:

Proper CPOE implementation and utilization has been shown to reduce errors and improve the quality of care in a variety of health care settings. AHRQ's work to date has developed the evidence base critical to the increased utilization of CPOE by providers. Until recently a majority of CPOE related information came from a small number of institutions. This highly selective process left gaps in the knowledge base. Current AHRQ CPOE projects are changing that by expanding the makeup of participating institutions, e.g., East Huron Hospitals' predominately African American population. AHRQ grantees are exploring all phases of CPOE integration including planning, implementation and post-implementation evaluation. Projects can be found in a variety of settings including small community, rural and urban environments. Building on these robust experiential base future efforts will explore the specific impact CPOE has on patient care and safety with an initial effort aimed at the detection and mitigation of preventable adverse drug events.

Personal Electronic Health Record

The EHR and PHR are significant and important tools to improve the quality, safety and efficiency of care. Both offer providers and patients a powerful mechanism to understand and manage increasingly complex and disparate medical information. The administration has made access to personal electronic health records a key component to improving care. However, before this goal can become reality, a number of challenges and barriers must be overcome. AHRQ projects and programs are presently informing both public and private stakeholders regarding successful strategies to overcome these obstacles.

The Agency's Transforming Healthcare Quality through IT (THQIT) grant program, located in 38 states, encompasses a wide variety of EHR and PHR projects and demonstration programs. THQIT seeks to better understand the intersection between health IT, improvements in quality, safety and efficiency. Knowledge and a greater understanding of EHR implementation and impact are constantly being harvested from the grants.

Without effective means of exchanging information between personal electronic health records, even the best systems will remain digital silos of information. AHRQ is funding on-the-ground implementation of regional and state level health information exchanges, both through grants and contracts. As an example, the AHRQ-funded Utah Health Information Network is expanding their claims infrastructure to exchange clinical and public health information, covering 97 percent of the healthcare providers in Utah. These high-value projects will continue to inform the Federal Government as it moves toward interoperable personal electronic health records.

In 2005 AHRQ co-sponsored a national summit to discuss and explore the PHR core capabilities, as well as the challenges and benefits facing increased uptake and utilization. The summit demonstrably moved the field forward, creating momentum among a wide variety of stakeholders. In FY 2006 and FY 2007 the Agency will move these efforts forward by increasing our understanding of the core elements of PHR needed to improve the quality, safety and efficiency of care.

In addition the Agency has been a critical partner to the Indian Health Service in the enhancement and deployment of the IHS Resource and Patient Management System (RPMS) electronic health record. The ability of the IHS clinical reporting system to report and improve at the point of care was recently recognized by the Public Health Davies Award.

AHRQ has also been in partnership with the Nation's Community Health Centers (CHC) and rural hospitals/clinics through technical assistance and program support. The AHRQ National Resource Center for Health IT recently opened up a knowledge portal to the CHC's and rural partners. A CHC specific portal is being developed in collaboration between AHRQ and the Health Resources and Services Administration (HRSA).

Most recently, AHRQ has been an active participant in the American Health Information Community, convened by Secretary Mike Leavitt. As a result, our staff on the AHIC workgroups has helped establish short-term goals for healthcare improvement using health IT. We have also been tasked by the Secretary with achieving some of these goals, in particular relating to the personal health record.

Clinical Decision Support & Engineered Clinical Knowledge

Health IT applications are highly dependent on accurate, relevant and usable clinical decision support (CDS) technologies to impact and improve care. Many personal and electronic health records include a CDS component. However, in both ambulatory and hospital settings provider experience with CDS has been uneven. AHRQ has long history of improving the clinical knowledge base that forms the infrastructure for CDS. In recent years, government, academic and industry leaders have become increasingly interested in the concept of improving CDS systems and standardized development of engineered clinical knowledge. AHRQ grantees are currently exploring the challenges with CDS integration and its impact on clinical outcomes. As an example, AHRQ is working with the Florida Initiative for Children's Healthcare Quality and the National Institutes of Health (NIH) to develop an improved process for the development of clinical guidelines which will directly enhance CDS.

E-prescribing is an immediate opportunity to impact the safety, efficiency and quality of healthcare. AHRQ has sponsored ground-breaking research through its Clinical Informatics to Promote Patient Safety (CLIPS) grants and other programs, and with CMS is currently conducting standards testing as required by the Medicare Modernization Act of 2003. The Agency is prepared to leverage its research and implementation infrastructure and experience to advance this opportunity.

Additional efforts are needed to fully appreciate the issues including a better understanding of the barriers at both the provider and industry level, further definition of the CDS engineered clinical knowledge requirements and fostering a collaborative developmental environment.

AHRQ is making progress towards accomplishing this challenge. In 2005 an expert meeting was convened (in cooperation with the Office of the National Coordinator for Health Information Technology [ONC] and AMIA) to better understand and define core CDS requirements. We are presently partnering with the Florida Initiative for Children's Healthcare Quality (FLICHQ) and the National Heart Lung and Blood Institute (NHLBI) to improve the utility of the NIH Asthma Care Guideline, and plan on convening expert meetings with AHRQ's Center for Outcomes and Evidence to consider improvements in guideline creation and synthesis. In FY 2007, the Agency will continue this work through further development of engineered clinical knowledge and improved integration into EHR and CDS workflow.

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Current as of February 2007
Internet Citation: Performance Detail: Performance Budget Submission for Congressional Justification. February 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/cpi/about/mission/budget/2008/perf08.html