Meeting Minutes, July 2021
Call to Order and Approval of March 18, 2021, Meeting Summary
Recent AHRQ Accomplishments
AHRQ Budget Opportunities
Patient Safety Opportunities
Chair's Wrap-Up and Final NAC Input
NAC Members Present
Edmondo J. Robinson, M.D., M.B.A., M.S., Moffitt Cancer Center (NAC Chair)
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, Columbia University
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital
Melinda B. Buntin, Ph.D., Vanderbilt University School of Medicine
Gretchen M. Dahlen, M.H.S.A., FACHE, Consumer Health Ratings
Susan Edgman-Levitan, P.A., Massachusetts General Hospital
Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, MedStar Health
Omar Lateef, D.O., Rush University Medical Center
Hoangmai Huu Pham, M.D., M.P.H., Institute for Exceptional Care
Ramanathan Raju, M.D., M.B.A., CPE, FRCS, FACS, FACHE, Northwell Health
Patrick S. Romano, M.D., M.P.H., University of California, Davis
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Ex Officio Members and Alternates Present
Naomi Tomoyasu, Ph.D., Veterans Health Administration (for David Atkins)
Lee Fleisher, M.D., Centers for Medicare & Medicaid Services (for Shari M. Ling)
AHRQ Staff Members Present
David Meyers, M.D., FAAFP, Acting 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., Director, Office of Extramural Research, Education and Priority Populations
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
Erin Grace, M.H.A., Deputy Director, Center for Quality Improvement and Patient Safety
Monika Haugstetter, M.H.A., R.N., Division of General Patient Safety
Keith T. Kanel, M.D., M.H.C.M., FACP, Director, Division of Practice Improvement, Center for Evidence and Practice Improvement
Mamatha S. Pancholi, M.S., Center for Delivery, Organization, and Markets
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of March 18, 2021, Meeting Summary
Edmondo J. Robinson, M.D., M.B.A., M.S., Moffitt Cancer Center, NAC Chair, and Jaime Zimmerman, M.P.H., PMP, Senior Program Advisor, AHRQ
Ms. Zimmerman called the meeting to order at 10:00 a.m., welcoming the NAC members and other speakers, participants, and viewers. She noted that the meeting was being recorded and will be made available on the AHRQ website. She encouraged the NAC members to use the Zoom online technology to indicate that they have questions or comments during the meeting, and she encouraged non-NAC members to email any public comments.
Ms. Zimmerman reported the recent passing of former NAC member J. Sanford (Sandy) Schwartz, M.D., M.B.A., who served on the council from 2014 to 2017. Dr. Schwartz also served on study sections, expert panels, and the U.S. Preventive Services Task Force. Dr. Robinson joined the meeting and also welcomed the NAC members and others. He extolled the life and career of Dr. Schwartz, who had served as a mentor for Dr. Robinson and greatly aided him in his career.
Ms. Zimmerman reminded the NAC members that AHRQ is recruiting new members. She asked the members to forward any nominations by August 29. Candidates should have expertise in the conduct of research, medicine, or other health professions. They might be versed in aspects of the private healthcare sector, healthcare economics, information systems, law, ethics, business, or public policy. They might represent the interests of patients and consumers of healthcare.
Dr. Robinson referred to the draft minutes of the previous NAC meeting (March 18, 2021) and asked for changes and approval. The NAC members voted unanimously to approve the March meeting minutes with no changes. Dr. Robinson reviewed the meeting agenda and introduced the first session.
Recent AHRQ Accomplishments
Research and Education
Francis D. Chesley, Jr., M.D., Office of Extramural Research, Education and Priority Populations, AHRQ
Dr. Chesley reported that the agency recently awarded three research grants in the following areas:
- Patient engagement in reporting medication events during transitions of care (to develop a cancer patient-oriented reporting system).
- Safety-net hospitals under mandatory bundled payment (to examine the impact of the Centers for Medicare & Medicaid Services’ [CMS] Comprehensive Care for Joint Replacement Model).
- Predictive modeling for social needs in emergency department settings (to identify patients needing a referral to social support providers).
Recent publications of research findings by AHRQ grantees included the following topics:
- Cultural and structural features of zero-burnout primary care practices (Health Affairs, June 2021).
- Soft consolidation in Medicare ACOs: Potential for higher prices without mergers or acquisitions (Health Affairs, June 2021).
- A learning health system approach to integrating electronic patient-reported outcomes across the healthcare organization (Learning Health Systems, Epub March 1, 2021).
In May, to align with the Biden administration’s statement on equity, AHRQ expanded its definition of priority populations to include black, Latino, and indigenous/native American people, Asian Americans, Pacific Islanders, other people of color, members of religious minorities, lesbian, gay, bisexual, transgender, and queer people, people with disabilities, people who live in rural areas, and people who are affected adversely by persistent poverty or inequality. The changes will be incorporated into funding announcements.
Health Systems Research
Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ
Dr. Brady reported that AHRQ had released a toolkit to improve antibiotic use in long-term care settings. This was a result of an AHRQ study of 400 long-term care facilities and founded on the principles of the Comprehensive Unit-based Safety Program (CUSP).
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program developed a revised survey in response to the increased use of telehealth. It features questioning that accommodates all synchronous visits and a new “lookback” period. It assesses changes in healthcare delivery and monitoring of impacts on the patient’s experience.
AHRQ released its draft version of the new document “Common Formats for Event Reporting—Diagnostic Safety.” It will help healthcare providers identify and report missed opportunities in the diagnostic process in a standardized manner and across healthcare settings and specialties. Eventual widespread use will make it possible to collect, aggregate, and analyze diagnostic safety-related information.
Arlene S. Bierman, M.D., M.S., Center for Evidence and Practice Improvement, AHRQ
Dr. Bierman reported that AHRQ has begun three new EvidenceNow initiatives with emphasis on improving primary care:
- Screening, brief interventions, and treatment for unhealthy alcohol use in primary care.
- Building State capacity to advance equity in heart health (cardiovascular health focus).
- Improving diagnosis and management of urinary incontinence in women in primary care.
Evidence-based Practice Center (EPC) reports have been adopting innovative synthesis methods in response to the desires of end-users, who, for example, seek to learn how population and intervention characteristics and context interact to achieve outcomes.
An AHRQ project is studying the integration of digital patient-generated health data in electronic health records in the ambulatory setting. Its goal is to develop a practical guide for ambulatory care providers.
Data and Analytics
Joel W. Cohen, Ph.D., Center for Financing, Access and Cost Trends, AHRQ
Dr. Cohen reported that AHRQ, in its efforts to make information more accessible, has offered new data visualizations of, for example, monthly trends in State hospitalizations, incorporating effects of COVID-19. AHRQ is constructing a data tools site that will lead users to data in, for example, the various components of the Medical Expenditure Panel Survey (MEPS) and the National Healthcare Quality and Disparities Report. It will feature customizable selections. The site is within the AHRQ website.
AHRQ Budget Opportunities
David Meyers, M.D., FAAFP, AHRQ Acting Director
Dr. Meyers reported that the President has proposed a FY2022 budget for AHRQ of $489 million, an increase of $52 million over the previous year. The proposal comprises $380 million in a congressional appropriation and $109 million in transfers from the Patient-Centered Outcomes Research Trust Fund (PCORTF). The proposed budget features a substantial increase in funding investigator-initiated health services research. It increases funding of opioid and polysubstance abuse prevention, management, and recovery in primary care research and in maternal health research. It addresses equity in research, resource development, and organizational improvement. The proposed budget addresses health services research, including new grants to understand the effects of health system innovations that have responded to the COVID-19 pandemic and equitable healthcare. The proposal features large increases in funding for the opioid care initiative and the primary care initiative.
The budget proposal features support for a maternal health initiative to seek timely and accurate data and analytic resources to aid in informed policy decisions. It features the inclusion of the concept of equity across agency activities. It supports level funding of current programs in patient safety and data/analytics.
Dr. Meyers stated that the agency is engaged in strategic planning of future investments, seeking stakeholder feedback and organizing a NAC subcommittee. In light of the proposed increase in support, AHRQ is expanding its staff. Dr. Meyers put forth the following questions to guide discussion by the NAC members:
- With whom should we partner to help ensure success?
- What other opportunities should we take advantage of?
- If this budget is passed, where should AHRQ be looking?
- How can we make the greatest impact?
Dr. Robinson asked the NAC members to consider the intersection of AHRQ’s competencies and the new energies made available—to consider especially opportunities to leverage.
Ramanathan Raju, M.D., M.B.A., CPE, FRCS, FACS, FACHE, cautioned that people have a tendency to return to business as usual. Therefore, AHRQ should encourage its grantees/institutions to become ongoing enterprises.
Yanling Yu, Ph.D., suggested considering as a model, the COVID relationship to transparent reporting. What have we learned? Perhaps AHRQ could obtain data that can influence policies. The patient reporting system is important. And priority populations.
Dr. Robinson cited the need for collaboration across HHS and the need to define the roles of agencies. These are needed to optimize resources and accelerate work.
Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, stated that the interest in collaboration is strong. We must get the private sector involved in AHRQ’s work, respecting limited budgets. The agency should consider funding work in resilience engineering, as in where things work. Dr. Robinson asked how we might extend and accelerate work of AHRQ in private partnerships. Dr. Yu added a need to develop partnerships with patients/consumers, who can contribute in important ways, as in offering data. Dr. Robinson added the possibility of getting at impacts on mental health and patient finances.
Asaf Bitton, M.D., M.P.H., stated the importance of doing the right thing in reporting adverse events and in bundling things that work and testing them. He asked whether there are areas that need independent investigators.
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, raised the issue of COVID long-term effects. He cited the need for evidence on how to use telehealth, including for long-term care. Could AHRQ help to build collaborations and systems? Could it address assisted-living situations? Dr. Meyers responded that AHRQ is pursuing a “systems-thinking” approach for long-term care and seeking ways to empower the enterprises.
Jaime Zimmerman, M.P.H., PMP, Senior Program Advisor, AHRQ, and Keith T. Kanel, M.D., M.H.C.M., FACP, Center for Evidence and Practice Improvement, AHRQ
Ms. Zimmerman, co-lead of AHRQ’s telehealth initiative, noted the strong increase in the use of telehealth beginning in March 2020 (as shown by claims data). Medicare flexibility during the public health emergency (PHE) in part caused the rise, leading to changes in the care paradigm. Evidence from some of AHRQ’s EPC reports helped to guide the changes. Ms. Zimmerman noted that telehealth issues are dominating some of the online discussions supported by AHRQ. She presented questions about telehealth use that AHRQ has been considering:
- Are diagnoses being missed or delayed?
- Is preventive care compromised?
- Will telehealth increase or decrease overall utilization?
- Are we worsening disparities through the “digital divide”?
- Is care better or worse for people living with disabilities?
- How will primary care offices need to adjust workflow and staff for a digital future?
- How can telehealth expand access to underserved communities?
Dr. Kanel, new to AHRQ and co-lead of AHRQ’s telehealth initiative, defined telehealth as the “use of electronic information and telecommunication technologies to provide care when the patient and doctor are not in the same place at the same time.” Principal telehealth modalities are video office visits, audio-only, store-and-forward, apps (mHealth), and remote patient monitoring. Audio-only has been especially important and discussed. Dr. Kanel reviewed briefly the history of AHRQ telehealth-related activities prior to the COVID pandemic. AHRQ’s telehealth-related portfolio today includes evidence reviews, digital healthcare research, the ECHO nursing home network, primary care implementation research, the Patient Safety Network (PSNet), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and the Medical Expenditure Panel Survey (MEPS) modified for telehealth.
The EPC program features many past and upcoming systematic reviews targeting telehealth. AHRQ’s Division of Digital Healthcare Research supported 26 research grants to explore essential questions about delivery of healthcare during the PHE, including aspects of telehealth. Within the CAHPS program, the Clinician and Group Visit Survey (CG CAHPS 4.0) features modifications that include telehealth and is being beta tested. The MEPS program added a telehealth question in 2020 and will track disparities related to the use of telehealth. Dr. Kanel stated that telehealth technologies and systems have the potential to increase access and convenience yet also have the potential to create new patient safety issues and to increase utilization without improving outcomes. We must evaluate the effect of telehealth implementation efforts on healthcare quality, safety, equity, access, utilization, and value.
Dr. Kanel asked the NAC members to consider the following questions:
- How might AHRQ engage the telehealth private sector?
- Which stakeholders should be engaged?
- How can AHRQ support primary care practices in implementing telehealth?
- What new data and analytics tools are needed?
- Given AHRQ’s capacities, how can it have the most impact in advancing the goals of access, equity, and quality in telehealth?
Dr. Robinson brought up the idea of telehealth as a channel to care. Perhaps, rather than tracking utilization, we should focus on the outcome we are trying to achieve. Dr. Kanel agreed. We don’t know whether, on balance, utilization is a good or bad thing. We need high-level information.
Dr. Bitton suggested there are significant policy level worries, especially in some outpatient disciplines, as in using a fee-for-service mindset for telehealth. We have entered a new phase, and we should not simply encourage phone visits and the unintended consequences. We should think about nuances regarding bundling mechanisms and other payment models.
Dr. Alexander cited the digital divide and a lack of measures of structural capabilities. There are unique services and systems with, for example, differences in access mechanisms. Understanding use and capabilities can be difficult. Integration varies. Ms. Zimmerman noted that the NAC subcommittee on quality measures can study measurement issues for telehealth.
Dr. Goeschel stressed that it is appropriate for AHRQ to study the values of telehealth and propose baselines. Melinda B. Buntin, Ph.D., added that AHRQ could study the idea of addressing new audiences, as in expanding the MEPS with regard to telehealth. Gretchen M. Dahlen, M.H.S.A., FACHE, encouraged the agency (the subcommittee) to consult with the National Quality Forum.
Dr. Kanel stated that people are looking for data to guide policymaking, and right now there are population segments not being reached. AHRQ has a framework for the needs of primary care practices. How do we engage practices? How do we address their economic struggles?
Patrick S. Romano, M.D., M.P.H., stressed the role of primary care physical examinations, for which there are challenges and opportunities in the telehealth environment. We need to determine how to incorporate interpreters and perhaps create best practices. There are many practical issues, including the digital divide.
Susan Edgman-Levitan, P.A., cited the need to educate patients (e.g., about physical exams) and to promote partnerships among agencies so as to ensure consistent measurement. The issue of duplicate visits should be addressed, perhaps by consulting with private vendors.
Dr. Yu encouraged AHRQ to engage the State medical boards, to survey rural populations about obstacles in telehealth, and to study how shared decision making can have differences when moving to telehealth.
Patient Safety Opportunities
Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ, and Erin Grace, M.H.A., Center for Quality Improvement and Patient Safety, AHRQ
Dr. Brady introduced a session on AHRQ’s patient safety programs. He posed a series of questions for discussion and introduced Ms. Grace. She began by referring to the agency’s history of addressing patient safety and by noting the agency’s strategy of supporting the integration of research, practice, and data to effect safety improvement. Its patient safety priorities include the following:
- Understanding causes of patient harm.
- Applying knowledge to accelerate improvement.
- Improving organizational culture, teamwork, and communication.
- Supporting patient and family engagement.
- Integrating patient safety improvement with clinical workflow.
- Employing strategies to prevent harmful events (e.g., diagnostic errors and hospital-acquired conditions).
AHRQ has a history of publishing evidence reports on safe practices. It has developed tools for practice improvement, has supported research to reduce hospital-acquired conditions, and has developed national data on issues such as patient safety and equity. The AHRQ Patient Safety Network (PSNet) has been synthesizing and disseminating patient safety information across the healthcare field.
Dr. Brady described AHRQ’s National Action Plan to Advance Patient Safety, which has been informed by the Institute for Healthcare Improvement and 27 leading organizations and has sought to address the issue of preventable harm. A National Steering Committee advises in the coordination of national efforts. The National Action Plan includes emphases on culture, leadership, governance, patient/family engagement, workforce safety, and learning systems. It features core principles, including the advancement of health equity. In 2020, AHRQ held a summit and roundtable, which identified patient safety research opportunities.
AHRQ’s activities for improving diagnosis have included the development of issue briefs and other resources. It created a document, “Operational Measurement of Diagnostic Quality and Safety: State of the Science,” which provided practical guidance for healthcare organizations in applying measurement to enhance diagnostic safety.
Dr. Brady also emphasized AHRQ’s programs for reducing hospital (or healthcare)-acquired infections (HAIs) and combating antibiotic-resistant bacteria. The funding for those efforts has been steady for 12 years. The efforts have supported the Comprehensive Unit-based Safety Program (CUSP) which is a proven method for preventing HAIs.
Dr. Robinson mentioned the intersection between the provider’s well-being and patient safety. Providers can experience burnout due in part to dealing with the safety and data systems in place. Dr. Brady agreed that the cognitive load can be demanding. AHRQ is looking at such issues.
Ms. Edgman-Levitan emphasized the potential to learn about diagnostic error by use of systematic reviews and patient comments. At times a physician will ignore what a patient is saying. Comments must be appreciated. Ms. Dahlen noted the potential benefits of electronic triggers. Dr. Goeschel cited the need for more front-line tools for diagnosis. She encouraged AHRQ to fund research involving partnerships. Dr. Alexander noted that in some cases, for example, patients with dementia or Alzheimer’s, interactions with healthcare teams and technologies can cause the patients to feel unsafe.
Dr. Yu noted the issue of which data sources are most useful for determining a diagnosis. Patient feedback is important and should be advanced. AHRQ could play a role there, as in developing a taxonomy and identifying patterns to guide providers. Dr. Robinson suggested a methodological approach in which we pull information from patient reporting regarding safety and scale it to help all providers. Ms. Edgman-Levitan added that many vendors have that capability. Dr. Robinson stated that there are pros and cons surrounding some algorithmic procedures.
Dr. Romano stressed patient safety challenges in the move to telehealth. How will we measure safe care? Concerning the switch to ambulatory care, a surgery patient can stay overnight in a hospital and not be considered an inpatient, in fact, returning home the next day. This offers problems in data and measurement—in contradistinction to our many mature measures for fully inpatient care, offering problems in risk adjustment.
Shannon Davila, M.S.N., R.N., Associate Director of ECRI and the Institute for Safe Medication Practices PSO, described the PSO National Safe Table Program, which brings together healthcare professionals and others to improve the delivery of patient care. PSO Safe Tables are a primary mode for raising awareness. They conduct analysis and deliberations and distribute clinical solutions, protocols, and other practices that improve patient outcomes and the culture of safety. The program’s goals are to create a national learning system to promote advances in patient safety on a national scale and to align with the work of the PSOs in implementing the National Action Plan to Advance Patient Safety. The program promotes a national safe table forum that will address patient safety needs. It continues to grow and has attained proof of concept. Safe tables tend to occur at national specialty medical meetings. Clinicians are leading many of the efforts. Safe tables have helped develop national practice guidelines, tools, and best practices. The program is committed to improving patient safety and the quality of care. It seeks patient safety learning. It supports physicians to drive better care and outcomes. The best practices are distributed through a healthcare continuum across the PSO community.
Paul Epner, M.B.A., M.Ed., Chief Executive Officer of the Society to Improve Diagnosis in Medicine, expressed appreciation for AHRQ’s and the NAC’s prioritization of improving diagnosis and safety. Diagnostic error may be the most common, catastrophic, and costly of medical errors. Mr. Epner encouraged the NAC to consider framing care delivery as part of a health problem investigation (diagnosis) or part of a resolution (treatment), with equal opportunity for improvement. Treatment issues have relatively more discrete choices. Diagnosis features variability in presentation. Telehealth is a unique setting, and telediagnosis is complex. The opportunity for improved access and timely encounters has to be balanced by research on unique failure modes. The Society has been developing a research agenda for telediagnosis, with input from various players. As for patient engagement, the delivery of care is increasingly fragmented, and the only participant with complete knowledge across settings is the patient. We need to focus on the co-production of diagnostic and treatment plans. Open notes represent a promising new data source and increased engagement. The Society will hold a virtual conference in the fall, with a theme of disparities in diagnosis.
Chair's Wrap-Up and Final NAC Input
Dr. Robinson asked for final comments, especially about the day’s topics and future topics.
Dr. Raju encouraged AHRQ to support more research on operations, as in making them easier for the patient and less expensive. Dr. Robinson raised the idea of considering AHRQ’s effect—how has it moved the needle? He proposed that the NAC look backward and forward. Dr. Bitton suggested addressing research on systematizing and implementing ideas/innovations, that is, follow-through.
Dr. Goeschel applauded this meeting’s schedule, with much time devoted to the members’ comments. Dr. Alexander agreed and noted the potentially positive future for AHRQ. Dr. Robinson raised the issue of equity, as broadly applied and a target for further discussion. Patient/consumer interest and engagement also should be discussed.
Ms. Zimmerman noted that this would be the final NAC meeting coordinated by Karen Brooks. She thanked her for many years of support (nearly two decades) for the program.
Dr. Robinson thanked the NAC members, presenters, and AHRQ staff. He stated that the next NAC meeting will occur on November 17, 2021, possibly in person. He adjourned the meeting at 2:00 p.m.
Edmondo J. Robinson, M.D., M.B.A., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality