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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.

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Building a bridge over the quality chasm the role of ahrq and the ut system l.jpg

Building a Bridge Over the Quality Chasm: The Role of AHRQ and the UT System

Carolyn M. Clancy, MD


Agency for Healthcare Research and Quality

UT Clinical Safety and Effectiveness Inaugural Conference

Austin, TX – October 15, 2009

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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

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  • 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

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Building a Bridge at the Quality Chasm

  • AHRQ’s Role

  • The Quality Chasm

  • Getting There from Here

  • Q&A

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AHRQ’s Mission

Improve the quality, safety, efficiency and effectiveness of health care for all Americans

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HHS Organizational Focus


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

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AHRQ 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


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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

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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)

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Building a Bridge at the Quality Chasm

  • AHRQ’s Role

  • The Quality Chasm

  • Getting There from Here

  • Q&A

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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

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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

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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

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  • =Most Recent Year = Baseline Year

Texas: Dashboard on Overall Health Care Quality vs. All States




Very Weak

Very Strong

Performance Meter: All Measures

2008 National Healthcare Quality Report, State Snapshots

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Texas Snapshot

2008 National Healthcare Quality Report, State Snapshots

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Tools to Address the Chasm

  • Health IT (efficiency, timeliness)

  • Comparative effectiveness research (safety, effectiveness)

  • Direct engagement with consumers (equity, patient-centeredness)

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AHRQ Health IT Investment: $260 Million

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

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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

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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

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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

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AHRQ National Resource Center for Health IT Web Site

  • Features AHRQ’s portfolio of health IT projects

  • Funding opportunities

  • News releases

  • Emerging lessons and best practices

  • Meetings and events

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Ambulatory Safety andQuality (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

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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

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What is Comparative Effectiveness Research?

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Essential Questions Posed by Comparative Effectiveness

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Essential Questions Posed by Comparative Effectiveness

Is this treatment right?

Is this treatment right for me?

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AHRQ Comparative Effectiveness Research


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Effective Health Care Program

  • Evidence synthesis (EPC program)

    • Systematically reviewing, synthesizing, comparing existing evidence on treatment effectiveness

    • Identifying relevant knowledge gaps

  • Evidence generation (DEcIDE, CERTs)

    • Development of new scientific knowledge to address knowledge gaps.

    • Accelerate practical studies

  • Evidence communication/translation (Eisenberg Center)

    • Translate evidence into improvements

    • Communication of scientific information in plain language to policymakers, patients, and providers

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Arthritis and non-traumatic joint disorders


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


Peptic ulcer disease and dyspepsia

Pregnancy including pre-term birth

Pulmonary disease/Asthma

Substance abuse

AHRQ Priority Conditions

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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

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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)

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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 October 30, 2008

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AHRQ Patient Engagement Campaigns

Primary Campaign

Spanish-Language Campaign

Men’s Preventive Health Campaign

PSA by Fran Drescher

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Plain Language Guidesin English & Spanish

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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

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Building a Bridge at the Quality Chasm

  • AHRQ’s Role

  • The Quality Chasm

  • Getting There from Here

  • Q&A

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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

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What Does It Mean to Be‘Patient-Centric?’

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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!

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21st Century Health Care

Using Information to Drive Improvement: Scientific Infrastructure to Support Reform

Information-rich, patient-focused enterprises

Information and evidence transform interactions from reactive to proactive (benefits and harms)

Evidence is continually refined as a by-product of care delivery

21st Century Health Care

Actionable information available – to clinicians AND patients – “just in time”

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According to Yogi Berra

“If you don't know where you are going, you might wind up someplace else.”

Yogi Berra

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Funding Opportunities

  • Opportunities for the field to become involved are made available as soon as possible:

    • To sign up for updates, visit

    • To review AHRQ’s standing program and training award announcements

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Building a Bridge at the Quality Chasm

  • AHRQ’s Role

  • The Quality Chasm

  • Getting There from Here

  • Q&A

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