Improving Quality and Safety Through Value-Driven Health Care

1. Improving Quality and Safety Through Value-Driven Health Care Carolyn M. Clancy, MD Director Agency for Healthcare Research and Quality Medicare Advantage Quality Measurement & Performance Assessment Training Conference Baltimore, MD – April 8, 2007

3. Improving Quality and Safety • Perceptions of the U.S. Health Care System & the Quality Challenge • AHRQ Roles & Resources • Value-Driven Health Care • Turning Evidence Into Action • Q&A

4. The Quality Challenge What Is Quality? The Right Care For The Right Person At The Right Time A Quality Disconnect Health care costs up 6.7% per year Health care quality up 2.3%

5. 95% 64% 35% 4% Cost of Health Care Quality of Health Care Public Perceptions of U.S. Health Care Are you generally satisfied or dissatisfied with… Satisfied Dissatisfied In addition, 95% of people with insurance are dissatisfied with cost and 62% are dissatisfied with quality Health Care for America Survey – AFLCIO – March 2008

6. Public Perceptions of U.S. Health Care Overall, what do you think about today’s health care system? Should Be Completely Rebuilt Not Sure Works Pretty Well – Minor Changes Fundamental Changes needed Health Care for America Survey – AFLCIO – March 2008

7. Physician Involvement in Collaborative Efforts to Improve Quality of Care Percent indicating involvement in any collaborative efforts in past two years* Involved in at least one effort (32%) * Multiple answers possible The Commonwealth Fund National Survey of Physicians and Quality of Care, 2005

8. Physician Opinions on Effectiveness of Collaborative Activities, by Practice Size Percent saying that involvement in collaborative efforts is “very/somewhat” effective in improving quality of care The Commonwealth Fund National Survey of Physicians and Quality of Care, 2005

9. Social Workers Disease Management Patients Nurses Physicians Medical Home PHRs Family & Care Givers Care Managers Coordination of Care

10. Improving Quality and Safety • Perceptions of the U.S. Health Care System & the Quality Challenge • AHRQ Roles & Resources • Value-Driven Health Care • Turning Evidence Into Action • Q&A

11. AHRQ’s Mission Improve the quality, safety, efficiency and effectiveness of health care for all Americans

12. 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 health IT 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, HRSA and CMS • 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

13. AHRQ FY 2008 Priorities Patient Safety • Health IT • Patient SafetyOrganizations • New PatientSafety Grants Effective HealthCare Program AmbulatoryPatient Safety • Comparative Effectiveness Reviews • Comparative Effectiveness Research • Clear Findings for Multiple Audiences • Safety & Quality Measures,Drug Management andPatient-Centered Care • Patient Safety ImprovementCorps Other Research & Dissemination Activities Medical ExpenditurePanel Surveys • Visit-Level Information on Medical Expenditures • Annual Quality & Disparities Reports • Quality & Cost-Effectiveness, e.g.Prevention and PharmaceuticalOutcomes • U.S. Preventive ServicesTask Force • MRSA/HAIs

14. FY 2008 Funding • $334.6 million • FY 2008 Request – $329.6 million • FY 2007 Appropriation – $318.7 million • FY 2008 appropriation includes: • $30 million for comparative effectiveness research • Double the $15 million designated in FY 2007 • $5 million for research and activities to reduce Methicillin Resistant Staphylococcus aureus (MRSA) and related infections • The first such federal grant to AHRQ for MRSA/HAIs • Congress also encouraged AHRQ to: • Consider proposals to detect medical errors and preemptively control injury via compact medical devices • Investigate the feasibility of an open-source, no-cost license computer model capable of predicting the effects of health care policy alternatives to improve quality and cost-effectiveness

15. Distributed Network Prototypes for Population-Based Studies • The aim is to develop a federated network prototype that supports secure analyses of electronic information across multiple organizations to study risks, effects and outcomes of various medical therapies • The long-term goal is a coordinated partnership of multiple research networks that provide information that can be quickly queried and analyzed: • Model 1: Colorado DEcIDE center with American Academy of Family Practice will develop the “Distributed Ambulatory Research Network” (DARTNet) using electronic health record (EHR) data from eight organizations representing over 200 clinicians and over 350,000 patients • Model 2: HMO Research Network (HMORN) DEcIDE will develop the “Virtual Data Warehouse” to assess the effectiveness and safety of different anti-hypertensive 5.5 to 6 million individuals cared for by six health plans

16. Health IT: Where We’ve Been; Where We’re Going • Long-term agency priority • Since 2004, AHRQ has supported more than 200 projects and demonstrations to improve the safety, quality and efficiency of health care in virtually every state • Special attention to best practices that can improve quality of care in rural, small community, safety net and community health center care settings • New focus on ambulatory safety and quality AHRQ Health IT Investment: $216 Million

17. Ambulatory Safety andQuality Program (ASQ) • Purpose: Improve safety and quality of ambulatory health care in the U.S. More than 60 grants in 3 areas: • Enabling Quality Measurement through Health IT (EQM) • Improving Quality Through Clinician Use of Health IT (IQHIT) • Enabling Patient-Centered Care Through Health IT (PCC) • Types of Health IT used in projects: • Personal Health Records • Clinical/Medication Reminders • Clinical Decision Support • Telehealth • Human/Machine Interface

18. ASQ Example: Enabling Quality Measurement through Health IT • Medication Monitoring for Vulnerable Populations via Health IT – Johns Hopkins University, Baltimore • Demonstrates the ability of HIEs and EHRs to provide quality and safety measures for vulnerable populations served by a community health center • Type of Health IT: System integration, quality of care decision support Estimated Total Funding: $994,325 Project Start – September 21, 2007 Project End – August 31, 2009

19. AHRQ’s National Reports on Quality and Disparities 2007 Reports: Some Good News, Need for Improvement • More than 93% of heart attack patients received the recommended hospital care in 2005, up from about 77 percent in 2000/2001 • The percent of heart attack patients who were counseled to quit smoking increased from about 43% in 2000/2001 to about 91% in 2005 • Measures of patient safety showed an average annual improvement of about 1% New Efficiency Chapter Disability Data Added More on Health Literacy

20. =Most Recent Year = Baseline Year Maryland: Overall Health Care Performance vs. All States, One-Year Performance Change Average Weak Strong Very Weak Very Strong Performance Meter 2007 National Healthcare Quality Report, State Snapshots

21. Examples: MD Snapshot *National Healthcare Quality Report, State Snapshots, 2007

22. AHRQ is funding a randomized control trial to clarify the added value of genetic testing to improve warfarin dosing. AHRQ and CDC are finalizing a DEcIDE project to review databases focusing on utilization and outcomes ofgene-based tests and therapies EPC Reports: The Promise of Genomics: Recent Activities • Genomic testing in ovarian cancer (completed) • CYP450 testing in depression (completed) • HNPCC testing in colorectal patients (completed) • Horizon scan on cancer genetic tests for CMS (completed) • BRCA testing in breast and ovarian cancers (w/USPSTF recommendation) • HER-2-Neu testing in breast cancer (ongoing) • Expression profile tests in breast cancer (completed) • Family history in breast, ovarian, colorectal and prostate cancers (completed) • Screening for hemochromatosis (w/USPSTF recommendation)

23. Improving Quality and Safety • Perceptions of the U.S. Health Care System & the Quality Challenge • AHRQ Roles & Resources • Value-Driven Health Care • Turning Evidence Into Action • Q&A

24. Quality Standards Design systems to collect quality of care information and define what constitutes quality health care Incentives Reward those who provide and purchase high-quality and competitively priced health care Price Standards Aggregate claims information to enable cost comparisons between specific doctors and hospitals Interoperability Set common technical standards for quick and secure communication and data exchange Cornerstones of Value-Driven Health Care

25. Getting to Value-Driven Quality Health Care "All health care is local, and we need cooperative local action just as we need common national goals." Michael O. Leavitt, Secretary US Dept. of Health and Human Services January 5, 2007

26. Chartered Value Exchanges

27. What Will This Take? • Good measures and data • Local data, but national benchmarks • Strong local coalitions • Evidence-based reporting, payment strategies • Evidence, tools, strategies for improvement • Collaboration, TA across sites

28. Encourage sharing of experiences and lessons learned Identify and share promising practices that improve health care value Identify gaps where innovation is needed Provide face-to-face and virtual opportunities for peer-to-peer sharing of experience Identify interventions or tactics that yield the best outcomes Translate interventions into adaptable change strategies Create a user-friendly, Web-based knowledge repository Goal: have all Community Leaders become or join Chartered Value Exchanges AHRQ Learning Network for Value Initiative Measurement Data aggregation Report Cards Provider Incentives Consumer Incentives

29. Better Quality Information (2006 AQA Pilot Project*) 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 *Supported by funding from CMS and AHRQ

30. HQA and AQA Collaborate • National Quality Alliance Steering Committee • Formed by two key health care quality alliances, the AQA Alliance and the Hospital Quality Alliance • Purpose: To better coordinate the promotion of quality measurement, transparency and improvement in care • First Step: Expand pilot project sites to identify, collect and report data on the quality of physician performance across care settings, including hospital and cost-of-care. Will work closely with AHRQ and CMS

31. Hospital Compare update announced March 28 H-CAHPS data from 2,500 hospitals nation-wide Easy to understand Reflects ‘tangible” experiences of patients‘ Collaboration of AHRQ, Centers for Medicare & Medicaid Services and Hospital Quality Alliance HCAHPS Data Added to Hospital Compare

32. Improving Quality and Safety • Perceptions of the U.S. Health Care System & the Quality Challenge • AHRQ Roles & Resources • Value-Driven Health Care • Turning Evidence Into Action • Q&A

33. New User’s Guide to Patient Registries Registries for Evaluating Patient Outcomes: A User’s Guide* • The first government-supported handbook for establishing, managing and analyzing patient registries • Designed so patient registry data can be used to evaluate the real-life impact of health care treatments • A milestone in growing efforts to better understand what treatments actually work best, and for whom • http://effectivehealthcare.ahrq.gov, print versions coming soon * Co-funded by AHRQ & CMS EHC Research Report May 16, 2007

34. Other Program Outputs: Spreading the Word Research Reports Consumer Guides Systematic Reviews

35. www.innovations.ahrq.gov AHRQ Health Care Innovations Exchange Web-based Repository of Cutting-Edge Service Innovations • National electronic learning hub for sharing health care service innovations, bringing innovators and adopters together • Searchable database featuring innovation successes and failures, expert commentaries, lessons learned, etc., • Designed to help health care “Agents of Change” improve quality

36. Transparency and Transformation More effortless information sharing with Health IT More transparent cost/quality information Transparency Transfer More collaboration for improvement Trust More trust between purchasers, providers and consumers

37. Near-Term Frontier • Focus on disparities reduction as core component of quality improvements • Combine administrative data with selected clinical IT data elements (e.g., lab, pharmacy) to enhance efficiency of data aggregation • Build quality reporting functionality – and decision support – into certified electronic health records • Engineer value-driven health care on a national scale via regional/local public-private collaboration

38. Improving Quality and Safety • Perceptions of the U.S. Health Care System & the Quality Challenge • AHRQ Roles & Resources • Value-Driven Health Care • Turning Evidence Into Action • Q&A