Technology and Caregiving: Technology and Caregiving: Research PrioritiesResearch Priorities

Carolyn Clancy, MDCarolyn Clancy, MDDirectorDirector

October 3, 2003October 3, 2003

OverviewOverview

About AHRQ: The Evidence AgencyAbout AHRQ: The Evidence Agency Health-information technology: Health-information technology:

essential to improving health and essential to improving health and health carehealth care

Research opportunitiesResearch opportunities

AHRQ Customers and GoalsAHRQ Customers and Goals

OutcomesOutcomes

QualityQuality

Cost, UseCost, Useand Accessand Access

ClinicalClinicalDecision-Decision-makersmakers

Health SystemHealth SystemDecision-Decision-makersmakers

Public PolicyPublic PolicyDecision- Decision- makersmakers

AHRQ RESEARCH FOCUS:AHRQ RESEARCH FOCUS:HOW IT DIFFERS HOW IT DIFFERS

Patient-centered, not disease-specificPatient-centered, not disease-specific Dual Focus -- Services + Delivery Systems (including Dual Focus -- Services + Delivery Systems (including

home)home) Effectiveness research focuses on actual daily practice, not Effectiveness research focuses on actual daily practice, not

ideal situations (“efficacy”)ideal situations (“efficacy”) AHRQ mission includes production AHRQ mission includes production andand use of evidence- use of evidence-

based informationbased information

OverviewOverview

About AHRQ: The Evidence AgencyAbout AHRQ: The Evidence Agency Health-information technology: Health-information technology:

essential to improving health and essential to improving health and health carehealth care

Research opportunitiesResearch opportunities

New York TimesNew York Times, December 18, 2002, December 18, 2002

RAND Study: Quality of HealthRAND Study: Quality of Health Care Often Not Optimal Care Often Not Optimal

Patients’ care often deficient, study says. Proper treatment given half the time. On average, doctors provide appropriate health care only half thetime, a landmark study of adults in 12 U.S. metropolitan areas suggests.

Medical Care Often Not Optimal Failure to Treat Patients Fully Spans Range of What Is Expected of Physicians and Nurses

Study: U.S.Doctors are not following the guidelines for ordinary illnesses

.

The American healthcare system,often touted as a cutting-edge leader in the world, suddenlyfinds itself mired in serious questions about the ability of itshospitals and doctors to deliverquality care to millions.

Medical errors corrodequality of healthcare system

RAND Study: Quality of Health Care RAND Study: Quality of Health Care Often Not OptimalOften Not Optimal

Doctors provide appropriate health care only Doctors provide appropriate health care only about half the timeabout half the time

Percentage of timePercentage of time

Alcohol dependenceAlcohol dependenceHip fractureHip fracturePeptic ulcerPeptic ulcer

DiabetesDiabetesLow back painLow back painPrenatal carePrenatal careBreast cancerBreast cancer

CataractsCataracts

11%11%23%23%

33%33%45%45%

69%69%73%73%76%76%

79%79%

E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults E. McGlynn, S. Asch, J. Adams, et al., The Quality of Health Care Delivered to Adults in the United States, in the United States, N Engl J MedN Engl J Med, 2003, 2003

Potential of IT for Assessing QualityPotential of IT for Assessing Quality

IT can enhance the precision and decrease the cost of IT can enhance the precision and decrease the cost of measurement – i.e., getting to the “right” measuresmeasurement – i.e., getting to the “right” measures

IT can also enhance translation of strategies to IT can also enhance translation of strategies to improve quality (e.g., decision support)improve quality (e.g., decision support)

IT can greatly enhance the timeliness of data collectionIT can greatly enhance the timeliness of data collection

““Potential is what you have when Potential is what you have when you haven’t done it yet” you haven’t done it yet”

Darrel RoyallDarrel RoyallUniversity of TexasUniversity of TexasFootball coachFootball coach

Percent of Americans Saying“I Have A Chronic Condition” Percent of Americans Saying“I Have A Chronic Condition”

15%

24%

35%

58%66%

0%

10%

20%

30%

40%

50%

60%

70%

18-29 30-39 40-49 50-64 65+Age

Chronic Illness and Caregiving Survey, Harris 2000Chronic Illness and Caregiving Survey, Harris 2000

Patient-Centered CarePatient-Centered Care

Information technology can support:Information technology can support:– CommunicationCommunication– Clinical knowledgeClinical knowledge– Online support groupsOnline support groups– Decreased hospitalizations and shorter lengths of Decreased hospitalizations and shorter lengths of

stay stay – Improve health care outcomesImprove health care outcomes– Improved quality of lifeImproved quality of life

Gustafson et al. Am J Prev Med. 1999Gustafson et al. Am J Prev Med. 1999

Research in Progress - 1Research in Progress - 1

Clinical decision support to reduce Clinical decision support to reduce medication errors and adverse events in medication errors and adverse events in nursing homesnursing homes

Use of HIT to identify patients at high risk of Use of HIT to identify patients at high risk of adverse outcomes in long term care settingsadverse outcomes in long term care settings

Use of HIT to improve pain management for Use of HIT to improve pain management for patients at homepatients at home

Impact of shared medical records on quality, Impact of shared medical records on quality, safety and patient-MD communicationsafety and patient-MD communication

Research in Progress - 2Research in Progress - 2

Computerized tool to help individuals choose Computerized tool to help individuals choose which Medicare plan is best for themwhich Medicare plan is best for them

CHESS: on-line information and support to CHESS: on-line information and support to improve patient outcomes (HIV; other improve patient outcomes (HIV; other conditions)conditions)

Decision support: should I be screened for Decision support: should I be screened for prostate cancer?prostate cancer?

OverviewOverview

About AHRQ: The Evidence AgencyAbout AHRQ: The Evidence Agency Health-information technology: Health-information technology:

essential to improving health and essential to improving health and health carehealth care

Research opportunitiesResearch opportunities

IT and ResearchIT and Research

Identify and prioritize critical questions: e.g., Identify and prioritize critical questions: e.g., clinical variations as a reflection of clinical variations as a reflection of inadequate knowledgeinadequate knowledge

Accelerate collection of relevant dataAccelerate collection of relevant data Facilitate consistent measurement of key Facilitate consistent measurement of key

outcomesoutcomes Enhance participation of communities Enhance participation of communities

and stakeholdersand stakeholders ““Reinvent” dissemination and translationReinvent” dissemination and translation

Shared Decisionmaking:Shared Decisionmaking:Decisions and OutcomesDecisions and Outcomes

Alternative 1Alternative 1

Alternative 2Alternative 2

PatientPatient

IT and Population HealthIT and Population Health

Enhance healthy behaviorsEnhance healthy behaviors – e.g., exercise, – e.g., exercise, dietdiet

Facilitate data sharing within and across Facilitate data sharing within and across communities regarding potential threats to communities regarding potential threats to public healthpublic health

Facilitate registries (e.g., immunizations) and Facilitate registries (e.g., immunizations) and exchange of information exchange of information acrossacross systems systems

Linking data sources: Linking data sources: targettarget improvement improvement effortsefforts

Admissions per100,000

Population --County of Patient

Residence

Diabetes – Long-Term ComplicationsDiabetes – Long-Term Complications

Dallas-Fort Worth Hospital Council -- Data Initiative -- 2000 Hospital Discharge Data

September 26, 2002

< 1

1 to 13

85 to 109

26 to 84

14 to 25

110 to 178

DFW Area Hospitals

Texas

ExampleExample

““Dorothy,” a very obese 32 year old woman, Dorothy,” a very obese 32 year old woman, is seen for a suspected UTI and found to is seen for a suspected UTI and found to have diabeteshave diabetes

Her physician provides information about Her physician provides information about diet and exercise – but is only cautiously diet and exercise – but is only cautiously optimisticoptimistic

One month later, Dorothy returns, having lost One month later, Dorothy returns, having lost 30 lbs – and shows Dr. C how she is using a 30 lbs – and shows Dr. C how she is using a customized application for her Palm Pilot to customized application for her Palm Pilot to track her progress with diet and exercisetrack her progress with diet and exercise

IT Challenges IT Challenges

Put IT that we know works into practicePut IT that we know works into practice Support the development and implementation of IT innovationsSupport the development and implementation of IT innovations Develop IT and other health care innovations that put the patient at Develop IT and other health care innovations that put the patient at

the center of care the center of care Translate these new IT innovations into practiceTranslate these new IT innovations into practice Researchers, health care professionals, engineers, and others need to Researchers, health care professionals, engineers, and others need to

work together to ensure that clinical care design and infrastructure work together to ensure that clinical care design and infrastructure support the full potential of ITsupport the full potential of IT

Critical ChallengesCritical Challenges Common data elements and definitions; build capacity to make Common data elements and definitions; build capacity to make

improvementsimprovements

Clear rules of the roadClear rules of the road: Who owns the data? Who decides what : Who owns the data? Who decides what is in a record? Who can make changes? IRB’sis in a record? Who can make changes? IRB’s

Transparency of purpose of data collection and useTransparency of purpose of data collection and use

Making it Making it easyeasy

Secretary ThompsonSecretary ThompsonMarch 21, 2003March 21, 2003

In the modern era, every century has had itsIn the modern era, every century has had its

major advance that has brought medical major advance that has brought medical

science another giant step forward. …. What will science another giant step forward. …. What will

the major advance of the 21st century be?the major advance of the 21st century be?

I am convinced that the medical revolution I am convinced that the medical revolution

of our children’s lifetimes will be the of our children’s lifetimes will be the

application of information technology to application of information technology to

health care.health care.