Meeting Minutes, April 2019
National Advisory Council
Contents
Summary
Call to Order and Approval of November 15, 2018, Meeting Summary
AHRQ Accomplishments
Budget Update
Director's Vision Update
NAC Member Discussion
Public Comment
Wrap-Up and NAC Input
Adjournment
Summary
NAC Members Present (Webex)
Andrew L. Masica, M.D., M.S.C.I., SFHM, Baylor Scott & White Health (Meeting Chair)
Karen S. Amstutz, M.D., M.B.A., Magellan Healthcare
Cathy J. Bradley, Ph.D., M.P.A., University of Colorado School of Public Health
Beth Ann Daugherty, M.P.H., R.N., Sparrow Clinton Hospital
Barbara A. Fain, J.D., M.P.P., Betsy Lehman Center for Patient Safety
Sally C. Morton, Ph.D., M.Sc., M.S., Virginia Tech
Jerry L. Penso, M.D., M.B.A., American Medical Group Association
Alternates Present (Webex)
David Atkins, M.D., M.P.H., Veterans Health Administration (accompanied by Naomi Tomoyasu, Ph.D., Veterans Health Administration)
Michael Lauer, M.D., National Institutes of Health
AHRQ Staff Members Present
Gopal Khanna, M.B.A., Director
Virginia L. Mackay-Smith, Associate Director
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Francis D. Chesley, Jr., M.D., Acting Deputy Director
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
Lucie M. Levine, Chief Financial Officer
David Meyers, M.D., Chief Medical Officer
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of November 15, 2018, Meeting Summary
Andrew L. Masica, M.D., M.S.C.I., SFHM, meeting chair, welcomed the NAC members, who were participating via the Webex system, AHRQ speakers, other AHRQ staff, and other guests. He referred to the draft minutes of the previous NAC meeting (November 15, 2018) and asked for changes and approval. The NAC members voted unanimously to approve the November meeting minutes with no changes.
AHRQ Director Gopal Khanna reviewed the meeting agenda and introduced Virginia Mackay-Smith, who was recently appointed as Associate Director, Office of the Director, AHRQ.
AHRQ Accomplishments
Virginia L. Mackay-Smith, Associate Director, AHRQ
Ms. Mackay-Smith reviewed recent AHRQ findings and activities:
- AHRQ’s National Scorecard on Hospital-Acquired Conditions (HACs) revealed that reductions in HACs helped prevent 20,000 hospital deaths and save $7.7 billion in healthcare costs from 2014 to 2017.
- New reports on updated statistics from the Medical Expenditure Panel Survey (MEPS) and the Healthcare Cost and Utilization Project (HCUP) helped to quantify opioid use, hospitalizations, and emergency department visits for older adults. For example, in 2015-2016, about 10 million elderly adults filled at least 1 opioid prescription and about 4 million elderly adults filled 4 or more opioid prescriptions.
- An AHRQ-funded study, reported in The BMJ, stated that nearly a quarter of the 15.5 million antibiotic prescriptions filled in 2016 by a population of 19.2 million privately insured U.S. children and adults younger than 65 were unnecessary. AHRQ is supporting development of an evidence-based toolkit focused on prescribing.
- AHRQ’s CDS Connect program has grown and now includes an interoperable pain management summary that extracts relevant factors from patient electronic health records. The factors include medical history, pain assessments, historical treatments, and risk considerations. The CDS Connect progprogram demonstrates how evidence-based care can be more rapidly incorporated into clinical practice through decision support. AHRQ is funding a pilot project to bring U.S. Preventive Services Task Force (USPSTF) recommendations to patients.
- AHRQ released the new EvidenceNOW Tools for Change, an online collection of more than 100 tools and resources to help primary care practices improve quality by providing evidence-based care.
- AHRQ began distributing its new “QuestionBuilder” app, a digital tool that:
- Prepares and organizes potential questions for use in medical encounters.
- Allows a user to take photos of insurance cards, pill bottle labels, and more.
- Saves the information to a calendar of appointments or forwards to an email address.
In discussion, Dr. Masica noted that the recent accomplishments track with the current main priorities for the Agency (opioid abuse, patient engagement/decision support, etc.). Ms. Mackay-Smith and Director Khanna agreed and stated that this trend will continue, as AHRQ builds on its programs and expertise while pivoting to new needs.
Jerry L. Penso, M.D., M.B.A., referred to the EvidenceNOW project and wondered whether it has collected data on the audience, including its utilization of the program’s tools. David Meyers, M.D., responded that the Agency will be examining such trends in the near future.
Budget Update
Lucie M. Levine, Chief Financial Officer, AHRQ
Ms. Levine reviewed the President’s proposed fiscal year (FY) 2020 budget for AHRQ:
- The FY 2020 budget proposal features a transitioning of AHRQ to become an institute within the National Institutes of Health. Its new name would be the National Institute for Research on Safety and Quality.
- The proposed budget for the Agency (or institute) is $256 million, a decrease of $82 million from AHRQ’s enacted FY 2019 budget.
- The total FY 2020 request no longer includes funds from the Patient-Centered Outcomes Research Trust Fund, which totaled $113 million in FY 2019. The total FY 2020 program level request therefore amounts to a decrease of $195 million.
- The proposed 2020 budget includes $65 million for patient safety research (that includes $32 million for preventing HACs), $57 million for health services research, data, and dissemination, and $43 million for investigator-initiated research.
- The proposal features a $4.5 million research contract to accelerate evidence on preventing and treating opioid abuse in primary care, especially in older adults. The figure is a $1.5 million increase.
- Research in health information technology will compete for funding opportunities within the patient safety and research/data/dissemination spheres.
- The USPSTF will receive $7.4 million, a decrease of $4.2 million from the previous year. That will reduce the number of USPSTF recommendations to be made.
- The budget proposes an increase in funding for the MEPS—to $71.8 million. That will allow for increases in sampling and the redistribution of results.
- The proposed budget for research management and support is $53.6 million, a decrease of $17.7 million. This assumes that, in transitioning to the NIH, AHRQ will eliminate some of its current support activities.
Ms. Levine reported that AHRQ has commissioned an independent, congressionally requested study of health services and primary care research. This project will assess the current breadth, scope, and impact of health services research and primary care research that is supported by the Department of Health and Human Services (HHS) and the Department of Veterans Affairs (VA). It will identify research gaps and make recommendations for maximizing outcomes, value, and impact of the investments in going forward. It will consider strategies for coordination and consolidation of research agendas. The study’s report is expected in September.
In discussion, Dr. Masica asked about the timing for review and completion of the FY 2020 budget process. Ms. Levine responded that AHRQ representatives are visiting the House and Senate committees right now to answer questions about the AHRQ budget. Markups likely will begin in May. The conference process will occur weeks after that. The final budget likely will be realized sometime after September.
Director's Vision Update
Gopal Khanna, M.B.A., Director, AHRQ
Director Khanna reviewed AHRQ’s role in Federal support for the U.S. health system, stressing its emphasis on research into the administering of care. While science and research to discover cures are needed, we also need science, research, and implementation that seeks to improve care. AHRQ works to improve the lives of patients (the “why”), having an aim of increasing care that is safe and of high quality and value (the “what”), and utilizing health systems research, practice improvement, and data/analytics (the “how”).
AHRQ is working to increase capacity of resources, address HHS priorities, and support innovations. It is offering foundational work in health systems research, practice improvement, operations, and data/analytics. AHRQ has team leads and cross-agency workgroups that are responding to the HHS Secretary’s priorities in drug pricing, opioids, value-based transformation, and health care reform.
Director Khanna listed some future challenges:
- The need to support initiatives that identify significant problems and bold solutions.
- The need to create programs and implementation plans to achieve goals over time.
- The need to ensure that AHRQ’s initiatives in quality, safety, and value leverage its competencies and build on its foundational work.
Director Khanna asked three AHRQ directors to speak on the Agency’s efforts in, respectively, quality, value, and safety.
Quality: Transforming Care for People With Multiple Chronic Conditions
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement
Dr. Bierman described efforts to address problems and issues for people with multiple chronic conditions. Nearly one in three American adults and four in five Medicare beneficiaries live with multiple chronic conditions. There is a mismatch between the way care is delivered (disease specific) and such patients’ needs. As a result, care is fragmented and of suboptimal quality. That leads to poor outcomes and increased costs. Patients with multiple chronic conditions account for 64 percent of clinician visits, 70 percent of in-patient stays, 83 percent of prescriptions, and 71 percent of all healthcare spending. AHRQ seeks to foster a sustainable healthcare system that delivers high-value, coordinated, integrated, patient-centered care. It seeks to prevent and manage effectively multiple chronic conditions.
Dr. Bierman referred to the Care and Learn model, which addresses the intersection between care protocols and learning from the execution of those protocols. AHRQ is using the model to help prioritize its investments. Dr. Bierman described AHRQ’s new 5-year agenda for addressing multiple chronic conditions. It draws on unique AHRQ resources and competencies as it attempts to do the following:
- Support real-world research to develop, implement, and evaluate effective models of care.
- Develop and use new data-driven tools of informatics to enhance care coordination and deliver 360-degree, whole-person, patient care.
- Disseminate and implement nationwide, using learning collaboratives and other vehicles.
The Agency also is seeking to improve care coordination and integration by developing interoperable e-care plans, developing a playbook and tools for integrating behavioral health with primary care, and addressing screening and management of unhealthy alcohol use. It is seeking to improve patient-centeredness in care by advancing the use of patient-reported outcomes and funding a study on data analytics to improve chronic disease management.
AHRQ hopes to increase value by reducing the use of acute and institutional care, eliminating duplication of services, and reducing adverse events resulting from conflicting management. It will develop and foster measures of success.
Value: Powering Decision Making Through Analytics
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
Dr. Cohen described AHRQ efforts in data and analytics. He recognized a major problem—decisionmakers often lack access to timely, reliable data and analytics with which to make informed policy and operational decisions. Unintended and undesirable consequences can result. AHRQ has a 5-year agenda to attack the problem. This includes establishing an integrated data, analytics, and information platform with the technical expertise required to capture a 360-degree view of the healthcare system. Elements of such a program are:
- Predictive analytics teams to address emerging policy issues.
- State partnership platforms for State and local data and analytics.
- A national platform for small-area social determinants of health data and analytics.
- National databases of physician practices and organizations.
- Expansion of the MEPS sample to enhance capacity for State estimates.
AHRQ chartered a cross-agency data enterprise working group. It has developed a Federal database of social determinants of health. The Agency intends to increase the capacity of policymakers and program makers to:
- Make more timely responses to complex policy questions.
- Make better predictions regarding health care access, costs, and outcomes.
- Improve the 360-degree understanding of the healthcare system.
- Improve State-specific estimates.
- Monitor, track, and fine tune state programs.
- Understand programs related to costly and policy-relevant populations.
Safety: Improving Diagnosis
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Dr. Brady described AHRQ’s current efforts to improve diagnosis, that is, to reduce diagnostic errors in U.S. healthcare. About 12 million U.S. citizens experience a diagnostic error each year. More than 4 million U.S. citizens each year suffer severe consequences as a result of diagnostic errors and delays. To solve that problem, AHRQ is seeking to support and promote patient safety strategies, predictive analytics, personalized and precision medicine, and new technologies. It is investing in research to improve diagnosis in each of the “Big Three” conditions: cancer, vascular events, and infections. It is developing, testing, and disseminating tools to apply strategies at the point of care. It is encouraging advancements in data collection and use. AHRQ’s Action Network is playing a key role.
Particular initiatives include the following:
- Offering new grant research opportunities, including patient safety learning laboratories with emphasis on diagnostics and a health services research project to enable diagnostic excellence.
- Leading a Federal interagency workgroup on diagnostic safety and quality.
- Creating the “QuestionBuilder” app to help patients and caregivers prepare and organize questions and information relating to conditions and medical visits.
- Featuring a diagnostic safety microsite at the AHRQ website.
Dr. Brady stated that the Agency’s goal is to reduce the rate of diagnostic errors occurring each year in the United States by 1 million per year by 2025—a very significant reduction in patient and family harm. A reduction of 1 million diagnostic errors in 1 year would potentially result in a savings of $500 million in spending.
NAC Member Discussion
Dr. Masica began the open discussion by listing themes that arose during the presentations. He asked NAC members to consider whether AHRQ’s goals are on track and whether the areas for investing resources are correct. What steps should be taken? He further asked them to consider the following questions:
- How do you see this vision addressing the needs of the American people and AHRQ’s stakeholders for improved care and care delivery?
- What challenges might AHRQ encounter in moving the initiatives (quality, value, safety) forward and how can the Agency best mitigate them?
- Within the initiatives, what additional opportunities are there for further increasing AHRQ’s impact?
- What opportunities do you see within your own organizations and networks to advance the goals of the initiatives?
Dr. Penso cited his organization’s collaborative work with high-risk, high-cost patients with chronic conditions. He asked whether AHRQ might address segmentation within populations regarding multiple chronic conditions. How should outcomes be measured? Dr. Bierman responded that there is a challenge to identify generic aspects in models. It will be important to learn as we go along, especially about separate groups or constellations.
Dr. Penso asked Dr. Brady about issues of overdiagnosis and underdiagnosis as well as timeliness. Are those issues being addressed? Dr. Brady responded that they are. Balance is a key, such as in antibiotic stewardship, and we must get that right. Dr. Masica raised the idea of professional culture changes as they relate to diagnostic error. Dr. Brady noted that AHRQ has considered that area and has added supplemental items in its patient safety culture survey. Cultural aspects drive decision making. Moving from the conceptual to the operational is not trivial. The transition often involves measurement and the use of data. How does culture become different? How is it assessed? How do we measure teamwork, strategies of communication, and feedback loops? These are complex. What data systems will be most helpful? Electronic health records have potential. We can derive wisdom from the field, as from physicians. Some organizations have made progress in that area.
Dr. Masica added that there is an evidence gap relating to the setting of specific goals. What goals might a healthcare system build into its annual plan? That is a gap that AHRQ might address. Dr. Brady suggested that some ideas are ready for implementation, for example, measurement of laboratory test followups and the actions taken.
Dr. Masica raised the issue of payments. How do we manage the population with multiple chronic conditions? What is AHRQ’s role? How do we use data? Dr. Bierman responded that AHRQ does not focus on payment models. It seeks good care—and quality and safety—within such structural constraints. We need integrated systems that better recognize conditions for optimal care.
Dr. Cohen added that issues of payment methods are addressed mainly by the Centers for Medicare & Medicaid Services (CMS). However, AHRQ at times has advised CMS on methodologies and data. AHRQ can provide CMS with certain information on activities of health care systems. HCUP data are an example. AHRQ thereby can have an indirect effect on payment issues.
David Atkins, M.D., M.P.H., suggested that AHRQ partner more with the VA in the areas of diagnostics and multiple chronic conditions. Focusing on high-cost patients does not necessarily save money. Care coordination and patient centeredness are important. Many different models of care can be used. We need more approaches to look at specific subpopulations. Work at the VA has shown that segmenting in certain ways does not ensure improvement. Dr. Bierman suggested collaborating in a program with a strategy like that of Care and Learn.
Dr. Masica raised the issue of workforce development and capacities. Dr. Meyers cited the continuing need for AHRQ to build the next generation of researchers (e.g., through K-awards) and to embed researchers in healthcare systems. AHRQ has been working with the Patient-Centered Outcomes Research Institute in those areas.
Dr. Masica asked about efforts addressing priority populations. Francis Chesley, M.D., responded that such AHRQ programs are ongoing. They include support for research on social determinants, and they are parts of the programs for priority topics that have been discussed in this meeting. For example, various efforts in safety and in data/analytics address priority populations.
Dr. Masica asked about designs for moving the results, or best practices, from learning collaboratives to adoption. Dr. Bierman suggested that AHRQ could play a larger role. Right now it is rolling out a national initiative to increase the uptake of cardiac rehabilitation strategies. Perhaps the NAC could provide guidance on how to proceed with such efforts effectively. Dr. Brady noted that he serves on a national steering committee that has touched on learning health systems and supported patient safety practices.
Barbara A. Fain, J.D., M.P.P., reported that her organization is engaged in a collaborative project that will help to create a diagnostic error taxonomy. It has surveyed the State of Massachusetts and is analyzing narrative responses regarding diagnostic errors and delays. It has identified a pool of individuals who have experienced diagnostic errors.
Beth Ann Daugherty, M.P.H., R.N., emphasized that rural health care institutions support the work in diagnostic errors and multiple chronic conditions. They seek ways to collaborate within State and local programs to bring findings into rural care. Elderly populations and the use of tools (as in informatics) remain a challenge. Sally C. Morton, Ph.D., M.Sc., referred to challenges in partnerships in the area of data collection and analysis. She applauded AHRQ’s momentum in moving forward in that arena.
Public Comment
There were no public comments.
Wrap-Up and NAC Input
Dr. Masica proposed, as topics to be addressed in upcoming NAC meetings:
- AHRQ’s support for the standardization of data.
- The addition of pragmatic elements (including timelines) to AHRQ’s goals and issues.
He asked the NAC members to forward any additional ideas and questions to Ms. Zimmerman at AHRQ staff headquarters.
Adjournment
Dr. Masica and Director Khanna thanked the NAC members and AHRQ presenters and noted that the next meeting will take place on July 24. Dr. Masica adjourned the meeting at 1 p.m.
Respectfully submitted,
Andrew L. Masica, M.D., Meeting Chair
National Advisory Council
Agency for Healthcare Research and Quality
