Morning Session 1 - Transcript

National Advisory Council, July 13, 2012

Transcript from Morning Session 1

Agency for Healthcare Research and Quality
National Advisory Council (NAC) Meeting
Friday, July 13, 2012
Director’s Update

BRUCE SIEGEL: Good morning, everybody. And welcome to the AHRQ National Advisory Council Meeting. It is a thrill to have you all here and our members of the public as well as those who are joining us on the Webcast or who are otherwise visiting with us this morning. I want to mention that this is the first meeting for Dr. Henry Ng. So, welcome. It’s great to have you here. I’m thrilled to have you with us.

A couple of issues just on housekeeping. If you need transportation after the meeting, please sign up at the registration desk behind me out in the foyer by the end of lunch. Also note that during the lunch break we’re changing the process slightly. We are going to more of a market model here and Cozy will be selling sandwiches and salad in the reception area. Think of it as sort of an exchange. And it is purely voluntary, by the way.

We ask that the meeting attendees allow for the NAC members to be able to purchase their lunches first because they have other business to attend to during the lunch hour, which I will talk about a little bit in a minute. Once the Council members have purchased their lunch, Jamie Zimmerman is going to escort all of us up to the third floor for photographs. And then quickly, after the photographs we are going to be taken up to the fifth floor to room 5206 for an executive session that will be closed to members of the public.

If folks want to make a public comment, either at 11:45 or 2:45, folks in our audience, please sign up at the registration desk, also behind me in the foyer. At the point I’d like to go around the table and have everybody introduce themselves for those in the meeting as well as for those who are viewing us on the Web. And I’ll start. My name is Bruce Siegel. I’m the CEO of the National Association of Public Hospitals and Health Systems and I’ll start with Jamie here.

JAMIE ZIMMERMAN: Hi. I’m Jamie Zimmerman, the coordinator for the NAC.

BOYCE GINIECZKI: Boyce Ginieczki., Acting Deputy Director of AHRQ.

MIKE JOHNSON: Mike Johnson, the Division Director of Bayata Home Health Care.

JANE CROWLEY: Jane Crowley, Executive Vice President of Catholic Health Partners.

WELTON O’NEAL: Welton O’Neal, the new Executive Director for the Foundation, for the Academy of Managed Care Pharmacy and also the VP of Pharmacy Affairs.

LOUISE MARIE DEMBREY: Louise Dembrey, Infectious disease physician, Yale University Hospital, epidemiologist, Yale New Haven Hospital.

JEFF THOMPSON: Jeff Thompson, Healthcare Authority, Washington State.

ALAN SPITZER: I’m Alan Spitzer, Sr. Vice President for Research Education and Quality for Mednax, Inc

MITRA BEHROOZI: Mitra Behroozi, the Executive Director of the 1199 SEIU, Health and Pension Funds.

NEWELL MCELWEE: Good morning. I’m Newell McElwee. I’m Executive Director of Outcomes Research at Merck.

CATHERINE SCHNEIDER: Good morning. I’m Catherine Schneider, Chief Medical Office for Med Decision.

DAVID ATKIN: David Atkin, Health Services Research and Development Division of the VA.

JULIA HOMES: Julia Homes from the National Center for Health Statistics.

KATE GOODRICH: Kate Goodrich, Sr. Advisor in the Office of Clinical Affairs and Quality at CMS.

HARRY SELKER: Harry Selker, Dean of Clinical and Translational Science at Tufts University.

HELEN HASKELL: Helen Haskell, President of Mothers Against Medical Error.

DAVID PENSEN: David Pensen, Professor of Urology at Vanderbilt University.

ARDEI DEE HOVEN: Good morning, Ardis Dee Hoven. I’m and infectious disease specialist in Lexington, Kentucky and President Elect of the American Medical Association.

HENRY NG: Good morning. I’m Henry Ng. And I’m and internist and pediatrician at Case Western Reserve School of Medicine. And I am the President Elect of the Gay and Lesbian Medical Association.

JAN WYATT: Good morning. I’m Jan Wyatt, nurse practitioner and part of the Institute of Pediatric Nursing.

CHRIS QUERAM: Hello. I’m Chris Queram with the Wisconsin Collaborative for Healthcare Quality.

CAROLYN CLANCY: Carolyn Clancy, Director of AHRQ.

BRUCE SIEGEL: I believe we have several people on the phone joining us as well, members of the Council. Are you there?


BRUCE SIEGEL: Please introduce yourselves.

SILVIA FERETTI: Silvia Feretti, Dean of the Lake Erie College of Osteopathic Medicine.

BRUCE SIEGEL: Welcome. Is Dr. Casale there?

ANDY MCGUIRE: Andy McGuire is there.

BRUCE SIEGEL: Great, Andy. Thank you.

ANDY MCGUIRE: And I’m President of Meridian Health Plan.

BRUCE SIEGEL: Fantastic. Great to hear you. Is Dr. Paul Casale there? Guess not. I hope he will be joining us later. I’ll just mention for the record that Carolyn Coleman, I think, will be joining us, representing the NIH because Nancy Miller is unable to attend. Dr. Goodrich, thank you for being here and attending in the place of Patrick Conway from CMS and also, Dr. Homes, thank you for being in the place of Sandra Decker from the CDC. We are thrilled to have you here.

As our first order of business, you should have minutes from our April 14th meeting in your folder. Are there any suggested changes or edits to the minute? I assume you have all seen them before. Hearing none is there a motion to approve.

MALE: Motion to approve.


MALE: Second.

BRUCE SIEGEL: Okay. Motion has been made and seconded. All those in favor say aye?

MALE/FEMALE: Aye [Multiple]

BRUCE SIEGEL: Like sign. All right. The minutes are approved. We are going to turn to Carolyn for her Director’s update in a few seconds. One thing I do want to comment on is, as you look through the agenda today there are a number of important items. And some of these items are here at the direct request of some of our Council members. So I thank the agency for being responsive for our thinking on some of these issues. And with that said, I’ll turn to Dr. Clancy.

CAROLYN CLANCY: Well, thanks very much Bruce and good morning everyone. And people on the phone, if you have trouble hearing, would you hit one of the buttons just so that we know?

So, just in terms of updates from members of this Council. Catherine Schneider is now the Executive Vice President and Chief Medical Office for Med Decisions in Philly, a job that she told us is completely different and not at all different at the same time. So that’s very, very recent news. And as Dr. Hoven said, he is the President Elect of the American Medical Association. I’m not sure a day goes by that I’m not seeing some news about Ardes. So, she’s in for a wild ride. But we are going to take credit for a lot of it here, Ardis.

And Welton O’Neal, as he said, has also changed positions, is now the Executive Director of the Academy of Managed Care Pharmacy and the Vice President of Pharmacy Affairs. Do I have that right?

WELTON O’NEAL: That is correct.

CAROLYN CLANCY: So as is customary I’m going to start first with the big picture talking about budget issues at about 10,000 feet. They are much more pleasant up there, I must say. And then talk about some recent accomplishments and then get into a program updates and today’s agenda

So our fiscal year ’12 budget, the year we are in, is shown here. A core allocation of $16.6 million dollars for patient centered outcomes research plus—this is independent of the $24 million allocation from, excuse me, the Patient Centered Outcomes Research Trust Fund. Just under think $16 million for prevention and care management, and there is an additional $12 million dollars that comes from the Prevention and Public Health Fund.

$3.7 for value, $25.6 million for health IT, $65.6 for patient safety research of which $34 million is focused on evidence-based solutions and implementation to reduce healthcare associated infections and $108.4 million for what until very recently we’ve been calling cross cutting. Now these are cross-cutting investments that contribute to many portfolios. And we’ve recognized for some time that actually cross cutting doesn’t have a lot of what you would call market appeal. It’s not instantly sort of attractive or resonant. So we are renaming that research innovations because that is actually the pot from which investigator-initiated research is derived as well as many other kinds of investments. This year $15.9 million dollars in new grants, which is, we’re very, very excited about.

The President’s request for fiscal year 2013 has us getting $10 million dollars for patient-centered outcomes research. So that’s down $6.6 million. The same amount for prevention and care management, a tiny bit less for value, about the same for health IT, a little bit less for patient safety and quite a bit less for this research innovations or cross cutting activity.

So that means that instead of $15.9 million in new grants it would be $2.7. The appropriations committees and the Congress are just beginning to do their work. So the Senate Appropriations Committee actually gave us a very generous mark a few weeks ago. So that was lovely to look at on the screen. The House is getting to work next week. So I’m sure that will be another perspective on where we may end up, although many people expect that it’s unlikely that we will get to a resolution until after the election, until final appropriations. So that’s just a brief backdrop.

So turning to recent accomplishments—I will make just one other comment about the budget. One of the things that we are still learning how to do effectively is how the discretionary appropriated dollars, which is the main portion of our budget is something we know how to do. We know there are, you know, set times for when you communicate about this. So when the budget goes to the Congress every year and it is announced by the President, you know, we’ve got budgets and brief an all that.

Making a similar presentation that is easily accessible, that includes other sources of funding, like the patient centered outcomes trust fund and so forth, is a little bit trickier. The truth is they move on very different timelines. So we may be coming back to you to get some feedback on that challenge.

So April this year, the 2011 National Healthcare Quality and Disparities reports were released. And once again we saw statistically significant improvements in quality of care across all settings and populations. But as some of you have heard me say before, the absolute magnitude of that increase, and this was a better year, is still relatively modest. This year was about 2.5 percent from last year. Obviously, that is not evenly and uniformly distributed. General performance is better for measures of acute care that it is for chronic care or prevention.

Access is—cardiac care has seen some pretty dramatic improvements, reduced hospital admissions for congestive heart failure, fewer heart attack deaths in hospitals and so forth. And access is not improving yet for most minority groups. And we added some new data this year. Now, just to draw out the point about quality improving slowly, the color code here is the black parts of the graph are where things are improving. The blue is where things are staying the same. And that funky kind of green is where things are actually headed in the wrong direction.

So this just gives you a little bit more of a sense across various population groups show on the bottom of this graphic, how we’re doing. And you can see that how we are doing varies with specific groups—probably the least improvement for low income Americans. And few disparities in quality of care are getting smaller. Some, in fact, are actually heading in the other direction.

Now for those of you who really, really love these reports, Dr. Spitzer I would be looking at you because I know you like this kind of data—we have a huge number of metrics in the reports. We use a smaller subset that actually came to us from a subcommittee of this group, of core measures to track. So when I’m giving these percentages it is actually derived from that smaller subset of core measures. But the bottom line is few disparities are showing significant improvement. And the number that are getting smaller actually exceeded the number that were getting larger. So I guess that’s positive news; but a lot of good work to do.

Now the Affordable Care Act actually creates a requirement that the Secretary submit to the Congress every year a national quality strategy, which is kind of a brand new idea—and that it be updated every year. So, what I’m showing you on this slide are the three, very high level, overarching aims: better care; better health, which doesn’t mean that healthcare systems do this alone but that they can be a very powerful, positive force in that direction; and getting to affordability of care through innovations in payment and care delivery and so forth—and then the six priorities.

So we were able to report pretty substantial progress. So in first priority of making care safer, the partnership for patients has quite an astonishing number of hospitals and many, many other stakeholders committed and working together. Indeed, I do believe Dr. Siegel’s team is one of the hospital engagement networks. Do I have the right? So everyone is getting to be part of this. There has been quite a bit of work on the fourth priority here about—via something called the Million Hearts Campaign. And if you haven’t heard about this, I’d actually be shocked because there’s been a huge amount of outreach.

But this is another area where the rate limiting step is not the availability of good evidence. It’s much more about the availability of knowhow and innovation in terms of making sure that that evidence is routinely applied. The most recent data that I have at the top of my brain is that just under half of Americans with high blood pressure are well controlled, which is challenging. That’s all I’m going to say. And I think those of you who have been following the Center for Medicare and Medicaid Innovations at CMS know that they have been rolling out an releasing beyond the partnership for patients many, many different patients in care to test different models and so forth. So it was quite dramatic to actually do the first update.

Now one of the issues that we struggle with at HHS was does a national strategy mean. And when I first raised this with the group, very, very early—it may have actually been before it was passed because we were doing a lot of preplanning, prepositioning if you will at HHS. Some people immediately thought that meant the federal government. Other people said, “No. It’s got to be the federal public and private sector, to say nothing of states.” And that was actually the path that we chose.

So we rely a great deal on frequent opportunities for public comment and an ongoing close relationship with the National Priorities Partners, where they give us feedback from a variety of private sector stakeholders. So at a very high level, they actually identified three areas that are in need of work. One is a national strategy for data collection measurement and reporting. I don’t think we are going to have such a strategy by the time of the next update. But what it reflects to me very clearly is that people are sort of hoping to get beyond the kind of patchwork approach we are using in many different areas right now.

The second one I think truly needs to be deconstructed and more collaboration about organizational community infrastructure, assuming responsibility for improvement efforts. Some communities have almost no infrastructure. Some have many, many potential partners but not an obvious way for them to work together. And as I said, CMMI has been very, very busy. I’m really thrilled that Kate Goodrich is here today. I knew Dr. Conway could not be with us.

But what we’ve seen this past year is, particularly on the physician and hospital quality reporting side is steady convergence with what’s required for a meaningful use. So if you do something for a meaningful use, you also get credit in the physician quality reporting system and so forth. On some level this sounds so logical. It is. But that doesn’t mean it is easy or necessarily a given. So a real tribute to our colleagues. And we are continuing to work on this kind of alignment across HHS programs.

So we also recently released the 2011 state snapshots. Now, I don't know is Dr. Moye is here anywhere. He deserves an enormous amount of credit for all the work he has been doing recently, talking to reporters. These actually tend to get far more press than the national report I think because local data is actually more compelling and, frankly, a little bit more personal, right? Because the national report tends to inspire the response, “Wow! I thought we were doing better than that. Thank God it’s not us.” But, you know, the closer data are to home, the more of an impact it has.

So what I’m showing you here is—what we did when we started this line, which is derived from the national reports—it’s not every metric in the national reports because not all our data sources support that. But we were trying to figure out a way to make it more compelling to state policymakers. And so we came up with the idea of a speedometer in place of spreadsheets with very, very tiny fonts. So this is the speedometer for Maryland, which you will see is actually heading in the wrong direction, still in the average range.

But states can actually see where they are doing very well. The top ranked stage was Minnesota. But even they have some specific challenges are not at the top of all states in terms of home healthcare I believe and so forth. We’re hoping and continue to hope that this inspires some cross state learning.

In our continuing efforts to try to bring the best possible healthcare information to people where they are rather than requiring that they first require how to navigate a healthcare system and get it that way—we’ve actually created a video novella to help patients compare diabetes treatments. So those, as I understand it is a little bit like a soap opera. And it’s very similar to, you know, getting a very important message about, say, patient safety in an episode of “ER.”

But it’s also—I’m told it is very entertaining. They are on our Websites. We debated showing them today. But I believe the shortest is five minutes. And I wasn’t precisely sure how many of you are fluent in Spanish. And the closed captioning only takes you so far. It gets old in a few minutes. So I would commend that for you attention. They are available on our Website.

Another recent report from our Effective Healthcare Program is about muscle training effective in treating urinary incontinence in women. Years ago when I was at an academic center, there was a colleague who was then trying to break new ground in studying this issue—which was challenging, because a lot of people don’t want to talk about it, either clinicians or individuals who are suffering. But, obviously, a very, very important problem, an important source of loss of independence or cause of loss of independence and subsequent challenges.

And this review found that pelvic muscle floor training is effective and does not have side effects. Some drug treatments can work but they do have side effects. So, again, consistent with all of our reports about comparative effectiveness, patient-centered outcomes research—this is not prescriptive. It is not telling you what to do. It’s simply saying here are the options. Here’s the benefits and potential downsides.

The Arizona Healthcare Cost Containment System, which is another name for their Medicaid program actually used our evidence report on vaginal birth after Caesarian section—this report and the evidence there suggested that VBAC may be safe in large hospitals but that the research was mixed in outcomes in other settings. And the Medicaid officials in the state of Arizona used these findings to identify settings where VBAC services could be performed safely.

The High Mark Blue Cross Plan—and Catherine, this should say Pennsylvania, West Virginia and Delaware, shouldn’t it—actually used our information on health literacy. So they’ve actually used the toolkit from the questions, or the answer (?) Public Education Campaign. You can see the picture on the right is a clinician and patient video. And they use this to educate physicians about the relationship between health literacy and outcomes. And their provider Website features our toolkit, a training module and so forth as well as the downloadable tools for patients.

Hospitals in three states, Nebraska, New Mexico and New York have been taking advantage of our report from the patient safety side about preventing hospital acquired venous thromboembolism. And this has actually been a terrific opportunity for us to learn from hospitals. This effort actually resulted from a grant, the solicitation for which said, “What we want are applications for practical tools that can be implemented in real life, like right now.” And we got some really terrific applications.

And what we’ve also learned over time is, even the most practical tools are not quite plug and play. So we are very, very excited that as a result of collaboration and working with this QAO learning network, we’re now seeing those efforts pay off.

From our health IT portfolio, we have a toolkit called MATCH, Medication and Transition and Clinical Handoffs. And, again, working with this QAO learning network, hospitals in the states shown at the top of this slide, Maine, Georgia, Indiana, Maryland, Missouri and Michigan actually were able to identify that need for a single medication history list. I have yet to hear any insights from real life that medication reconciliation has suddenly gotten easier or has been solved yet.

So I would commend this for your attention. And that a lot of their hospitals redesigned their medication history list based on the toolkits, One Source of Truth.

Some of you are aware of the free software we make available to states, communities and anyone called MONARHQ, not a butterfly but My Own Network Powered by ARHQ. We’ve created a learning network for people to know how to use this. And this was used by the state of Arkansas. And, again, we’re just giving them free software so that they can organize their own data much more effectively. And for many states this is a huge boon because they don’t all have extensive programmers. And they certainly don’t have the kinds of people, Chris, that I know you have at the Wisconsin Collaborative for Healthcare Quality. Also, used by the Maine Health Data Organization

Some of you got to hear a presentation by phone from someone from Utah who kept saying that this, you know, she just wanted to write to everyone because this was a gift, fabulous work funded by taxpayers and everyone should know about it. And Utah is fairly advanced in how they collect data and so forth. And also, there are a couple of other states as well. The Ohio Medicaid program actually used our Maternal and Neonatal Outcomes of Elective Induction of Labor.

So working the Medicaid Medical Directors Learning Network, they found and increase in C-sections when labor is induced versus allowed to occur spontaneously. And based on an AHRQ report, the Medicaid program reduced labor inductions without clear medical indications in near-term infants by 40 percent over 18 months. This is a big, big national initiative from HHS right at the moment as well. And they were able to prevent nearly 200 NICU admissions.

Some years back we funded the development of something called the Emergency Severity Index Triage System. And the Woodhull Medical and Mental Health Center, part of the Health and Hospitals Corporation in New York City, actually used this at a time when their annual visits to the Emergency Department were increasing pretty dramatically from 65,000 to 100,000 in 2011. And they used this to handle the increase by improving the patient flow in the Emergency Department and so forth. And actually saw as a result higher patient satisfaction scores and decreased waiting times.

So that was a breathless tour of some recent, selected accomplishments. I’m going to shift gears now to our program updates. So we are redesigning our Web page. So if any of you have a specific issue with our Web site that you would like to share, please don’t hesitate to let us know. Obviously, a big, big challenge is that there is so much great information it’s hard to figure out how to organize it. There will be a specific update, I may be using the wrong word, in September, after which the next phase of this redesign will include revisiting all of what are called third level Websites in terms of which ones ought to be more accessible or easily connected to the main Website or actually part of that Website. That will probably take a little bit longer.

The proposed, new primary navigation for this—you can see the navigation levels, health information for specific groups, research and data, funding and grants, something about the anatomy and nuts and bolts of AHRQ, the Center’s portfolios and so forth as well as news and events and what is called the utility navigation labels are shown on the right side (?), and that all important, I’m appreciating, text size adjuster.

So, also recently, in the new is a paper from Steve Hill from the Center for Financing, Access and Costs Trends. What he did was to model, using the Medical Expenditure Panel Survey data. How much people insured in the individual market could have saved between 2001 and 2008. And it turns out they could have saved quite a bit. Not only would they have saved money in the actual premiums, they would have gotten more extensive coverage.

Very soon we will be seeing a new release of the 2011 employer health insurance offerings and premiums from the Medicare Expenditure Panel’s Survey later this month, in fact. And we’ve been working very closely with colleagues at the National Cancer Institute to enhance the survey content to support cancer survivorship research. I mean one, incredible strength about the MEPS, and you will be hearing more about this from Steve Cohen a little bit later in the morning, on a specific topic.

But you’ve got longitudinal follow-up of individual households for two and a half years. And they are replaced by similar households. So the capacity to understand what happens to people over time in terms of their care needs, how much they are spending and so forth is really important. The Patient Safety Organization Program remains with 75 PSOs and strong, who are now working with over 2,000 US providers, including over 1,600 hospitals. Now, Bill Munier (?) and his colleagues and the Center for Quality Improvement and Patient Safety do quite a bit of work with these folks.

They have an annual meeting and a variety of activities in an ongoing way. The law, actually, does not allow us to collect information from them in a detailed fashion about what precisely they are doing and which PSOs are working with whom and so forth. But the fact that over 1,600 hospitals are involved I think is a very, very positive sign. And a new Patient Safety Organization includes a component of the American College of Physicians.

Now the bill that created Patient Safety Organizations, the Patient Safety and Quality Improvement Act, I know it was right on the tip of all your tongues, also allowed but did not require the HHS Secretary to release common formats or common approaches to measuring patient harms. And, indeed we did, on behalf of the Secretary, release these common formats. Bill’s team has been hard, hard at work on this. In fact, today a Federal Registered Notice will go out about a readmissions format, to be published in this summer.

And what I’m very, very proud of this work is there’s been a lot of outreach and collaboration with IT vendors and, also, quite a bit of opportunities for people who are using these formats to provide tools so that Bill’s team can constantly update these. And we didn’t make these up. These are derived from long-standing metrics and really draw from the best and the strength of our colleagues across HHS, the Center for Disease Control, the FDA, Veterans Affairs and so forth—so very, very much a team sport.

In addition, the Office of the National Coordinator is now sponsoring a Purple Button Challenge Award. And this is calling for the development of an app to enhance patient safety event reporting, using common format. I keep reading about these great app challenges. So now we have one for the common formats. I don't know where purple came from but perhaps we can discuss that at the break.

The curriculum that we developed with our colleges from the Department of Defense and was our lead person, Dr. Jim Battle and his college at Defense, Heidi King have been announced as finalists for what are called the Sammies Medals, the Service to America Medals. That was just a couple of months ago. But this curriculum continues to be very popular and widely used.

Just last month the sixth, annual national conference held in Nashville and my colleagues were very, very excited to see an unprecedented number of new people at this. If you have ever met anyone who has worked with this curriculum, you want to be really careful that you are near the door because they tend to get very, very excited. And you don’t want to trap yourself into a corner of the room where you can’t get out. And they also previewed upcoming modules for long-term care, a module for primary care and for limited English proficiency.

Our work in healthcare associated infections, which is obviously a big, big part of our budget for patient safety is tightly linked and aligned with work going on at CMS. I mean CMS has got the power of the purse to help motivate people to get very, very focused on reducing and hopefully eliminating HAI’s. CDC really does the groundbreaking work in epidemiology. All of our research uses there definitions. And the Office of the Assistant Secretary for Health, I think has played a very important, convening leadership role. And Don Wright who works there has been really terrific.

And we actually have agency priority goals. So we take this business of evaluating what we do very, very seriously here at AHRQ. The Department in turn takes it seriously. But the Secretary has got a very, very short list of the highest priority goals. And one of these is HAIs. So the specific goals are to reduce catheter-associated urinary tract infections by September 30th of 2013, 20 percent This is compared with 2010—and continued reductions in central line associated infections of 25 percent.

The good news with central line-associated bloodstream infections is we are seeing really terrific work from the work that we’re doing with states, hospital associations, and others across the country.

Our colleagues that what is sometimes referred to as the Military Medical School, formerly known as the Uniform Services University of the Health Sciences, have actually created a pilot, graduate level course called “Patient Safety and Quality in an IT-driven world. So a very exciting partnership for us. We’re also very, very pleased that the OECD is using some of our quality indicators for its Health at a Glance Program, specifically some patient safety indicators. And what we call preventable quality indicators—these are actually indicators of potentially avoidable hospital admissions.

All right. Just to brag a moment. Health Affairs periodically releases, I think about every six months, sort of a top 10 list. What are the articles that people are downloading the most or reading the most. I presume they get this from their Website. So, number two was actually an article that a couple of us co-authored with colleagues at the Assistant Secretary for Health, including Dr. Coe (?) on health literacy—and really reinforcing how important addressing literacy is to meaningful implementation of the Affordable Care Act and many, many other initiatives.

And number nine was an AHRQ-funded study. A team led by Judith Heberd (?), very, very creative approach to showing that a well-designed report on cost and quality can actually help consumers choose high value healthcare. What I found most fascinating about this was that the early, sort of pre-experimental work with focus groups and so forth, kind of suggested that people weren’t too interested in cost, except for people in high deductible plans. But, in fact, the randomized trial that they did or actually found that a well-designed report can do this.

So what is a well-designed report? A lot more interpretive and higher level than much of what we are putting out now for quality report cards. So it’s not—they want to know that the measures are endorsed by a trusted source. I don’t think endorsed is the word they use—but have been vetted and approved. And they don’t want the, what I sometimes think of as atomic measures—you know, the proportion of patients with congestive heart failure who had their left ventricular ejection fraction checked. That doesn’t have a great deal of meaning. They want it more pulled together. And they like symbols, like stars and so forth.

In addition to the Affordable Care Act, of course, was landmark, groundbreaking legislation a couple of years ago for parity for the coverage of mental health benefits. So throughout all of our efforts, and in particular HHS’ efforts to improve quality, delivery and value and so forth, there has always been a focus on how do you make sure that this also refers to mental health and substance abuse services.

And that is not just, “Well, we have to do it.” It’s also very, very much about, “If we don’t do this, we probably won’t achieve some of our goals.” So just as a practical example, people who are readmitted frequently, often have one diagnosis that is a behavioral or a mental health disorder. So it makes infinite sense to connect the dots. We’ve been focusing a lot on the science of integrating mental health and primary care. So I wanted to just show you a screen shot of a new public portal on the integration of behavioral health and primary care.

As part of our ongoing work, led by Dr. Myers and his team on the sort of supporting science underpinning patient-centered medical home, there is a new Website on self-management support resources. Interesting, probably one of the most popular, self-management approaches that was originally developed at Stanford by Dr. Kate Lorig (?) actually derives from an AHRQ supported grant.

The Preventive Services Task Force is meeting here next week and actually has been incredibly busy. Five, final recommendations released just since the last Advisory Council Meeting shown here, counseling to prevent skin cancer, screening for prostate cancer, interventions to prevent falls, screening for and management of obesity in adults—and this has raised a very, very interesting question in the news this week. Because the recommendation clearly states that weight loss programs can help. And the characteristics of such programs are defined.

But it raised a very important coverage question, how often should they be covered? And there is not a scientific answer for that. So that will continue to be an interesting sort of challenge. And then last, behavioral counseling to promote a healthful diet and physical activity for preventing cardiovascular disease in adults. In addition, consistent with their new approach to transparency of their work, five draft recommendations have been posted for public comment since the last NAC meeting.

We have also had the opportunity to support efforts to make the recommendations a bit more digestible by different audiences. The task force historically has focused a great deal on the best possible information for clinicians. But is now continuing and continuing to enhance those efforts but also adding consumers. And, indeed, a lot of the coverage of some recent recommendations seem to me to draw directly from the consumer materials, which I think is also another benefit.

I talked about MONARHQ again. This is also a program that continues to get updated and improved. The new version is 3.0. And, Irene, is that out now or coming shortly.

IRENE: Out now. 4.0 is month.

CAROLYN CLANCY: Out now. Great. So 4.0 in month, for people on the phone, a month or two. For people on the phone, 3.0 is out now. So this includes additional indicators and health topics, including a new health topic on sensitive care. That is to say, those aspects of care quality that are most sensitive to nursing’s input. Am I saying that right, Jan?

JAN: That would be right.

CAROLYN CLANCY: Okay. Also, some new customization options as well as updated coding changes and new technical design features. This, I think, got a little bit out of order. But this is just an example or screenshot of some of the new materials for clinicians from the Preventative Services Task Force. Also wanted to just let you know about a tool set for ePrescribing in independent pharmacies.

ePrescribing is great. We still have not yet figured out for every single transaction in this country, how to have end-to-end coverage where everything works very, very smoothly. This tool actually illustrates how to assess pharmacy workflow, to determine whether changes or updates are needed to their software system and discusses hurdles and problems that people can anticipate when they are implementing electronic prescribing.

There is also a sort of comparable or counterpart tool set for electronic prescribing implementation in physicians’ offices. And this is explicitly designed for small, independent offices, although large, medical groups could also benefit from it. Supports implementation, whether as a standalone system or as a component of a full, electronic health record. And it’s very—we think it is very useful for providers who have not achieved the full potential of their ePrescribing system. These are, again, available free of charge from the Health IT Website.

A recent evidence report was actually focused on the benefits of Health IT. We had published one, supported someone (?) leading to a publication in 2006. So this is continuing to build on that great work. And found that while Health IT was shown to improve outcomes, few studies demonstrated the impact on patient-centered care as defined by the Institute of Medicine. Fourteen studies focused on improving responsiveness to the needs and preferences of individual patients. A larger number focused on improving shared decision making or related measures of patient – clinician communication and access to information.

Also continuing on the HIT theme, two action task orders, this is our research network of research teams that work with us under contract, which include components of care delivery systems as well as— researchers are studying the implementation of Health IT to support practice redesign in ambulatory care settings. After all, just putting in, just digitizing what we are doing now is not going to achieve the kind of value I think we are all hoping for. And another that is focused on understanding the causal relationships between Health IT implementation and workflow processes and so forth.

Three practices from the Billings Clinic in Montana are doing time and motion studies, observation, software logs, interviews to study pre, during and post implementation. And then RTI is looking at six practices at different stages of implementing.

Now, Project ECHO—I’m glad you are here David. This is a project that was funded by AHRQ in 2004 and it is all about Health IT and telemedicine and not all about Health IT and telemedicine. It used telemedicine as a platform to extend specialty expertise from the University of New Mexico, the only academic medical center in New Mexico, to fairly remote, rural and frontier communities across the state.

The first focus that we funded was on hepatitis C. An article published in the New England Journal had demonstrated that the patients [00:53:52]. So these specialists are reaching out to primary care clinicians in these communities and sharing with them and essentially training them all about this disease. And the results published last year showed reduced, greatly reduced disparities in care associated with where you live and improved provider satisfaction in those rural communities.

Since then they’ve gone on to get some support from Robert Wood Johnson. They got a grant from the Innovation Center, the big health innovations grant that have been released over the past several months. And this week at the National Press Club, Veterans Affairs announced their big initiative. Are you familiar with this?

DAVID: Yeah.

CAROLYN CLANCY: Great. I only know the press release version. So do you want to talk about it for a second?

DAVID: So in our version, called SCAN ECHO, we’re adopting it for four conditions. I think they are hepatitis C, heart failure, diabetes and pain. And so we’re rolling out a series of skin ECHO centers. And, of course, for the VA it’s critical because we have problems with a very dispersed population and getting access to specialty care is one of our biggest challenges. So it’s been great to have a model like this to test and adopt. And we’re funding in research a couple of evaluation centers to explore issues about how to roll it out and issues of effectiveness.

CAROLYN CLANCY: Great. And I think we will also learn about how implementation varies with the context, both because there is unique features of VA healthcare and also because Director Arura (?) who’s been the lead for this is truly a unique, charismatic individual. Which is fantastic but you’d also like to hope that this work can be learned by others who may not have been necessarily born with those precise, same characteristics.

Here we are. One of the most exciting aspects of the Recovery or ERA (?) funds that we got for comparative effectiveness research was how much and what a huge opportunity this was to invest in data infrastructure. And the rationale from HHS for this, and some of you may recall that in order to invest $1.1 billion, the Congress allocated this as $300 million to AHRQ, $400 million to the NIH, and then $400 million to the Office of the Secretary.

Now the Secretary was not going to be writing grant solicitations. So we worked very closely with colleagues across HHS to invest that last $400 million dollars, both with ARHQ resources as well as some of the resources allocated to the Secretary. We were able to make big investments in registries, both support for developing new registries as well as enhancing existing ones. In other approaches to collecting clinically detailed data as a part of routine care that would be distributed data networks and the like—and all of this is incredibly promising if our methods are up to the task of using these data to glean scientifically valid inferences about care, about comparative effectiveness of different interventions and so forth.

So we thought it was incredibly important to support a function, which we call the Electronic Data Methods Forum. And Academy Health won the contract for this opportunity. And they just had a full-day meeting preceding the Academy Health Meeting in Florida, very, very exciting work. They are collecting, synthesizing and sharing lessons learned and very importantly advancing methods, not just research methods and analytics but also issues related to informatics and, very importantly, issues related to governance

Those of you who have been anywhere near conversations about health information exchange at a state level or somewhere else will know it’s a lot of work to get people on the same page about what does it mean that we collect data once but can use it for multiple purposes. And so we see that governance function as quite critical. So we’re very excited about this. And this is just a picture of the first journal supplement to medical care. And there will be more coming and more electronic publications coming as well.

Yes, the electronic publications is called eGEMS, Generating Evidence in Methods. So this is really responding to a very clearly expressed need that there’s lots and lots of people using registries. I know that the number that you all recognize for physician quality reporting is growing. They can be very, very powerful tools both for assessing and improving quality of care and also for conducting research. But people want to learn very, very much about the analytics, about the informatics and so forth.

I’m going to skip over this. Some recently released translation products from our ongoing work in patient-centered research, ADHD in children, ANA and rheumatoid factor tests for multiple, musculoskeletal complaints in children, chronic pelvic pain and the list goes on.

And finally, consistent with resource constraints confronting all Americans in everyday life we, too, have had to do some streamlining of our annual meeting but we are still on. You may have seen a slide, I’m sure I showed you one that said the 9th through the 12th. It will, indeed, be the 9th through the 11th at the same place. And I can tell you my colleagues worked incredibly hard to make sure we get the biggest bang possible for our investment. And, you know, we’re compliant with new regulations and so forth.

We’re very, very excited about this. The 9th is a Sunday. Sunday is a lot of meetings by invitation only, which are largely working meetings with grantees and so forth. But if any of you see anything on the site that you would be interested in, please let us know. And notwithstanding our efforts to be streamline and be as high value and efficient as possible, there is still no registration fee. So it is free of charge to join us.

So with that, I will stop here and thank you for your attention. I’m happy to take any questions.

BRUCE SIEGEL: Thank you, Dr. Clancy for that very informative report. I’m going to turn to our members here and see if they have any questions or comments they would like to make. Usually not a shy bunch. Dr. Spitzer.

ALAN SPITZER: Yes. Much of my work in the past decade has involved Health IT, working with our IT department and developing a system of electronic health records and a system that is now being used by Duke and UNC in an NIH-AHRQ (?) grant to look at comparative effectiveness outcomes. One of the disconcerting things though, that I’ve seen in my personal experience, and obviously, this is very anecdotal—is when I go to my internist he’s still writing notes. When I go to my cardiologist, he is dictating notes.

When I went to my orthopedist, obviously I have a lot of problems that I’m trying to deal with here Laughter]—fortunately they are pretty minor. When I go to my orthopedist, he’s dictating notes. And I ask each of them about electronic records and why they are not using them. And I get the same response all the time, that it would cut into their ability to see patients rapidly enough. Because of the pressure of reimbursement, they can’t go to a computer screen and type in to any type of electronic record the kind of information that would allow them, with their colleagues, to put together information that I think all of us are interested in.

And I think this is one of the real shortcomings that I’m seeing and I think this is more widespread. I don’t think it is just my anecdotes. And I guess the issue that I’m trying to raise is how do we get the examples that you cited, Dr. Clancy of the centers and people who are doing this well—how do we get this information out to those that just don’t even want to think about it because they think it would be too disruptive to their daily work as a physician. And I think it is one of the real stumbling blocks to getting everybody up on electronic records.

CAROLYN CLANCY: So the good news is that the HITECH Act part of the Recovery Bill actually created these regional extension centers. So that’s one way that we can reach out to a variety of communities, providers and so forth. But it becomes this kind of interesting challenge where they are most likely to connect with people who are already interested. And my impression about people continuing to dictate and so forth has to do with, it’s hard to slow down. And I think almost every implementation reports some decreases in productivity for a while.

Now most will say after a period of time it gets better. And I think it may be partly generational. I mean obviously we’ve got people who grew up—

ALAN SPITZER: Let me just address that also. I didn’t mention that but I had the opportunity to take my grandchildren, recently, to their physician’s offices, which are part of a university setting. And I’ve seen this also in a couple of universities in the ambulatory setting, where they also are not using electronic records. And I think if there was a setting where I would really feel strongly that they should be using electronic health records to train the next generation of physicians—so it becomes automatic to them and they don’t even think about dictating or writing notes by hand—it would be in the university departments. And I have a feeling that it is not as widespread as it should be there.

BRUCE SIEGEL: I’m going to ask our members if you have a comment to put your card up as Dr. Crowley just did. Dr. Ng, I think you had a comment before.

HENRY NG: Yes, I do. The comment and reflecting about Health IT and how it can be used as a tool for vulnerable populations. We’ve talked about issues related to race – ethnicity. And IOM (?) report from 2009 suggests that certainly we should be including data. And we are actually collecting that for institutions that have Health IT and EHRs. Now the IOM report from 2011 has also indicated that there should be a consideration of a mechanism to include sexual orientation, gender identity and gender expression.

I know that there has been some discussion about this, both at LGT organizations and also nationally. But there is also this need to have additional training for providers and to figure out in this diversity of methods how we would collect that type of information. I think, again, give a better picture, a sense of the overlapping shades and intersectionality of identities. Those are one of the things that came to mind as I’m thinking about urban populations and rural populations and all different kinds of folks who live there.

CAROLYN CLANCY: I just wanted to ask Ardis a question, if that’s okay. I mean Ardis I would have to imagine that in your ongoing leadership work with the AMA and especially now, that you hear from clinicians all over the place about how beautifully designed their electronic health records are. I mean some of what I think you are seeing is actually a design problem.

ARDIS DEE HOVEN: Absolutely.

CAROLYN CLANCY: I was a hospital patient once where, as they wheeled me upstairs they dropped the paper orders on the little gurney with me. And I said, “Wait a minute. I thought you had electronic records.” And they said, “Oh, we do. But it’s too slow for the doctors. So they write and someone else, you know, types it in for them.” And all I could think of was that famous statement about, you know, the giant sucking noise you just heard was a lot of the value going down the drain.

HENRY NG: Thank you. I think there are multiple issues in play here with physician practices, be they small, little bitty ones or large integrated practices. The large, integrated practices are doing a better job. My primary care physician uses a tablet and pecks on things. And things go pretty smoothly. Although, when I’m trying to see patients and trying to have eye contact with a patient, typing on a machine at the same time, I do a crappy job. I’m either going to do a bad job looking at the patient and talking and listening to the patient or I’m going to do a lousy job inputting data.

And I end up taking shortcuts and not putting stuff in the data, into the EMR simply because it’s better for the patient at the end of the day. So I think you’ve got workflow issues in practices of various kinds. You’ve got issues of docs are out there trying to do it. They’ve all got these variable systems in place but there is no interoperability. And I know we talk about this extensively. But the interoperability with all kinds of systems is an absolute key to this thing for us to want to use them.

I need to be able to get Medicaid data from a patient in the eastern half of the state who tells me they’ve had three CAT scans, a brain scan and a bunch of lab tests. And I can’t get the data. So I think there are issues out there with interoperability right now that are getting in our way as well. So it’s—I think there are multiple issues. There are practices that are highly advanced, have been using the EMRs for a long period of time that are better at it and even they’re still struggling. They struggle with data, you know, for PQRS, for example, trying to get it sent upstream because of the systems involved again.

So I still think in the end of the day we all agree it’s good. At the end of the day we all agree there are probably 3,000 problems out there that we are going to have to address and we have not gotten this to the place where we need to be. And we keep working on it. And it’s the health information technology piece is a big key. I love it because I can go in and dig data up within my own system from the hospital, from the clinic, from labs. But the interoperability thing has got to be address as well, Carolyn.

BRUCE SIEGEL: Let me make a couple of comments before going to Dr. Crowley, first on Dr. Ng’s point before. I think we face huge obstacles, a steep hill in addressing what you, so appropriately raised. Even the area of race – ethnicity and language. You know, hospitals still are like they were five years ago, collecting it, not doing it in a standard fashion, and not knowing what to do with the data. I think in terms of sexual preference and identity issues, we (?) are even further behind even knowing what to do.

So I think we have our work cut out for us. But at least there is an understanding that understanding these issues and begin to actually take action on them that really results in a quality interaction and a better patient experience is important. But I hate to be too optimistic with the timeline, unfortunately.

HENRY NG: But the good news is that electronic records that are certified have to include the capability of collecting this information. So all of the—I mean that’s a requirement. And an incredible coalition came together when Congress was debating the Recovery Act. You know, and this is in the middle of a transition and so forth. All of the action is going to be around the training and how do you use the information and how do you share that with patients. And frankly, I think that’s a brand new business in all parts of healthcare, for all kinds of—

ARDIS DEE HOVEN: (?) But frankly, it won’t happen until there is a mandate. EHRs have the capacity. But to set aside the time, the money and the energy to do it, there is no incentive until it is required, just like race, ethnicity and language was.

BRUCE SIEGEL: Right. The other comment I just wanted to make briefly, and this is just a personal experience I recently had around the electronic health record and ePrescribing. And certainly all of these challenges remain. But I recently change physician practices. And my physician, you know, she was clearly typing into a terminal, going through her menu. And she was somewhat distracted by that. That was the bad news. The good news is that she ePrescribes. And I have to tell you, in my last practice, who will remain unnamed, most of my energy was chasing down lost prescription pieces of paper, which I mean literally, I was taking the Metro to go to the office to pick up the paper so I could hand mail it to our pharmacy, you know, benefit provided. And then it would get lost.

And so we would spend weeks on this and I was reduced—I shouldn’t say reduced. But I was forced to ask my wife to start writing scripts for me, which she really doesn’t like doing it. You know what I mean? [Laughter] But okay. Sorry I admitted to that here in public. [Laughter] You know it’s long past now. I mean it wasn’t for a controlled substance, either. [Laughter] And in this practice it was, you know, seamlessly done. And two days later I had my meds. So it was—you are making a difference when you work in that area.

Dr. Crowley?

JANE CROWLEY: Thank you. And for the record, I’m not doctorally prepared, although I would love to be.

BRUCE SIEGEL: Just by being a member her.

JANE CROWLEY: I get the honorary degree. That is very, very kind of you. I’ll just make a comment from our experience in Ohio about electronic records and then I have a request. We’ve put about 800 providers up on an electronic health record, largely from small community, independent practices, fairly underfunded in their historic infrastructure in the last 18 months. And I can’t emphasize enough that I think we, as a country, have underestimated this challenge.

The implementation has to be heavily supported. And our physicians return to full productivity within about four weeks. But it needs to be a very intense process. And most of the work happens pre-Go Live. Because the individual, clinical practice of the physician has to be understood. And then the workflows redesigned for him or her, with him or her so that when they start seeing patients again, using the electronic tools, the way they think clinically is replicated in the system. Or they know how to replicate that mental process that is so important to their care.

And then, optimization has to occur at some period later, like six weeks or three months later when—it’s like all of us, when you get your new iPhone, you know, you learn the basics the first day. And then it is sometime later that you learn all the fun stuff. And then it’s an ongoing process. And I think we have just grossly underestimated how much support is going to be needed. The opportunity for the agency, perhaps, is to help the Department, or Office of Health IT measure those implementation processes out of the reqs that are most effective.

So in Cincinnati, like Chris, we have a huge Beacon grant and are doing that work largely for the least well prepared physicians. The large practices are often now affiliated with health system so the reqs are handling the onesies, twosies, and often very rural practices. But I don’t think there is a lot published about what is the best way. And we tend to follow the lead of our vendors, which may or may not be evidence based, you know. We don’t know that. I think that is a huge opportunity.

The request or question I was going to ask relates to a different topic from your report, Dr. Clancy, and has to do with the, I think it was called ECHO work. I think a very fertile opportunity for research is the boundary, if you will, and Dr. Hoven probably hears a lot about this, between primary care and specialty. So what is the appropriate boundary in heart failure management? Understanding that that will probably vary by what is available, but our physicians are honestly struggling with that now that PCMH is fairly well accepted and many are reentering risk contracts.

I don’t think it is well documented when heart failure patient should leave their general internist and be seen regularly, i.e., move their home from their primary care physician to a specialist. And you can replicate that question for every specialty, right?

That area of what is the best way is, I think, going to be important or the work to incentivize basic primary care with care management fees of PCMH bonuses, I think will be somewhat effective. But I think many of us think it has an upside limit, because so many patients are probably too complex to be managed in a general environment. And Dr. Hoven, if you have experienced these questions around the country—

ARDIS DEE HOVEN: Yes, it is something we hear a lot about because, for example, many times you will hear many primary care doctors, family medicine physicians, and internal medicine, particularly saying things like, “I can do this up to a point but now am I going to get penalized because I am now maybe earlier than some other primary care doctors handing this complicated patient off to a specialty person who can do it. And what part of that am I going to be responsible. We get to the whole issue of attribution when you do the numbers and the whole issue of risk adjustment as well. So I think that is a very clear issue.

On the other hand, you know, healthcare is local. And I hear this so much that I say, “Okay, within your own community of care delivery, be it in an academic medical center or be it in a small rural hospital or set of clinics, within your own healthcare community have got to figure this out so that you as a physicians are giving the best care you can give, given the opportunities available. So I think we have to be very careful when we start looking at data as opposed to real healthcare delivery at the ground level, as to what is going to happen.

It is an issue. And I think we are getting better at dealing with it. But I think when people start looking for quality indicators that there are measures that they are going to have to adapt to and all the issues of attribution and risk adjustment, there is going to be some downsides as well.

CAROLYN CLANCY: So Jane, just back to the question about working with—John White is not here today but I will definitely bring that back to him.


CAROLYN CLANCY: I’m sure that they are evaluating. But I’d also guess, off the top of my head without knowing the details, that they are probably looking at more quantitative metrics, how many people are doing this now as opposed to some of the more qualitative aspects, which I think could be incredibly interesting.

We just went through an IT implementation around here that has nothing to do with clinical care. And I was dreading it. I did not do any of the dress rehearsals. I waited until the last possible second. And what I learned was not, actually—was that it is much, much easier than any of the training had suggested or the bulletins about this. It is far less oppressive and why I had to do it before knowing that seems unclear to me. So it affects all of our daily lives, right? They are taking over the world.

The issue—we have actually studied this interface between primary and specialty care over the years. And I’ve worked a lot with NCHS data in the past to try to figure this out. It’s pretty interesting and a lot of it does come back to this healthcare being local. I will say that one area where I think improvements could be made, and I’m saying this based on personal experience with family members and so forth. I don’t think it is part of physician training or culture to be thinking about shared operating rules.

Some people who have known each other for a really, really long time develop them over time. They’ve got their informal networks. So I’ve heard experienced physicians, I don’t use the “O” word anymore, say that they have long had a stable of consultants. And if they want an opinion, they will send somebody over here. If they want a procedure, they send them over there and so on and so forth. You know, there is a lot of mobility for younger physicians. But the notion that there is an explicit conversation about, okay, I handle this. And when it gets to this, I’m going to give him back.

I mean I have never been part of such a conversation in ongoing patient care. And, you know, when I used to call my dad’s docs, they knew each other. They worked in a multi-specialty, fee-for-service group practice. That is what is supposed to be Nirvana, I guess. But they didn’t have that same shared sense of understanding. Tests got repeated. So that might be something to explore. I know one of Kate’s colleagues is very interested in this continuing education and working with many other groups. So maybe that’s something we could look into.

BRUCE SIEGEL: I’m going to change things just a slight amount and ask, do any of our members on the phone have a question. We want to make sure we don’t ignore you.

SILVIA FERETTI: (?) No, I don’t.

BRUCE SIEGEL: All right. Hearing none, I’ll turn to Ms. Darling. I’m going to move around the table with this direction.

FEMALE: [01:21:17] to Dr. Thompson.

MALE: I dropped mine. [Laughter]

BRUCE SIEGEL: Very tricky.

JEFF THOMPSON: Just a couple of things from the field. As Medicaid is paying for a lot of the EMRs, what we are finding out is that when they get the EMR, the version or the option in the version isn’t available for the interoperability. So, yes, it is potentially there but it’s not there unless you sort of purchase the app or get the next version. And so—but I think that interoperability is really actually key. You know, it’s working nicely with the Epic systems in hospitals and other things. But they don’t talk to each other.

So in Washington State one of the things that happened with all this ER thing that is going on is, 100 percent of hospitals will actually have an EMR that will talk to each other through what we call the EDI system. And so what that’s generated as an interesting thing is, how do you file a treatment record for the migraine headache person who’s had 16 CAT scans and seeks narcotics? And one of the things we are struggling with now is what is the standard treatment plan look like that will inform the ER physician about what the PCP wants done for that 17th visit.

And then how do you actually inform the ER physician that, no, you really don’t need the CAT scan for, quote, the worst headache of their life because the just got a CAT scan yesterday. Or maybe you should do the CAT scan. So, I think, you know, it is starting to get really, fairly complex now a you sort of step out a little bit from just the IT portion, which to me is easy. And it’s the person portion, which is really difficult. What does the standard treatment plan look like for the new edit systems that you can put in, so that somebody can read it?

And then the last thing is, the interoperability is, as many states have prescription monitoring programs for narcotic abuse, usually sponsored through whatever. How do you actually input that into the EMR so that they can find out that, when they get ready to write the OxyContin script will know, then I got to go to another terminal or I got to go to another login or I got to remember to do this. Rather than treating it like a lab test, where it could actually be, you know, in my EMR and it could be just like a potassium of 7, know somebody else wrote OxyContin just two days ago.

So it’s getting, actually, interesting. It’s getting complex. And I guess what I’m asking Carolyn is, just as we step out, what is the standard treatment plan even look like? You know, so that they would actually, you know input it so it is not differential by physician.

CAROLYN CLANCY: So, again, I would come back to Ardis’ comment about healthcare being local. Because I’m not sure how much ought to be standardized. AHRQ is not in a position to standardize it. But I know some smaller countries have actually had this thing, you know, where they’ve got the national specialty organizations and the general practitioners or whoever is their primary care sector. And they get together and they hammer out these guidelines.

This being an incredibly large country there the local ecosystem varies quite a bit from community to community, it seems to me that the more important issue is sort of the functionality of being able to communicate that information. I do have to say that a recently published study from one of our early health information exchange aspects, did find that if you checked the HIE you reduced the number of CAT scans for frequent flyers to the Emergency Department for headaches.

The rate limiter for them and what them and what they are working on now is trying to make that a standard part of workflow, sort of just like vital signs, as opposed to like, “Oh, God. Who’s got the code? Who can get in and so forth?” It did, actually, make quite a big difference. And to say nothing, both cost and radiation safety.

JEFF THOMPSON: And I agree. All politics is local. And I’m just suggesting that—not standardizing but suggesting what could best practices be that would actually improve your effectiveness I think.

BRUCE SIEGEL: Just a quick comment. We have to break in about five minutes. And we need to stay on time today because we have a pretty agenda and some complex logistics. So if you can defer your questions to later in the day that would be great. Otherwise, if you are going to ask a question now, just for some brevity in terms of your question. Dr. Schneider.

KATHERINE SCHNEIDER: So, very briefly. Just to follow up on your comments—what we are talking about is really collaborative care management IT. And the EMRs, even those that are optimal are really designed for the transaction and possibly even for coding that transaction and less around kind of managing the care. But I think we are coming to a point where there may be some really great opportunities to look at what are the IT tools that can really support that care management function.

And even in a multi-payer environment, for example, because the payers actually have those 360 views of maybe not the content of the results of all the scans but even just knowing that they were done or that these prescriptions were filled using a pharmacy benefit. I mean those tools are out there and can be pushed or pulled to a provider’s office. So the question becomes, you know, how can they be built into the workflows optimally particularly in a multi-payer environment.

And like with the comprehensive care initiative that is starting up in seven markets, that may be a really great opportunity to actually research what tools are most effective to support—you still always need that transactional documentation system in place. But how do you augment that now to really create collaborative care management knowledge. It is not even around standardization. It is around shared knowledge I think more than anything.

CAROLYN CLANCY: Yes, I would agree with that.


HARRY SELKER: Two things I wonder if Carolyn could comment more on. And she won’t be surprised that I would ask these questions. But they are very important. There is a real need for more of a workforce and the kinds of work we are talking about. We had a lot of interesting comments about this because (?) people aren’t being trained so much. I know that you didn’t mention your training in faculty development. At least I didn’t hear. Maybe I missed. And we know that, for example, the T-awards are going down this year, for example, rather than up.

And similarly you showed us that the innovations, which I like the new name—that is surely what it should be, is also going down, not up. A miniscule amount of investigative initiated research, which is, of course, the bedrock of innovation. It is a couple of percent of the overall budget. Could you comment on both of those because it’s really a—I worry about our future with those two things diminishing.

CAROLYN CLANCY: So the first, just for people who aren’t familiar with the terminology—T-awards are institutional training grants. And have, frankly, been a phenomenal resource. We actually fund these from a stream of resources that comes directly from the NIH. And, by law, some of this, a very, very small proportion goes to AHRQ and some goes to HRSA (?) as well. The really good news on that front is that we have this patient-centered outcomes research trust fund allocation, which I think can, in terms of training and building capacity can be a helpful adjunct there.

In terms of the support for investigator, initiator research—

HARRY SELKER: is it true the training grants are going down. The number of T-awards, are they not going down?

CAROLYN CLANCY: I’d have to check back with Dr. Chesley (?) and some of his colleagues. The stream we get for that comes from NIH. So how much we get depends on the NIH budget. So when their budget goes up or it goes down, so does that primary funding source. But I can check back with you on that. But we’ve already issued solicitations for a number of different types of training and career development awards that were we’re very excited about. And as the allocation from that trust fund goes up, in ’13 And ’14, there will be more such opportunities.

Investigator-initiated research and innovation, I think we’ve got to think through how do we most effectively communicate where this is and educate people about where this innovation is most desperately needed. Because I stumbled on the fact that Project ECHO got one of the Health Innovation Awards from the Innovation Center recently—in other words, we funded this core piece and now they are scaling it up, which is fantastic.

We’re actually doing an analysis right now to try and figure out what proportion of the innovation awards released by that center actually derived from our grants. Which is one way, I think, of looking at it. I think it’s a longer dialogue as well and one that I would very much welcome with SGIM, with Academy Health and others.


CHRIS QUERAM: So we’ve dropped the doctor honorific already, have we?

BRUCE SIEGEL: We have. Sorry. [Laughter] Only in your case.

CHRIS QUERAM: Only in my case. Okay. I’ll be brief. But the subtext of the tension between national and local or state realities of how healthcare is organized and delivered is nicely encapsulated in the discussion, brief discussion related to the National Quality Strategy and moving forward with a national strategy for data collection, measurement and reporting. But also at the same time, trying to build capacity for quality improvement at a community level.

Carolyn you’ve heard me say, and Ardis and maybe others who are in—when we find ourselves in forums where this gets discussed—you’ve heard me express the concern that the many different data mandates or requirements associated with the Affordable Care Act, whether it is PQRS or Meaningful Use or ACO or value-driven healthcare initiatives are having the consequence intended, but most likely unintended—of starting to crowd out the local and state-based initiatives that have been shown to have an impact on a both quality and cost of care in local and state based initiatives.

And that is frankly a concern and one that I hope will be given prominent consideration in the development and the implementation of the National Strategy for Data Collection. And time won’t allow you to elaborate on what the mechanism is for how that strategy will be developed but I would hope that there will be an opportunity for organizations like the one Jane alluded to, and Cincinnati or ours here in Wisconsin to play a role in that regard.

CAROLYN CLANCY: The short answer to that is absolutely and without question. I don’t think we get to a national strategy for data collection rapidly in any case. And I think the what we would really want is to make it as local as possible but with some uniformity in terms of, if we measuring heart failure that people are collecting the same kinds of information—rather than that it all goes centrally.

If there is one thing I got out of the Michigan Keystone Project it was this add-on data collection on the local level. A little bit of data enabled rapid, timely feedback. And so much so that these folks now regard quarterly feedback as acceptable absolutely not the optimum. They are continuing to work in other venues and their work with Blue Cross and so forth to figure out how can they do it faster than that. Because if you don’t get some feedback on how you are doing, it’s not value added.

BRUCE SIEGEL: Last word, Dr. Johnson.

MIKE JOHNSON: Thank you. So two, what should be quick points. One EMR issue, I just would ask for AHRQ and the group to keep in mind that as much of a challenge that it has been for physicians and primary care providers, a lot of care is provided by people that are not physicians, so nurses and physical therapists and social workers and so forth. And we’re all looking at trying to get on the EMR wagon as well and looking for ways to communicate across, within disciplines. But then the challenge is across disciplines. So if docs have a difficult time communicating with one another, add a PT and a nurse and a social worker into that mix and really then we start to worry about the patient’s outcome.

So just keeping in mind, and the one point I would make is the ePrescribing requirement for those becomes a challenge for EMRs for the rest of us, prescription filling or prescription writing is not an option or a need. So just keeping that in mind. We talked in the last meeting about interdisciplinary care and so forth. The EMR has to facilitate that process as well.

And then my last comment is just back to the muscle training and urinary incontinence, which I found very interesting, just want to make everyone aware that that’s an area of basic training for a physical therapist. There is a specialty certification in women’s health with the APTA. And so the physical therapists have been working in this area for a long time. We had that practice in the clinic where I worked before. And the outcomes are really amazing, for not a lot of input, teach the client how to manage that.

So just to make sure that folks know that that is a place where that non-operative care can happen, has been happening for a long time and being delivered very well.

BRUCE SIEGEL: Great. Thank you all. I’m hearing no further questions. It is time for a break. We will break and reconvene at 10:15.


Page last reviewed August 2012
Page originally created August 2012
Internet Citation: Morning Session 1 - Transcript. Content last reviewed August 2012. Agency for Healthcare Research and Quality, Rockville, MD.