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Transparency and Transformation: Initiatives for Improving Health Care Quality

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Implementation of EHRs. Over $2.3 million ... Only 12.5 percent of practices with five or fewer FTE physicians have EHRs ... Clinical benefits of EHRs. ... – PowerPoint PPT presentation

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Title: Transparency and Transformation: Initiatives for Improving Health Care Quality


1
Transparency and Transformation Initiatives for
Improving Health Care Quality
Carolyn Clancy, M.D. Director Agency for
Healthcare Research and Quality West Virginia
Medical Institute 2006 Annual Retreat Hot
Springs, VA - October 7, 2006
2
Transparency and Transformation
  • AHRQs portfolio
  • Evidence base for Health IT
  • Transparency and role of health IT and
    value-based purchasing
  • Culture change and transformation
  • Q A

3
AHRQs Mission
Improve the quality, safety, efficiency and
effectiveness of health care for all Americans
4
AHRQ Roles and Resources
  • Health IT Research
  • Funding
  • Support advances that improve patient
    safety/quality of care
  • Continue work in hospital settings
  • Step up use of HIT to improve ambulatory patient
    care

Source FY 2007 Budget Summary for HHS and BNA
Health Care Policy Report 2-13-06
5
AHRQ Roles and Resources
  • Health IT Research
  • Funding
  • Support advances that improve patient
    safety/quality of care
  • Continue work in hospital settings
  • Step up use of HIT to improve ambulatory patient
    care
  • Develop Evidence Base for Best Practices
  • Four key domains
  • Patient-centered care
  • Medication management
  • Integration of decision support tools
  • Enabling quality measurement

Source FY 2007 Budget Summary for HHS and BNA
Health Care Policy Report 2-13-06
6
AHRQ Roles and Resources
  • Health IT Research
  • Funding
  • Support advances that improve patient
    safety/quality of care
  • Continue work in hospital settings
  • Step up use of HIT to improve ambulatory patient
    care
  • Develop Evidence Base for Best Practices
  • Four key domains
  • Patient-centered care
  • Medication management
  • Integration of decision support tools
  • Enabling quality measurement
  • Promote Collaboration
  • and Dissemination
  • Support efforts of AHIC, ONC, NHII and Centers
    for Medicare and Medicaid Services
  • Build on public and private partnerships
  • Use web tools to share knowledge and expertise

Source FY 2007 Budget Summary for HHS and BNA
Health Care Policy Report 2-13-06
7
Health IT Research Funding
  • Over 125 projects and demonstrations to better
    understand how health IT can improve the safety,
    quality and efficiency of health care
  • Projects in 43 states
  • Special attention to best practices that can
    improve quality of care in rural, small
    community, safety net and community health center
    care settings

AHRQ HIT Investment 166 Million
8
Health IT Research
  • Partnering to Improve Patient Safety in Rural
    West Virginia West Virginia Medical Institute
    and 24 rural hospitals
  • Reduce preventable medical errors through health
    IT
  • Connecting Healthcare in Central Appalachia
    Appalachian Regional Healthcare, Inc. 20
    counties in southern WV and eastern KY
  • Implementation of EHRs

Over 2.3 million invested in active health IT
projects in Rural Appalachia
9
Online Learning Resources
  • AHRQ National Resource Center on Health
    Information Technology
  • Lessons learned from the field for providers
  • Repository of nearly 6,000 health IT knowledge
    products
  • Evaluation toolkit
  • Other resources

Launched February, 2006
10
Transparency and Transformation
  • AHRQs portfolio
  • Evidence base for Health IT
  • Transparency and role of health IT and
    value-based purchasing
  • Culture change and transformation
  • Q A

11
Growing HIT Evidence Base
  • Health IT helps improve quality of care in large
    health care organizations that create their own
    systems and devote substantial resources to EHR,
    CPOE,e-prescribing, and other applications
  • HIT has potential to enable dramatic
    transformation of health care safety,
    effectiveness and efficiency

AHRQ Southern California Evidence-Based Practice
Center- RAND Corporation, April, 2006
12
Challenge Low Adoption Rates
  • Only 14.1 percent of all medical group practices
    use an electronic health record
  • Only 12.5 percent of practices with five or fewer
    FTE physicians have EHRs

AHRQ contract 290-00-0017 University of
Minnesota
13
Preliminary Learning from the AHRQ HIT Research
Portfolio
  • Computerized Provider Order Entry and Electronic
    Health Records. Study found these technologies
    reduced certain costs in hospitals, increased
    certain quality measures, and increased nursing
    documentation from 0-43 to 65-100
  • Patient Safety. About one-third of all orders
    were modified due to clinical decision support
    provided by CPOE and EHR

14
Preliminary Learning from the AHRQ HIT Research
Portfolio
  • Online Diabetes Registry. California MDs nearly
    doubled adherence to diabetes treatment
    guidelines. Clinical decision support tools
    alerted clinicians when patients needed exams or
    tests
  • Clinical benefits of EHRs. Study focusing on HIV
    patients found that EHRs are less likely than
    paper charts to have missing data. Also led to
    decreased time between patient visits and better
    clinical outcomes

15
Preliminary Learning from the AHRQ HIT Research
Portfolio
  • Telemedicine. In-school modules were used by
    trained staff to connect children to their PCP
    without leaving day care or school. Project has
    reduced absence due to acute illness in urban
    child care centers by 63. May hold promise to
    significantly impact costs associated with office
    visits or ER admissions

16
Transparency and Transformation
  • AHRQs portfolio
  • Evidence base for Health IT
  • Transparency and role of health IT and
    value-based purchasing
  • Culture change and transformation
  • Q A

17
Healthcare Transparency Executive Order
Directs Federal agencies to
August 22, 2006
  • Increase transparency in pricing to beneficiaries
  • Increase transparency in quality to beneficiaries
  • Encourage adoption of health information
    technology standards
  • Provide options that promote quality and
    efficiency of care

18
Agencies affected by Healthcare Transparency
Executive Order
Together, these agencies spend 40 of all U.S.
health care dollars
  • Department of Health and Human Services
    (Medicare, Medicaid and SCHIP)
  • Department of Defense
  • Veterans Affairs Department
  • Indian Health Service
  • Federal Employees Health Benefit Program

Implementation date January, 2007
19
Information Transparency
  • Transparency of Pricing information Agencies
    will make available the prices they pay providers
    to beneficiaries and enrollees
  • Promoting Quality and Efficiency of Care
    Agencies will develop approaches that encourage
    and facilitate quality healthcare. May include
    pay-for-performance models of reimbursement

Cost Quality
20
Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
Quality Standards Design systems to collect
quality of care information and define what
constitutes quality health care
21
Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
22
Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
23
Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
24
AQA Pilot Project
  • Ambulatory Care Quality Alliance project designed
    to increase the transparency of health care
    quality information
  • Supported by funding from CMS and AHRQ
  • Will, for first time, combine public and private
    information to measure and report on physician
    practice
  • Will identify high quality providers who deliver
    appropriate care to patients while avoiding
    unnecessary complications and costs

25
AQA Pilot Project
  • Last year, AQA, founded in 2004, endorsed a
    starter set of 26 standard performance measures
    that are now being incorporated around the
    country
  • When AQA pilot is completed, the health care
    system will have effective models for providing
    consumers with meaningful information that can be
    used to make informed choices about which
    providers will meet their needs

26
6 AQA Pilot Sites
Wisconsin Collaborative for Healthcare Quality
Minnesota Community Measurement
Indiana Health Information Exchange
Massachusetts Health Quality Partners
California Cooperative Healthcare
Reporting Initiative
Phoenix Regional Healthcare Value Measurement
Initiative
27
Hospital Quality Alliance
  • HQA Improving Care Through Information, a
    public-private collaboration to improve the
    quality of care in U.S. hospitals by measuring
    and publicly reporting care
  • Includes CMS, AHA, Federation of American
    Hospitals, and AAMC
  • Supported by AHRQ, NQF, JCAHO, AMA, American
    Nurses Association, National Assoc. of Childrens
    Hospitals, Consumer Purchase Disclosure Project,
    AARP, AFL-CIO and U.S. Chamber of Commerce

28
Hospital Quality Alliance
  • Hospital Compare website started on April 1, 2005
  • 20 measures reported on Hospital Compare include
    10 starter set measures and additional measures
    for voluntary reporting by hospitals, with
    additional measures to come.
  • Ultimate goal All hospitals will report to this
    set of measures, and measures will be accepted by
    all purchasers, oversight and accrediting
    entities, payers and providers

29
Quality Alliance Steering
Committee
  • Formed in July between the AQA and the Hospital
    Quality Alliance
  • Tasked to improve the coordination and promotion
    of quality measurement, transparency and
    improvement of care
  • First step Coordinate and expand 6 pilot sites
    to include hospital and cost-of-care measures
  • Also identify opportunities to expand and refine
    existing measures
  • Will work closely with AHRQ and CMS

30
Consumer exposure to and use of quality
information
Percent of consumers who say they saw information
in the past year comparing quality among.
29
24
12
Health Plans Doctors Hospitals
Source Kaiser Family Foundation/AHRQ 2006
Update on Consumers View of Patient Safety and
Quality Information
31
Consumer exposure to and use of quality
information
Percent of consumers who say they saw information
in the past year comparing quality among.
Percent who say they saw information on ANY of
these sources
36
35
29
24
27
12
Health Plans Doctors Hospitals
Health Plans Doctors Hospitals
Source Kaiser Family Foundation/AHRQ 2006
Update on Consumers View of Patient Safety and
Quality Information
32
Consumer exposure to and use of quality
information
Percent who say they saw quality information in
the past year and used it to make health care
decisions
12
10
7
Health Plans Doctors Hospitals
Source Kaiser Family Foundation/AHRQ 2006
Update on Consumers View of Patient Safety and
Quality Information
33
Consumer exposure to and use of quality
information
Percent who say they saw quality information in
the past year and used it to make health care
decisions
Percent who say they saw and used information on
ANY of these sources
20
19
12
10
7
12
Health Plans Doctors Hospitals
Health Plans Doctors Hospitals
Source Kaiser Family Foundation/AHRQ 2006
Update on Consumers View of Patient Safety and
Quality Information
34
Growth of Incentive Programs
Americans covered by P4P Programs
100
50
In Millions
53 Million
0
2005
Source 2005 National Pay for Performance
Survey-Med-Vantage
35
Growth of Incentive Programs
Source 2005 National Pay for Performance Survey,
Med-Vantage
36
Growth of P4P Programs
4
Other Government Employer Medicaid
Only Commercial Plan TOTAL
Number of P4P programs, by sponsor type
6
5
November, 2004
8
November, 2005
6
Source National Pay for Performance Survey 2005,
Med-Vantage
7
10
13
59
73
84
107
37
Drivers Behind Value-Based Purchasing
  • Large gaps in quality and safety
  • Rapid rise of health care costs
  • Perverse incentives Compensation typically
    based on quantity of services provided, not
    quality of care
  • Huge budget problems in private and public sector
  • Purchasers want to use market forces to move the
    needle on quality and cost

38
AHRQs Role in P4P
  • AHRQs authorizing legislation identifies
    research role in payment and finance
  • IOM Chasm report asks AHRQ and CMS to develop a
    research agenda to identify, pilot test and
    evaluate various opinions for better aligning
    current payment methods with quality improvement
    goals
  • MMA Sec. 646 describes AHRQ as learning
    laboratory to evaluate, monitor, and disseminate
    information about CMS demonstrations
  • Private sector payers and providers see AHRQ as a
    neutral source of evidence

39
Aligning Incentives
New report highlights
Rewarding Provider Performance Aligning
Incentives in Medicare Institute of Medicine
  • P4P may improve health care quality
  • Might not reduce costs
  • CMS should establish pools of funds to reward
    providers whose care is demonstrated to improve
    health of beneficiaries
  • Focused on Medicare, but has significant
    implications for private sector payers and
    purchasers

Institute of Medicine, September, 2006
40
Incentive Challenges
Unintended consequences
  • Can be as strong as intended ones will pursuing
    quality related initiatives distract providers
    from other important clinical activities for
    their patients?

41
Incentive Challenges
Strategic questions
  • How do we integrate process/efficiency measures
    with quality/outcomes measures?
  • What is the role of incentives in areas such as
    chronic disease management, and prevention and
    wellness programs?
  • How can P4P programs work in small group
    practices, the settings where the majority of
    Americans receive care?

42
Opportunity P4P Incentives
  • Growing number of incentive programs to reward
    improvement in quality and safety performance
  • P4P may provide new revenue stream to enable
    purchase of health IT systems
  • Without electronic records, providers may not be
    able to participate in P4P contracts

43
Transparency and Transformation
  • AHRQs portfolio
  • Evidence base for Health IT
  • Transparency and role of health IT and
    value-based purchasing
  • Culture change and transformation
  • Q A

44
IOM Quality Chasm SeriesPreventing Medication
Errors
Adopting a Safety Culture Key Recommendations
  • All health care organizations should immediately
    make complete patient-information and
    decision-support tools available to patients and
    clinicians in an interoperable format
  • Health care systems should capture information on
    medication safety and monitor this information to
    improve the safety of their care delivery systems
  • All prescribers should have plans in place by
    2008 to implement electronic prescribing

45
Patient Safety Act of 2005
  • Creates Patient Safety Organizations (PSOs)
  • Establishes Network of Patient Safety Databases
  • Mandates Comptroller General to study
    effectiveness of Act (by 2010)
  • Is completely voluntary
  • Would be impossible without health IT backbone

46
PSO Activities
  • Conduct efforts to improve patient safety and
    quality
  • Collect analyze data, reports, records, root
    cause analyses
  • Develop/disseminate information to improve
    patient safety
  • Encourage culture of patient safety
  • Maintain procedures to keep work product
    confidential

47
PSOs-Next steps from AHRQ
  • Develop publish proposed rules governing
    operations of PSOs
  • Finish inventory of data elements, definitions
    encoding schemes
  • Consider options for fostering development of a
    network of patient safety databases
  • Plan for inclusion of patient safety information
    on performance, trends AHRQs NHQR/DR

48
Privacy Security Contract
  • AHRQ awarded Privacy and Security Solutions for
    Interoperable Health Information Exchange (9/05)
  • Overall contract managed by RTI International in
    partnership with National Governors Association
  • 19-month period increased to 17.4 million
    overall
  • RTI is subcontracting with 33 states and Puerto
    Rico to
  • Identify within the state business practices that
    affect electronic health information exchange
  • Propose solutions and implementation plans
  • Collaborate on regional and national meetings to
    develop solutions with broader application
  • Provide final report on overall project outcomes
    and recommendations

49
Privacy and Security Contract Purposes
  • Identify variations in business privacy and
    security policies and practices that affect
    electronic clinical health information exchange
  • Find best practices, identify practices with
    negative impact and propose alternatives
  • Preserve privacy and security protections as much
    as possible, consistent with interoperability
  • Incorporate state and community interests
  • Leave behind a knowledge base about privacy and
    security issues that informs future HIE activities

50
Opportunity Closing Disparities
  • Health IT is not only for big health plans
  • Huge opportunity to help racial, ethnic and
    socioeconomic minorities get access to EHRs,
    e-Rx, telemedicine and other applications
  • Aftermath of Katrina showed significance of
    health IT in protecting and accessing patient
    records

51
Perspectives on the role of
technology
Placing too much faith in technology, skeptics
warn, could be counterproductive. Dr. David
Himmelstein, a physician and associate professor
at Harvard Medical School, said, It encourages
the belief that we dont need real reform, all we
need is computers. New York Times, August 20,
2006
52
Reengineer Processes to Improve Patient Safety
  • As we migrate to a health information technology
    infrastructure, put effective processes in place
    at the same time
  • Augment health IT applications for error
    reduction, CPOE, and other clinical decision
    support tools
  • Build in the necessary disciplines and team
    approaches

53
Transparency and transformation
More transparent cost / quality information for
informed choices
Transparency
54
Transparency and transformation
More transparent cost / quality information for
informed choices
More effortless information sharing with Health IT
Transparency
Transfer
55
Transparency and transformation
More transparent cost / quality information
More effortless information sharing with Health IT
Transparency
Transfer
More collaboration for improvement
Trust
More trust between purchasers, providers and
consumers
56
In e-Health, e also needs to stand for
evidence-based medicine
  • E-health records, e-prescribing and e-reporting
    of adverse drug events are significant
    applications of health IT
  • However, integrating evidence-based medicine with
    health IT provides greatest opportunity to
    improve the value of health care in America
  • We must continue to develop ways for health IT to
    deliver the best and most current evidence on
    treatment effectiveness and outcomes to
    providers, payers and consumers

57
Getting to value-based health care
The most powerful contribution information
technology can make to improving health care
quality
58
Getting to value-based health care
The most powerful contribution information
technology can make to improving health care
quality
Make the right thing to do the easy thing to do
59
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