Meeting Minutes, April 4, 2014

Contents

Call to Order and Approval of November 15, 2013, Meeting Summary
Director's Update
Accelerating PCOR:  A New Initiative to Disseminate and Implement PCOR Findings in Primary Care
Patient Safety:  Generating and Using Evidence to Make Health Care Safer
Innovation and Health System Transformation
Health Insurance Coverage Expansion Update
Update from the Subcommittee on Strategic Direction
Public Comments
Chairman's Wrap-Up and NAC Input
Adjournment

NAC Members Present

Bruce Siegel, M.D., M.P.H., Essential Hospitals Institute (NAC Chair)
Gregory Baker, R.Ph., Take Care Employer Solutions Group
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health (by phone)
Francis J. Crosson, M.D., American Medical Association
Jane Durney Crowley, Catholic Health Partners
Shari Davidson, National Business Group on Health
Mary Fermazin, M.D., M.P.A., Health Services Advisory Group, Inc.
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Caritas Family of Companies (by phone)
Leon L. Haley, Jr., M.D., M.H.S.A., FACEP, Grady Health System (by phone)
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health
Michael P. Johnson, P.T., Ph.D., OCS, Bayada Home Health Care
Carol Matyka, M.A., National Breast Cancer Coalition
Newell E. McElwee III, Pharm.D., M.S.P.H., Merck Global Medical Affairs
Henry H. Ng, M.D., M.P.H., FAAP, FACP, MetroHealth Medical Center
Harry P. Selker, M.D., M.S.P.H., Tufts Medical Center
Paul E. Sherman, M.D., M.H.A., CPE, FAAP, Group Health Physicians
Patricia J. Skolnik, Citizens for Patient Safety
Jed Weissberg, M.D., Kaiser Permanente

Alternates Present

Patrick Conway, M.D., M.Sc., Centers for Medicare & Medicaid Services
Amy M. Kilbourne, Ph.D., M.P.H., U.S. Department of Veterans Affairs
Charles J. Rothwell, M.B.A., M.S., Centers for Disease Control and Prevention

AHRQ Staff Members Present

Richard Kronick, Ph.D., Director
Boyce Ginieczki, Ph.D., Acting Deputy Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator

Call to Order and Approval of November 15, 2013, Meeting Summary

Bruce Siegel, M.D., M.P.H., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, invited speakers, visitors, and viewers of the Webcast. He asked the NAC members to introduce themselves.

Dr. Siegel referred to the draft minutes of the previous NAC meeting (November 15, 2013) and asked for changes and approval. The NAC members approved the November 15, 2013, meeting minutes with no changes.

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Director's Update

Richard Kronick, Ph.D., AHRQ Director

Dr. Kronick welcomed the NAC members, speakers, and other attendees and viewers. He thanked the NAC members for taking time to advise the Agency. He emphasized that AHRQ will continue to work to expand access to health care and insurance coverage, noting the recently announced figure for enrollment in the new health care insurance exchanges (7.1 million people).

The following eight new NAC members were participating in the meeting:  David J. Ballard, M.D., Ph.D., M.S.P.H., FACP; Shari Davidson; Mary Fermazin, M.D., M.P.A.; Ann L. Hendrich, Ph.D., R.N., FAAN; Charles J. Rothwell, M.B.A., M.S.; Paul E. Sherman, M.D., M.H.A., CPE, FAAP; Patricia J. Skolnik; and Jed Weissberg, M.D.

Mission and Priorities

Dr. Kronick referred to the new AHRQ mission statement:

To produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work with HHS and other partners to make sure that the evidence is understood and used.

The Agency has the following four main priorities:

1. Produce evidence to improve health care quality.
2. Produce evidence to make health care safer.
3. Produce evidence to increase access to health care.
4. Produce evidence to improve health care affordability, efficiency, and cost transparency.

Dr. Kronick announced that the first priority, which has a focus on patient-centered outcomes research (PCOR), has led to a new large grant program to improve the capacity of primary care practices, putting PCOR evidence into practice. The focus is on cardiovascular risk, and the program will feature an evaluation component.

The second priority includes work to prevent healthcare-associated infections, to increase patient safety, to reduce harm in obstetrical care, to reduce medical liability (by increasing safety), and to advance safety improvements in nursing homes.

The third priority includes a collaborative effort between AHRQ and the Centers for Medicare & Medicaid Services (CMS) to provide evidence for the effects of health insurance coverage expansion on the health and financial security of the uninsured, on labor markets, on health care providers (especially those in the safety net), and on employer and employee decisions regarding insurance.

Within the fourth priority, AHRQ will improve data, measures, and public reporting strategies needed to convey information about health care prices, costs, and quality. It will develop and spread evidence and tools to measure and enhance the efficiency of health care delivery systems.

AHRQ Budget

Dr. Kronick reported that the enacted FY 2014 AHRQ budget was $364 million (from the PHS Evaluation Fund), to which was added $7 million from the Prevention and Public Health Fund and $92.8 million from the PCOR Trust Fund (PCORTF). This represented a slight decline from the FY 2013 budget. The year saw increases in funding for PCOR, health information technology (IT), and patient safety. Funding for patient/care management declined slightly. The increase in patient safety funds is supporting a program of patient safety learning laboratories, featuring multidisciplinary teams developing and testing interventions in simulated settings.

The President's requested FY 2015 AHRQ budget features $334 million from the PHS Evaluation Fund, $105.6 million from the PCORTF, and $0 from the Prevention and Public Health Fund. Dr. Kronick noted that the President's proposed budget includes a focus on primary care and nursing homes (developing tools to obtain evidence for successful strategies) and the funding of investigator-initiated projects to increase the efficiency, effectiveness, and value of the health care system. Overall, AHRQ funding for investigator-initiated research has been flat for the past 6 years, including the President's FY 2015 request.

AHRQ Program Updates

Dr. Kronick provided the following program updates:

• AHRQ staff transitions included the appointments of Yen-pin Chiang, Ph.D., as acting Director of the Center for Outcomes and Evidence; Jeffrey Brady, M.D., M.P.H., as Director of the Center for Quality Improvement and Patient Safety; Bill Munier, M.D., as Director of the Patient Safety Organizations Team; and Robert M. Kaplan, Ph.D., as AHRQ Chief Science Officer.
• An AHRQ study published in the New England Journal of Medicine compared adverse events rates in the periods 2005–2006 and 2010–2011 for people being treated for heart attack and heart failure, finding 81,000 fewer events in the latter period. No such reduction in events was seen for surgery patients and patients treated for pneumonia.
• An AHRQ study published in the Journal of the American Medical Association reported on rates of surgical site infections, using Healthcare Cost and Utilization Project (HCUP) databases in eight States. It found that 3.09 of every 1,000 surgeries involved serious surgical site infections treated within 14 days. At 30 days, the rate of serious infections rose to 4.84 per 1,000 surgeries.
• An AHRQ study published in Health Affairs reported that, for the States that have been expanding Medicaid enrollment, newly eligible adults tend to be healthier than the current nondisabled enrollees. The results suggest a "welcome mat" effect.
• As noted in the mention of priority 1, AHRQ will award competitive grants for up to 3 years to regional cooperatives that will disseminate PCOR evidence to primary care practices, supporting the implementation of clinical and organizational evidence. The cooperatives will advance the implementation of the Million Hearts Campaign, which has a goal of preventing 1 million heart attacks and strokes by 2017.
• AHRQ and the Centers for Disease Control and Prevention (CDC) have multiple ongoing collaborations, for example, in the area of preventing and reducing healthcare-associated infections. The two agencies took part in a large conference in Atlanta on March 7, 2014.
• HHS administered its Employee Viewpoint Survey within agencies and found that AHRQ was ranked number 2 among small agencies in the Best Places To Work in the Federal Government 2013 rankings. The survey report suggested actions to improve the work environment, some of which are being implemented. For example, supervisors' performance plans are featuring standardized, transparent elements regarding issues of addressing poor performance and conduct.

Dr. Kronick asked the NAC members to consider, in their discussions, the roles of Federal, State, and industry groups in the implementation of research on health care delivery systems—especially the stages of early, small-scale implementation and the uses of incentives to stimulate change. What has AHRQ accomplished?

Discussion

Dr. Siegel asked whether efforts in priority 3 might investigate the demand for and effects on the various types of health care professionals (their supply, training, etc.). Dr. Kronick suggested that the stress will be on the effects on providers and other health care workers, effects on part-time work, and effects on employer decisions regarding offered insurance.

Harry P. Selker, M.D., M.S.P.H., encouraged AHRQ to consider potential types of evaluation of the Affordable Care Act as it is implemented. Dr. Kronick suggested that AHRQ will be seeking some long-term, investigator-initiated work in that area. In-house analyses using, for example, AHRQ datasets also will be made. AHRQ's Quality and Disparities Reports might serve as platforms for such analyses.

Newell E. McElwee III, Pharm.D., M.S.P.H., encouraged AHRQ to maintain emphasis on particular aspects of better health within its efforts under the priorities for quality, safety, and access (all of which, Dr. Kronick noted, lead to better health). Henry H. Ng, M.D., M.P.H., FAAP, FACP, pointed to priority 2 (safety) and encouraged efforts that address vulnerable populations, focusing on both people and place and supporting care that is both clinically and culturally competent. He stressed vulnerable populations, including ethnic/racial minorities, people who do not speak English, and LGBT individuals (and supporting, for example, affirming environments).

Dr. Selker remarked that emergency settings often are not included in studies/measurements of quality in ambulatory care. Jeffrey Brady, M.D., M.P.H., responded that AHRQ's patient safety portfolio includes—for example, in simulation research—emphasis on system function, competencies, and training. Also, HCUP collects data from emergency departments. Jane Durney Crowley added the issue of IT safety in the ambulatory setting—much data exist.

Francis J. Crosson, M.D., noted that the American Medical Association supported a study and analysis of change and learned that more difficult than creating a knowledge base and using incentives is establishing a capacity to change. That is especially hard to envision in small practices. Gregory Baker, R.Ph., suggested talking with physicians to determine their sense of quality in baseline work. Dr. Weissberg referred to the Million Hearts Campaign and cited the problem, during multiyear implementation, of shifts in the underlying biological evidence.

Amy M. Kilbourne, Ph.D., M.P.H., noted that the Quality Enhancement Research Initiative, of the VA, seeks to get involved in clinical trials design, to suggest what might be implemented early. The CDC's Research to Practice Framework has employed theories from anthropology and technology transfer to replicate effective programs.

Michael P. Johnson, P.T., Ph.D., OCS, encouraged the Agency to consider all members of the health care community/neighborhood who affect patients (nurses, dieticians, physical therapists, et al.). Dr. Hendrich pointed to the stage between early implementation/adoption and large-scale spread, where we need to know the reasons for rapid adoption and spread. Experiences in the Partnership for Patients Program are revealing. What are the early variables that will predict success?

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Accelerating PCOR:  A New Initiative to Disseminate and Implement PCOR Findings in Primary Care

David Meyers, M.D., Center for Primary Care, Prevention, and Clinical Partnerships, AHRQ

Dr. Meyers provided an overview of current and planned AHRQ activities in the area of PCOR. The Affordable Care Act directs funds to AHRQ, through the PCORTF, to be used for disseminating and translating PCOR findings. The scope of activities under the Act extends to training and career development for researchers and institutions, working with stakeholders, and assisting users of health IT to incorporate findings into clinical practice. Dr. Meyers described initial AHRQ investments, or activities, in PCOR, including the following:

• The Effective Health Care Program, which develops systematic evidence reviews.
• The John M. Eisenberg Clinical Decisions and Communications Science Center, which develops summaries of comparative effectiveness reviews and research reports.
• Closing the Gap in Disparities with PCOR, a cooperative agreement program (U18) that identifies strategies to engage stakeholders.
• Deliberative Approaches for Patient Involvement in Implementing Evidence-based Health Care, a grant program (R21) that features deliberative approaches to gather input from patients about implementation of evidence-based care.
• A number of training programs (K awards) supporting PCOR.
• An Accelerating PCOR initiative, featuring grants (R01, R18) for accelerating the dissemination and implementation of PCOR findings into primary care practices.

Dr. Meyers focused on that final program (Accelerating PCOR) of large 3-year grants to support as many as eight regional collaboratives that will disseminate PCOR evidence to primary care practices, will support implementation, and will focus on the Million Hearts heart-health project. The collaboratives will work directly with primary care practices, use evidence-based quality improvement techniques, and use tactics such as change agents. Each collaborative will work with a minimum of 250 diverse primary care practices. Each study design will include a control.

Dr. Meyers described other features of the study designs, such as measurement and both internal and external evaluation. Early results of improvement in delivery of the care strategy within the initiative will start to be available 18 months after the grants are awarded. Preliminary results on the effectiveness and sustainability of quality improvements will start to be available after 24 months. Grant applications are due to AHRQ on July 3, 2014. The awarded grants will begin in February 2015. AHRQ eventually will be sharing the results with health care delivery systems and policymakers.

Dr. Meyers described the team of cross-agency experts who are developing the PCOR efforts at AHRQ. The team is collaborating with colleagues at other HHS agencies.

Discussion

Dr. Siegel remarked that other models for such work exist and that the Accelerating PCOR initiative is visionary and contains some risk. He encouraged the program administrators to consider the organizational capacities of the potential grantees, including management history. Ms. Davidson added that some large employers and their payers have initiatives of their own. Might their work be incorporated into the program?

Dr. Weissberg wondered whether the new funding opportunity announcements would replace older announcements devoted to building research capacity. Dr. Meyers responded that the new projects would be supplemental. Other grants will remain ongoing. Dr. Weissberg encouraged AHRQ to consider the work at the regional extension centers for meaningful use.

Dr. Selker cited the factor of the common rules for human subjects and expressed concern that too many programs might be addressing the area of implementing evidence for cardiac health. Perhaps AHRQ should focus on specific aspects. Dr. Fermazin agreed, based on the experience of her organization. It might be helpful to consider whom grantees might target. Dr. Crosson encouraged AHRQ to consider, in selecting grantees, not only the goals of improving population health, but also what is needed for diffusion to take place. There could be a benefit in choosing some grantees who have thinner track records, will take risks, and will allow us to learn from failure.

Patient Safety:  Generating and Using Evidence to Make Health Care Safer

Jeffrey Brady, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ

Dr. Brady reviewed AHRQ programs in patient safety, which address priority 2 in the Agency's mission. AHRQ seeks to obtain evidence that will help to prevent healthcare-associated infections, will accelerate patient safety improvements in hospitals, will reduce harm associated with obstetrical care, will reduce medical liability, and will accelerate patient safety improvements in nursing homes. Almost half of the proposed FY 2015 AHRQ budget for patient safety research focuses on the prevention of healthcare-associated infections.

Dr. Brady noted two large successful AHRQ safety programs, the Comprehensive Unit-based Safety Program (CUSP) and the TeamSTEPPS® training program. The former has been implemented in more than 1,000 hospital intensive care units and 100 neonatal intensive care units, leading to large reductions in central line-associated bloodstream infections. The latter has been implemented in more than 1,500 hospitals, training more than 300,000 frontline health care professionals.

AHRQ has developed patient safety tools, including a falls-prevention toolkit, a venous thromboembolism toolkit, and a pressure ulcer toolkit. The Agency recently created a safety program for perinatal care, which is in the pilot testing stage. It features the use of CUSP, TeamSTEPPS, simulations, and a toolkit.

As part of the HHS patient safety and medical liability initiative, AHRQ supports seven demonstration grants that focus on patient safety, reducing preventable injuries, fostering doctor-patient communication, ensuring that patients are compensated while reducing frivolous lawsuits, and reducing liability premiums.

AHRQ has developed a toolkit for increasing communication and resolving issues surrounding safety adverse events. It has developed an On-Time Pressure Ulcer Prevention Program, which features IT for clinical decision support to enable early intervention. It contributes to the HHS initiative, Partnership for Patients, which has generated significant decreases in preventable conditions for hospital patients and has reduced readmissions.

Discussion

In response to a question, Dr. Brady noted that issues of shared decisionmaking and informed consent are addressed in a patient/family engagement toolkit. Dr. Hendrich raised the issue of the patient care continuum. It is important for research to shift with the patient as the patient moves within the continuum. We need human factors research and research on products that contribute to errors. Dr. Brady stated that human factors would be addressed in an upcoming grant program.

Carol Matyka stressed the need to advance provider-patient communication. Application of informed consent and discharge instructions are opportunities for education (and they should be easy to understand). Dr. Johnson raised the issue of evidence not being used in practice. He called for research on behavioral change.

Ms. Crowley cited the safety implications attending changes in payment methodology, as when Medicare Advantage arrived. Dr. Selker called for more studies of payment issues. Also, how can we ensure that the use of toolkits can change health care practice? Implementation and motivation in various settings involve variety and complexity. We need to appreciate that to improve the spread of good behaviors.

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Innovation and Health System Transformation

Patrick Conway, M.D., M.Sc., Centers for Medicare & Medicaid Services

Dr. Conway reviewed efforts at CMS to improve health systems. CMS has a goal of moving toward health care delivery systems that are people centered, outcomes driven, and sustainable and feature coordinated care and better payment systems. He referred to the transformational value of clinical efficacy research, outcomes research, comparative effectiveness research, quality measurement and improvement, health care system redesign, and spread of effective interventions.

Dr. Conway stated that health care transformation requires quality measurement, aligned payment incentives, comparative effectiveness evidence, health IT, quality improvement collaboratives, and the training of clinicians and multidisciplinary teams. Recent efforts have led to improvements in cost growth, readmissions, central line infections, value-based payments, and insurance coverage. AHRQ has played a role in improvements in per capita spending growth and hospital readmission rates. Reduction in bloodstream infection rates is an example of the value of bringing evidence to the bedside. The Partnership for Patients program has extended to more than 3,500 hospitals, leading to reduced harm.

Dr. Conway listed elements in the CMS Innovations Portfolio, which focuses on new models to improve quality. The elements include accountable care organizations (ACOs), primary care transformation, bundled payments for care improvement, and capacity to speed innovation. The Innovations Center is now focused on implementation of models, monitoring and optimization of results, evaluation and scaling, integration of innovation between CMS and the private sector, and portfolio analysis leading to new models (for example, outpatient specialty care models). Dr. Conway referred to published papers dealing with the future of health care quality measurement and challenges for a lifelong health care system. He suggested financial instruments and models that might incentivize lifelong health management.

Discussion

Dr. Siegel encouraged AHRQ and CMS to consider when work in population health and measurement will result in policy changes and behavioral changes. Dr. Kilbourne cited the high cost of treating people with mental disorders. Bundled payments might lower those costs, yet separate budget structures (silos) exist.

Dr. Selker raised the issue of measurement systems that can be detrimental to care. For example, the CMS Outcome and Assessment Information Set (OASIS) features burdensome form-filling. Dr. Crosson added that ACOs are undergoing changes that increase the importance of the issue of attribution. Dr. Conway responded that CMS is addressing what it refers to as "attestation" and cost-sharing among ACOs. Ms. Crowley cited differences when Medicare Advantage is available and a general strategic problem. Helping smaller practices to improve is difficult. Dr. Ng cited the potential influence of more enrollment by members of the LGBT communities. It will be important to measure outcomes.

Dr. Ballard asked about an interest in population-based reimbursement for care for Medicare beneficiaries. Dr. Conway responded that CMS is considering IT systems that will allow for such reimbursement—for example, in ACOs. Dr. Kronick emphasized that the work of the CMS innovation group deals with payment models and levers. The work of AHRQ deals with the delivery of care.

Health Insurance Coverage Expansion Update

Joseph W. Thompson, M.D., M.P.H., Arkansas Surgeon General; Cindy Mann, J.D., Centers for Medicare & Medicaid Services; and Thomas M. Selden, Ph.D., Center for Financing, Access, and Cost Trends, AHRQ

Dr. Thompson described the Arkansas Health Care Independence Program (HCIP), a new program that his State developed to expand health insurance coverage. The program responds to factors of population, health, and health insurance in Arkansas and to the new changes in Federal law. The Arkansas HCIP features the following characteristics:

• It offers an alternative approach to Medicaid expansion.
• It utilizes premium assistance in the individual private insurance marketplace (not in Medicaid managed care).
• It places a majority of the newly insured with private carriers (medically frail individuals are better served by traditional Medicaid).

Dr. Thompson reviewed details of the program, stressing aspects of its private option. It uses private insurance plans to purchase coverage through the health insurance marketplace for some people who are below 139 percent of the Federal poverty level. The HCIP developers defined the medically frail as (1) those people who are more effectively covered through the standard Medicaid program and (2) those people with exceptional medical needs, for whom coverage through the insurance marketplace is determined to be impractical or overly complex, or would undermine continuity or effectiveness of care. Arkansas is working to link features of the health system to improve payments and contain costs. It encouraged a multi-payer system whose participants use consistent incentives and standardized reporting rules and tools. A 2013 Arkansas health care act stipulated that health insurance carriers participate in payment improvement initiatives including (1) assignment of primary care clinician, (2) support for patient-centered medical homes, and (3) access of clinical performance data for providers.

Ms. Mann presented progress in activities at CMS for expanding Medicaid enrollment. She noted a gap in Medicaid eligibility (some poor adults and childless adults), which was present prior to the Affordable Care Act and which remains—although it can be closed by the States, with Federal support. At the end of February 2014, national Medicaid enrollment was estimated to have increased by 3 million. There was an expansion of 8.8 percent in the States that chose to expand Medicaid enrollment. The non-expansion States witnessed smaller growth. Ms. Mann noted that the new application for enrollment in Medicaid features a single process for families. CMS is offering IT support for the States. Challenges include refining the application, handling renewals and transitions, reducing churning, and developing more outreach and enrollment. CMS needs better data reporting, and it needs to address gaps in quality of care.

Dr. Selden reviewed AHRQ-supported research on the Medicaid and CHIP programs. In December 2013, AHRQ issued a special emphasis notice, seeking research on take-up, churning, facilitating improvement in access to health care, and moderating the growth in the cost of health care. Dr. Selden noted that AHRQ's HCUP program has assessed readmissions involving Medicaid, finding them to be at higher rates than readmissions for privately insured and uninsured individuals. AHRQ has begun to address this problem by supporting the Partnership with Medicaid Medical Directors Learning Network and producing the document "Crafting Solutions:  Hospital Guide to Reducing Medicaid Readmissions." Mr. Selden referred to analyses by a Medicaid and CHIP Payment Advisory Commission for changes in CHIP premiums and potential for children's eligibility in Affordable Care Act insurance programs. The analyses led to a recommendation to reauthorize CHIP.  Another analysis found that adults newly eligible under Medicaid expansion in the Affordable Care Act tended not to be among the severely ill.

Discussion

Dr. Siegel expressed frustration with reporting, among the States, of different datasets for quality. Ms. Mann suggested that the States and CMS are moving toward greater uniformity (e.g., common measures). Dr. Thompson proposed greater standardization within geographic regions and among payers.

Ms. Matyka expressed a hope that more States will examine the progress that Arkansas has accomplished in coverage expansion. Ms. Mann noted that other States are studying and debating the issues and have taken interest in the Arkansas model. Dr. Weissberg asked about continuity of care in the Arkansas model. Dr. Thompson responded that Arkansas measures continuity of care in provider networks and continuity of coverage, which leads to that continuity of care.

Referring to Dr. Selden's remarks about the people accepted thus far into Medicaid expansion, Ms. Crowley suggested that the sickest people have yet to be enrolled.

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Update from the Subcommittee on Strategic Direction

Michael P. Johnson, P.T., Ph.D., OCS, Co-chair

Dr. Johnson reported on the work of the Subcommittee on Strategic Direction for AHRQ, which developed the following goal and recommendation:

Goal:  Identify key barriers to patients and caregivers acting to make good use of health care, as well as similar barriers for clinicians to support this process; then explore strategies to reduce or eliminate those barriers in ways that effectively improve the value of health care (better care, better health, and lower costs).

Recommendation:  We want AHRQ to fund research and quality improvement efforts on ways in which health care can meet the needs and wants of patients and their caregivers.

Dr. Johnson presented the draft document featuring those statements and the following proposed types of conversations with patients, families, and the public, which the Subcommittee recommended that AHRQ pursue:

1. Conversations about co-creating research.
2. Conversations about making collaborative health care management decisions (diagnosis and treatment).
3. Conversations about co-designing health care delivery.

The document provided sample issues/questions for each conversation. Dr. Johnson reported that Helen Haskell, co-chair of the Subcommittee, had noted that, in some cases, patients are engaged while clinicians downplay that engagement.

Discussion and Vote

Dr. Siegel asked about the phrase "new disparities" in the Subcommittee's text for conversation 2. Dr. Johnson suggested that the phrase referred to the ability of some patients to benefit more from shared decisionmaking. Dr. McElwee noted that AHRQ has been addressing the issue of patient engagement to improve outcomes for some time. Dr. Kronick assured the group that this will continue. Dr. Hendrich suggested that use of the word "patient" might be too restrictive. Family, advocates, and future patients may engage in the communication. Ms. Matyka noted that consumers define engagement in various ways. Trust in the system and quality of the conversations are always important. Dr. Fermazin called for research on measuring engagement.

Dr. Selker suggested using the term "public engagement." He stated that the document should indicate that AHRQ funds research in health care quality—it does not actually perform quality improvement. Dr. Ballard and the other NAC members agreed. Dr. Siegel proposed stressing the integration of patients in research design. The NAC members agreed that, where the document says "patient engagement," it should say "patient and public engagement." They moved to a vote on the recommendation document and approved it with the discussed changes and additions.

Dr. Johnson stated that "patient engagement" as presented in the document could refer to patient behaviors in treatment, shared decisionmaking involving clinician and patient, and even patient activities in supporting research. The group agreed that the document should state, perhaps at the end, that the recommended actions are not meant to replicate the actions of the Patient-Centered Outcomes Research Institute.

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Public Comment

There were no public comments.

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Chairman's Wrap-Up and NAC Input

The NAC members made final comments. Ms. Skolnik stated that she appreciated the discussion about shared decisionmaking. Dr. Johnson proposed that an upcoming NAC meeting include a discussion of measurement throughout the continuum of care. Dr. Crosson proposed that an upcoming meeting feature an update on the Office of the National Coordinator for Health Information Technology (ONC).

Jaime Zimmerman noted that the next annual AHRQ meeting would take place in February or March 2015. AHRQ is seeking cosponsors for the meeting. The cosponsors will be able to defray their costs by charging registration fees. Dr. Siegel noted that the planned presentation by Michael Harrison about AHRQ research on delivery system improvement would be rescheduled for the July 2014 NAC meeting.

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Adjournment

Dr. Siegel stated that the next NAC meeting would take place on July 25, 2014. He thanked the NAC members and other participants and adjourned the meeting.

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