Meeting Minutes, July 2019
National Advisory Council
Contents
Summary
Call to Order and Approval of April 11, 2019, Meeting Summary
AHRQ Accomplishments
Budget Update
Director's Overview
Public Comment
Wrap-Up and Adjournment
Summary
NAC Members Present
Donald A. Goldmann, M.D., Institute for Healthcare Improvement, Harvard Medical School (Chair)
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, University of Missouri
Karen S. Amstutz, M.D., M.B.A., Stutz & Company
Cathy J. Bradley, Ph.D., M.P.A., Colorado School of Public Health
Beth Ann Daugherty, M.P.H., R.N., M.P.H., Sparrow Clinton Hospital
Peter J. Embi, M.D., M.S., FACP, FACMI, Regenstrief Institute
Barbara A. Fain, J.D., M.P.P., Betsy Lehman Center for Patient Safety
Christine A. Goeschel, Sc.D., M.P.A., M.P.S., R.N., FAAN, MedStar Health
Rahul Gupta, M.D., M.P.H., M.B.A., FACP, March of Dimes
Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine
Charles N. Kahn III, M.P.H., Federation of American Hospitals
George Kerwin, M.B.A., Bellin Health
Andrew L. Masica, M.D., M.S.C.I., Baylor Scott & White Health (via telephone)
Jerry L. Penso, M.D., M.B.A., American Medical Group Association
Edmondo J. Robinson, M.D., M.B.A., M.S., Christiana Care-Wilmington
William H. Shrank, M.D., M.S.H.S., Humana
Yanling Yu, Ph.D., Washington Advocates for Patient Safety
Ex Officio Alternates Present
Cathie Plouzek, Ph.D., Veterans Health Administration (for David Atkins)
Paul McGann, M.D., Centers for Medicare & Medicaid Services (for Kate Goodrich)
Michael Lauer, M.D., National Institutes of Health
Robin M. Wagner, Ph.D., Centers for Disease Control and Prevention (for Chesley Richards)
AHRQ Staff Members Present
Gopal Khanna, M.B.A., Director
Virginia L. Mackay-Smith, Associate Director (via telephone)
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Lucie M. Levine, Chief Financial Officer
David Meyers, M.D., Chief Medical Officer
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of April 11, 2019, Meeting Summary
Donald A. Goldmann, M.D., 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, other participants, visitors, and webcast viewers. He noted that eight new members were attending a NAC meeting for the first time: Gregory L. Alexander, Peter J. Embi, Christine Goeschel, Rahul Gupta, Charles N. Kahn III, George Kerwin, , Edmondo J. Robinson, and Yanling Yu.
Dr. Goldmann stated that the contributions of the NAC members are critical for the AAgency. The members can help AHRQ plan its future directions. The AAgency is open to compelling ideas for healthcare. Dr. Goldmann asked the NAC members to introduce themselves, and they responded with brief biographies.
Dr. Goldmann referred to the draft minutes of the previous NAC meeting (April 11, 2019) and asked for changes and approval. The NAC members voted unanimously to approve the April meeting minutes with no changes.
AHRQ Director Gopal Khanna also welcomed the NAC members and other participants. He especially welcomed the perspectives and expertise of the new members. He presented the day’s agenda, which began with a report on recent AHRQ activities.
AHRQ Accomplishments
Virginia L. Mackay-Smith, Associate Director, Office of the Director, AHRQ
Ms. Mackay-Smith reported on recent AHRQ activities in support of the U.S. Department of Health and Human Services’ stated priorities. The Agency has supported research and applied expertise in many programs as it continues to advance work in health systems research, practice improvement, and data and analytics.
- AHRQ has been supporting peer-reviewed research to describe and analyze the opioid crisis from the perspective of the healthcare system. Such research has included studying the effects of reformulation of OxyContin, studying the influence of physician networks on prescribing patterns, and studying relationships among social determinants of health and race. One published study found that, for dentistry, opioid prescribing rates in the United States were 40 times higher than those in England.
- AHRQ’s Medical Expenditure Panel Survey (MEPS) is revealing trends and analyses in drug pricing. One analysis indicated that, in comparing 2009 and 2016, there was a 31 percent increase in costs for people with at least one outpatient prescription medication.
- In the area of health systems research, AHRQ’s support for research in understanding and improving care has generated a number of publications. These have described identifying unnecessary antibiotic prescribing prior to dental procedures and redesigning team-based clinics to improve opioid prescribing in primary care.
- AHRQ’s new TAKEheart initiative (a collaboration with the CDC) is helping hospitals adopt proven care-improvement strategies that increase the use of cardiac rehabilitation.
- The Agency is supporting a Network of Patient Safety Databases that captures non-identifiable information on patient safety events to help understand safety risks and harms and to help create strategies for reducing errors and improving safety. It is an online resource.
- A Data Tools Harmonization Project is working to harmonize user the interface for AHRQ’s data programs to allow for consistent user experiences and lead to reduced costs.
- AHRQ has released two new requests for applications:(1) Partners Enabling Diagnostic Excellence will seek to use existing data and analytic approaches to examine patterns in the diagnostic process, considering various conditions, populations, and healthcare settings; (2) Patient Safety Learning Laboratories will allow transdisciplinary teams to identify threats to diagnostic and treatment activities that are associated with a high burden of harm and cost.
Budget Update
Lucie M. Levine, Chief Financial Officer, AHRQ
Ms. Levine reported that the FY 2019 AHRQ budget features $338 million in discretionary funds, which is an increase of $4 million over the FY 2018 level. It is an increase of $82 million over the President’s budget request. Another final result of the budget deliberations was that AHRQ would be maintained as a separate Agency. The FY 2019 funding increase is supporting two research portfolios: (1) grants for diagnostic safety and (2) grants for health services research, data, and dissemination for population health.
The President’s FY 2020 budget request features $65.3 million for patient safety research, $71.8 million for the MEPS program, $42.9 million for existing investigator-initiated research and training, $9.7 million for the HCUP program, $7.4 million for the U.S. Preventive Services Task Force, and $4.5 million for opioid research. The request calls for incorporating AHRQ into the NIH; ending the health IT portfolio; ending the portfolio for health services research, data, and dissemination; and reducing funding of research management and support. The House has responded with a proposed markup budget of $358.2 million (the largest increase in more than a decade), which includes maintaining AHRQ as a separate Agency. The Senate has yet to provide its proposal.
Director's Overview
Gopal Khanna, M.B.A., Director, AHRQ
AHRQ Director Khanna described strategies for the Agency in light of HHS Secretary Azar’s challenge for the Agency to improve the health and well-being of all Americans. Director Khanna noted that this is the 20th anniversary of AHRQ’s presence as an independent Agency within HHS. In those years, AHRQ has awarded nearly 4,000 grants to about 3,000 investigators. It is the premier funder of health services research.
AHRQ has had a noteworthy impact across the American health sector, supporting life-saving programs, such as reducing infections. Its Extension for Community Healthcare Outcomes has brought healthcare to rural and underserved patients using virtual clinics and specialized mentors. It has fostered increases in value by disseminating discharge tools.
The healthcare landscape has changed and is changing. Six important disruptors are influencing the healthcare system: an aging population, mergers and consolidation of healthcare services, network medical devices, digitization, data in high volume, and new players in the healthcare delivery space (Google, Amazon, et al.). Therefore, we need new strategies and we need to reshape care delivery. We need research on care implementation. Health services research must identify new knowledge and new areas for research. We should employ the perspective of process improvement. We must focus on the whole person patient. We must advance data on social determinants of health and expand learning health systems.
AHRQ will focus on using its core competencies as it supports research, practice improvement, and data andanalytics. It will be addressing three challenges in particular: patients with multiple chronic conditions (MCC), the need to engage data and analytics to inform processes, and the need to reduce diagnostic error. It will create, expand, and engage large data resources (MEPS and new data platforms), seeking to integrate them and make them accessible. We need to turn diagnostic data into helpful information. This can be accomplished by employing centers of excellence that test models and approaches. AHRQ has been moving toward more advanced data collection. It has received funds to support the enhancement of provider information and data resources and will be expanding provider surveys. It is addressing social determinants of health, in part by linking data and including geographical information.
Discussion
Dr. Embi cautioned that the area of data on social determinants of health needs foundational work. We need to develop standards and determine how to track data. There are multiple platforms to manage. We need to collect evidence that will support decisions. Perhaps AHRQ could foster the science to inform such issues. It could develop a framework for addressing social determinants of health and perhaps link MEPS data to policymaking.
Dr. Yu noted the proposed cuts to the budget for quality indicators. Director Khanna cited the potential for partnering with organizations in that area. Dr. Goeschel added the idea of reaching out to partners broadly. These could include community agencies and hospitals.
Cathy J. Bradley stressed the need to study implementation following the identification of social determinants of health. Much information is lacking: understanding environments, levels, support systems, and integration of factors. It was noted that the MEPS program is working to expand its sample and obtain more detailed information. Arlene Bierman noted that the Agency recently issued a funding announcement aimed at combining clinical data and data on social determinants of health, especially in high-risk environments.
Karen S. Amstutz suggested that community organizations partner with AHRQ in developing standards regarding social determinants of health data. Credentialing will be an important topic. Tina M. Hernandez-Boussard noted the importance of incorporating social determinants data into analyses. AHRQ might support studies of what can be extracted from the digital data and which data should be acquired.
George Kerwin cautioned about the issue of healthcare delivery systems trying to address social determinants of health. There is a complexity, a messiness. We grasp only a few elements of the fundamental concepts. It will be important to confer with a variety of agencies—the police, schools, etc.
Dr. Alexander raised the issue of long-term care and its need for innovation and advanced practices (including the 360-degree patient perspective). This area has, for example, a need for nurses to work at the proper levels. AHRQ could support quality improvement here.
Jerry L. Penso referred to issues of mergers, consolidation, and new participants within the healthcare arena. He stressed a need to understand the context surrounding organizations, which can affect data and analysis. The healthcare ecosystems are changing and affecting care delivery.
Dr. Embi raised the issue of how healthcare systems will incorporate artificial intelligence and machine learning systems into processes such as decision support. He suggested that the NAC discuss AHRQ’s role.
Dr. Goldmann suggested that the group consider what we mean by care and the role of the Agency. What competencies are present, and what competencies are needed? What is the role of AHRQ in artificial intelligence systems? What is the relevance of data platforms in service to the role of AHRQ? Should AHRQ be involved in implementation science? What are the boundaries for AHRQ around data and care?
Advancing Patient-Centered Care for People Living with Multiple Chronic Conditions
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement, AHRQ
Dr. Bierman began a session on MCC by presenting some key facts:
- Nearly one of three American adults and four of five Medicare beneficiaries are living with multiple chronic conditions.
- There is a mismatch between the way care is delivered and patient needs, resulting in care that is fragmented and suboptimal. This leads to poor outcomes and increased costs.
- Low-income individuals and racial/ethnic minorities develop MCC at earlier ages. Women are more likely to have MCC across all age groups.
- People with MCC account for 64 percent of all clinician visits, 70 percent of all inpatient stays, 83 percent of all prescriptions, 71 percent of all healthcare spending, and 93 percent of Medicare spending.
- People with MCC represent about 70 percent of all cases of hospital readmissions.
The NAC members agreed that care for people with MCC is not properly connected and features multiple doctors and poor communication across care teams. The healthcare system is not welcoming or people friendly. It offers unsatisfactory experiences.
Questions and Discussion
Dr. Bierman stated that AHRQ is addressing the issue of MCC in light of its mission to foster a sustainable healthcare system that delivers high-value, coordinated, integrated, patient-centered care based in primary care by optimizing individual and population health and preventing and managing MCC. MCC can occur at all stages of a person’s life course. Multimorbidity is a term that defines in slightly different ways (slightly different factors) MCC. Dr. Bierman asked the NAC members to consider four questions:
- What is the scope of this problem?
- What terms describe this problem?
- How is the issue being talked about in your organization?
- What problems relating to MCC are you hearing about?
AHRQ will address the MCC pandemic by supporting prevention interventions (reducing risk factors), targeted interventions to improve health and reduce risk for people with “rising risk,” and targeted interventions for people at high risk for avoidable adverse events.
Dr. Robinson stated that healthcare delivery systems have been designed for and by the healthcare deliverers. How might we design systems more attuned to individuals? How can the approaches be scaled properly?
Dr. Penso proposed a focus on exploiting data assets, such as data on total cost of care, practice efficiency, high-risk patients, and quality measurement. Perhaps institutions should use benchmarks in these areas to address high-risk patients in a cost-effective manner. That could cause a movement toward value and might help reduce physician burnout.
Dr. Gupta stated that care models exist. We can improve our understanding of return on investment for at-risk populations. Such analyses could lead to better investing. Cultural competencies must be part of the equation. Looking at the scene through the lens of prescriptions could be beneficial. Is the physician spending time with the patient or mainly offering prescriptions?
Dr. Hernandez-Boussard noted the difficulty of treating high-risk MCC patients. They are not featured in clinical trials, and few care models address multiple treatments. AHRQ could serve to develop a research agenda. Dr. Bierman added that today’s guidelines are for singular conditions. Some chronic care models are including multiple conditions.
Dr. Alexander cited the benefit of performing fundamental assessments that are evidence based and can detect illness early. Costs can be shifted such that better (even more expensive) care leads to less expensive stays. How can doctors bill with regard to the prevention of illness or hospitalization? We could adopt risk-management approaches.
Dr. Bradley called for better decision tools, addressing the complexities and better advising the physician. Mr. Kerwin proposed efforts to define and segment populations. We should identify better the elements of managed care and where costs go. This could bring down costs.
Dr. Yu stressed the personal level. Patients are uncomfortable with a lack of coordinated care. Family perspectives and priorities are important. How are patient records shared?
Andrew Masica pointed to the work of the evidence-based practice centers, which have addressed issues such as chronic diseases and bundled payments. AHRQ could pursue those avenues further.
Mr. Kahn stressed the importance of payment issues, suggesting that fee for service and capitation are the only ways to go.
Dr. Bierman described shared principles and qualities of good primary care, including person and family-centeredness, continuous, comprehensive, equitable, team-based, coordinated, integrated, accessible, and high value. She referred to the medical home construct and the idea of a medical neighborhood surrounding it. She referred to the Learning Health System concept and strategy. AHRQ has considered its own model. Does primary care need to be redesigned? Dr. Bierman asked the NAC members to consider the research, tools, practice improvement, and data and analytics that are needed to achieve better quality and outcomes.
Dr. Goldmann asked, “What if primary care, with a physician in charge, were not the medical home?”
Dr. Bierman stated that AHRQ faces a number of opportunities today. Its strategies going forward may involve demography and epidemiology, payment incentives and penalties, recognizing social determinants of health, new information technology tools, and new scientific methods. Twenty-first century healthcare can be patient-centered, with the patient as co-producer of healthcare. It can involve the system rather than the hospital, a network rather than a bureaucracy, and it can focus on value. AHRQ has been engaging stakeholders to help understand the Agency’s role, identify needs, and explore opportunities for collaboration. It is offering grants, such as through a funding opportunity announcement on screening and management of unhealthy alcohol use in primary care, an announcement on targeting data analytics to improve chronic disease prevention management on primary care, and a forthcoming announcement on efforts in interoperable e-care plans.
Value: Powering Decision Making Through Analytics
Joel W. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends
Dr. Cohen described AHRQ efforts in data and analytics. He recognized a major problem—decisionmakers often lack access to timely, reliable data and analytics with which to make informed policy and operational decisions. Unintended and undesirable consequences can result. AHRQ has a 5-year agenda to attack the problem. This includes establishing an integrated data, analytics, and information platform with the technical expertise required to capture a 360-degree view of the healthcare system. Elements of such a program are:
- Predictive analytics teams to address emerging policy issues.
- State partnership platforms for State and local data and analytics.
- A national platform for small-area social determinants of health data and analytics.
- National databases of physician practices and organizations.
- Expansion of the MEPS sample to enhance capacity for State estimates.
AHRQ chartered a cross-agency data enterprise working group. It has developed a Federal database of social determinants of health. The Agency intends to increase the capacity of policymakers and program makers to:
- Make more timely responses to complex policy questions.
- Make better predictions regarding health care access, costs, and outcomes.
- Improve the 360-degree understanding of the healthcare system.
- Improve State-specific estimates.
- Monitor, track, and fine tune state programs.
- Understand programs related to costly and policy-relevant populations.
Safety: Improving Diagnosis
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Dr. Brady described AHRQ’s current efforts to improve diagnosis, that is, to reduce diagnostic errors in U.S. healthcare. About 12 million U.S. citizens experience a diagnostic error each year. More than 4 million U.S. citizens each year suffer severe consequences as a result of diagnostic errors and delays. To solve that problem, AHRQ is seeking to support and promote patient safety strategies, predictive analytics, personalized and precision medicine, and new technologies. It is investing in research to improve diagnosis in each of the “Big Three” conditions: cancer, vascular events, and infections. It is developing, testing, and disseminating tools to apply strategies at the point of care. It is encouraging advancements in data collection and use. AHRQ’s Action Network is playing a key role.
Particular initiatives include the following:
- Offering new grant research opportunities, including patient safety learning laboratories with emphasis on diagnostics and a health services research project to enable diagnostic excellence.
- Leading a Federal interagency workgroup on diagnostic safety and quality.
- Creating the “QuestionBuilder” app to help patients and caregivers prepare and organize questions and information relating to conditions and medical visits.
- Featuring a diagnostic safety microsite at the AHRQ website.
Dr. Brady stated that the Agency’s goal is to reduce the rate of diagnostic errors occurring each year in the United States by 1 million per year by 2025—a very significant reduction in patient and family harm. A reduction of 1 million diagnostic errors in 1 year would potentially result in a savings of $500 million in spending.
NAC Member Discussion
Dr. Masica began the open discussion by listing themes that arose during the presentations. He asked NAC members to consider whether AHRQ’s goals are on track and whether the areas for investing resources are correct. What steps should be taken? He further asked them to consider the following questions:
- How do you see this vision addressing the needs of the American people and AHRQ’s stakeholders for improved care and care delivery?
- What challenges might AHRQ encounter in moving the initiatives (quality, value, safety) forward and how can the Agency best mitigate them?
- Within the initiatives, what additional opportunities are there for further increasing AHRQ’s impact?
- What opportunities do you see within your own organizations and networks to advance the goals of the initiatives?
Dr. Penso cited his organization’s collaborative work with high-risk, high-cost patients with chronic conditions. He asked whether AHRQ might address segmentation within populations regarding multiple chronic conditions. How should outcomes be measured? Dr. Bierman responded that there is a challenge to identify generic aspects in models. It will be important to learn as we go along, especially about separate groups or constellations.
Dr. Penso asked Dr. Brady about issues of overdiagnosis and underdiagnosis as well as timeliness. Are those issues being addressed? Dr. Brady responded that they are. Balance is a key, such as in antibiotic stewardship, and we must get that right. Dr. Masica raised the idea of professional culture changes as they relate to diagnostic error. Dr. Brady noted that AHRQ has considered that area and has added supplemental items in its patient safety culture survey. Cultural aspects drive decision making. Moving from the conceptual to the operational is not trivial. The transition often involves measurement and the use of data. How does culture become different? How is it assessed? How do we measure teamwork, strategies of communication, and feedback loops? These are complex. What data systems will be most helpful? Electronic health records have potential. We can derive wisdom from the field, as from physicians. Some organizations have made progress in that area.
Dr. Masica added that there is an evidence gap relating to the setting of specific goals. What goals might a healthcare system build into its annual plan? That is a gap that AHRQ might address. Dr. Brady suggested that some ideas are ready for implementation, for example, measurement of laboratory test followups and the actions taken.
Dr. Masica raised the issue of payments. How do we manage the population with multiple chronic conditions? What is AHRQ’s role? How do we use data? Dr. Bierman responded that AHRQ does not focus on payment models. It seeks good care—and quality and safety—within such structural constraints. We need integrated systems that better recognize conditions for optimal care.
Dr. Cohen added that issues of payment methods are addressed mainly by the Centers for Medicare & Medicaid Services (CMS). However, AHRQ at times has advised CMS on methodologies and data. AHRQ can provide CMS with certain information on activities of health care systems. HCUP data are an example. AHRQ thereby can have an indirect effect on payment issues.
David Atkins, M.D., M.P.H., suggested that AHRQ partner more with the VA in the areas of diagnostics and multiple chronic conditions. Focusing on high-cost patients does not necessarily save money. Care coordination and patient centeredness are important. Many different models of care can be used. We need more approaches to look at specific subpopulations. Work at the VA has shown that segmenting in certain ways does not ensure improvement. Dr. Bierman suggested collaborating in a program with a strategy like that of Care and Learn.
Dr. Masica raised the issue of workforce development and capacities. Dr. Meyers cited the continuing need for AHRQ to build the next generation of researchers (e.g., through K-awards) and to embed researchers in healthcare systems. AHRQ has been working with the Patient-Centered Outcomes Research Institute in those areas.
Dr. Masica asked about efforts addressing priority populations. Francis Chesley, M.D., responded that such AHRQ programs are ongoing. They include support for research on social determinants, and they are parts of the programs for priority topics that have been discussed in this meeting. For example, various efforts in safety and in data/analytics address priority populations.
Dr. Masica asked about designs for moving the results, or best practices, from learning collaboratives to adoption. Dr. Bierman suggested that AHRQ could play a larger role. Right now it is rolling out a national initiative to increase the uptake of cardiac rehabilitation strategies. Perhaps the NAC could provide guidance on how to proceed with such efforts effectively. Dr. Brady noted that he serves on a national steering committee that has touched on learning health systems and supported patient safety practices.
Barbara A. Fain, J.D., M.P.P., reported that her organization is engaged in a collaborative project that will help to create a diagnostic error taxonomy. It has surveyed the State of Massachusetts and is analyzing narrative responses regarding diagnostic errors and delays. It has identified a pool of individuals who have experienced diagnostic errors.
Beth Ann Daugherty, M.P.H., R.N., emphasized that rural health care institutions support the work in diagnostic errors and multiple chronic conditions. They seek ways to collaborate within State and local programs to bring findings into rural care. Elderly populations and the use of tools (as in informatics) remain a challenge. Sally C. Morton, Ph.D., M.Sc., referred to challenges in partnerships in the area of data collection and analysis. She applauded AHRQ’s momentum in moving forward in that arena.
A 5-Year AHRQ Agenda
The Agency has a 5-year agenda for transforming care for people with MCC. It features a multifaceted initiative that draws on unique AHRQ resources and competencies to develop, implement, evaluate, scale, and spread innovative approaches to care delivery. Enhancing value will be a focus. Dr. Bierman referred to the new TAKEheart initiative, which will increase the scale and spread of cardiac rehabilitation. Use of its model will lead to a reduced number of hospitalizations, reduced mortality, and reduced level of disparities. Dr. Bierman asked for suggestions about the 5-year agenda.
Robin M. Wagner asked about operationalizing the AHRQ plan, especially with regard to the use of a patient-centered view. Dr. Bierman responded that AHRQ will be able to use tools, information, and the tracking of people. It will seek to integrate one-on-one conversations within the healthcare practice, with a goal of bringing forward the best evidence-based care.
Mr. Kahn asked about AHRQ resources, especially with regard to scaling programs. Dr. Bierman responded that the Agency has mechanisms and can begin to support experiments, thereby making some progress using a moderate level of funding. For example, the efforts could be in the form of a learning collaborative. Fifteen million dollars could give the agenda a start. NAC members cautioned about the need to develop sustainability within the agenda’s programs. It will be important to recognize which parts of programs can be sustained on their own. Otherwise, targeted support will be needed. Dr. Wagner suggested partnering with the CDC. She noted that the Joint Commission has information on building a database to support the idea of patient-centered homes.
Dr. Embi noted the advancing capabilities of technologies, which can lead to better care management. Multidirectional communication is now possible. AHRQ could enable and encourage solutions that allow such communication. As such, AHRQ could advance innovation in patient-centered care.
Mr. Kerwin stressed the cost to the system of people with MCC and wondered about ways to segment the patient populations to benefit individuals. Perhaps AHRQ could study past efforts to improve delivery systems and note what has and has not worked. Dr. Bierman noted an AHRQ centers of excellence program that has created a rich database.
Dr. Goldmann noted an earlier effort to accumulate models and produce an evidence review. Few of the models were found to have strong evidence, and few had spread beyond the particular organization of origin. (The data were from for-profit health systems.) Should AHRQ be a scientific partner in CMS demonstration projects? How long will such evaluations take? We really do not know what works, although there are some claims. Evaluation is difficult. There are fundamental questions: Is a program holistic? Is it causing fragmentation? AHRQ needs to offer clarity in ideas to move forward.
Dr. Yu suggested getting consumers involved and featuring a focus on patient-reported outcomes. We should consider metrics and safety signals for outcomes. Dr. Bierman noted the NIH’s PROMIS tool (Patient-Reported Outcomes Measurement Information System), which is designed to incorporate new measures.
Dr. Gupta encouraged AHRQ to address specific conditions and to state goals (not just request proposals). Dr. Alexander suggested that, for the AHRQ agenda, the timing is good. He noted that hospitals tend to be familiar with those individuals in the community who provide the best care. Disparities in the continuum of care must be addressed. AHRQ could study partnerships and how they affect the quality of care. It could study the infrastructures for long-term care.
Dr. Bradley encouraged AHRQ to study the community’s partners in communication and the ways in which information reaches the patients. How can it be made more understandable, leading to wider adoption? Dr. Goldmann agreed, adding the idea of information dissemination in general. AHRQ has a mandate to engage in the dissemination and implementation of evidence.
Dr. Goeschel raised the issue of healthcare practitioner burnout. Models should incorporate that phenomenon. AHRQ could encourage collaboration and peer communication. Dr. Amstutz encouraged AHRQ to support studies of how patients implement treatment plans. That issue involves aspects of social determinants. Mr. Kerwin suggested that AHRQ play a role in analyzing or modeling MCC, filling in gaps in understanding.
Dr. Goldmann brought up the idea of learning collaboratives, suggesting that there are a few types. He asked whether AHRQ should focus on areas in need of extensive work or those that are mature and could benefit nonetheless. Dr. Robinson responded, saying that some approaches are less effective and present no clear pathway for scaling or generalizing. High-level frameworks and concepts are not very helpful, although they have their virtues. Structures are continuously changing. Frustration can result from accepting solutions without evidence reviews or evaluation. We should have evidence-based management.
Dr. Goldmann asked whether we should be promoting the research model that features the embedded researcher bringing research skills (including objectivity) to the care delivery scene. Dr. Robinson called that a great approach. Cathie Plouzek noted that the U.S. Department of Veterans Affairs has employed a patient-alliance care team model in transitional care. She added that scaling and spreading best practices require incentives. Perhaps AHRQ could consider supporting evaluation of healthcare facilities, especially regarding the spread of best practices.
Public Comment
There were no public comments.
Chairman's Wrap-Up and Adjournment
Dr. Goldmann and Director Khanna thanked the NAC members and speakers for their input. Dr. Goldmann noted that the next NAC meeting will take place November 21, 2019. He adjourned the meeting at 2:30 p.m.
Respectfully submitted,
Donald A. Goldmann, M.D., Meeting Chair
National Advisory Council
Agency for Healthcare Research and Quality
