Initiatives in Healthcare Quality and HIT P. Jon White, MD Health IT Portfolio Director Agency for Healthcare Research and Quality March 28, 2007

Core Values and Principles Improve the quality, safety, efficiency and effectiveness of healthcare for all Americans Evidence through Research, Evaluation and Demonstration Convene Key Stakeholders Inform Policy 2

Portfolio Goals Patients will receive appropriate care for prevention and treatment Patients will report a positive experience with healthcare Patients will be able to routinely access reports of quality and safety for their providers and practices. Improve the safety and quality of prescription drug management via the integration of utilization of medication management systems and technologies. By 2016, the percentage of patients receiving the appropriate medication therapy for priority conditions increases by 50% from baseline. By 2010, 50% of ambulatory clinicians use electronic prescribing systems and/or medication management technologies. By 2010, certified electronic prescribing systems will include evidence-based decision support for priority conditions. By 2012, 50% of patients can electronically access information about their medication therapy. By 2012, patient-level medication information will be available across sites of care. By 2014, pharmacists and other clinicians will have training available for the use of medication management systems and technologies to improve quality and safety of care. Improve the delivery and utilization of evidence-based care in ambulatory settings (clinical workflow, health information exchange, and with an emphasis on chronic disease). By 2016, 80% of the time patients receive appropriate care for the prevention and treatment of priority conditions. [NHQR/DR] By 2010, 50% of clinicians can electronically access evidence-based information about prevention or treatment of priority conditions. By 2012, 50% of clinician organizations report adoption, or plans for adoption, of proven healthcare technologies that bring evidence-based decision support to the point of care. By 2014, 50% of ambulatory safety net organizations will have access to proven health care technologies appropriate for their settings. By 2012, 20 states will have involvement of their Medicaid and other state health care agencies in HIE development Improve the delivery of patient centered care in ambulatory care settings, including specific focus on transitions of care, personal health records, and improved patient-provider communication and decision-making. By 2016, the percentage of patients who report a positive experience with their ambulatory care for priority conditions increases 50% from baseline. By 2010, 50% of ambulatory clinicians will routinely use CAHPS and other measures to evaluate the patient’s experience of care. By 2012, 50% of patients will have access to their personal health information and decision support in ambulatory care settings and across transitions. By 2012, 50% of developing health information exchanges will promote the inclusion of patients and consumers in the design and deployment of health IT systems for improving patient-centered care and transitions in care. By 2014, 75% of medical, nursing, and allied health professional educational programs will include training focused on the components of patient- centered care. Foster the development, deployment, and reporting of measures of safety and quality in ambulatory care settings and across high risk transitions in care. By 2016, 80% of patients will be able to routinely access reports of data on measures of ambulatory care quality and safety for their providers and practices. By 2010, all high prevalence priority conditions will have consensus measures of ambulatory care quality and safety. By 2012, 50% of ambulatory practices measure and improve their patient safety culture. By 2012, 50% of certified electronic health record systems will be able to produce and export electronic data on measures of ambulatory care quality and safety for priority conditions. By 2014, data on ambulatory safety and quality measures can be routinely aggregated through health information exchanges or other data organizations. By 2016, 80 % of ambulatory practices will be able to electronically report and utilize data on measures of ambulatory care quality and safety for improvement, including through PSOs, HIEs or other data organizations. 3

Where have we been? Transforming Healthcare Quality through IT State and Regional Demonstrations AHRQ’s National Resource Center for Health IT Over 120 projects in 43 states Impacts the healthcare of 40 million Americans THQIT grants: 3 large groups Plannign Implementation Demonstrating Value SRDs: 6 projects, 5 years, $30 million State and regional level health information exchange Pharmacy and Lab data rrequired, includes other information 4

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Privacy and Security $17.4 million dollar contract 33 states and Puerto Rico Final report this summer National meeting in March Additional regional meetings and TA 18 months into the $17.4 million dollar contract work on privacy and security, 33 states and Puerto Rico are submitting their reports on the variations in privacy and security policies and laws they are finding, as well as proposed solutions. They will soon be submitting proposed implementation plans for the solutions RTI, the prime contractor, will be summarizing all reports and analyzing them for regional and national issues and trends, and will identify any recommendations for national action; the final report is expected at the end of the summer. A national meeting of all interested states working on privacy issues was held in early March, where they comapred their work and made plans for continued collaboration. We hope to convene additional regional meetings and continue with technical assistance to the states through the summer. HHS also plans to fund the proposed implementation plans; stay tuned! 6

Where else have we been? E-prescribing TV Pilot for PBS Medicare Modernization Act Pilots TV Pilot for PBS Questions Are The Answer 7

What are we learning? One part IT, one part culture, one part workflow Privacy and security are foundational Be a healthy skeptic of technology, but ignore it at your peril It’s about the quality (stupid) I couldn’t possibly begin to tell you everything were are learning – but here’s some highlights. 9

Where are we now? Ambulatory Safety and Quality AHRQ NRC Patient Centered Care IQHIT Enabling Quality Measurement AHRQ NRC Centers for Research and Education in Therapeutics (CERTs) 10

2007 CERTs CERTs is a national demonstration program whose mission is to conduct research and provide education that advances the optimal use of drugs, biologicals, and medical devices. In addition, CERTs also provides clinical information to practitioners, pharmacy benefit managers, insurers, governmental agencies, patients, and consumers. The ultimate goal of the CERTs program is to provide access to evidence-based research and education programs, for all who need such access, throughout the spectrum of health care. Administered by AHRQ, in consultation with FDA, as cooperative agreements. 300 peer-reviewed publications. Example: FDA is co-sponsoring a pilot study with the CERTs -- using data extracts created via AHRQ funded safety studies -- to assess when adverse drug reactions discovered after marketing could have been identified through routine screening of administrative datasets. Example: The CERTs have developed an Internet-based international registry for drug-induced arrhythmias (QTdrugs.org). The registry was used to detect that IV Methadone induced torsades de pointes (after 45 years of monitored administration in MMT centers). The CERTs subsequently determined the mechanism. Example: Using TennCare data, the CERTs found an association between the oral use of erythromycin and the risk of sudden death from cardiac arrest. Example: The CERTs are evaluating computer-based clinical decision support systems to support appropriate prescribing in the ambulatory setting. Potential: The CERTs can develop and test a wide array of interventions to improve prescribing in the general population and in high risk groups. These interventions can be tested in CERTs-affiliated inpatient and ambulatory settings, and through available data resources. Health IT CERT Role and use of health IT tools in the safe and effective use of therapeutics. Potential areas of study include: Barriers and opportunities to the utilization of health IT based medication management systems. Information sharing, prescribing, and efficacy/safety monitoring of prescription drugs across multiple care settings using health IT. Improved health IT tools to enhance coordination of care among multiple providers. Improving therapeutic decision making. Patient education. 11

Where are we now? ACTION Practice Based Research Networks Dissertation and Training Awards Innovations Exchange National Guidelines Clearinghouse and National Quality Measures Clearinghouse 12

Where are we now? American Health Information Community Workgroups Demonstrations for Breakthroughs State work AHIMA HITSP, CCHIT, NHINs, State eHealth Federal Partners DoD, VHA, CMS, FDA, NIH, ONC, HRSA, HIS, SAMHSA AHIC We participate in many of the workgroups: Quality EHR Consumer Empowerment Chronic Care Medication Management AHRQ staff are on the HITSP (Mike Fitzmaurice), CCHIT (me) AHRQ projects are part of the NHIN prototypes and State Alliance for eHealth initiative Our Federal partners include…. 13

Quality Measurement and HIT The “Quality Enterprise”: AQA, HQA, QASC Providers Healthcare Data Collection Conference AHIC Quality Workgroup RFI on Health Data Stewardship Report on barriers and expert suggestions for available on the AHRQ Health IT website. Recommendations Recommendation 1.1: The Quality Alliance Steering Committee, with support from HHS and other relevant federal agencies, should convene an expert panel that would accelerate the current efforts to identify a set of common data elements to be standardized in order to enable automation of a prioritized set of AQA and HQA measures through electronic health records and health information exchange. The Quality Alliance Steering Committee, with support from HHS and other relevant federal agencies, should establish the priority order for the measures. This panel will build on work already done by NQF and others. The first group of recommendations from the expert panel should be shared with the Community by June 5, 2007. Recommendation 1.2: The Health Information Technology Standards Panel (HITSP) should use the work of the Quality Workgroup’s expert panel recommended in 1.1 to identify the data standards to fill identified gaps for data elements required for automation of core sets of AQA and HQA quality measures. Recommendation 1.3: The Certification Commission for Health Information Technology (CCHIT) should develop appropriate criteria necessary to support the reporting of core sets of AQA and HQA measures in the next round of criteria development. Recommendation 2.1: The expert panel convened by the Quality Alliance Steering Committee in Recommendation 1 should gather, synthesize and refine clinical workflow maps, focusing on care processes related to the care underlying the conditions targeted by the prioritized set of AQA and HQA measures. The Quality Alliance Steering Committee, with support from HHS and other relevant federal agencies, should establish the priority order for the measures. The panel should determine mechanisms and opportunities within these workflows for identifying patients who are eligible for inclusion in the AQA and HQA measure populations, for gathering performance measurement data, and for providing clinical decision support to optimize performance in targeted areas. In addition to a generic framework that could be used across many clinical conditions, the deliverable should include at least one scenario for how the workflows operate for AQA/HQA targeted conditions. Measure inclusion mechanisms must protect privacy and confidentiality. The results of this analysis should be reported to the Community by September 18, 2007. Recommendation 3.1: HHS, working with relevant public and private sector leaders and the BQI projects, should identify and articulate the key challenges associated with linking claims data from multiple sources (e.g., physician IDs, claims adjudication processes, data storage/purge policies), and the benefits and challenges of linking clinical data to other data sources, including claims. A report should be submitted to the Quality Workgroup by June 30, 2007. Recommendation 3.2: HHS should enable, through the NHIN contracting process and Value Exchanges, efforts to combine clinical and non-clinical electronic data for quality measurement and timely reporting of results. Recommendation 4.1: HHS, through the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ), along with major measure developers, should identify opportunities to enhance measure development by considering the data needs at the time a measure is developed, especially for measures targeted for public reporting. This effort should also include clinical practice guideline developers and should coordinate their role in developing performance measures. Recommendation 4.2: The National Quality Forum, through its endorsement process, should apply criteria that reinforce the use of standardized data elements in measures to allow quality measures to be embedded in EHRs. The NQF may do so by incorporating such criteria into its endorsement criteria for new measures. GAO report on Hospital Quality Measurement RFI 14

Where will we go? AHRQ Annual Meeting September 26-28, 2007 Bethesda MD Value Exchanges Personalized Medicine: Network of Networks CDS and Medicaid 15

Fin Never doubt that a small group of thoughtful, committed people can change the world. Indeed, it is the only thing that ever has. Margaret Mead Thank you! healthit.ahrq.gov