Meeting Minutes, November 2015
National Advisory Council
NAC Members Present
Elizabeth A. McGlynn, Ph.D., Kaiser Permanente (Chair)
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health
Francis J. Crosson, M.D., Medicare Payment Advisory Commission
Shari Davidson, National Business Group on Health
Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R., Oregon Health & Science University
Mary Fermazin, M.D., M.P.A., Health Services Advisory Group, Inc.
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Caritas Family of Companies
Paul B. Ginsburg, Ph.D., University of Southern California
Leon L. Haley, Jr., M.D., M.H.S.A., CPC, Emory Medical Care Foundation, Emory University
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health
Carol Matyka, M.A., National Breast Cancer Coalition
Victor M. Montori, M.D., M.Sc., Mayo Clinic
Mary D. Naylor, Ph.D., R.N., FAAN, University of Pennsylvania School of Nursing
Jean Rexford, Connecticut Center for Patient Safety
J. Sanford Schwartz, M.D., University of Pennsylvania (via telephone)
Paul E. Sherman, M.D., M.H.A., CPE, FAAP, Group Health Physicians
Jed Weissberg, M.D., FACP, Institute for Clinical and Economic Review
David Atkins, M.D., M.P.H., Veterans Health Administration
Paul E. McGann, M.D., Centers for Medicare & Medicaid Services (for Patrick Conway, M.D.)
Charles J. Rothwell, M.B.A., M.S., National Center for Health Statistics, Centers for Disease Control and Prevention
AHRQ Staff Members Present
Richard Kronick, Ph.D., Director
Sharon Arnold, Ph.D., Deputy Director
Jaime Zimmerman, M.P.H., Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Elizabeth McGlynn, Ph.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, other participants, and visitors. She noted that this would be the final meeting for seven members who were rotating off the council: Gregory Baker, R.Ph., Francis J. Crosson, M.D., Andrea Gelzer, M.D., M.S., FACP, Leon L. Haley, Jr., M.D., M.H.S.A., CPC, Carol Matyka, M.A., Victor M. Montori, M.D., M.Sc., and Jean Rexford.
Dr. McGlynn referred to the draft minutes of the previous NAC meeting (July 24, 2015) and asked for changes and approval. The NAC members voted unanimously to approve the July meeting minutes with no changes.
How AHRQ Makes A Difference
Richard Kronick, Ph.D., AHRQ Director, welcomed the NAC members, speakers, and other guests. He began his update by focusing on the benefits of AHRQ. It is the leading Federal agency devoted to improving the safety and quality of health care for all Americans. The agency engages in the following main activities:
- Investing in research and evidence to understand how to make health care safer and improve quality.
- Creating materials that teach and train health care systems and professionals to catalyze improvements in health care.
- Generating measures and data used to track and improve performance and to evaluate progress in the U.S. health system.
Dr. Kronick pointed to improvements in patient safety during the period 2010–2013, when, for example, hospital-acquired conditions diminished by 17 percent in the United States, with many lives saved. He listed ongoing AHRQ efforts in research and evidence gathering, such as investigator-initiated research, the Centers of Excellence in Comparative Health Systems Performance, the EvidenceNow program, the U.S. Preventive Services Task Force (USPSTF), and the Evidence-based Practice Centers (EPCs). In the area of data collection, AHRQ continues to support the Consumer Assessment of Healthcare Providers and Systems (CAHPS®), the Medical Expenditure Panel Survey (MEPS), the Healthcare Cost and Utilization Project (HCUP), the Quality Indicators, and the National Quality and Disparities Report.
Ellen Murray, Assistant Secretary for Financial Resources, Department of Health and Human Services (HHS), stated that she mentions AHRQ, the Centers for Disease Control and Prevention, and other agencies in various discussions about health care safety and Federal appropriations. She noted recent efforts to increase the proposed budgetary caps and outlays for AHRQ and patient safety. The discussions resulted in a preliminary agreement on larger nondefense discretionary numbers—about 90 percent of the President’s proposed budget—to be presented to the appropriations subcommittees. A final vote by December 11 is planned. Dr. Kronick helped to establish background information for the discussions
Jim Esquea, Assistant Secretary for Legislation, HHS, pointed to the budget deal recently reached, which likely will lead to less uncertainty for the agency down the road. The appropriations bill has yet to be passed, and some uncertainties remain. Nevertheless, the larger deals within the government have been made.
In discussion, Jed Weissberg, M.D., FACP, wondered whether the negotiators held a zero-sum idea regarding health care-related spending among the agencies. Ms. Murray suggested that the debates focused more on a lack of dollars and the presence of duplication in government activities. Mr. Esquea stressed that the debate in the House was reasonable and that decisions had to be made. Regarding possible repeal of the Affordable Care Act, Ms. Murray suggested that President Obama would veto any broad repeal and that the act is wrapped up in a number of large activities now, making it necessary. Mr. Esquea added that many individual aspects of the act could be fixed.
Dr. Montori noted the virtues of Federal agencies regarding aspects of health care delivery and suggested a need to define where AHRQ fits in trajectories and the deployment of resources. Should the agencies be combined, or should they target certain jobs? Ms. Murray responded that HHS seems to serve as a combination, with overall goals of communication and collaboration. Dr. Kronick stressed that AHRQ performs distinct work. Regarding the effort to defund AHRQ, Mr. Esquea cautioned that elimination does not always reduce overall costs. Paul B. Ginsburg, Ph.D., added that AHRQ can support basic research that no others will perform.
Dr. Kronick reviewed recent AHRQ activities.
- The AHRQ Research Conference took place October 4–6, 2015, at the Crystal City Marriott and was cohosted by AcademyHealth. More than 1,000 attendees witnessed 70 sessions, 272 speakers, and 112 posters. Main speakers included Mary Wakefield, Ph.D., R.N., Acting Deputy Secretary of HHS, Alice Rivlin, Ph.D., Brookings Institution, Bruce Siegel, M.D., America’s Essential Hospitals, and Beverley Johnson, Institute for Patient- and Family-Centered Care. Nearly half of the sessions focused on issues in research and evidence. The Director’s Award for Outstanding Research was presented to Robinson et al. for their study of the use of reference pricing in the California Public Employees’ Retirement System, which led to large cost savings for colonoscopies.
- AHRQ has been moving its offices from Gaither Road to the refurbished Parklawn Building on Fishers Lane in Rockville.
- AHRQ’s Steven Cohen, Ph.D., retired as Director of the Center for Financing, Access, and Cost Trends. Joel W. Cohen, Ph.D., has become the Center’s new Director, and Doris Lefkowitz, Ph.D., has become the Center’s new Associate Director. Thomas Selden, Ph.D., has become Director of the newly formed Division of Social and Economic Research and Modeling and Simulation. Arlene S. Bierman, M.D., has become the new Director of the Center for Evidence and Practice Improvement.
- In September, AHRQ held a meeting with insurance industry representatives and third-party vendors to discuss price transparency. They sought to understand the information on out-of-pocket costs and quality of services that is available to consumers. Nearly all large insurers provide some information on expected out-of-pocket costs. Small insurers face greater challenges in providing such information, which is not yet widely used. The availability of useful information on quality remains limited.
- The CAHPS team is developing a rigorous scientific method to elicit narrative information from patients on their experiences of care.
- Dartmouth College, the National Bureau of Economic Research, and RAND are receiving AHRQ grants to operate centers to study the dissemination of patient-centered outcomes research (PCOR). The centers will identify characteristics of health systems that successfully disseminate and apply evidence from PCOR.
- AHRQ is developing an analysis of the percentages of physicians working in health systems in the States. The analysis considers, for each State, the presence of one or more hospitals that manage community physicians.
- AHRQ’s EvidenceNow program features $112 million in grant awards to support seven regional cooperatives in 12 States. It seeks to help 5,000 primary care physicians to improve heart health for some 8 million patients. All seven cooperatives are now engaged. Practices are being recruited. Oregon Health & Science University will conduct an evaluation of the initiative.
- The USPSTF produced a long list of final recommendations and draft recommendations during the past 4 months. Topics for final recommendations included screening and supplementation for iron deficiency anemia in pregnant women and screening for high blood pressure in adults. Topics for draft recommendations included screening for vision impairment in adults and screening for adult depression. Upcoming draft recommendations include screening for syphilis and screening for skin cancer.
- The EPCs continued to produce systematic reviews, methods reports, and technical briefs. Topics included behavioral programs for diabetes mellitus and environmental cleaning for the prevention of healthcare–associated infections.
- AHRQ is supporting the development of a new model for kidney-paired donation. The program is modest, but, if adopted at the national level, could reduce financial barriers to kidney-paired donation and facilitate more than 1,000 additional transplants each year.
- Fast Stats, a new online tool, is allowing users to analyze State data on hospital discharges by providing data on numbers of discharges paid for by Medicare, Medicaid, and private insurance. It draws on data from HCUP.
- AHRQ’s National Center for Excellence in Primary Care Research is providing coordination of primary care efforts throughout the agency. It fosters collaboration among AHRQ staff members and serves as a point of contact for the primary care community. AHRQ investments in primary care include the EvidenceNow program, the Centers of Excellence for Comparative System Performance, the primary care transformation grant initiative, and the primary care Practice-Based Research Networks.
Regarding the meeting about price transparency, Ms. Rexford suggested investigating a successful program in New York (Fair Health) and prioritizing issues in delivering cost and quality information to patients. Dr. Kronick noted that a recent AHRQ-funded effort to develop measures for cost and quality caused some States to examine their practices and improve their collections of hospital discharge data.
Dr. Montori cited the ongoing challenge of consumers who do not use the data. Perhaps they do not shop for health care in the manner of customers. Paul E. Sherman, M.D., M.H.A., CPE, FAAP, added that some experts discourage the idea of having health care consumers use such data. Improper assumptions might be made (e.g., is the surgery necessary?). Shari Davidson noted that some large employers are working with transparency vendors, leading to patients making calls and obtaining information and links to possible actions.
Dr. Montori cautioned that transferring the work of finding care to the patients and families may be overwhelming for some. Dr. McGlynn agreed, suggesting that patients and families should not have to shop. Perhaps, added Dr. Ginsburg, it would be more productive to shift responsibility to medical institutions.
Referring to the AHRQ analysis of physicians working in health systems in States, the NAC members agreed that the word "systems" needs to be better defined.
Regarding the EvidenceNow program, it was suggested that the cooperatives work with Quality Improvement Organizations. Paul E. McGann, M.D., stated that offering resources to clinicians is a new reality. But that must be done carefully. Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R., wondered how to sustain the promise of primary care extension programs and assistance. How do we invest for the long term? Can Dartmouth College, RAND, and the National Bureau of Economic Research develop evidence?
Regarding the HCUP Fast Stats data, Dr. Ginsburg suggested that the tool should allow a greater capacity for users to construct tables.
Ms. Matyka stressed the need to bring the ideas of patients into research programs. J. Sanford Schwartz, M.D., suggested that basic research be included in all programs.
Ms. Davidson noted that employer health care organizations have not yet embraced the medical home idea. How might AHRQ forward information to them?
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement, AHRQ
Dr. Bierman presented an overview of AHRQ’s efforts in the area of health information technology (IT). Since 1968, AHRQ and its predecessor agencies have funded research grants and contracts to:
- Assess the effectiveness of new health IT solutions.
- Evaluate the impact of health IT on quality and safety.
- Work to ensure that evidence is understood and used in practice.
Dr. Bierman referred to the three main activities of AHRQ, as listed by Dr. Kronick. The agency’s portfolio of health IT research addresses the following areas: telehealth, health information exchange, personal health records, e-prescribing, clinical decision support, learning health systems, patient safety, primary care research, and learning health communities.
One new effort is the Electronic Data Methods Forum, which supports a learning network of researchers, clinicians, and informatics experts. It sponsors collaborations to improve data quality, establishes best practices, and more. Its patient-centered portable consent project led to an e-consent module, which is present in the first five apps of Apple’s new ResearchKit. The forum publishes an online journal, eGems, featuring papers that can be downloaded.
Other health IT activities at AHRQ include ImproveCareNow, an inflammatory bowel disease registry, Project Echo, a teleconsultation platform to provide clinical support to rural primary care physicians, and a very new initiative to use clinical decision supports to increase the uptake of PCOR. Areas being addressed include the following: patient-reported outcomes, patient-generated data, care coordination and integration, population health management, patient safety, and support for learning communities.
Ms. Rexford encouraged the Center to include patients in its meetings and discussions. She cited the difficulties that occur when transferring from system to system. Mary D. Naylor, Ph.D., R.N., FAAN, raised the issue of population health management for patients with complex health problems, stressing that it should be considered a process.
Dr. Weissberg encouraged the center to consider the “green button” search-and-management technology developed at Stanford University, which identifies patients with conditions similar to that of a patient under consideration.
Dr. Crosson asked about interactions with vendors. Dr. Bierman responded that the Center will include consideration of vendors and address both built-in and customizable technologies.
Dr. Montori spoke for the potential integration of the health care systems around the patient. He encouraged the center to focus on what can be done for the individual. We need basic science on the clinical activities. David Atkins, M.D., M.P.H., added that the scope is large. What constitutes health IT? Private sector activity is rapid. We need to address cross-cutting activities. Today we actually have computer-centered care. How is technology affecting communication? The area of patient-reported outcomes becomes health IT because of mobile phones. How might technology create a better model of care?
Dr. Weissberg noted that the health outcomes survey asks general questions and produces data. What should be done with that data? Dr. McGlynn stated that clinical workflows vary a great deal. There is a need for customizable technologies. Perhaps we should focus on patients with complex multiple chronic diseases. Dr. Naylor noted that resources change with medical conditions. Care transformation is important. Dr. Schwartz encouraged the development of tools that can translate to actions.
Ann L. Hendrich, Ph.D., R.N., FAAN, stated that many collected data will not lie within a traditional definition of a medical record. We must ask how information connects to the medical record—and consider measurement. Dr. Atkins suggested answering the question of the functionality of a successful app. Charles J. Rothwell, M.B.A., M.S., encouraged work on interoperability of tools.
Erin Holve, Ph.D., of AcademyHealth, proposed that AHRQ can help create an understanding of the idea of "system" regarding the use of health IT and the desire for effectiveness. What is the role of apps? How does evidence matter? She stressed the need to understand interoperability and to determine how systems work together.
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends, AHRQ; Jessica Banthin, Ph.D., Deputy Assistant Director, Health, Retirement, and Long-Term Analysis Division, Congressional Budget Office; Chapin White, Ph.D., Senior Policy Researcher, RAND Corporation; and Genevieve Kenney, Ph.D., Co-Director, Health Policy Center, Urban Institute
Dr. Cohen introduced a session on MEPS, a family of three main surveys which sample, respectively, the household, the medical provider, and patient insurance. He described aspects of the three surveys. The household component samples the U.S. noninstitutionalized population. The medical provider component is a gold standard for expenditure estimates. The insurance component surveys 40,000 employer establishments.
MEPS offers assistance to Congress in evaluating coverage trends and costs. Dr. Cohen noted that MEPS data have been used to support efforts in health care reform. He gave the example of its use to establish a small employer tax credit and the example of its use in studies of drug safety. The American Association for Public Opinion Research gave an award in 2008 to MEPS/AHRQ for its effort to contribute timely data to inform U.S. health care policy.
Dr. Banthin described the Health Insurance Simulation Model (HISIM) of the Congressional Budget Office. Its first version was developed in 2005 to model proposals for expanding coverage. It addressed direct subsidies, changes to tax incentives, and insurance market reforms. The model has been expanded and updated through the years and was used, in particular, to make estimates for the Affordable Care Act. It uses data from the MEPS household and insurance component, in addition to surveys.
HISIM can model effects on the Federal budget into the future and changes in coverage by source of coverage. By simulating behavior for the individual and family units, the estimates capture the distribution of responses rather than average response by cell or subgroup. The estimates better reflect outcomes under new policies.
Dr. White described the power of using MEPS to reveal trends in spending on medical care. He noted RAND’s new Payment and Delivery Simulation Model, which produces profiles of health care utilization and prevalence of capitation and relies to a large extent on MEPS data. Dr. White praised MEPS for being comprehensive, longitudinal, free, de-identified, and documented.
Dr. Kenney described the use of MEPS data in products of the Urban Institute. The Institute employs a microsimulation model to gauge effects of the Affordable Care Act and other health reform proposals and to support research on preventive care, health care spending trends, uncompensated care, costs of dependent coverage, out-of-pocket spending on health care, and prescription drug spending. It has used the data to project changes in health care spending for low-income uninsured adults who gain Medicaid coverage. It has used the data to reveal trends in the receipt of preventive care. The Institute has used MEPS data in evaluations of the potential impacts of people losing insurance coverage because of a lack of tax credits and the potential rise in out-of-pocket premiums for children losing Children’s Health Insurance Program (CHIP) support.
Dr. Kronick suggested that the NAC members develop ideas for making the MEPS data even more useful. Others proposed making MEPS more useful as a tool, as in offering tables that users can customize more easily and offering ways of making unique tables. Dr. DeVoe stated that presenting out-of-pocket expenditures more often would be helpful. Dr. Cohen noted that the program has some methodological explorations in that area but does not collect data on over-the-counter expenditures. Drs. Weissberg and Montori and Mr. Rothwell encouraged the MEPS program to develop illustrative stories about the impacts of changes in insurance/CHIP, to help increase the response rates for MEPS data collection.
Elizabeth A. McGlynn, Ph.D., Institute of Medicine, and Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ
Dr. McGlynn, NAC Chair, reviewed the results of a large study, conducted by the Institute of Medicine (IOM), on reducing diagnostic errors. The study was published as "Improving Diagnosis in Health Care." It evaluated diagnostic error as a quality-of-care challenge and examined the epidemiology, burden of harm, economic costs of error, and efforts to address the problem. The study addressed the following eight goals toward reducing diagnostic errors: facilitating more effective teamwork; enhancing professional education and training; ensuring the support of health IT; developing approaches to identify, learn from, and reduce errors; establishing a work system and culture; developing a reporting environment and liability system; designing a payment and care delivery environment that supports the diagnostic process; and providing funding for research.
It produced recommendations for each of the eight goals, including the following:
- Health care organizations should ensure that health care professionals have the appropriate knowledge, skills, resources, and support to engage in teamwork in the diagnostic process.
- Educators should ensure that curricula and training programs across the career trajectory address performance in the diagnostic process and include evidence from the learning sciences.
- Health IT vendors and the HHS Office of the National Coordinator for Health IT should work together with users to ensure that health IT used in the diagnostic process has usability, incorporates human factors knowledge, integrates measurement capability, fits well in the clinical workflow, and more.
- Accreditation organizations and the Medicare Conditions of Participation should require that health care organizations monitor the diagnostic process, identify errors, and provide systematic feedback.
- Health care organizations should promote a nonpunitive culture that values open discussion and feedback on diagnostic performance.
- AHRQ and others should encourage and facilitate the voluntary reporting of diagnostic errors and near misses.
- The Centers for Medicare & Medicaid Services and other payers should provide coverage for evaluation and management activities, reorienting value fees for time spent on those activities.
- Federal agencies should develop a coordinated research agenda on the diagnostic process and diagnostic errors.
Dr. Brady described AHRQ initiatives to improve diagnostic safety. He described diagnostic error issues, such as the fact that diagnostic error is notoriously difficult to measure and define. Diagnosis is not an event. It often is an evolving process encumbered by uncertainty and fragmentation. Dedicated funding for diagnostic error projects at AHRQ has been modest during the past dozen years. In addition to AHRQ-supported research on diagnostic quality, the agency offers a toolkit for rapid-cycle patient safety and quality improvement, a guide to patient and family engagement, and the TeamSTEPPS® training program.
Dr. Montori cited the difficulty of defining diagnostic problems and the potential to overreact, to overdiagnose. We need to understand multiple aspects, the effects of consultation time, and the downstream consequences of diagnostic errors, which are complex. Dr. Weissberg agreed especially on a need to specify the timing of steps in the diagnostic cycle. Ms. Davidson noted that many large employers have programs that support second opinions. In those cases, about one third of diagnoses are changed.
Ms. Rexford applauded the fact that the IOM report addressed both patients and patients’ families. Where should team-based care come in? Is it a problem or a solution? Dr. McGlynn suggested that the report developers considered team-based care to be part of a solution to diagnostic error. Team-based diagnosis is part of team-based care. Training and culture related to team-based skills are a key. New analytic tools will be helpful.
Dr. Haley agreed on a need to consider overdiagnosis and overtesting. He raised the issue of the different effects of different care settings. Dr. Atkins stressed that there is an interaction among three main issues—diagnosis, treatment, and the time relationship. He proposed a focus on constellations and how factors are related as they play out. We need longitudinal data on diagnostic error, and we need to determine error rates. Researchers might study how overtesting can lead to unintended harmful diagnostic consequences. In addition, they could evaluate cases in which a patient leaves the physician’s office less than sure about a diagnosis, never to return.
Dr. DeVoe stated that ethnographic assessment plays a role. We need to determine the characteristics of deviations and pathways, perhaps by using IT methods and multidisciplinary collaborations. Dr. Naylor proposed creating a case study of system improvement and considering frailty/functional decline and behavioral health.
David Newman-Toker, M.D., Ph.D., of the Society to Improve Diagnosis in Medicine, stated that his society is a supporter of the IOM diagnostic report. It has received funds from AHRQ to support an annual conference on diagnostics. The society is focusing on three goals from the IOM report—goal 6 concerning improving learning from diagnostic errors and developing a common format and local reporting, goal 8 concerning coordinated diagnostic safety research and a supporting agenda, and goal 8, providing dedicated funding in diagnostic processes and errors. The Society encourages AHRQ to support the diagnostic safety research agenda.
Dr. McGlynn asked the NAC members for final comments and suggestions for the next meeting agenda.
- Ms. Matyka stated that it was an honor and privilege to serve on the Council. She encouraged AHRQ/researchers to include the advocate perspective in all levels of research.
- Ms. Rexford agreed and proposed the inclusion of more patient/public members.
- Dr. Haley thanked ARHQ for the opportunity to serve on the Council. He encouraged AHRQ to strengthen its focus on training.
Drs. McGlynn and Kronick thanked the NAC members, speakers, and other guests, and adjourned the meeting.
Elizabeth A. McGlynn, Ph.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality