AHRQ Annual Highlights, 2010 (continued)

Health Information Technology Portfolio

AHRQ's Health Information Technology (Health IT) initiative is part of the Nation's efforts to put information technology to work in health care. Since its inception in 2004, the Health IT Portfolio has supported projects that develop and disseminate evidence and evidence-based tools about health IT's impact on the quality, safety, efficiency, and effectiveness of health care in three main strategic focus areas:

• To improve health care decisionmaking.
• To improve the quality and safety of medication management.
• To support patient-centered care, the coordination of care across transitions, and the use of electronic exchange of health information.

AHRQ has invested over $300 million in contracts and grants to over 200 communities, hospitals, providers, and health care systems in 48 States to promote access to and encourage the adoption of health IT. These projects constitute a real-world laboratory for examining health IT at work and aim to achieve the following:

• Help clinicians provide higher quality, safer health care.
• Put the patient at the center of health care.
• Stimulate the implementation of health IT, especially in rural and underserved areas.
• Identify the most successful approaches and barriers to health IT implementation.
• Make the business case for health IT by evaluating costs and benefits.

In FY10, the AHRQ Health IT Portfolio published new reports on the development, challenges, and implementation of health IT systems, and released several new products including the Health IT Evaluation Measures: Quick Reference Guides, the Health IT Survey Compendium, and the HIE Evaluation Toolkit. The Health IT Portfolio team works closely with the Office of the National Coordinator for Health IT through the Health IT Resource Center, an online resource focused on disseminating practical approaches to clinicians, patients and communities. In addition, the Health IT Portfolio created a new Patient Centered Medical Home Web site as a part of its focus on using health IT to deliver patient-centered care.

Improving Health Care Decisionmaking, Medication Management, and Patient-Centered Care

The AHRQ Health IT Portfolio published several new reports on the development, challenges, and implementation of health IT systems and released several new products.

In support of its focus areas on improving health care decisionmaking, medication management, and patient-centered care, the Health IT Portfolio produced the following publications:

• Impact of Consumer Health Informatics (CHI) Applications Evidence-based Practice Center Report reviews the literature on the evidence of the impact of currently developed CHI applications on health and health care process outcomes to identify the gaps in the literature and to recommend future research endeavors to better assess these IT applications. CHI applications are defined as any electronic tool, technology, or system that is primarily designed to interact with health information users or consumers and may be used with a health care professional, but is not dependent on a health care professional.
• Industrial and Systems Engineering and Health Care: Critical Areas of Research explores the critical areas of research at the intersection of industrial and systems engineering (ISyE) and health care, with a special emphasis on the supportive role of health IT. Investing in ISyE research may help in creating a fundamentally better health care delivery system. The report provides a vision of the new health system and a detailed research and action agenda.
• Incorporating Health IT Into Workflow Redesign: Request for Information Summary Report synthesizes comments submitted in response to a request for information (RFI) regarding developed methods and tools or initiatives for ambulatory workflow analysis and redesign and how health IT could support workflow redesign. Relevant RFI responses will be incorporated into a toolkit that health care organizations and decisionmakers can use to assess their workflows and determine when and how health IT may be used.
• Practice-Based Population Health (PBPH): Information Technology to Support Transformation to Proactive Primary Care describes the concept of PBPH-an approach to care that uses information on a group ("population") of patients within a primary care practice or group of practices ("practice-based") to improve the care and clinical outcomes of patients within that practice-and the information management functionalities that may help primary care practices to move forward with this type of proactive management.
• Transforming Health Care Quality Through Information Technology (THQIT): Systematic Review of Peer-Reviewed Publications From the THQIT Value Grantees analyzes the peer-reviewed publications of 24 THQIT research projects, finding commonalities in process and outcomes, and presenting new knowledge about the real outcomes of health IT across diverse health care environments. It also describes the other avenues that grantees used to disseminate their findings.
• Challenges and Barriers to Clinical Decision Support (CDS) Implementation examines the challenges and barriers to implementing CDS and found workflow, design, and clinician's level of support are just some of the issues that can affect successful CDS implementation. The report describes the challenges and barriers that AHRQ contractors encountered as part of their CDS demonstration project, which can be successfully addressed by employing several key strategies such as utilizing standard data exchange formats, providing clinicians with appropriate training, and modifying CDS to address clinicians' needs.
• Electronic Health Record Usability: Vendor Practices and Perspectives provides insight into the current processes, practices, and perspectives of certified electronic health record (EHR) vendors with regard to key aspects of the usability of their products including the existence and use of standards and "best practices" in designing, developing, and deploying products; testing and evaluating usability throughout the product life cycle; supporting postdeployment monitoring to ensure patient safety and effective use; and the role of certification in evaluating and improving usability.
• Electronic Health Record Usability: Evaluation and Use Case Framework synthesizes the literature and best practices regarding the usability of EHRs, and it provides a set of use cases to evaluate information design in primary care IT systems.
• Electronic Health Record Usability: Interface Design Considerations provides recommended actions to support the development of an objective EHR usability evidence base and formative policies to systematically improve the usability of EHR systems.
• Managing Personal Health Information: An Action Agenda presents key recommendations and an action agenda developed during a 2-day workshop convened by AHRQ, entitled "Building Bridges: Consumer Needs and the Design of Health Information Technology." As a result of the workshop, the participants developed a framework for studying personal health information management and patient-centered health IT to advance research, implementation, and policy development.

Medicaid/CHIP Technical Assistance

AHRQ is providing technical assistance (TA) to Medicaid and Children's Health Insurance Program (CHIP) agencies to help them develop, implement, and participate in health IT and health information exchange (HIE). During FY10, this assistance included case studies designed to support dissemination of information and best practices in health IT and HIE for Medicaid and CHIP agencies to agency personnel, policymakers, and stakeholders. The case studies provide Medicaid and CHIP agency staff with detailed information about peer agency projects in health IT and HIE. The TA program also includes a needs assessment to determine the types of technical assistance that will be offered in subsequent years, a repository of information to support the technical assistance and disseminate best practices, and Webinars along with other Web-based and in-person workshops.

Patient-Centered Medical Home Web Site

In FY10, the Health IT Portfolio launched a new Patient-Centered Medical Home (PCMH) Web site. The PCMH is a promising model for transforming the organization and delivery of primary care. Health IT plays a central role in successfully operationalizing and implementing the key features of the medical home. This Web site provides policymakers and researchers with access to evidence-based resources about the medical home and its potential to transform primary care and improve the quality, safety, efficiency, and effectiveness of U.S. health care. The Web site can be viewed at http://www.pcmh.ahrq.gov.

National Resource Center for Health Information Technology

As part of its health IT initiative, AHRQ created the National Resource Center for Health Information Technology (NRC), which supports the Agency's mission of developing and disseminating evidence and evidence-based tools on how health IT can improve health care quality, safety, and efficiency. AHRQ initially established the NRC for health IT in 2004 as a way of communicating and delivering technical assistance to its grantees. Since then, AHRQ has made the NRC available as a public resource for sharing research findings, best practices, lessons learned, and funding opportunities with health IT researchers, implementers, and policymakers. More than 10,000 documents, presentations, articles, and tools are freely available on the NRC. Traffic on the NRC has steadily grown since its inception, with recent usage averaging more than 40,000 unique site visits per month.

In FY10, the Health IT Portfolio, through its NRC, added, updated, or continued support for a key set of products focused on applying lessons learned from AHRQ research activities to improve the successful adoption, evaluation, and meaningful use of health IT and HIE activities. These products include:

• Health IT Evaluation Measures: Quick Reference Guides provide details about individual measures that can be incorporated into a health IT evaluation plan. Eleven guides were developed based on the literature and each guide includes a brief description of the measure, summary of current literature on the measure, measurement methodology, and study design and analysis considerations. The guides provide a starting point for evaluators in the development of an evaluation plan for a given measure.
• Health IT Survey Compendium is a searchable resource containing a set of publicly available surveys to assist organizations in evaluating health IT. The surveys in the compendium cover a broad spectrum, including user satisfaction, usability, technology use, product functionality, and the impact of health IT on safety, quality, and efficiency.
• HIE Evaluation Toolkit provides guidance on how to evaluate health information exchange. Example measures are provided along with suggested data sources and the relative costs to collect those measures. This Toolkit was enhanced in April 2010.
• Issue Papers: Findings from the AHRQ Health IT Portfolio are a series of reports on various topics that comprehensively record and disseminate lessons learned from the health IT grantees.
  • Implementation of Health IT in Long-Term Care Settings summarizes the key challenges noted, solutions identified, and lessons learned by AHRQ-funded projects implementing health IT in long-term care (LTC) settings. The report is an examination of the project work that AHRQ has funded thus far in the LTC field, developed within the Agency's continued research interests in the care and support of persons with chronic or disabling conditions.
  • Medication Adherence profiles the different approaches grantees have used to calculate medication adherence and the data sources that are being used by the projects.
  • Medication Reconciliation examines how AHRQ-funded projects have implemented and evaluated medication reconciliation processes to help reduce medical errors and adverse drug reactions.
  • Health Information Technology and Health Information Exchange Implementation in Rural and Underserved Areas focuses on the challenges facing rural and underserved communities in integrating health IT into their health care delivery systems.

The AHRQ Health IT Portfolio held six national teleconferences during fiscal year 2010. A listing of those teleconferences is below. Additional materials from these national teleconferences, such as PowerPoint slides and transcripts can be found on our AHRQ Health IT Events page.

• Managing Patient Care Transitions: How Health IT Can Reduce Unnecessary Re-Hospitalization, February 24, 2010.
• Leveraging Health Information Technology for Patient Empowerment, April 8, 2010.
• Building and Maintaining a Sustainable Health Information Exchange (HIE): Experience from Diverse Care Settings, May 14, 2010.
• Impact of Health IT on Quality Assessment: Innovations in Measurement and Reporting, June 23, 2010.
• Using Health IT to Prevent Adverse Events, July 13, 2010.
• Health IT Adoption in Rural Clinical Settings, August 27, 2010.

In addition, the following technical assistance Webinars and meetings were held with grantees:

• Successful Dissemination Strategies: A Practical Approach to Effective Dissemination of Research Findings—January 2010

  With the ever-increasing emphasis on putting research into practice, AHRQ is interested in finding effective ways for stakeholders to learn about research in progress and rapidly become aware of new knowledge related to the use of health IT to improve quality. During this Webinar, experts provided grantees with guidance on effective dissemination techniques, submitting peer-reviewed manuscripts, working with AHRQ's Office of Communication and Knowledge Transfer and final report guidance.

• Institutional Review Boards: Challenges and Best Practices—January 2010

  A critical milestone for many health IT-focused research projects is approval of the research protocol by an IRB. This Webinar addressed several key considerations related to working with IRBs, including (1) different policies, procedures, infrastructure, and models (e-IRB versus in-person) that reside within different institutional and community settings, (2) common challenges and issues that may arise during the application and approval process, (3) methods to mitigate challenging issues, and (4) best practices for successful IRB review.

• Patient Recruitment: Challenges, Trends, and Best Practices—April 2010

  Recruiting patients for research studies is an essential component for many AHRQ research grants. Carefully planned design and implementation of sound recruitment and enrollment strategies, as well as follow-through, contribute to the efficiency and success of studies, from initiation to study completion. This meeting offered an opportunity for grantees to learn about possible strategies and approaches to common patient recruitment challenges.

• Roundtable Discussions, AHRQ 2010 Health IT Grantee and Contractor Meeting—June 2010

  The format for the multi-grantee meeting was facilitated roundtable discussions held during the AHRQ 2010 Health IT Grantee and Contractor meeting. The goal of the discussions was to promote peer-to-peer knowledge sharing and networking, and to identify potential issues for future technical assistance events. There were four roundtable discussions covering the following topics: Health IT Implementation, Medication Reconciliation, Provider Engagement, and Quality Reporting.

• Guidance and Recommendations for Ambulatory Safety and Quality (ASQ) Grants Closeout Requirements and Final Reports—July 2010

  HHS policy requires that a grant or cooperative agreement be "closed out" after the project ends. This Webinar was designed to review and discuss the grant closeout requirements, with a special emphasis on the Final Report. More specifically, this meeting focused on delineating the special ASQ reporting requirements that must be addressed by all grantees in receipt of an ASQ grant as well as FOA-specific requirements.

Support for Health Information Technology for Economic and Clinical Health (HITECH) Act

With the enactment of the Recovery Act in 2009, the role of health IT in improving the quality of the Nation's health dramatically changed. AHRQ, in collaboration with the Office of the National Coordinator (ONC) for Health Information Technology, developed the Health Information Technology Research Center (HITRC), part of the Health Information Technology for Economic and Clinical Health (HITECH) Act. A total of $50 million has been made available for this effort, which will involve the award of 13 task orders funded under the Recovery Act. The HITRC will provide a forum for the exchange of knowledge and experience; accelerate the transfer of lessons learned from existing public and private sector initiatives, including those currently receiving Federal financial support; and assemble, analyze, and widely disseminate evidence and experience related to the adoption, implementation, and effective use of health IT that allows for the electronic exchange and the use of information including through the Regional Extension Centers. HITRC, along with the Regional Extension Centers, are referred to as the Health IT Extension Program and form the National Learning Consortium.

Recent Research Findings from the Health IT Portfolio

During FY10, research findings from the Health IT Portfolio included:

• Based on a review of studies on the use of health IT to improve monitoring of prescription drugs in ambulatory care patients, researchers found that passive alerts are likely to have little or no effectiveness and alerts that require physicians to navigate multiple steps also seem likely to fail. Interventions that employ a team of clinical pharmacists are more likely to reduce drug monitoring errors. Examples of errors include the failure to monitor potassium levels among patients receiving potassium supplementation and the failure to monitor liver and thyroid function among patients receiving amiodarone (Pharmacoepidemiology and Drug Safety, December 2009).
• Using bar-code technology with an electronic medication administration record (eMAR) substantially reduces transcription and medication administration errors, as well as potential drug-related adverse events. Researchers compared 6,723 medication administrations on hospital units before bar-code eMAR was introduced with 7,318 medication administrations after bar-code eMAR was introduced. Having bar-code eMAR technologies in place was associated with reductions in errors related to the timing of medications, such as giving a medicine at the wrong time, and non-timing medication administration, such as giving a patient the wrong dose. The researchers documented a 41-percent reduction in non-timing administration errors and a 51-percent reduction in potential drug-related adverse events associated with this type of error. Errors in the timing of medication administration, meaning a patient was given medication an hour or more off schedule, fell by 27 percent. No transcription errors or potential drug-related adverse events related to this type of error occurred (New England Journal of Medicine, May 2010).
• Some EHR systems notify physicians when they deviate from guidelines in the care and treatment of a particular patient and allow them to indicate their reasons for making an exception to recommended practices (quality measures). This study found that in the vast majority of cases, the exceptions made by physicians are considered appropriate. A panel of medical experts reviewed all cases where physicians made an exception to 1 or more of 16 chronic disease and prevention quality measures. Physicians were then provided feedback regarding their exception decision and allowed to change their management of the patient. The expert panel found that 93.6 percent of 614 exceptions were deemed medically appropriate. Only 3.1 percent were considered inappropriate. After receiving feedback on their exception decisions, physicians changed the way they managed the patient in 42 percent of these cases (8 out of 19) (Annals of Internal Medicine, February 2010).

Health IT Implementation Stories

AHRQ-funded health IT projects are helping to revolutionize everyday clinical practice. Following are some stories and lessons learned from some of these pioneering projects.

Rural Hospitals Get Health IT Boost

To help rural hospitals across the United States make more informed investments in technology, researchers examined barriers to health IT adoption in rural Iowa hospitals as well as rural hospitals' health IT capacity, barriers to using technology, the costs of such technology for rural hospitals and which technologies were most strongly linked to better care for patients. Researchers then identified which technologies could have the greatest applicability for these hospitals, especially in the State's critical access hospitals (CAHs). They found several roadblocks to IT adoption in rural hospitals. These included high costs related to infrastructure and software, technology that was not ready for a hospital environment, and a lack of reimbursement for the use of technology. As part of their effort to better understand these barriers, researchers formed the Iowa CAH Health IT Interest Group. The group met several times a year over a 3-year period and gathered input from the CAH Health IT Interest Group. They created Web-based tools to provide hospitals with information that would help them make better health IT investments.

Project Seeks To Cure What Ails Electronic Health Records

Many EHRs are limited in their ability to provide physician performance feedback on quality. The Partners Healthcare System, along with researchers at Brigham and Women's Hospital and Harvard Medical School, are examining whether information technology tools that provide both clinical-decision support and population-based performance feedback will increase the value of EHRs to clinicians while improving patient safety and quality for patients with acute respiratory illness or coronary artery disease. To make their EHRs more useful, researchers began implementing "smart forms" and "quality dashboards" at clinical practices in the Boston area affiliated with Massachusetts General Hospital and Brigham and Women's Hospital. Smart forms help physicians to document relevant clinical information and integrate best practice information and ordering capabilities into care. The quality dashboard, which works hand-in-hand with the smart forms, is a system that provides feedback to physicians on their patient population and gives them the ability to see how they are performing on certain measures of quality. The physician can drill down from the population view and see individual information on patients through the smart forms. Currently, the dashboard and smart form for acute respiratory patients has been introduced to about 1,000 doctors in 10 practices. The coronary artery disease/diabetes smart form is being rolled out to a similar number of practices, while the dashboard for coronary artery disease is being pilot tested in 2 practices to 20 physicians.

AHRQ's Health IT Portfolio maintains a database of its new, current, and completed projects, as well as its initiatives, reports, tools, and products, at its Web site .

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