Meeting Minutes, March 2020

Contents

Summary
Call to Order and Approval of March 26, 2020, Meeting Summary
AHRQ Budget Update and Recent Accomplishments
AHRQ and COVID-19 Discussion
21st Century Care Initiative
Public Comment
Wrap-Up and NAC Input
Adjournment

Summary

NAC Members Present

Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine (NAC Chair)
Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, University of Missouri 
Karen S. Amstutz, M.D., M.B.A., FAAP, Indiana University Health
Asaf Bitton, M.D., M.P.H., Ariadne Labs, Brigham and Women’s Hospital
Cathy J. Bradley, Ph.D., M.P.A., Colorado School of Public Health
Gretchen M. Dahlen, M.H.S.A., FACHE, Consumer Health Ratings
Susan Edgman-Levitan, P.A., Massachusetts General Hospital
Peter J. Embi, M.D., M.S., FACP, FACMI, Regenstrief Institute
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
Andrew L. Masica, M.D., M.S.C.I., Baylor Scott & White Health
Hoangmai Huu Pham, M.D., M.P.H., Anthem, Inc.
Ramanathan Raju, M.D., M.B.A., CPE, FRCS, FACS, FACHE, Northwell Health
Edmondo J. Robinson, M.D., M.B.A., M.S., Christiana Care-Wilmington 
Patrick S. Romano, M.D., M.P.H., University of California, Davis
Yanling Yu, Ph.D., Washington Advocates for Patient Safety

Ex Officio Members and Alternates Present

Naomi Tomoyasu, Ph.D., Veterans Health Administration (for David Atkins)
Michael Lauer, M.D., National Institutes of Health
Paul Rosen, M.D., M.P.H., Centers for Medicare & Medicaid Services (for Shari Ling)
Robin M. Wagner, Ph.D., Centers for Disease Control and Prevention (for Chesley Richards)

AHRQ Staff Members Present

Gopal Khanna, M.B.A., Director
David Meyers, M.D., FAAFP, Deputy Director and Chief Physician
Lucie M. Levine, Chief Financial Officer
Bob McNellis, M.P.H., P.A., Senior Advisor for Primary Care
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator

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Call to Order and Approval of March 26, 2020, Meeting Summary

Gopal Khanna, M.B.A., Director of the Agency for Healthcare Research and Quality (AHRQ), welcomed the meeting participants and listeners. He pointed to the current COVID-19 crisis and the need for the country to address health and safety during trying times. He thanked the National Advisory Council (NAC) members for joining the meeting and introduced the new Chair of the NAC, Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S.

Dr. Hernandez-Boussard called the meeting to order at 12:30 p.m. She also welcomed the NAC members, other participants, and WebEx listeners. She noted, in addition to her new role as NAC Chair, the following changes in the professional positions of NAC members:

• Shari Ling, M.D., ex officio NAC member, was made Acting Chief Medical Officer at the Centers for Medicare & Medicaid Services (CMS).
• Gregory L. Alexander, Ph.D., R.N., FAAN, FACMI, was appointed Professor at Columbia University.
• Karen S. Amstutz, M.D., M.B.A., FAAP, became Vice President of Community Health at Indiana University Health.
• Andrew L. Masica, M.D., M.S.C.I., SFHM, became Senior Vice President and Chief Medical Officer at Texas Health Resources.
• Edmondo J. Robinson, M.D., M.B.A., M.S., became a Senior Vice President and Chief Digital Innovation Officer at Moffit Cancer Center.

Dr. Hernandez-Boussard announced the appointments of the following new NAC members:

• Asaf Bitton, M.D., M.P.H.
• Gretchen Dahlen, M.H.S.A., FACHE
• Susan Edgman-Levitan, P.A.
• Omar Lateef, D.O.
• Hoangmai Huu Pham, M.D., M.P.H.
• Ramanathan Raju, M.D., M.B.A., CPE, FRCS, FACS, FACHE
• Patrick Romano, M.D., M.P.H.
• Yanling Yu, Ph.D.

She asked the attending NAC members to introduce themselves.

Dr. Hernandez-Boussard referred to the draft minutes of the previous NAC meeting (November 21, 2019) and asked for changes and approval. The NAC members voted unanimously to approve the November meeting minutes with no changes.

AHRQ Director Khanna presented the meeting’s agenda, which featured sessions on AHRQ’s budget and efforts in research, practice improvement, and data/analytics. The meeting also included sessions/discussions on AHRQ’s efforts related to COVID-19 and AHRQ’s future vision (the 21st Century Care Initiative). Director Khanna encouraged the NAC members to bring their distinct perspectives and insights to the discussions and to consider their potential roles in supporting AHRQ’s work. He noted that David Meyers, M.D., FAAFP, recently assumed the position of AHRQ Deputy Director.

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AHRQ Budget Update and Recent Accomplishments

Lucie M. Levine, Chief Financial Officer, AHRQ, and David Meyers, M.D., FAAFP, Deputy Director and Chief Physician, AHRQ

Budget

Ms. Levine reported that AHRQ’s current enacted budget (FY 2020) is $338 million, which is identical to the previous year’s budget. The FY 2020 budget includes:

• $72.3 million for patient safety.
• $96.3 million for health services research, data, and dissemination.
• $16.5 million for digital healthcare research and technology.
• $11.6 million for the U.S. Preventive Services Task Force.
• $70 million for the Medical Expenditure Panel Survey (MEPS).
• $71.3 million for program support.

Congress reauthorized the Patient-Centered Outcomes Research Trust Fund for the next 10 years. AHRQ will receive about $100 million in each of those years. Those funds will be used to disseminate and implement patient-centered outcomes research (PCOR) findings, incorporate PCOR findings into practice, assist in digital healthcare research and technology, and provide training and career development.

President Trump’s FY 2021 budget request calls for transitioning the highest priority AHRQ activities to a new entity within the National Institutes of Health. The new entity would be named the National Institute for Research on Safety and Quality, and its proposed FY 2021 budget request is $256 million.

AHRQ Accomplishments

Dr. Meyers described recent accomplishments of the agency in five areas.

Health systems research

• AHRQ awarded four grants to measure the incidence of diagnostic errors and to enhance understanding of their contributing factors, impacts, and costs.
• AHRQ will support a midyear summit to develop a national agenda for patient safety research.
• AHRQ is offering two grants for researchers to address multiple chronic conditions. One is titled “Using Data Analytics to Support Primary Care,” and the other is titled “Improving Quality of Care and Patient Outcomes During Care Transitions.”

Practice improvement

• AHRQ produced a self-service how-to guide, which augments the Agency’s “Six Building Blocks” opioid treatment program.
• AHRQ’s Comprehensive Unit-Based Safety Program (CUSP) was used in a safety implementation program for improving antibiotic use and resulted in reduced antibiotic use in 400 hospitals.
• New funding will support primary care to advance cardiovascular health in States with a high prevalence of preventable cardiovascular events ($18 million in total).

Data and analytics

• AHRQ’s Healthcare Cost and Utilization Project (HCUP) produced a statistical brief on influenza care in recent years. The MEPS program produced a brief on population trends regarding influenza in 2016-2017.
• AHRQ launched a website on the Network of Patient Safety Databases, which includes data visualization tools and a chartbook of national analysis.
• AHRQ updated its Compendium of U.S. Health Systems, incorporating data from 2018. In particular, the data showed a continuing consolidation of providers and hospitals into systems.

Integrated initiatives

• AHRQ supported a study that showed increasing U.S. opioid-related hospitalizations and emergency department visits by patients age 65 years and over in the years 2010-2015. The Agency is supporting ongoing strategies to improve opioid management.

Operational excellence

• AHRQ created a new division, Digital Healthcare Research, to examine the evolving digital healthcare ecosystem and support efforts. The Agency is developing a strategic plan to guide investments in digital healthcare technologies. It will identify problem and pain-point areas, with an eye to the Agency’s priorities.
• AHRQ created the role of Chief Data Officer, supported a challenge for visualization resources of community-level social determinants of health, and supported an insight summit to explore data innovations. The Agency is supporting initiatives on synthetic healthcare data and social determinants of health data.
• AHRQ has been expanding its digital footprint, increasing the volume and frequency of messaging on social media sites, adding graphics and videos to the AHRQ website, adding real-time analytics, and adding a library of social media content.

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AHRQ and COVID-19 Discussion

Robert McNellis, M.P.H., Senior Advisor for Primary Care, AHRQ, and NAC Members

Director Khanna began a session on AHRQ and the COVID-19 crisis by noting the Agency’s efforts to maintain safety and counter the virus (teleworking, virtual meetings).

Mr. McNellis further described AHRQ efforts to address the challenge, noting that AHRQ is part of the all-government response. This response includes short-, intermediate-, and long-term approaches to fight the pandemic. AHRQ is engaging with sister agencies to identify gaps and opportunities in the fight and to contribute the Agency’s competencies and resources. The following are four primary areas of effort:

• Drafting proposals for possible intermediate and longer term projects, given funds.
• Considering options for generating grantee work related to COVID-19.
• Supporting, with data, modeling work in HHS to address, as examples, hospital bed capacity, ICU capacity, and ventilators.
• Working within an interagency group to identify agency assets, harness data, and develop new ideas.

Mr. McNellis asked the NAC members to consider the following questions:

• What do you see, from your delivery system perspective, as pain points?
• How can AHRQ help in 6 to 12 months and in 1 to 2 years?

Discussion

• Dr. Embi proposed that supplemental funding be used to advance capabilities in information exchange and data sharing. AHRQ could advance efforts to develop learning health systems. The pandemic is creating learning opportunities.
• Dr. Bitton suggested AHRQ consider ways to address financially the need for protective equipment and ventilators. The Agency could fund research on preparedness. Its research will be important as primary care practices shift to the use of virtual experience, especially for ambulatory care. AHRQ could work to obtain data.
• Ms. Edgman-Levitan agreed that AHRQ should support research in the evaluation of virtual care activities and their potential effectiveness. AHRQ could join the related new collaborative created by the Institute for Healthcare Improvement.
• Dr. Yu encouraged AHRQ to work with other agencies (NIH, CDC) on long-term projects, which might include development of a national surveillance system and use of digital resources.
• Dr. Pham suggested that, in the years to come, some independent medical practices will not survive. Telehealth will not be sufficient to sustain them. AHRQ could study issues of access and infrastructure. The marketplace will experience large changes.
• Dr. Alexander stressed the impact on the long-term-care community. AHRQ could support research to study effects of isolation and use of telemedicine.
• Dr. Romano agreed with the need to examine the use of telemedicine/telehealth. AHRQ could study issues of quality and safety, as in diagnostic error. There will be changes and issues regarding the workforce—teamwork, burnout, retraining.
• Dr. Masica encouraged AHRQ to study impacts on chronic health issues, especially within populations with disparities.
• Dr. Amstutz suggested that AHRQ consider natural experiments, as in the results of public health delivery. AHRQ could study community health organizations.
• Dr. Hernandez-Boussard noted the different State strategies in addressing COVID-19. AHRQ could work to collect and evaluate the evidence/effects.

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21st Century Care Initiative

Gopal Khanna, M.B.A., David Meyers, M.D., FAAFP, and NAC Members

Director Khanna introduced a session on AHRQ’s 21st Century Care Initiative. This new effort builds on the Nation’s 21st Century Cures Act, with AHRQ realizing its particular role in advancing care (reforming the financing of care, deriving better value, and attacking specific challenges).

Dr. Meyers noted that the 21st Century Cures Act of 5 years ago is being updated in new legislation, “Cures 2.0,” and features new aspects, such as digital healthcare and a focus on caregivers. AHRQ’s efforts will be directed toward digital health and data, health economics, real-world evidence for care, whole-person care, safe care, and primary care.

Dr. Meyers asked NAC members to consider and discuss the following questions:

• What are the likeliest areas for impact with new investment in improving care delivery?
• Where can AHRQ specifically have the greatest impact?
• What are the greatest challenges facing your organizations and members in the next 10 years related to the delivery of care?
• Are there other initiatives AHRQ should be aware of as it thinks about 21st century care?

Discussion

• Dr. Pham stressed the importance of machine learning and the broad issues and enterprise surrounding that.
• Dr. Raju encouraged AHRQ to study the area of profitable health services, strategies for increasing hospital capacity, and ways to extend care as the number of providers decreases.
• Dr. Bradley stressed the opportunity to advance the data science infrastructure, with AHRQ supporting its development and integration. AHRQ should continue to disseminate tools for studying health economics.
• Dr. Alexander welcomed the six research areas that were listed and added a need to examine where the various parts of the healthcare system reside today (capabilities, disparities). He agreed on the importance of studying the use of artificial intelligence in each of those various parts of the system.
• Dr. Embi encouraged AHRQ to continue to support progress in learning health systems.
• Dr. Goeschel stressed the importance of community care and the need to maintain the human touch in healthcare.
• Dr. Amstutz stressed the area of digital healthcare and the importance of scaling care. Human factors are key in patient management, which features teamwork and communication.
• Ms. Dahlen stressed the importance of behavioral health, which is a cross-cutting issue. The consumer lens is important and should be considered. Ms. Dahlen encouraged AHRQ to study issues of affordability and access to care.
• Dr. Robinson also stressed the patient perspective and cautioned about the potential digital divide across patients and the need to consider social determinants of health. Interactions must be designed carefully. Dr. Embi agreed, calling for research in the area of knowledge management.
• Dr. Yu encouraged AHRQ to help advance the area of patient-reported outcomes. Ms. Edgman-Levitan suggested that the CAHPS databases be used to advance patient engagement (they offer data on communications). AHRQ could engage in the international “What Matters to You” initiative (Institute for Healthcare Improvement).
• Dr. Bitton encouraged AHRQ to support research that is systemic and takes risks, as in a focus on implementation.
• Dr. Bradley cited the problem of a lack of use of the large amounts of data that are collected today. AHRQ could study strategies for better use and for fitting data systems into delivery systems.

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Public Comment

Shanina C. Knighton, Ph.D., R.N., of Case Western Reserve University recalled her past experience as a nurse and investigator. Working in an emergency department, she observed that patients are often unaware of their potential for causing healthcare-associated infections. Patients usually are not familiar with the situations in the healthcare environment and perhaps could benefit from tailored education.

Dr. Knighton encouraged AHRQ to support work to increase information and discussion about such problems. She wondered about potential “moments of care” that can be missed. For example, old opioid medications should be collected from patients when they obtain new prescriptions. We need data and infrastructure to address such potential problems.

A member of the International Association of Plumbing and Mechanical Officials, which has a role in developing codes, referred to her research work on Legionella (Legionnaires’ disease) and wondered whether COVID-19 might exist in hospital patients in cross-contamination with Legionella, which can exist in hospital cooling towers. Perhaps AHRQ could support research into that possibility.

Lucy A. Savitz, Ph.D., M.B.A., of Kaiser Permanente Northwest and a former NAC member suggested that AHRQ use task orders and its ACTION Network research mechanism to support work on learning healthcare systems and the spread of tools to address the COVID-19 pandemic. The mechanisms could support research to understand health outcomes in general.

Announcement

Dr. Meyers announced that AHRQ has published two new notices of intent to fund (1) research on health system responsiveness to COVID-19 (for grantees already working in the field) and (2) research on novel high-impact studies evaluating health system personnel responses to COVID-19 (focus on telehealth, primary care, and system-level changes).

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Chairman's Wrap-Up and NAC Input

Dr. Hernandez-Boussard asked NAC members to offer final suggestions about AHRQ priorities and ways AHRQ’s work and messages might be disseminated.

• Dr. Alexander stated that he can share results of AHRQ-supported research with his and other organizations.
• Dr. Bitton encouraged AHRQ to support research on the science of scale, moving research results beyond the pilot level.
• Dr. Bradley urged AHRQ to partner with other Federal agencies to disseminate messages.
• Ms. Dahlen encouraged AHRQ to use mass media with messages that connect directly to the consumer.
• Dr. Goeschel stated that she can disseminate AHRQ messages at universities and MedStar Health’s research institute. She can promote AHRQ research opportunities and findings to groups such as the American Physical Therapy Association.
• Dr. Gupta encouraged AHRQ to produce more webinars and to record them for further dissemination by institutions on their websites.
• Dr. Pham suggested that AHRQ seek a balance in approaching both end-users (clinics) and researchers. The Agency might form new partnerships with practice organizations and associations of hospital executives.
• Dr. Embi encouraged AHRQ to be in contact with professional societies, such as the American Medical Informatics Association. AHRQ could cosponsor webinars and leverage infrastructures, including those of private enterprises.
• Dr. Amstutz encouraged the use of public-private partnerships for some grants. AHRQ could fund innovation health systems (sandboxes) that include such partnerships.
• Dr. Raju suggested that NAC members disseminate AHRQ messages at local and national medical meetings and through social media.
• Dr. Robinson encouraged AHRQ to partner with organizations such as the Digital Medicine Society. AHRQ potentially could be a major driver in that area.
• Dr. Yu stated that AHRQ could advertise its resources as it helps educate the public about the COVID-19 pandemic.
• Dr. Masica encouraged AHRQ to push forward its dissemination and implementation activities during the pandemic.
• Dr. Wagner suggested that AHRQ use its current partnerships to a greater extent, for example, identifying new opportunities to reach the public.

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Adjournment

Director Khanna and Dr. Hernandez-Boussard thanked the NAC members and presenters for their input. Dr. Hernandez-Boussard noted that the next NAC meeting will take place on July 14, 2020. She adjourned the meeting at 3:30 p.m.

Respectfully submitted,

Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Chair
National Advisory Council
Agency for Healthcare Research and Quality

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