Transcript Tie in HIT developments to improved quality and safety of
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care •
www.ahrq.gov
Advancing Excellence in Health Care
Carolyn M. Clancy, MD Director
Advancing Excellence in Health Care
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.
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Case Presentation - 2
Paul’s pc team has also reviewed Paul’s 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.
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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.
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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.
Advancing Excellence in Health Care
Overview
About AHRQ: The Evidence Agency
Health Care 2005: Current Context Recent Findings and Directions Future Challenges
Advancing Excellence in Health Care
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.
Advancing Excellence in Health Care
Advancing Excellence in Health Care
AHRQ RESEARCH FOCUS: HOW 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
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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
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AHRQ RESEARCH AND HIT
20+ year history of supporting evaluation of use of HIT to improve care (IHC; Regenstrief; Brigham and Women’s) Provide and update content: e.g., National Guideline Clearinghouse Critical component of research efforts across business lines (patient safety**) New: supporting change efforts – real time evaluation and learning
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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
Advancing Excellence in Health Care
Overview
About AHRQ: The Evidence Agency
Health Care 2005: Current Context
Recent Findings and Directions Future Challenges
Advancing Excellence in Health Care
Driving Forces
Rising health care expenditures Aging and increasingly diverse population Consumerism Biomedical advances: public and professional expectations Growing influence of purchasers
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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
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Percent of Americans Saying “I Have A Chronic Condition”
70% 60% 50% 40% 30% 20% 10% 15% 0% 18-29 24% 30-39 35% 40-49 Age 58% 50-64 66% 65+
Source: Chronic Illness and Caregiving Survey, Harris 2000
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New York Times
, December 18, 2002
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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 55% Stayed about the same 40% 44% 38% Don’t Know 4% 17% 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).
Personal Experience
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Have you been personally involved Did the error have serious health consequences, minor health in a situation where a preventable consequences, or no health medical error was made in your own medical care or that of a family consequences at all? member?
No 65% 34% Yes 21% 10% 3% Serious health consequences Minor health consequences No health consequences 1% Don’t 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).
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Role Of IT In Reducing Medical Errors Percent who say… The coordination among the different health professionals that they see is a problem 69% 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?
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 32% 48% 1% Don’t know 32% 67% 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).
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Pace of Change Varies Across Care Settings
Median change in performance by setting, 2003 NHQR vs 2004 NHQR
20.0% 18.0% 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 5.4% 1.4% 3.0% 17.7% Hospital care Ambulatory care
Setting
Home health care Nursing home care (24 measures) (49 measures) (12 measures) (3 measures) 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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Major Opportunities for Improvement
Quality of Pneumonia Treatment for Elderly, 2002
100 90 80 70 60 50 40 30 20 10 0
63.1
67.9
81 29.6
Received 1st dose of antibiotic within 4 hours of hospital arrival Received recommended antibiotics consistent with current guidelines Have blood cultures collected before antibiotics are administered Received all recommended treatment regimens
Measure Source:
Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2002.
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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Advancing Excellence in Health Care
The proportion of adults with diabetes who received all five recommended diabetic services (MEPS, 2000-2001 ) 40% 30% 20% 10% 0% W hi te B la N ck on -H is pa ni c W hi te H is pa ni c Po or N ea r Mi Po dd or le In co H m ig e h In co m e 2000 2001
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Environmental Change
“In its current form, habits, and environment, American health care is incapable of providing the public with the quality health care it expects and deserves.”
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Context
Structural measures do not reliably predict quality Growing demand for evidence of performance and
public reporting
of same (Process) Outcomes considered best – but outcomes are not actionable, and require substantial adjustment for fair comparison
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Categories of Care Activities
Technical care
– Application of science and technology of medicine to manage personal health problems
Interpersonal care
– Interaction between the patient/consumer and the health care system arrange and receive care
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HHS: Recent Developments
Nursing Home Initiative Home Health Care Initiative* AHA-JCAHO VHA …. Hospital reporting initiative* Patient experience in hospitals* Bar coding IT standards (*)
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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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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?
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Overview
About AHRQ: The Evidence Agency Health Care 2005: Current Context
Recent Findings and Directions
Future Challenges
AHRQ Research Study: Identifying
Advancing
Successful Hospital Quality Improvements
Care
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
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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
AHRQ Research Study: Outpatient
Advancing
Prescription Drug-Related Injuries in Elderly
in Health Care
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
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AHRQ Case Study: Computerized ICU System and Nursing Care
Computerized medical information management system in hospital intensive care units (ICU) significantly reduced time ICU nurses spent on documentation 11 1 Nurses were able to complete more tasks without interruption 9 10 2 3 8 4
52 minutes saved in an 8hr shift
7 6 5 D. Wong, Y. Gallegos, M. Weinger, et al., Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system,
Critical Care Medicine
, 2003
HIT + Systems approach
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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 2004;141:446-453
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AHRQ Recent Research Findings
Systematic review of randomized clinical trials of computer-assisted interventions in diabetes care – significantly improved patients' glycated hemoglobin and blood glucose levels – substantially improved physician compliance with diabetes care guidelines in six of eight studies
compliance with recommended diabetes care procedures was 71% to 227% higher among doctors prompted by computer systems to perform the procedures compared with doctors who did not receive the prompts
Balas, Krishna, Kretschmer, et al., Computerized knowledge management in diabetes care (2004).
Medical Care
42(6), pp. 610-621.
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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/hospcult ure/ or e-mail to [email protected]
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AHRQ WebM&M Web-Based Medical Journal
Online medical journal and forum on patient safety and health care quality Features expert analysis of medical errors reported anonymously by readers, interactive learning modules on patient safety, and forums for online discussion CME credit available
http://webmm.ahrq.gov
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Key Implementation Activities – QualityTools
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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 Nation’s largest health insurance plans, and other organizations
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Ambulatory Care Quality
Develop strategy for moving forward effectively and efficiently: – – Measuring performance at the provider level Collecting and aggregating data in least burdensome way – Reporting meaningful information to consumers, physicians and other stakeholders to inform choices and improve outcomes
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Overview
About AHRQ: The Evidence Agency Health Care 2005: Current Context Recent Findings and Directions
Future Challenges
Advancing Excellence in Health Care
The Future Delivery System: Baseline Assumptions
Today’s 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”
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What We Have Learned 2005
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’ Sutton’s Law: improving chronic illness care is essential Safety in health care delivery is critical
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Improving Quality and Safety
“We need to make the right thing the easy thing…”
Mark Chassin, MD October 12, 2000
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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
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The Costs/Value of IT
Limited data on return of investment for IT - is there a “business case for quality?” Significant capital investment for the purchase and installation The "opportunity cost" of physician time and use of IT have not been determined.
Economic impact uncertain -- hard to track all costs and savings following IT adoption (diffuse and indirect)
FY04: Transforming Healthcare
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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
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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
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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
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Errors As a Systems Problem
in Health
“We must stop blaming people and start looking at our systems. We must look at how we do things that cause errors and keep us from discovering them...before they cause an injury.”
- Leape 1994
AHRQ Research Study: Timing of
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Surgery for Hip Fracture and Outcomes
Major Finding:
the patient: Hip fracture surgery performed within 24 hours of hospital admission results in positive outcomes for – – – Reduces pain Shortens hospital stays May limit probability of major complications, such as pneumonia and arrhythmias GM Orosz, J. Magaziner, EL Hannan, et. al., The association of timing of surgery for hip fracture and patient outcomes,
JAMA
, April 14, 2004
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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
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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)
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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 $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
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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
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Patient SHARED DECISION MAKING: DECISIONS AND OUTCOMES Alternative 1 Alternative 2
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All We Need Is…..
P
ayment changes: p4p + FFS = ??
Smart
P
olicies
P
eople who get it “
P
ull” – demand for change; urgency
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How has practice changed?
Agency for Healthcare Research and Quality
Advancing Excellence in Health Care •
www.ahrq.gov
www.ahrq.gov
AHRQ’s Publications Clearinghouse
800-358-9295 (weekdays, 9 - 5 eastern time)
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The End
Please continue to the post test Download the post test Complete the post test Return the post test to Dr. Sandra Oliver at TAMU II 407 I
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Post test Question 1
The mission of the AHRQ is to improve the quality, safety, efficiency, and effectiveness of health care : 1. for all Americans.
2. for underserved Americans.
3. through evidence based medicine.
4. through scientific exploration of diseases.
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Post test Question 2
Which of the following is not in health care quality: a role of government 1. Purchase health care 2. Provide health care 3. Assure access for vulnerable populations 4. Monitor health care quality 5. Regulate health care decision makers
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Post test Question 3
The NHQR quality measures of care settings, showed which of the following: 1.
2.
2.
3.
Change in performance was the same across settings.
Nursing homes showed the greatest change.
Hospitals showed the greatest change.
No change in one year in any setting.
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Post test Question 4
Which of the following is true: 1. Knowing the right thing to do is equal to doing it!
2. Change must be based on practice patterns of physicians 3. Patients as participants are far more effective than patients as ‘recipients’ 4. Safety in health care delivery is irrelevant