Building a Bridge Over the Quality Chasm:
The Role of AHRQ and the UT System
Carolyn M. Clancy, MD
Director
Agency for Healthcare Research and Quality
UT Clinical Safety and Effectiveness Inaugural Conference
Austin, TX – October 15, 2009
The Fundamental Problem
“The fundamental
problem with the quality
of American medicine is
that we’ve failed to view
delivery of health care as
a science. … That’s a
mistake, a huge
mistake.”
Peter Pronovost, MD
Challenges
 Concerns about health spending – about
$2.3 trillion per year in the U.S. and growing
 Pervasive problems with the quality of care
that people receive
 Large variations and inequities in clinical
care
 Uncertainty about best practices involving
treatments and technologies
 Translating scientific advances into actual
clinical practice and usable information both
for clinicians and patients
Building a Bridge at the
Quality Chasm
 AHRQ’s Role
 The Quality Chasm
 Getting There from Here
 Q&A
AHRQ’s Mission
Improve the quality, safety,
efficiency and effectiveness of
health care for all Americans
HHS Organizational Focus
NIH
CDC
AHRQ
Biomedical
research to
prevent,
diagnose and
treat diseases
Population health
and the role of
community-based
interventions to
improve health
Long-term and
system-wide
improvement of
health care quality
and effectiveness
AHRQ Priorities
Patient Safety
 Health IT
 Patient Safety
Ambulatory
Patient Safety
Organizations
 New Patient
 Safety & Quality Measures, Safety Grants
Drug Management and
Patient-Centered Care
 Patient Safety Improvement
Corps
Medical Expenditure
Panel Surveys
Effective Health
Care Program
 Comparative
Effectiveness Reviews
 Comparative Effectiveness
Research
 Clear Findings for
Multiple Audiences
Other Research &
Dissemination Activities
 Visit-Level Information on  Quality & Cost-Effectiveness, e.g.
Medical Expenditures
 Annual Quality &
Disparities Reports
Prevention and Pharmaceutical
Outcomes
 U.S. Preventive Services
Task Force
 MRSA/HAIs
AHRQ Roles and Resources
Health IT Research
Funding
• Support advances
that improve safety
and quality
• Continue work in
hospital settings
• Step up use of HIT to
improve ambulatory
care
Develop Evidence Base
for Best Practices
• Patient-centered care
• Medication management
• Integration of decision
support tools
• Enabling quality
measurement
Promote Collaboration
and Dissemination
• Support efforts of other
federal agencies (e.g.,
CMS, HRSA)
• Build on public and
private partnerships
• Use web tools to share
knowledge and
expertise
AHRQ FY 2009 Funding
 $372 million
– $37 million more than FY 2008
– $46 million more than the president’s
request
 FY 2009 appropriation includes:
– $50 million for comparative effectiveness
research, $20 million more than FY 2008
– $49 million for patient safety activities
– $45 million for health IT
Plus: significant ARRA funding (more on that later)
Building a Bridge at the
Quality Chasm
 AHRQ’s Role
 The Quality Chasm
 Getting There from Here
 Q&A
The Quality Chasm:
The STEEEP Challenge
 In 1999, in To Err is Human,
Institute of Medicine
estimated that 44,000 to
98,000 patients die each
year in the United States as a
result of medical error
 In 2001, IOM observed that a
“quality chasm” exists
between the care that should
be provided and care that
actually is provided
 IOM defined quality care as
care that is safe, timely,
effective, efficient, equitable,
and patient centered
2008 Healthcare Quality Report
 Key Themes
– Health care quality is
suboptimal and improves
at a slow pace (1.8%
annually for core
measures; 1.4% for all
measures)
– Reporting of hospital
quality is spurring
improvement, but patient
safety is lagging
– Health care quality
measurement is evolving
but much work remains
2008 Healthcare Disparities Report
 Key Themes:
– Disparities persist in
health care quality and
access
– Magnitude and pattern
of disparities are
different within
subpopulations
– Some disparities exist
across multiple priority
populations
Texas: Dashboard on Overall
Health Care Quality vs. All States
Average
Weak
Strong
Very
Weak
Very
Strong
Performance Meter: All Measures
= Most Recent Year
= Baseline Year
2008 National Healthcare Quality Report, State Snapshots
Texas Snapshot
Measure
Performance
% of hospital patients age 65 and over
with pneumonia who received
pneumococcal screening or vaccination
Better than
average
% of hospital patients with heart attack
who received aspirin within 24 hours of
admission
Average
% of adult surgery patients who received Worse than
appropriate timing of antibiotics
average
2008 National Healthcare Quality Report, State Snapshots
Tools to Address the Chasm
 Health IT (efficiency,
timeliness)
 Comparative effectiveness
research (safety,
effectiveness)
 Direct engagement with
consumers (equity, patientcenteredness)
AHRQ Health IT
Research Funding
 Long-term agency priority
 AHRQ has invested more
than $260 million in
contracts and grants
 More than 150
communities, hospitals,
providers, and health care
systems in 48 states
AHRQ Health IT
Investment: $260
Million
AHRQ Health IT Initiative
 State and regional
demonstrations
 Health IT grants
 Privacy and security solutions
for interoperable health




information exchange
ASQ Initiative
E-prescribing pilots
CDS demonstrations
Technical assistance for
Medicaid and CHIP agencies
AHRQ National Resource Center
for Health IT
 Established in 2004
 Central national source of
information and assistance for
advancing health IT goals
 Maintains operation of the
AHRQ health IT Web site
 Direct technical assistance to
AHRQ grantees
 Repository for lessons learned
from AHRQ’s health IT initiative
Health IT EPC Report
 First synthesis of existing
evidence on factors
influencing the usefulness,
usability, barriers and drivers
to use, and effectiveness of
consumer applications
 The top factor associated
with use by patients was the
perception of a health benefit
 Patients prefer systems
tailored to them that
incorporate familiar devices
AHRQ National Resource Center for
Health IT Web Site





http://healthit.ahrq.gov/
Features
AHRQ’s
portfolio of
health IT
projects
Funding
opportunities
News releases
Emerging
lessons and
best practices
Meetings and
events
Ambulatory Safety and
Quality (ASQ) Program
 Purpose: Improve safety and quality of ambulatory
health care in the U.S. More than 60 grants
 Sample types of health IT used in projects:
– PHRs
– Clinical/medication reminders
– Clinical decision support
– Telehealth
– Human/machine interface
ASQ Grants: Texas
 Using Electronic Records To Detect and Learn
From Ambulatory Diagnostic Errors – University
of Texas Health Science Center at Houston
– Type of Health IT: Operational decision support
(quality of care)
– Duration of Project: 9/30/2007 – 9/29/2009
 Using Information Technology To Provide
Measurement-Based Care for Chronic Illness –
Texas Southwest Medical Center at Dallas
– Type of Health IT: CDS (provider-focused)
– Duration of project: 9/3-/2007 – 9/29/2010
What is Comparative
Effectiveness Research?
Essential Questions Posed by
Comparative Effectiveness
Essential Questions Posed by
Comparative Effectiveness
Is this treatment right?
Is this treatment right for me?
AHRQ Comparative
Effectiveness Research
http//:effectivehealthcare.ahrq.gov
Effective Health Care Program
A. Evidence synthesis (EPC program)
–
–
Systematically reviewing, synthesizing, comparing existing
evidence on treatment effectiveness
Identifying relevant knowledge gaps
B. Evidence generation (DEcIDE, CERTs)
–
–
Development of new scientific knowledge to address
knowledge gaps.
Accelerate practical studies
C. Evidence communication/translation
(Eisenberg Center)
–
–
Translate evidence into improvements
Communication of scientific information in plain language
to policymakers, patients, and providers
AHRQ Priority Conditions
 Arthritis and non-






traumatic joint disorders
Cancer
Cardiovascular disease,
including stroke and
hypertension
Dementia, including
Alzheimer Disease
Depression and other
mental health disorders
Developmental delays,
attention-deficit
hyperactivity disorder
and autism
Diabetes Mellitus
 Functional limitations






and disability
Infectious diseases
including HIV/AIDS
Obesity
Peptic ulcer disease
and dyspepsia
Pregnancy including
pre-term birth
Pulmonary
disease/Asthma
Substance abuse
Comparative Effectiveness
and the Recovery Act
 The American Recovery and Reinvestment
Act of 2009 includes $1.1 billion for
comparative effectiveness research:
–
AHRQ: $300 million
–
NIH: $400 million (appropriated to AHRQ and
transferred to NIH)
–
Office of the Secretary: $400 million (allocated at
the Secretary’s discretion)
Funding for health IT, prevention and other areas
have implications for the Agency
Translating the Science into
Real-World Applications
 Examples of Recovery Act-funded Evidence
Generation projects:
– Clinical and Health Outcomes Initiative in Comparative
Effectiveness (CHOICE): First coordinated national effort
to establish a series of pragmatic clinical comparative
effectiveness studies ($100M)
– Request for Registries: Up to five awards for the creation
or enhancement of national patient registries, with a
primary focus on the 14 priority conditions ($48M)
– DEcIDE Consortium Support: Expansion of multi-center
research system and funding for distributed data network
models that use clinically rich data from electronic health
records ($24M)
The Bottom Line
“Patients’ ratings of
hospital care are of
interest because they
are, in many ways,
“the bottom line.”’
New England Journal of Medicine
Patients’ Perspectives of Care in the United States New England
Journal of Medicine 359;18 www.nejm.org October 30, 2008
AHRQ Patient
Engagement Campaigns
Primary Campaign
Spanish-Language Campaign
Men’s Preventive Health Campaign
PSA by Fran Drescher
Plain Language Guides
in English & Spanish
Hispanic Elderly Initiative
 HHS pilot initiative aimed at
improving the health and quality
of life for Hispanic elders
 Eight metropolitan communities
selected to participate in the pilot:
Chicago, Houston, Los Angeles,
McAllen, Miami, New York, San
Antonio, and San Diego
 Medicare participation and
diabetes care are target areas of
work for each of the communities
Building a Bridge at the
Quality Chasm
 AHRQ’s Role
 The Quality Chasm
 Getting There from
Here
 Q&A
Future Challenges
 Downstream effects of policy applications
 Using technology, but not letting technology
determine our priorities
 Care coordination: what can we learn from
large integrated systems?
 Public-private funding and participation
likely a necessity
 Patients should always be engaged as
partners: it’s about them, not about you
What Does It Mean to Be
‘Patient-Centric?’
Technology and Consumers
 We create tools that make care
more efficient for clinicians
 Consumers already are
comfortable with the technology;
they’re leading us, not the other
way around
 Consumers are demanding
tools to make their care more
about them; let’s satisfy the
demand!
21st Century Health Care
Using Information to Drive Improvement:
Scientific Infrastructure to Support Reform
Information-rich, patientfocused enterprises
Evidence is
continually refined
as a by-product of
care delivery
21st Century
Health Care
Information and
evidence transform
interactions from
reactive to
proactive (benefits
and harms)
Actionable information available – to
clinicians AND patients – “just in time”
According to Yogi Berra
“If you don't know where
you are going, you
might wind up
someplace else.”
Yogi Berra
Funding Opportunities
 Opportunities for the field to become
involved are made available as soon as
possible:
– To sign up for updates, visit
http://effectivehealthcare.ahrq.gov
– To review AHRQ’s standing program and
training award announcements
http://www.ahrq.gov/fund/grantix.htm
Building a Bridge at the
Quality Chasm
 AHRQ’s Role
 The Quality Chasm
 Getting There from Here
 Q&A