Meeting Minutes, July 25, 2014

Contents

Summary
Call to Order and Approval of April 4, 2014, Meeting Summary
Director's Update
Delivery System Reform
Office of The National Coordinator For Health Information Technology (ONC)
AHRQ Health IT Update
Public Comments
Chairman's Wrap-Up and NAC Input
Adjournment
 

Summary

NAC Members Present

Bruce Siegel, M.D., M.P.H., Essential Hospitals Institute (NAC Chair)
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health (by phone)
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. (by phone)
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Caritas Family of Companies
Leon L. Haley, Jr., M.D., M.H.S.A., CPE, FACEP, Emory Medical Care Foundation
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
Victor M. Montori, M.D., M.Sc., Mayo Clinic College of Medicine
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., Institute for Clinical and Economic Review

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Chisara N. Asomugha, M.D., M.S.P.H., Centers for Medicare & Medicaid Services
Sandra Decker, Ph.D., National Center for Health Statistics, CDC

AHRQ Staff Members Present

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

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Call to Order and Approval of April 4, 2014, 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 and asked for changes and approval. A NAC member asked that, in the section on patient engagement and proposed conversations, the minutes note that conversations should be "with patients, families, and the public." The NAC members approved the April 4, 2014, meeting minutes with that addition.

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Director's Update

Richard Kronick, Ph.D., AHRQ Director

General Updates

Dr. Richard Kronick welcomed the NAC members, speakers, and other attendees and viewers. He noted that NAC member Jed Weissberg, M.D., retired from Kaiser Permanente and now serves as a senior fellow at the Institute for Clinical and Economic Review. Sharon Arnold, Ph.D., has become AHRQ's Deputy Director. David Meyers, M.D., has become AHRQ's Chief Medical Officer, and Robert Kaplan, Ph.D., has become AHRQ's Chief Science Officer. The U.S. Department of Health and Human Services (HHS) recently recognized the distinguished service of William B. Baine, M.D., conferring the HHS Career Achievement Award. Samuel Zuvekas, Ph.D., recently received the Annual NIHCM Foundation Health Care Research Award.

Dr. Kronick reported that AHRQ has created a new center, the Center for Evidence and Practice Improvement. The center consolidates two AHRQ centers, the Center for Outcomes and Evidence and the Center for Primary Care, Prevention, and Clinical Partnerships. The new center will unify efforts and investments aimed at accelerating practice improvement across the health care system. The Evidence-Based Practice Centers (EPCs) Program and the U.S. Preventive Services Task Force (USPSTF) will operate within the new center. Dr. Meyers is serving as Acting Director, and Yen-pin Chiang, Ph.D., is serving as Acting Deputy Director of the new center, pending the identification of new leadership.

Recent AHRQ-supported research/publications include the following:

• A report of AHRQ-supported research in the New England Journal of Medicine (July 3, 2014) revealed that the addition of a corticosteroid to epidural injection of anesthetic did not enhance pain reduction in patients with lumbar spinal stenosis. The reported study involved 400 patients in 16 hospitals.
• An AHRQ-funded EPC review found that serious adverse events resulting from routine use of vaccines in the United States are rare. The report found no link between MMR vaccines and autism, no link between pneumonia and flu vaccines and cardiovascular or cerebrovascular events in the elderly, and no link between several vaccines and childhood leukemia.
• A report of AHRQ-supported research published in The Journal of the American Medical Association (June 16, 2014) revealed that an intensive outreach program targeting vulnerable patients dramatically improved screening rates for colorectal cancer. The study involved community health centers and featured the use of phone calls and text messages.
• Another report published in The Journal of the American Medical Association (June 11, 2014) revealed that patients with type 2 diabetes who receive metformin plus insulin may be at higher risk for cardiovascular disease and death (compared to those receiving metformin plus sulfonylurea). This was an observational study.
• AHRQ published its latest Health Care Quality and Health Care Disparities reports. The former indicates that hospitals are leading the movement to improve quality, compared with home health care, nursing home care, and ambulatory care. The latter indicates that disparities in access to care persist.
• A report of an AHRQ-supported meta-analysis published in BMJ Quality & Safety (April 17, 2014) revealed that diagnostic errors (missed opportunities to make a correct or timely diagnosis) occur in about 5 percent of U.S. adults. Half of such errors can severely harm patients.
• The USPSTF developed five new draft recommendations, which are being presented for public comment. The topics are low-dose aspirin for the prevention of morbidity and mortality from preeclampsia, behavioral counseling to prevent sexually transmitted infections, screening for gonorrhea and chlamydia, behavioral counseling to promote a healthy diet and physical activity for CVD prevention in adults with risk factors, and screening for vitamin D deficiency.
• The USPSTF released six final recommendations in the following areas: screening for cognitive impairment, prevention of dental caries in children from birth through age 5 years, screening for suicide risk in adolescents, adults, and older adults in primary care, screening for hepatitis B virus infection in nonpregnant adolescents and adults, screening for abdominal aortic aneurysm, and screening for asymptomatic carotid artery stenosis.
• Dr. Kronick noted that AHRQ recently released results from the Medical Expenditure Panel Survey (MEPS) insurance component showing that premiums in 2013 increased by about 3.5 percent. CMS recently published a report, based on AHRQ data, revealing a decline in adverse events in hospitals during 2010-2012.

Paying for Value Project

Dr. Kronick described AHRQ's Paying for Value Project, which has a goal of pursuing research that determines when, in medical care, strong incentives are appropriate or not appropriate. The project has commissioned papers that frame the issues and is proposing a research agenda that produces evidence about how to pay for value in ways that improve the quality and efficiency of health care delivery. The commissioned papers and their projects will target areas of medical care in which incentives should be used, the effects of the levels at which incentives are given, how the unit of payment affects the appropriateness of incentives, and how gaming, risk selection, teaching to the test, and effects of racial, ethnic, and socioeconomic disparities apply. Dr. Kronick listed the following five commissioned papers, noting that the Agency expects drafts in the fall:

• The theory of incentives and its application to medical care.
• Categorize and summarize what is known to date about pay for performance and public reporting of provider performances in medical care.
• Using measures of patient experience to induce improvements in clinical practice.
• Alternatives to financial incentives.
• Outline for a research agenda on improved incentives.

Patient-Centered Outcomes Research Trust Fund (PCORTF)

Dr. Kronick reviewed the history of AHRQ's patient-centered outcomes research (PCOR) dissemination activities and the PCORTF, which was authorized by the Affordable Care Act of 2010. Prior to that, AHRQ had been supporting effectiveness and comparative effectiveness research for clinicians, consumers, and policymakers, especially under the American Reinvestment and Recovery Act.

Under the Affordable Care Act, 16 percent of PCORTF funds are to be given to AHRQ to be used to disseminate research findings to providers, patients, vendors, and Federal and private health plans. AHRQ also incorporates the research results into clinical decision support tools, seeks feedback, and helps to train researchers. The larger bulk of PCORTF funds is slated to develop evidence through PCOR (and not involving AHRQ). Dr. Kronick stated that ultimate levels of funding for AHRQ in 2014 and 2015 will be revealed in March 2015.

AHRQ is focusing on grants to small- and medium-sized primary care practices for the dissemination of PCOR findings. It is supporting the Million Hearts ABCS project (aspirin use among people with heart disease, blood pressure control, high blood-cholesterol control, and smoking cessation). Applications for projects to work with primary care practices to use PCOR findings for management in those areas were due at AHRQ in June. As many as eight grants will be awarded.

In addition, AHRQ will be accepting applications (due by October 17) for grants to support three centers of excellence on comparative health system performance. Grantees will develop methods of measuring health system performance in cost and quality domains, emphasizing performance in disseminating PCOR.

Evaluating AHRQ Programs

Dr. Kronick presented a graphic listing AHRQ activities arranged within the rubrics of quality, safety, accessibility, and affordability and indicating degrees of emphasis on investigator-initiated grant programs. He asked the NAC members to suggest areas requiring evaluation and to suggest structures for evaluation. One example is the need to evaluate dissemination tactics.

Discussion

Dr. Siegel and Shari Davidson noted efforts by their organizations to incorporate AHRQ evidence into their work. Dr. Kronick noted that, following the subcommittee discussion at the previous NAC meeting, AHRQ is developing plans to increase dissemination and patient engagement.

Regarding the cited study of routine vaccine use, Newell E. McElwee III, Pharm.D., M.S.P.H., noted the issue of a fear of an autism-vaccine connection by some members of the public. The vaccine report should be advertised. Some practices do not accept patients who refuse vaccines. What might be done? Dr. Kronick reminded the group that AHRQ's mission is to develop and disseminate evidence and to work with others to ensure that it is understood and used. Ann L. Hendrich, Ph.D., R.N., FAAN, raised the issue of contamination in corticosteroids and stated that it needs to be publicized.

Regarding the outreach program for potential colorectal cancer patients, Jane Crowley predicted difficulty in applying the program on a large scale. David Atkins, M.D., M.P.H., suggested the use of automation technologies. Patricia J. Skolnik encouraged AHRQ to avoid the use of brochures and instead stress dissemination avenues such as video channels and YouTube.

Regarding the Paying for Value Project, Harry P. Selker, M.D., M.S.P.H., cautioned about issues around the calibration of risk projections. He suggested producing an article about alternatives to risk adjustment—especially new ideas—noting an importance within pay for value. David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, suggested promoting incentives for accountable care organizations. Dr. Arnold stated that AHRQ is encouraging the commissioned writers to address both near-term and long-term changes, which will lead to a research agenda. Ms. Crowley suggested that AHRQ consider the purposes of incentives and identify past efforts and effects (people respond differently). Has there been research on the idea of base payment being aligned with expected work—for example, in primary care?

Victor M. Montori, M.D., M.Sc., cautioned that pay for value, emphasizing efficiency, might not be a best choice of concept. He encouraged AHRQ to investigate a variety of quality domains—patient-centeredness, bioethics, and professionalism. Lawrence P. Casalino, M.D., Ph.D., of AHRQ, stated that he has spoken with the authors of the commissioned papers and the authors have suggested that they will not emphasize financial costs. They will emphasize quality. At least two papers will address issues of professionalism. Sandra Decker, Ph.D., raised the issues of unit of payment, size of the organization, and its spread of risk. Chisara N. Asomugha, M.D., M.S.P.H., questioned the use of efficiency in defining value. She suggested considering the ways in which services are paid across community organizations.

Dr. Atkins proposed that one or more of the commissioned papers address ways to minimize unintended consequences of incentives. He wondered whether the papers will miss a fuller consideration of incentives, including shared savings and reducing overuse. Leon L. Haley, Jr., M.D., M.H.S.A., CPE, FACEP, raised the issue of the impact of assessment on educational systems (for example, training nurses). Michael P. Johnson, P.T., Ph.D., OCS,  proposed that the papers include discussions of incentivizing collaborations and focusing on outcomes.

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Delivery System Reform

Lawrence P. Casalino, M.D., Ph.D., Special Advisor to the Director, AHRQ, and Irene Fraser, Ph.D., Director, Center for Delivery, Organization, and Markets, AHRQ

Dr. Kronick introduced a session on delivery system reform by referring to a presentation by Patrick Conway, of CMS, at the previous NAC meeting. Dr. Conway had discussed the intended movement of private and public sectors to delivery systems that are people-centered, outcomes-driven, and sustainable, with coordinated care, new payment systems, and lifelong results. To those ends, a CMS Innovations Portfolio is testing new models and seeking to raise quality. In particular, the program is seeking to obtain evidence on how to produce change in the delivery system.

Dr. Casalino presented on delivery system research and a goal of ensuring that discoveries of basic scientific and clinical research are used effectively in the delivery system. Delivery system research examines structures, processes, and outcomes. It seeks to identify the linkages between outcomes and incentives and the types of organizations that achieve better outcomes. AHRQ has initiated a grant program (U19 mechanism) to study comparative health system performance in accelerating PCOR dissemination. The Agency is interested in answering questions such as whether delivery system reforms lead to more use of PCOR, which incentives lead to increased use of PCOR, and whether increased use of PCOR leads to better outcomes. Another question to be addressed is whether delivery system reform leads to improved population health. Culture and leadership are important to the performance of provider organizations and their response to delivery system reforms. How can culture and leadership be measured? Delivery system reforms may create an atmosphere in which provider organizations desire to change, anticipate that they must change, and begin to change even when incentives to do so are not strong.

Dr. Fraser reported on AHRQ efforts. She reviewed general aspects of system redesign, including the uses of incentives and evidence, facilitation by information technology, and the measurement of results. AHRQ-supported research has focused on effects of major system variables, including markets and competition, payment and other incentives, science of public reporting, and delivery system design. It has developed measures and datasets for measuring and tracking performance. Research also has focused on ways to create and sustain improvements resulting from changes in those variables.

Dr. Fraser noted the AHRQ QI Toolkit, which can guide hospitals in the use of AHRQ inpatient and patient safety quality indicators for improving care. It addresses improvement practices, implementation steps, monitoring progress, and analyzing return on investment. Some hospitals have reported significant improvements after using the toolkit (reducing pressure ulcers, reducing complications of elective surgery). AHRQ seeks to partner with organizations that are in a position to leverage change, including hospitals, CMS, Medicaid medical directors, nursing homes, and quality improvement organizations. Dr. Fraser stated that, considering the stages of the health care delivery system, AHRQ's work tends to fit in the area of early implementation and evaluation of new processes. She noted again the new AHRQ initiative to fund three centers of excellence to compare the uptake of PCOR, system performance, and outcomes. The awards are up to $3.5 million per year for up to 5 years. The project will feature a data core and up to six major research projects. 

Discussion

Dr. Siegel encouraged AHRQ to study the effects of Medicaid delivery system waivers now being used in 11 States. The waivers focus on quality measures and improvement and are intended to incentivize change.

Dr. Weissberg stated two challenges to consider—the length of time needed to conduct a study with only one result (in the midst of a complex issue) and the need to hardwire good results. Dr. Fraser noted that the ABCS project touches on the issue of hardwiring (organizational permeation and sustainability).

Dr. Johnson focused on culture and leadership and how they affect provider engagement. Two important ideas to foster are a noble shared purpose and the sense of tradition. Dr. Casalino noted that there is no research on engaging physicians and there is a trend in which hospitals are hiring them. Perhaps the new U19 grant program could address these issues. There is some research on the effects of incentives on outcomes, with mixed results.

Ms. Davidson wondered how AHRQ might engage private payers in paying for value and assess accountable care organizations. Dr. Fraser noted that AHRQ has evaluated some private sector efforts. Dr. Casalino suggested that the issue is large, beyond AHRQ. Providers and employers should be involved. Dr. Decker wondered whether State licensing boards could provide information that would help to describe the care delivery system.

Henry H. Ng, M.D., M.P.H., FAAP, FACP, also referred to issues of physician engagement and certification. He cited instances where physicians are required to engage in quality improvement projects. There is a need to assess the effects of such projects. Dr. McElwee stressed the need to include the issue of disparities in system reform. Team science should be considered.

Ms. Crowley stated that the case for system integration is not strong right now, yet we need integration to get to better quality and safety. Dr. Fraser responded that the new AHRQ funding opportunity announcement might lead to research in that area. Dr. Siegel cautioned that consolidation can go too far and raise legal issues.

Dr. Selker raised the idea of learning from patient experiences, and Dr. Casalino responded that one of the commissioned papers will deal with that area. 

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Office of The National Coordinator For Health Information Technology (ONC)

Karen B. DeSalvo, M.D., M.P.H., M.Sc., National Coordinator for Health Information Technology

Dr. DeSalvo reviewed the history of the ONC and described the office's progress and current state. The office was created within HHS by President George W. Bush and was authorized by the Health Information Technology for Economic and Clinical Health Act of 2009. Since its inception, the office has been associated broadly with issues of population health and public equity. The ONC coordinates policies, budgets, and actions regarding health information technology (IT) across Federal agencies and works with the private sector. Initiatives have included developing a strategic plan, assessing and monitoring health IT progress, creating a governance structure, supporting CMS efforts in certifying electronic health records, and supporting meaningful use. The office has distributed some $25 billion over the years to help eligible providers adopt practices. Dr. DeSalvo noted that about 70 percent of physicians and more than 90 percent of hospitals now use electronic health records.

The ONC is supporting regional extension centers that serve to foster the adoption of practices, leading to information exchange, improved care, and population health. It supports the Beacon Community Program to encourage cooperation for population health and change the culture around the use of health IT. Dr. DeSalvo suggested that, after 10 years of work, the ONC now must reflect on its progress and the current state and build upon past successes. The ONC has a talented team and recognizes technologies that could be adopted more widely. It has aspirational models showing how the movement of data can be useful, making a difference in people's lives. Today the Nation is wired to a remarkable extent and data are aggregated and can be put to important uses (precision medicine, public health preparedness).

Time has passed, and payers and providers now have experiences and expectations regarding health IT. Dr. DeSalvo expressed strong optimism. Current areas of effort of the office include interoperability, resetting priorities to focus on improved health rather than improved care (involving more partners), and new policy and programmatic levers in the Federal Government to drive adoption and interoperability. In June, the office invited stakeholders to convene to develop a vision of interoperability, defined as the exchange and use of data. It is developing goals and addressing standards and technology, continuous feedback to improve care, science, quality, certification requirements, governance, and privacy/security. One visionary idea is wearable underwear that can perform sensing and tracking of various health metrics, collecting and transmitting the data.  Another visionary idea is the use of ramps allowing a patient to forward data to particular hosts.

Discussion

Dr. Siegel asked about ways to stimulate communities to achieve the type of success found in, for example, Indianapolis. Dr. DeSalvo cited the hurdle of differences—in care delivery models, payment reform, available data, and consumer/provider education. ONC is pushing to raise the floor without leaving some folks behind. Keys include interoperability, the feedback of data, and return on investment. As for paying for advancements, Dr. DeSalvo suggested that communities consider the system infrastructure as a utility, supported by funds outside the health care system. Federal grants, of course, can help with specific projects.

Dr. Ng asked about challenges involving disparities and enrolling underserved populations, such as LGBT individuals, in health record systems. Strides in interoperability will help. Dr. Selker wondered how hospitals could be brought into the environment of the research-data warehouse. Dr. Asomugha wondered about portability and health disparities. Dr. DeSalvo responded that standard data elements and natural language will be helpful. Lack of data portability is a barrier to usability. Work in health IT is multidisciplinary, and it can leave some people behind. The ONC is addressing diversity within its staff.

Dr. DeSalvo stated that she is working to continue the regional extension centers, which are a valuable asset and feature a database of 150,000 providers across the Nation. The centers act as a feedback loop and learning mechanism. They produce local capacity and can be sustainable.

Dr. Kronick again raised the issue of interoperability, wondering how AHRQ might help to advance it. Dr. DeSalvo suggested that AHRQ help to establish an evidence base of functionalities being used. That could lead to an understanding of what drives providers and others to use the systems. A final issue to consider is how the introduction of new technology in health care can have effects on safety. 

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AHRQ Health IT Update

Teresa Zayas Cabán, Ph.D., Chief of Health IT Research, AHRQ

Dr. Zayas Cabán reviewed the AHRQ IT portfolio, which has a focus on building the evidence base. During the past 10 years, the Agency has awarded projects in 178 institutions in 46 States and the District of Columbia. It has funded projects that demonstrate effectiveness of new health IT solutions, that evaluate the impact of health IT on quality and safety, and that help evidence to be understood and used.

AHRQ has supported regional demonstrations of health information exchange, addressing community trust, technical considerations, project planning and management, implementation, demonstration of value, and sustainability. It funded early foundational work in clinical decision support. More recent efforts have included the following:

• A My Wellness portal project of personal health records to support preventive service management.
• A Health IT Hazard Manager for reporting health and safety events, being used by patient safety organizations.
• A tele-consultation project that links community-based medical teams with university-based specialists.
• An electronic prescribing system focused on creating and transmitting prescriptions for controlled substances.
• A published literature review/meta-analysis of the use of computerized provider order entry systems to reduce medication errors in hospitals.
• National health IT teleconferences covering many topics and involving hundreds of participants.
• An evidence report on the effectiveness of clinical decision support and knowledge management.
• An online U.S. health information resource ("knowledgebase") arranged by initiative (for example, a proposed children's electronic health record format) (www.ushik.org)

Dr. Zayas Cabán stated that AHRQ will continue to work with the ONC and offer research grants, including support for research on the safety of health IT systems. The Agency will continue to facilitate the incorporation of PCOR findings into clinical decision support tools. John White, M.D., who directs the health IT portfolio at AHRQ, noted that the Agency currently has underway a large systematic review of effects of health information exchange on health outcomes.

Discussion

Dr. Hendrich asked how the work of the patient safety organizations relates to work at AHRQ, especially regarding interoperability. Dr. Kronick cited work in developing common formats for reporting adverse events, with many PSOs using the formats. AHRQ also is working with the ONC to have common formats used in electronic health records. 

Dr. Weissberg proposed that AHRQ address the areas of medication reconciliation and automating the collection of quality data elements for improvement initiatives.  

Dr. Asomugha asked about the purpose of the health IT teleconferences. Dr. Cabán responded that the gatherings are meant to disseminate lessons learned from AHRQ-funded projects. Dr. White added that the thousands of people signed up for the Agency's Listserv are invited to join the teleconferences.

Dr. McElwee stressed that interoperability in the pharmacy setting is lacking. Problems with vaccine claims adjudication for pharmacists point to the need for better systems. Dr. Cabán noted a recent grant to support personal health records for patients requiring medication management, which showed that providers were not interested in yet another interface. Ms. Davidson raised the idea of placing the diagnosis on the prescription to ensure that information on outcomes is collected properly. Dr. Hendrich added the idea of ensuring disclosure, of indicating on the record when bad results occur for a patient.

Dr. Selker suggested that AHRQ consider developing tools for shared decisionmaking by physicians and patients. He also encouraged a study of the transition from the community to hospital via emergency medical systems. EMS providers are very receptive to advances in health IT.

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Public Comment

There were no public comments.

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Chairman's Wrap-Up and NAC Input

Dr. Siegel asked for final thoughts. Dr. Kronick asked the NAC members to forward ideas for AHRQ evaluation efforts—how should resources be directed?  He referred again to the many areas of effort at AHRQ.

Dr. Selker encouraged AHRQ to determine the vectors for influential science and to touch those vectors, seeking evidence and evidence of impact. Dr. Ballard suggested that there be greater clarity about the different roles of PCORI and AHRQ. Ms. Davidson stressed the importance of the health care innovations exchange. Dr. Kronick noted that the exchange has catalogued about 800 innovations. However, that fact does not address the AHRQ mission to foster adoption. Dr. Siegel suggested creating a map of the vectors relevant to AHRQ.

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Adjournment

Jaime Zimmerman noted the callout for new NAC members. The final day for submitting applications is August 18. Dr. Siegel stated that the next NAC meeting will take place on November 7, 2014, at the Hubert Humphrey building in Washington. He thanked the NAC members and other participants and adjourned the meeting.

Respectfully submitted,

Bruce Siegel, M.D., M.P.H., Chair
National Advisory Council
Agency for Healthcare Research and Quality

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