Transparency and Transformation: Initiatives for Improving Health Care Quality

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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
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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
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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
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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
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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
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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
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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
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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
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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

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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
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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
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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

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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

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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

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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

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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

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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
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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
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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
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Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
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Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
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Building a Transparent Health Care System
Cornerstones of Value-Based Health Care
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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

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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

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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
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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

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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

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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

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Consumer exposure to and use of quality
information
Percent of consumers who say they saw information
in the past year comparing quality among.
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24
12
Health Plans Doctors Hospitals
Source Kaiser Family Foundation/AHRQ 2006
Update on Consumers View of Patient Safety and
Quality Information
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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
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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
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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
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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
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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
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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

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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

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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
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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?

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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?

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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
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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

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Transparency and transformation
More transparent cost / quality information for
informed choices
Transparency
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Transparency and transformation
More transparent cost / quality information for
informed choices
More effortless information sharing with Health IT
Transparency
Transfer
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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
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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

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Getting to value-based health care
The most powerful contribution information
technology can make to improving health care
quality
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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
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Your questions?