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Advancing Excellence in Health Care

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... appointment because the provider did not have all their medical information ... you and all of your health care providers have all of your medical information? ... – PowerPoint PPT presentation

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Title: Advancing Excellence in Health Care


1
Advancing Excellence in Health Care
  • Carolyn M. Clancy, MD
  • Director
  • January 21, 2005

2
Case Presentation - 1
  • Paul, a 54 yo patient with diabetes and
    hypertension visits a primary care clinician for
    abdominal pain of 2-3 days duration.
  • Prior to his visit, he and his pc team leader
    have reviewed his symptoms and history by e-mail,
    and have examined possible causes by going to the
    PC Navigator, a system that has been developed to
    improve diagnosis and management of patients with
    undifferentiated symptoms.

3
Case Presentation - 2
  • Pauls pc team has also reviewed Pauls recent
    entries to the jointly held electronic medical
    record.
  • A diabetic for 10 years, Paul manages his
    condition with diet and exercise, after several
    bumpy years on insulin. His self-management is
    supplemented by e-mail consultations prn.

4
Case Presentation - 3
  • When Paul and his clinician meet -- at his
    convenience -- they discuss his options and agree
    on a diagnostic test, after reviewing possible
    outcomes of the test and options. The test is
    scheduled for that day.
  • Before leaving the practice, Paul leads a group
    visit at which there are several medical students
    -- required to attend to learn from patients
    about chronic illness management.

5
Case Presentation - 4
  • The patients in the group visit provide feedback
    to the students about how they can enhance
    patients skills in self management.
  • Paul then gets his diagnostic test, and before
    the end of the day his primary care clinician has
    e-mailed the results and suggested next steps.

6
Overview
  • About AHRQ The Evidence Agency
  • Health Care 2005 Current Context
  • Recent Findings and Directions
  • Future Challenges

7
Mission Statement AHRQ

The mission of the Agency for Healthcare Research
and Quality is to improve the quality, safety,
efficiency, and effectiveness of health care for
all Americans.

8
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9
AHRQ RESEARCH FOCUSHOW IT DIFFERS
  • Patient-centered, not disease-specific
  • Dual Focus -- Services Delivery Systems
    Effectiveness research focuses on actual daily
    practice, not ideal situations (efficacy)
  • AHRQ mission includes production and use of
    evidence-based information

10
Ten Roles of Government in Health Care Quality
  • Purchase health care
  • Provide health care
  • Assure access for vulnerable populations
  • Monitor health care quality
  • Regulate health care markets
  • Inform health care decision- makers
  • Support acquisition of new knowledge
  • Support development of health technologies and
    practices
  • Develop the health care workforce
  • Convene stakeholders

11
Overview
  • About AHRQ The Evidence Agency
  • Health Care 2005 Current Context
  • Recent Findings and Directions
  • Future Challenges

12
Driving Forces
  • Rising health care expenditures
  • Aging and increasingly diverse population
  • Consumerism
  • Biomedical advances public and professional
    expectations
  • Growing influence of purchasers

13
Current Environment
  • Unprecedented opportunities and innovations
  • Rising health care costs
  • Consumer and purchaser demand for value
  • Limited information on performance and how to
    improve
  • Numerous initiatives to address one piece of the
    puzzle

14
Public Perceptions
Percent who say they are dissatisfied with the
quality of health care in this country
Has the quality of health care in this country
2004
2000
Gotten worse
Stayed about the same
Dont Know
Gotten better
Gallup Poll conducted September 11-13, 2000
with 1,008 U.S. adults.
Source Kaiser Family Foundation / Agency for
Healthcare Research and Quality / Harvard School
of Public Health National Survey on Consumers
Experiences with Patient Safety and Quality
Information, November 2004 (Conducted July 7
September 5, 2005).
15
Personal Experience
Did the error have serious health consequences,
minor health consequences, or no health
consequences at all?
Have you been personally involved in a situation
where a preventable medical error was made in
your own medical care or that of a family member?
Serious health consequences
Yes
No
Minor health consequences
No health consequences
Dont Know
Source Kaiser Family Foundation / Agency for
Healthcare Research and Quality / Harvard School
of Public Health National Survey on Consumers
Experiences with Patient Safety and Quality
Information, November 2004 (Conducted July 7
September 5, 2005).
16
Role Of IT In Reducing Medical Errors
Percent who say
Have you or a family member ever created your own
set of medical records to ensure that you and all
of your health care providers have all of your
medical information?
The coordination among the different health
professionals that they see is a problem
Yes
They have seen a health care professional and
noticed that they did not have all of their
medical information
They had to wait or come back for another
appointment because the provider did not have all
their medical information
Dont know
No
Source Kaiser Family Foundation / Agency for
Healthcare Research and Quality / Harvard School
of Public Health National Survey on Consumers
Experiences with Patient Safety and Quality
Information, November 2004 (Conducted July 7
September 5, 2005).
17
Pace of Change VariesAcross Care Settings
  • Of 98 measures with trend data, 88 can be mapped
    to care settings
  • Some improvement seen in all settings
  • However, change in performance varies across
    settings

18
Major Opportunities for Improvement
  • 81 of Medicare pneumonia patients get blood
    cultures before antibiotics
  • 68 get the right antibiotics
  • 63 get their first antibiotic in a timely manner
  • Yet, only 30 get all of three recommended
    interventions

19
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20
The proportion of adults with diabetes who
received all five recommended diabetic services
(MEPS, 2000-2001)
21
HHS Recent Developments
  • Nursing Home Initiative
  • Home Health Care Initiative
  • AHA-JCAHO-VHA . Hospital reporting initiative
  • Patient experience in hospitals
  • Bar coding
  • IT standards ()

22
Patient Safety Achieving A New Standard For Care
  • Americans should be able to count on receiving
    health care that is safe..This requires, first,
    a commitment by all stakeholders to a culture of
    safety, and, second, improved information
    systems.
  • Institute of Medicine, 2003

23
Issues
  • Will public reporting ? improvements?
  • Paying for quality YES, but HOW??
  • Pay for quality OR use of HIT?
  • How to align measurement and improvement efforts?

24
Overview
  • About AHRQ The Evidence Agency
  • Health Care 2005 Current Context
  • Recent Findings and Directions
  • Future Challenges

25
AHRQ Research Study Identifying Successful
Hospital Quality Improvements
  • Major finding Hospitals that were more likely
    to prescribe beta-blockers shared similar
    characteristics
  • Solid support from their hospital administration
  • Strong physician leadership
  • Shared goals of improving medical practice
  • Effective way of monitoring progress
  • Conducted by Yale University School of Medicine

E Bradley, E Holmboe, J Mattera, et al., A
Qualitative Study of Increasing B-Blocker Use
After Myocardial Infarction, Journal of the
American Medical Association, May 23, 2001
26
AHRQ Research Study Sleep Deprivation and Safety
  • Major Finding Serious medical errors fell
    significantly when medical interns work schedule
    was reduced from 30-hour-in-a-row shifts and when
    continuous work schedules were limited to 16 hours


36 more serious medical errors
21 more serious medication errors
CP Landrigan, JM Rothschild, J W Cronin, et al.,
Effective of reducing interns work hours on
serious medical errors in intensive care units,
NEJM, October 28, 2004
27
AHRQ Research Study OutpatientPrescription
Drug-Related Injuries in Elderly
  • Major Finding Outpatient Medicare patients
    suffered as many as 1.9 million drug-related
    injuries a year due to medical error or adverse
    drug events (ADE) not caused by errors
  • Why did preventable ADEs occur?
  • 58 prescribing medications
  • 61 monitoring medications
  • 20 patients adhering to medication instructions

28
HIT Systems approach Can Make a Difference
Proportions of patients receiving the appropriate
discharge prescriptions
  • Intermountain Health Care QI effort on CVD
  • Results
  • 90 prescription rates
  • 27 decrease in unadjusted absolute death rates

Lappe JM et. al., Ann Intern Med 2004141446-453
29
Hospital Survey on Patient Safety Culture
  • New tool helps hospitals and health systems
    evaluate employee attitudes about patient safety
    in their facilities or within specific units
  • Includes survey guide, survey, and feedback
    report template to customize reports
  • AHRQ partnership with Premier, Inc., Department
    of Defense, and American Hospital Association
  • www.ahrq.gov/qual/hospculture/ or e-mail to
    ahrqpubs_at_ahrq.gov

30
Key Implementation Activities QualityTools
31
National Health Plan Learning Collaborative to
Reduce Disparities and Improve Quality
  • Public/private partnership to reduce disparities
    in health care for people with diabetes and other
    conditions
  • Over next 3 years, collaborative will test ways
    to improve collection and analysis of data on
    race and ethnicity and match data to existing
    quality measures to close gap in care
  • Sponsored by nine of Nations largest health
    insurance plans, and other organizations

32
Overview
  • About AHRQ The Evidence Agency
  • Health Care 2005 Current Context
  • Recent Findings and Directions
  • Future Challenges

33
The Future Delivery SystemBaseline Assumptions
  • Todays students will encounter a dramatically
    different health care system
  • Basic premise of health insurance is evolving
  • System fragmentation will increase
  • Consumer-directed options will increase ?
    increased price sensitivity and need for
    information
  • Disruptive challenges (BT, SARS, ???) a daily
    reality the new normal

34
What We Have Learned
  • Knowing the right thing to do is NOT doing it!
  • Improvement must be based on science
  • Patients as participants are far more effective
    than patients as recipients
  • Suttons Law improving chronic illness care is
    essential
  • Safety in health care delivery is critical

35
Implementation of Research Findings Debunked
Assumption
Question
Hypothesis
Study
Publications
Changes in practice
36
A Flawed Model
  • Receptor sites are assumed
  • Decisionmaking is not-linear evidence is only
    part of the solution
  • Broad dissemination ? modest effects

37
Improving Quality and Safety
We need to make the right thing the easy
thing Mark Chassin, MD October 12, 2000
38
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39
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40
If HIT is Such a Great Idea ..
  • Generalizability of promising findings open to
    question
  • Even successful hospitals use multiple vendors
    and have internal interoperability challenges
  • Implementation is challenging
  • Physicians are independent contractors

41
FY04 Transforming Healthcare Quality through IT
  • Planning up to 7M
  • assist healthcare systems and their partners in
    planning for activities that will lead to
    successful HIT implementation
  • Implementation up to 24M
  • support organizational and community-wide
    implementation and diffusion of HIT
  • Value up to 10M
  • assess the value derived from the adoption,
    diffusion, and utilization of HIT

42
State and Regional Demonstrations in Health IT
  • Identify and support statewide data sharing and
    interoperability activities on a discrete state
    or regional level.
  • Approximately 5 states
  • 25M over 5 years
  • Test Beds to produce demonstrable improvements
  • Improvements must be sustainable beyond end of
    contract and applicable to other states or regions

43
Critical Challenges
  • Common data elements and definitions build
    capacity to make improvements
  • Linking implementation to requisite clinical
    transformation
  • Avoiding the NIH syndrome
  • Aligning incentives and rewarding success
  • Making it easy

44
Contemporary Challenges
  • Scientific basis for safe and appropriate use of
    diagnostic, therapeutic and preventive
    interventions -- from and to the point of care
  • Quality improvement as science
  • Translating promising educational models into
    large-scale improvements in care and outcomes

45
What is Section 1013?
  • To improve the quality, effectiveness and
    efficiency of health care delivered through
    Medicare, Medicaid and the S-CHIP programs
  • 50 million is authorized in Fiscal Year 2004 for
    the Agency for Healthcare Research and Quality
    (AHRQ) to conduct and support research with a
    focus on outcomes, comparative clinical
    effectiveness and appropriateness of health care
    items and services (including pharmaceutical
    drugs), including strategies for how these items
    and services are organized, managed and delivered

46
What is Section 1013?
  • By June 2004, the Secretary shall establish an
    initial list of research priorities (including
    those related to prescription drugs)
  • Priorities may include health care items and
    services which impose a high cost on Medicare,
    Medicaid or S-CHIP, including those that may be
    underutilized or over utilized

47
SHARED DECISION MAKINGDECISIONS AND OUTCOMES
Patient
Alternative 1
Alternative 2
48
PREQUISITES FOR CHANGE
  • Integrating strategy to make existing information
    accessible with requisite data collection
  • Expected differences in patient experiences
    (e.g., disparities associated with race,
    ethnicity and SES)
  • How to present information in usable formats
    (different versions of the answers will be more
    effective for different audiences)

49
Focus Research and Policy
  • Describing problems policy window
  • Developing and testing solutions to problems
  • Evaluating solutions
  • Interaction with stakeholders and decision makers
    is not optional

50
Supply-Side Research Paradigm
  • Research world
  • Questions
  • Hypothesis
  • Study
  • User world
  • Many needs
  • Beliefs interests
  • Decision processes

Publication
34
c2
The winding road to a receptor site
51
Demand/Supply Side Model
  • Research world
  • Questions
  • Hypothesis
  • Study
  • User world
  • Many needs
  • Beliefs interests
  • Decision processes

34
c2
52
Approaching Knowledge Gaps
?
  • Not always head to head
  • Need to be creative
  • Explore new methodologies
  • Examine existing or forthcoming data sources
  • Reserve most expensive approaches for the most
    important and controversial questions

53
Essential Issues to be Addressed
  • Ethics and Quality Improvement (when is it
    research?
  • Identification of subgroups most likely to
    benefit
  • Identifying critical intervention points
    (teachable moments)
  • Conceptual blueprint for practical clinical
    trials
  • Integration of disease management with clinical
    decision support knowledge engineering
  • Patient engagement (including the
    pre-contemplative)

54
Questions in Search of Answers
  • Linking knowledge development to policy levers
    (e.g., payment regulation) role of
    demonstrations
  • When is good enough?
  • Vocabulary and pathways for translation of
    knowledge-based interventions under-developed
  • Concurrent -- or sequential -- evaluation and
    translation?

55
It is not enough just to develop new insights
into the fundamental nature of disease and its
prevention. It is not enough to test that
fundamental knowledge in rigorously controlled
clinical trials. We must also improve the
distribution of that knowledge so that it reaches
everyone in the world -- so that everyone will
benefit from it.
Robert H. Brook, M.D., Sc.D., remarks to
Research! America, March 20, 2001
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