Health Care IT and Academic Medical Centers

1
Health Care IT andAcademic Medical Centers

• Carolyn M. Clancy, MD
• Director
• March 30, 2005

2
Overview

• Quality and Safety Challenges
• AHRQs HIT Portfolio
• Future Opportunities

3
AHRQ Mission Statement

• To improve the quality, safety,
  efficiency, and effectiveness of health care for
  all Americans

4
AHRQ Context

• NIH -- focuses on specific disease to identify
  what might improve prevention, diagnosis, and
  treatment through biomedical research
• AHRQ -- focuses on how to improve the efficiency
  of the systems through which we receive personal
  health care and the effectiveness and comparative
  effectiveness of services
• CDC -- focuses on population health and the role
  of health departments and community-based
  interventions to improve health

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AHRQ focuses on the Health Care System

• Assess the effectiveness, comparative
  effectiveness, and cost- effectiveness of health
  care services
• Identify ways to improve patient safety and
  quality of health care systems
• Advance the appropriate use of health information
  technology
• Understand system issues role of organizational
  design, management, workflow, management, and
  incentives on efficiency and effectiveness
• Develop data on the health care system for
  monitoring and decision-making

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AHRQ Strategic Redirection

• Accelerating the Pace of Innovation
• Ensuring Value through More Informed Choice
• Assessing Innovation Faster
• Implementing Effective Interventions Sooner

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Major Opportunities for Improvement Still Exist
in Quality

• 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

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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

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Impact of information availability on care
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, 2004).
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AHRQ Research Study Risks Associated With
Erythromycin Combined With CYP3A Inhibitors

• Major Finding Concurrent use of erythromycin
  and strong inhibitors of CYP3A should be avoided
• Patients who took erythromycin with VYP3A drug
  enzymes (certain calcium-channel blockers and
  anti-fungal drugs, and some anti-depressants),
  had a 5x greater risk of sudden death from
  cardiac causes

W. Ray, K. Murray, S. Meredith, et al., Oral
Erythromycin and the Risk of Sudden Death
from Cardiac Causes, New England Journal of
Medicine, September 9, 2004
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AHRQ Research Study Medications Dispensed to
Pregnant Women

• Major Finding Nearly half of pregnant women who
  are prescribed drugs may get medications that are
  unsafe

Women who were dispensed a medication other than
a vitamin or mineral supplement prior to delivery
by FDA risk category
X 5
D 5
FDAs Risk Category List A Risk to fetus is
remote B Animal studies do not show fetal risk
and there are no controlled studies in
women C Human safety has not been
established D Positive evidence of fetal risk,
but benefits may be acceptable X Definite
fetal risks
C 40
A B 50
S. Andrade, J. Gurwitz, R. Davis, Prescription
drug use in pregnancy, Am J Obstet Gynecol,
August 2004
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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

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Systems Approach Measurement HIT ? Improved
Quality
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

Lappeacute, J. M. et. al. Ann Intern Med
2004141446-453
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Diffusion of knowledge
Balas EA, Boren SA., Managing Clinical Knowledge
for Health Care Improvement. Yearbook of Medical
Informatics 2000.
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Treatments Thought to Work but Shown Ineffective

• Sulphuric acid for scurvy
• Leeches for almost anything
• Insulin for schizophrenia
• Vitamin K for myocardial infarction
• HRT to prevent cardiovascular disease
• Flecainide for ventricular tachycardia
• Routine blood tests prior to surgery
• ABMT for late stage Breast CA
• BMJFebruary 28 2004 324474-5.

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Original research
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variable
Negative results
Dickersin, 1987
Submission
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0.5 year
Kumar, 1992
Koren, 1989
Acceptance
Negative results
0.6 year
Kumar, 1992
Publication
1714
Expert opinion
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0.3 year
Poyer, 1982
Balas, 1995
Lack of numbers
Bibliographic databases
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6. 0 - 13.0 years
Antman, 1992
Poynard, 1985
Reviews, guidelines, textbook
9.3 years
Inconsistent indexing
Implementation
It takes 17 years to turn 14 per cent of original
research to the benefit of patient care
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IT Impact on Quality and Safety

• Outpatient Advanced CPOE and EMR
• Avoid 2.1 million adverse drug events per year
  (national adoption)
• Inpatient CPOE and EMR
• Decrease serious medication errors by 55
• Healthcare information exchange and
  interoperability between settings
• Improve physician decision-making at the
  point-of-care through complete information access

Source CITL
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Overview

• Quality and Safety Challenges
• AHRQs HIT Portfolio
• Future Opportunities

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AHRQ Building the Evidence Base for HIT

• Electronic Health Records
• Shared Online Health Records for Patient Safety
  and Care
• Clinical Decision Support
• Automated Lab Test Follow-up to Reduce Medical
  Errors
• Electronic Prescribing
• Error rates and prescribing practices in
  pediatric clinics
• Use of hand-held devices
• Acceptance, benefits, and barriers in the use of
  hand-held decision support systems in ambulatory
  settings
• Consumer-directed IT
• Parent-Initiated Prevention Program

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Work in Progress

• Randomized trials of e-prescribing to reduce
  errors
• With substantial hand-holding, 46 of physicians
  will use
• Functionality challenges both the applications
  and their use
• Multiple reporting demonstrations for patient
  safety
• Multiple studies to improve care using one or
  more applications of HIT as an intervention

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Challenges to HIT Diffusion

• Absence of clear ROI.
• High costs and significant capital investment for
  the purchase and installation
• The opportunity costs of physician time has not
  been assessed
• Limited data on return of investment for HIT --
  is there a business case for quality?
• Preliminary estimates promising
• Does it get us to the map of incentives that we
  need?
• New AHRQ evidence report under development

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IT and Research

• Identify and prioritize critical questions e.g.,
  clinical variations as a reflection of inadequate
  knowledge
• Accelerate collection of relevant data
• Facilitate consistent measurement of key outcomes
• Enhance participation of communities and
  stakeholders
• Reinvent dissemination and translation

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FY04 Health IT Initiatives

• Transforming Healthcare Quality through
  Information Technology 3 RFAs
• National Health IT Resource Center
• State Demonstrations on Interoperability
• Indian Health Service EHR Collaboration
• CMSAHRQ demonstration collaboration
• Development of clinical data standards

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Transforming Healthcare Quality through Health
IT (THQIT)

• FY04 Grant Solicitations
• Determining the Value of Health IT
• assess the value derived from the adoption,
  diffusion, and utilization of HIT
• THQIT Planning
• assist healthcare systems and their partners in
  planning for activities that will lead to
  successful Health IT implementation
• THQIT Implementation
• support organizational and community-wide
  implementation and diffusion of Health IT

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Health IT Grants

• Promoting access to Health IT
• Over 100 grants to communities, hospitals,
  providers, and health care systems to help in all
  phases of the development and use of health
  information technology.
• The grants are spread across 38 states
• Special focus on small and rural hospitals and
  communities.
• First year funding is 41 million and will total
  nearly 96 million over three years.

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Value Grants Highlights

• Epic EHR installation at Kaiser
• CDSS in nursing homes on medication ordering
• State-wide rollout of e-prescribing
• EHR and/or web-based patient program for
  diabetics
• Human factor analyses and CPOE implementation
• Tele-ICU monitoring on outcomes and costs
• Health information exchange in ambulatory care

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Planning Grants Highlights

• Area-wide EHR in remote Alaska
• Regional planning for health IT in Michigans
  upper peninsula
• Electronic sharing of behavioral health
  information in Nebraska
• Unified EHR for hospitals, private providers, and
  hospice in rural New York State
• Community-driven effort to bring community health
  centers and hospitals together to share data in
  Hawaii.

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Implementation Grants Highlights

• Community-wide EHR to improve asthma care for
  inner-city children in Connecticut
• Emergency department EHR across Louisianas
  critical access hospitals
• Electronic radiology initiative across three
  hospitals in rural Maine
• CPOE in an inner-city, minority community in Ohio
• Patient-centered medication information system to
  improve health of chronically ill elders in rural
  Oregon

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State Interoperability Demonstrations

• Five-year state-based contracts
• Help states develop secure statewide networks
• Ensure privacy of health information
• Make an individuals health information more
  available to health care providers.
• FY04 Five states awarded 1M/year
• Colorado
• Indiana
• Rhode Island
• Tennessee
• Utah

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National Health Information Technology Resource
Center

• Provide technical support to Health IT grantees,
  selected other federal grantees, and general TA
• Develop repository of best practices
• Contract award to NORC (up to 18.5M over 5 yrs)
• In partnership with
• Vanderbilt University
• Center for IT Leadership (Partners)
• Indiana University
• Foundation for the eHealth Initiative
• CSC

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Overview

• Quality and Safety Challenges
• AHRQs HIT Portfolio
• Future Opportunities

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Working Definitions

• Effectiveness
• Can it work?
• Does it work in practice?
• Is it worth it?
• Haynes B Can it work? Does it work? Is it worth
  it? BMJ1999319 652-3

• Comparative Effectiveness
• Comparison of the effectiveness of various
  treatments and procedures - looking at which
  treatments for specific clinical problems work
  best for whom

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What is Section 1013?

• To improve the quality, effectiveness and
  efficiency of health care delivered through
  Medicare, Medicaid and the S-CHIP programs
• 15 million is appropriated in Fiscal Year 2005
  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

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Legs of the Program
Evidence Synthesis
Evidence Communication
Evidence Generation
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Priority List

• Ischemic Heart Disease
• Cancer
• Chronic Obstructive Pulmonary Disease/Asthma
• Stroke, Including Control Of Hypertension
• Arthritis And Non-traumatic Joint Disorders
• Diabetes Mellitus
• Dementia, Including Alzheimer's Disease
• Pneumonia
• Peptic Ulcer/Dyspepsia
• Depression And Other Mood Disorders

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Infrastructure

• Center for Decision Support
• Systematic Review translation for different
  levels of decision makers
• Translation into different mediums
• Medical decision support generally how to
  interpret acceptable risk, relative risk, rates,
  etc.

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Practical Clinical Trials

• Compare clinically relevant interventions
• Enroll a diverse study population
• Recruit from a variety of practice settings
• Measure a broad range of relevant health outcomes

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PCTs vs. ECTs
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• Improving the quality of clinical research
  will depend on more active involvement of
  clinical and health policy decision makers in all
  aspects of clinical research, including priority
  setting, study design, study implementation, and
  funding.

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Strategies for Improvement

• Systematically identify and prioritize knowledge
  gaps
• Decision makers Insist on high-quality evidence
  in making decisions
• Create operational infrastructure
• Address Methodological and Ethical Issues

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Increasing Supply of PCTs

• Development of a mechanism to establish
  priorities for these studies
• Significant expansion of an infrastructure to
  conduct clinical research within the health care
  delivery system
• More reliance on high-quality evidence by health
  care decision makers
• Substantial increase in public and private
  funding for these studies

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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

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Future Program Emphasis

• Regional collaborations
• Regional Health Information Organizations
• Linkage with existing and future initiatives
  (e.g. payment or quality)
• Delineate Privacy and Legal Framework
• Synergize ongoing and future initiatives
• ePrescribing (grants to physicians, MMA eRx
  programs)
• Chronic Disease Programs
• Integrate decision support with eRx
• Create avenues enhancing technical and resource
  support for stakeholders

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Future Research Emphasis

• Improving Quality and Decision Making
• Development of measures that are valid, reliable,
  clear and understood and valued by all
  stakeholders
• Common infrastructure for generating and
  communicating evidence, and accelerating
  diffusion
• Ability to evaluate value to stakeholders and
  investors
• Fiscal
• Non fiscal

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• For additional questions, please contact
• Dr.Carolyn Clancy, cclancy_at_ahrq.gov
• www.ahrq.gov