Meeting Minutes, November 2019
Call to Order and Approval of July 24, 2019, Meeting Summary
Challenges and Opportunities To Leverage AHRQ’s CDS Connect To Improve Care
Gaps and Opportunities To Improve Care: Special Focus on Social Determinants of Health
Wrap-Up and Adjournment
NAC Members Present
Donald A. Goldmann, M.D., Institute for Healthcare Improvement, Harvard Medical School (Chair) (by teleconference)
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, University of Missouri
Beth Ann Daugherty, M.P.H., R.N., M.P.H., Sparrow Clinton Hospital
Peter J. Embi, M.D., M.S., FACP, FACMI, Regenstrief Institute
Barbara A. Fain, J.D., M.P.P., Betsy Lehman Center for Patient Safety
Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, MedStar Health
Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine
Charles N. Kahn III, M.P.H., Federation of American Hospitals
George Kerwin, M.B.A., Bellin Health (retired)
Andrew L. Masica, M.D., M.S.C.I., Baylor Scott & White Health (meeting chair)
Sally C. Morton, Ph.D., M.Sc., M.S., Virginia Tech
Jerry L. Penso, M.D., M.B.A., American Medical Group Association
Edmondo J. Robinson, M.D., M.B.A., M.S., Christiana Care-Wilmington
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Ex Officio Members and Alternates Present
David Atkins, M.D., M.P.H., Veterans Health Administration
Shari M. Ling, M.D., Centers for Medicare & Medicaid Services (for Kate Goodrich)
Robin M. Wagner, Ph.D., Centers for Disease Control and Prevention (for Chesley Richards)
AHRQ Staff Members Present
Gopal Khanna, M.B.A., Director
David Meyers, M.D., Chief Medical Officer
Virginia L. Mackay-Smith, Associate Director (via telephone)
Lucie M. Levine, Chief Financial Officer
Edwin Lomotan, M.D., FAAP, Health IT Division
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Andrew L. Masica called to order the meeting of the National Advisory Council (NAC), of the Agency for Healthcare Research and Quality (AHRQ), at 8:30 a.m. He was substituting for NAC Chair Donald A. Goldmann, who joined the meeting by phone. Dr. Masica welcomed the NAC members, other participants, visitors, and webcast viewers. He noted that the following NAC members would be rotating off the council after this meeting: Sheila P. Burke, Barbara A. Fain, Donald A. Goldmann, George Kerwin, Sally C. Morton, Jerry L. Penso, and Yanling Yu. He asked the attending NAC members to introduce themselves.
Dr. Masica referred to the draft minutes of the previous NAC meeting (July 24, 2019) and asked for changes and approval. The NAC members voted unanimously to approve the July meeting minutes with no changes.
AHRQ Director Gopal Khanna also welcomed the NAC members and other participants. He presented the day’s agenda, which featured sessions on challenges and opportunities for AHRQ in two important areas—clinical decision support and social determinants of health. He referred to reorganization that is occurring in the Agency and asked the NAC members to consider three concerns as AHRQ aligns its expertise and positions itself for the future:
- How to apply AHRQ’s subject matter experts and tools in engaging medical practitioners.
- How to align AHRQ’s efforts with the DHHS management agenda presented by President Trump.
- How to optimize AHRQ assets and resources.
Director Khanna reported the following news about the Agency’s staff:
- David Meyers was appointed Acting Deputy Director of AHRQ. He also was chosen to be a member of the National Academy of Medicine, with a recognition of his executive leadership in AHRQ’s research functions and in directing the Agency’s primary care and practice transformation research portfolios.
- Mamatha Pancholi was appointed AHRQ’s Chief Data Officer.
Director Khanna expressed thanks to the seven NAC members cycling off the council, citing their contributed ideas and service. Dr. Goldmann responded by thanking the Director for his openness and curiosity.
Virginia L. Mackay-Smith, Associate Director, Office of the Director, AHRQ
Ms. Mackay-Smith reported on recent AHRQ activities in its main efforts to advance health systems research, practice improvement, and data and analytics.
- AHRQ has developed a 3-year, $6 million grant program (three grants) to promote health equity and improve the health of at-risk individuals and populations. The projects will integrate data on chronic diseases, social needs, and community services. They will create actionable dashboards that can be used to match primary care interventions with patients’ needs and to manage population health.
- AHRQ is supporting a 3-year effort to scale up and spread knowledge about enhancing the use of cardiac rehabilitation. This TAKEheart program will feature two 50-hospital cohorts and interventions to increase cardiac rehabilitation referral and uptake. Recruitment for the first cohort is underway.
- AHRQ has developed a 3-year, $13.5 million grant program (six grants) to reduce unhealthy alcohol use. It features the implementation and evaluation of a number of strategies (screening, medication) involving primary care practices.
- AHRQ’s Academy for Integrating Behavioral Health and Primary Care has developed a document titled “Medication-Assisted Treatment for Opioid Use Disorder Playbook,” which is an updated, searchable compendium of tools and resources.
- AHRQ has instituted a new database within the Healthcare Cost and Utilization Project (HCUP). The Nationwide Ambulatory Surgery Sample makes possible national-level analyses of ambulatory-surgery-related care. HCUP data from emergency departments were used to support predictive analytics on air quality, aiding responses to wildfires in California.
- Analytics from the Medical Expenditure Panel Survey (MEPS) produced updated results indicating continuing declines in the percentages of eligible private-sector employees who are enrolled in health insurance at establishments that offer it.
- A study using MEPS data showed that, while rural residents receive mental health medications at rates similar to those of urban residents, the rural residents have fewer than half as many office visits. Access is a substantial problem.
- AHRQ is supporting efforts to create synthetic healthcare data from existing data for use by researchers. The synthetic data maintain statistical properties of original data while protecting the privacy of people and institutions. Many applications are possible.
Lucie M. Levine, Chief Financial Officer, AHRQ
Ms. Levine reported that for FY 2020 AHRQ is operating under a continuing resolution based on the 2019 funding level. The resolution ceases on the day of this meeting. However, a new continuing resolution should be signed by the end of the day. That will ensure a $338 million budget for AHRQ. Ms. Levine suggested that the eventual enacted budget will likely lie between the House mark of $358.2 million and the President’s lower budget request. The Senate has not officially released its mark. Neither the House nor the Senate plans to incorporate AHRQ into the National Institutes of Health.
Dr. Morton asked whether funding from the Patient-Centered Outcomes Research (PCOR) Trust Fund will be forthcoming. Ms. Levine responded that a bill to reauthorize the Trust Fund is scheduled to be considered. The Trust Fund’s contribution to AHRQ has been about $100 million per year.
Dr. Yu asked about the adoption of the Opioid Use Disorder Playbook. Arlene Bierman, AHRQ, responded that the Agency has been considering what will produce the biggest result.
Dr. Yu asked about the scope of the ambulatory surgery sample. Ms. Mackay-Smith responded that the sample is derived from the State databases to produce a national representation.
David Atkins asked whether PCOR Trust Fund money is accompanied by instructions for its use. Ms. Levine responded that the funds are to be used for activities relating to dissemination, implementation, and training. If the PCOR Trust Fund were to cease, AHRQ would continue to support K awards using general funding sources. Dr. Atkins raised the issue of privacy concerns in developing and using the synthetic database. He recommended that AHRQ meet with the Veterans Health Administration to discuss the issue.
Edwin Lomotan, M.D., FAAP, Chief of Clinical Informatics, Health IT Division, AHRQ
Dr. Lomotan described AHRQ’s CDS Connect, an initiative that addresses clinical decision support (CDS), which began in 2016. It has engaged the stakeholder community, created a prototype infrastructure, and supported research and evaluation. It has fostered the translation of knowledge into CDS systems. It has sought to make CDS more evidence-based, shareable, standards-based, and publicly available. CDS Connect is a network with several important aspects. It is a website for discovering shared CDS systems, a platform for sharing CDS artifacts, a set of tools including software, and a community of users and workshop members. Dr. Lomotan asked the NAC members for guidance as the initiative moves forward.
Federal partners in the initiative are the Veterans Health Administration, Centers for Disease Control and Prevention, Office of the National Coordinator for Health Information Technology, and Centers for Medicare & Medicaid Services. Dr. Lomotan presented an example of an online dashboard for a patient undergoing chronic pain management. He described a team that has been created to identify models for sustainability of the program. The team recommended the use of a public-private partnership model. That model will be developed in a phased approach, including defining the mission, developing vision and purpose, recruiting partners, conducting pilots, and realizing full operating capacity. The CDS Connect program will serve as one of the source repositories in a broader knowledge-and-learning network.
Dr. Lomotan asked the NAC members to consider the following questions:
- How should CDS Connect fit into a digital healthcare evidence ecosystem of the future?
- What is AHRQ’s role?
- What do you think of a public-partnership model?
- What are the near- and long-term steps that AHRQ should consider?
Dr. Goldmann praised the program and asked when it might lead to widespread use as a primary resource. Dr. Lomotan responded that the program is serving initially as a kind of library or engine for discovery, with users downloading artifacts. Other services are and will be available. At this point, users are not being tracked.
Peter J. Embi praised the program, noting its attention to key elements: content/data, capabilities, governance/trust, and research/impact. Each of those areas would benefit from a public-private partnership. AHRQ’s primary roles could be to facilitate the convening of partners, to develop tools, and to evaluate the program’s impact.
Charles N. Kahn encouraged the project team to include the U.S. Food and Drug Administration in its planning and oversight. Dr. Lomotan noted that CDS Connect is meant to be a platform for transparency.
Gregory L. Alexander wondered about the project’s translation across healthcare domains and settings, such as acute care. Dr. Lomotan responded that the standards developed likely will be applicable in various domains. The project developers look forward to obtaining feedback and lessons learned.
Dr. Yu encouraged the project team to include tools that make patients and families aware of the content and services. Some population sectors are not very familiar with dealing with Web-based approaches. Perhaps special apps could be created. Dr. Yu also encouraged the team to engage healthcare-related organizations and universities and their curricula.
Mr. Kerwin encouraged the project team to engage software vendors which can bring partners together to help them understand how to use data. They can offer advice on dissemination. Edmondo J. Robinson agreed, noting that AHRQ has a capacity for convening relevant partners.
Dr. Masica pointed to AHRQ’s role in developing evidence and linking it to real-world solutions.
Leith J. States, M.D., M.P.H., Acting Chief Medical Officer, Office of the Assistant Secretary for Health, HHS, David Meyers, M.D., FAAFP, Acting Deputy Director, AHRQ
Dr. States described challenges for U.S. healthcare in the 21st century, beginning with the following major trends:
- U.S. spending on healthcare is about $3.6 trillion, which will rise to about $6 trillion by 2027.
- The United States ranks 28th in life expectancy, 33rd in infant mortality, and 30th in suicide rate among Organization for Economic Development and Cooperation countries.
- About 90 percent of U.S. annual healthcare costs are for people with chronic conditions.
- We will witness enhanced risks from influenza, pandemic influenza, emerging infectious diseases, antimicrobial resistance, sexually transmitted infections, HIV, and vaccine-preventable diseases.
To those trends, Dr. States added the opioid overdose crisis, which now is led by synthetic opioids (fentanyl and fentanyl analogues). The problem of obesity continues, with an estimate that today’s 2-year-old children will advance to an obesity prevalence of nearly 60 percent by age 35. Significant inequalities in U.S. life expectancies exist throughout the Nation. Significantly high rates of infant mortality occur in the Appalachian and Delta regions.
Dr. States referred to a report that suggested health-related behaviors have a stronger influence on health than do genetics, environment, and medical care. Another study found that nearly one-half of U.S. cancer cases are preventable. Nearly one-half of deaths due to heart disease, stroke, and diabetes in the United States could be prevented using simple dietary adjustments. The failure of many Americans to meet suggested levels of aerobic physical activity leads to $117 billion in annual healthcare costs and 10 percent of premature mortality. A study of more than 4,000 individuals aged 65 and older followed for 18 years found that older adults who adhere to four or five healthy behaviors experienced a 60 percent lower risk for developing Alzheimer’s dementia.
Those studies and results support the idea that social determinants can have a long-lasting biological impact on health. Social determinants can change human biology. For example, early experiences can affect the development of brain architecture. Researchers have found environmental factors that trigger chemical changes in the body, activating or silencing genes.
Dr. States noted that President Trump and HHS Secretary Alex Azar are committed to ending the opioid crisis, improving the availability and affordability of healthcare insurance, lowering the costs of prescription drugs, and transforming the U.S. system so that we pay for value in healthcare. As part of a strategic plan, the Office of the Assistant Secretary for Health is helping to transform the current sick-care system into a health-promoting system. In April 2019, the office sponsored a workshop, followed by a published report, on addressing nonmedical health-related social needs to improve population health and reduce healthcare spending. The Healthy People 2020 program includes goals relating to social and physical environments.
Questions and Discussion
Dr. Goldmann asked about efforts in other countries to address social determinants, and he raised the issue of structural racism. Dr. States responded that the Center for Health Innovation has studied efforts in Europe addressing social determinants. We have learned much from research on HIV that has taken place on the African continent. Many issues of racism are multifactorial and lie outside the HHS purview. Dr. Goldmann agreed that the issue is complicated. He suggested that a long-term effort and an attention to vocabulary will be needed.
Dr. Meyers asked the NAC members to offer advice regarding paths that AHRQ might take to address social determinants of health. He asked: What is your organization experiencing? Are you active? What programs and projects are you engaged in? What possible roles could AHRQ assume within the activities of your organization? He stated that organizations such as those represented by NAC members can help to change policies and create new societal structures. He referred to a handout describing current AHRQ efforts. These included the creation of a data platform for national small-area social determinants of health. It is a consolidated set of national standardized databases of reliable social factors that will build on existing databases developed by Federal agencies. Where are the greatest opportunities?
Beth Ann Daugherty stressed the importance and need for excellent nursing care in rural communities, where there often is less access to acute care and tertiary care. We need education, resources, and a generalist nursing care perspective.
Christine A. Goeschel added that within her system (MedStar Health) the social determinants issue is on everyone’s radar. We need to determine what should be disseminated and what is generalizable. We must move beyond the anecdotal and stratify to get to greater patient safety. Community health workers need more answers.
Ms. Fain noted that there is much research on social determinants but also a lack of direction on how to proceed. What are the roles for healthcare providers? Should the emphasis be elsewhere, rather than on them? We need to bring voices, including those of vulnerable populations, to the table and to build community.
Dr. Penso expressed the need to go upstream to foster better outcomes and lower costs. Some people lack transportation; some cannot afford food. Screening data are a key. Community partners and engagement are another key. What programs are effective? Tina M. Hernandez-Boussard raised the issue of capturing social determinant data at the point of care. Related to that is the need to offer such information to the patient.
Dr. Embi suggested that current methods to traffic healthcare data across health systems could be applied in efforts regarding social determinants. This speaks to the ideas of viewing the entire patient, using decision support, and connecting to wraparound services.
Dr. Robinson suggested that AHRQ play a role in providing clarity in effective digital solutions. He cautioned that some new technologies might have the effect of “baking in” biases and failing to ensure equity because of the algorithms used. Dr. Alexander added that the setting matters (e.g., walk-in care, nursing homes). We must seek interoperability and analyze better the elements of social determinants of health.
Dr. Yu stated that different communities have different needs. She called for plans to address measurement issues. We must watch for unintended consequences. Drs. Yu and Goeschel stressed the importance of the patient, of hearing from the patient and putting the patient in control. We need simple tools and guidance.
Dr. Masica cautioned that no ideas for solutions work in isolation. There always are multiple levers. Dr. Hernandez-Boussard cited the need to understand how sensitive data will be used.
Dr. Meyers asked each NAC member to state a desired action or result for the area of social determinants of health. The members responded as follows:
- Dr. Masica called for evidence that drills down to subgroups and for research approaches that allow rapid segmentation.
- Ms. Daugherty called for more secondary data (e.g., from electronic health records) and primary data from the patient.
- Dr. Alexander called for more research on sharing data relating to social determinants, including standardization.
- Dr. Yu called for information about what the patient and family can do to help resolve problems.
- Mr. Kerwin called for better descriptions of regions not being addressed well.
- Dr. Hernandez-Boussard called for more granular data from diverse populations, locations, healthcare settings, and areas outside the healthcare system.
- Dr. Penso called for better dissemination of current efforts and outcomes.
- Dr. Morton called for AHRQ leadership in developing methods.
- Mr. Kahn called for AHRQ to support the identification of meaningful measures.
- Dr. Goeschel called on AHRQ to raise awareness among funders and policymakers of the difficulties in dealing with social determinants of health.
- Dr. Robinson called on AHRQ to support a research framework and roadmap.
- Dr. Embi called for the development of good evidence to inform best practices for stakeholders across the spectrum for purposes of investment, adoption, etc.
- Robin Wagner called for a description of what CDC might do to help, perhaps in the areas of surveillance, data, or integrating healthcare and public health.
- Shari M. Ling called for the sharing of solutions and ways to support programs at the ground level.
- Dr. Atkins called for AHRQ to approach one area in which social determinants of health are important (e.g., maternal mortality) to demonstrate that AHRQ can effect progress there.
Laura Marcial of RTI International, encouraged AHRQ to continue to lead in the visioning and development of clinical decision support. She suggested that AHRQ engage in evaluation and foster systematic access to resources. It could help to develop multistakeholder engagement.
Dr. Masica asked for topic suggestions for future NAC meetings. The following ideas were offered:
- The intersection of NIH and personalized medicine.
- Implementation science and how AHRQ grantees will engage it.
- Tying work on social determinants of health to other AHRQ initiatives.
- Public-private partnerships and the development of platforms.
- Clinical burnout and workforce issues.
- Surveying consumers about gaps in healthcare delivery.
Dr. Masica thanked the NAC members and speakers for their input. He noted that the next NAC meeting will take place on March 26, 2020. He adjourned the meeting at noon.
Donald A. Goldmann, M.D., Meeting Chair
National Advisory Council
Agency for Healthcare Research and Quality