The Business of Government Hour

 

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The Business of Government Hour features a conversation about management with a government executive who is changing the way government does business. The executives discuss their careers and the management challenges facing their organizations. Past government executives include Administrators, Chief Financial Officers, Chief Information Officers, Chief Operating Officers, Commissioners, Controllers, Directors, and Undersecretaries.

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Join the IBM Center for a weekly conversation about management with a government executive who is changing the way government does business.

Dr. Carolyn Clancy interview

Wednesday, March 24th, 2004 - 20:00
Phrase: 
Leadership,Strategic Thinking, Missions and Programs, Organizational Transformation, Innovations
Radio show date: 
Thu, 03/25/2004
Intro text: 
Leadership; Strategic Thinking; Missions and Programs; Organizational Transformation; Innovations...

Leadership; Strategic Thinking; Missions and Programs; Organizational Transformation; Innovations

Complete transcript: 

Thursday, March 25, 2004

Arlington, Virginia

Mr. Lawrence: Good morning and welcome to The Business of Government Hour. I'm Paul Lawrence, partner in charge of The IBM Center for The Business of Government. We created the Center in 1998 to encourage discussion and research into new approaches to improving government effectiveness. You can find out more about the Center by visiting us on the web at businessofgovernment.org.

The Business of Government Hour features a conversation about management with a government executive who is changing the way government does business. Our special guest this morning is Dr. Carolyn Clancy, director, Agency for Healthcare Research and Quality, which is in the Department of Health and Human Services.

Good morning, Dr. Clancy.

Dr. Clancy: Good morning.

Mr. Lawrence: And joining us in our conversation is Vernecia Lee, also from IBM.

Good morning, Vernecia.

Ms. Lee: Good morning.

Mr. Lawrence: Well, Dr. Clancy, I’m curious, could you describe the mission of the Agency for Healthcare Research and Quality for our listeners?

Dr. Clancy: I’d be delighted. The Agency for Healthcare Research and Quality, or AHRQ, as we call it, is a research agency that’s part of HHS, as you noted. And our mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. In other words, we conduct and support research and work with partners to use the findings to make sure that health care is itself made as good as possible.

Ms. Lee: Dr. Clancy, how does AHRQ fit into the Department of Health and Human Services?

Dr. Clancy: We’re one of the 13 agencies of HHS, which is a very large department, and one of a smaller number of research agencies. So we work very closely with a number of the other agencies in the Department, particularly the Centers for Disease Control and Prevention, National Institutes of Health, the Food and Drug Administration, and we also work with the Health Resources and Services Administration, or HRSA, with their community health centers and so forth.

Mr. Lawrence: How would you describe the size of AHRQ, budget, employees?

Dr. Clancy: Our budget is $304 million, and we have just under 300 employees, so I often tell everyone that they’re a million-dollar employee.

Mr. Lawrence: And you described so many interesting things when you were going through the mission. What are the skill sets of the employees?

Dr. Clancy: Oh, a very, very broad mix. The research we support and do internally is actually multidisciplinary, so it draws on clinical science. So we have doctors and nurses and other health care professionals, including pharmacists. We also have a very broad array of social scientists, quite a few economists, sociologists, psychologists, and so forth. We also have people with a broad array of administrative skills.

Ms. Lee: What are the major areas of research currently being funded by AHRQ?

Dr. Clancy: A big, big focus for us is patient safety. You may have seen the Institute of Medicine’s first report on patient safety published in 1999, “To Err is Human.” When that report first came out, my brother-in-law had knee surgery about a month later. And he came home with “yes” on one knee and “no” on the other, and suddenly my family knew that what we did was, like, absolutely critical. Patient safety and errors I think are that tangible to members of the public. That’s a big part of what we do.

A lot of the research we support focuses on improving quality of care broadly; also focuses on promoting access to effective services. So we support a lot of data development that we use internally and that many others use as well to try to track what we’re spending on health care. Are we getting as much value as we could for our pretty substantial investment in health care services in this country? And we also focus on sort of the nuts and bolts of how to improve quality and safety in health care.

Ms. Lee: Why did you decide to even study medicine?

Dr. Clancy: A really good question. I decided when I was much, much younger than I had any idea what doctors did, and I don’t come from a medical family. But I think I had a gut instinct which is still pretty relevant today, which is that it was about bringing scientific skills to a job where you could work with people, and that’s still very much what I like about medicine.

Ms. Lee: Can you tell us about your experience as a Henry Kaiser Family Foundation fellow at the University of Pennsylvania?

Dr. Clancy: Sure. Yes, I’d be delighted. When I was doing my residency, I think I didn’t really have a clear career plan in mind. I thought I’d go into practice, but really hadn’t given it much thought at that point. Being up on call every third night, most of my thoughts were about sleep. And a faculty member came to me and suggested that I consider academic medicine. And he said if you don’t want to do that, that’s fine, but you need to make a decision, because I think you’d be really good at it. And my problem, of course, was that I thought all the subspecialties of internal medicine, like oncology and cardiology and so forth, I thought they were all great up to a point. The minute it got to bench and lab research, I was a little bit less interested.

And then I found out that the Kaiser Foundation was supporting fellowships in general medicine and, in particular, during this two-year period, you would learn more about doing research. And at that point in time, I’d gotten very interested in clinical decision-making; how do you make decisions when you’ve got a multiple array of factors, both related to the patient as well as the particular problem. Internists specialize in diagnosis, so that had a lot of appeal to me.

And in addition to that, the fellowship also gave us some time to learn how to teach. In medicine, that’s sometimes sort of assumed that you’ve watched the people ahead of you so you know how to do it automatically, but this was a little bit more focused attention to that.

So the fellowship was really fabulous. I actually got to go back to my birthplace and I met a terrific mentor, John Eisenberg, who ran the program. And subsequently, he and I worked together again at the Agency in 1997.

Ms. Lee: Can you tell us how you started with the federal government and a little bit about your progression, your career’s progression?

Dr. Clancy: Sure. When I finished my fellowship in Philadelphia, I took a job in Richmond, Virginia, at the Medical College of Virginia, which is now part of Virginia Commonwealth University, and it was great. I got to teach and do research and also see patients, and I also ran the medical clinic for the residents. Because of my interest in clinical decision-making, I became very interested in a kind of research which actually launched the Agency in 1989, which was looking at variations in practice.

There was work going on in Northern New England done by Jack Winberg and others showing that if you lived in one county, you were more likely to have surgical procedures done than if you lived in a neighboring county. So for example, you were more likely to reach age 50 with an intact uterus very much influenced by where you lived, and I thought this was quite amazing. And one of the theories underlying, trying to explain the variations in practice was that you saw the greatest variation where the scientific knowledge base was least well-developed. So it isn’t that people were guessing or flipping coins about what to do, the knowledge base just wasn’t that good. And part of the genesis of creating a new agency in 1989 was indeed to develop a better knowledge base, and to use that knowledge to help clinicians make better decisions. So that was a very good fit for my interests.

Mr. Lawrence: And then how did you get to be the director?

Dr. Clancy: I think some of my staff think just longevity. When I first came there to work in the primary care group, because that is the kind of practice I do and still find it very, very intriguing. This is when people come in and you get to translate often vaguely defined symptoms -- I don’t feel good or I’m weak or I’m tired -- and try to figure out what’s going on. And I still find that utterly fascinating. So they were starting a primary care research group. And we know very, very little about the natural history of a lot of these symptoms as well as how to make good decisions in primary care. So I thought that was terrific, and I eventually became director of that group.

And then one of my colleagues left, so I switched and ended up directing another center focusing on outcomes and effectiveness research. Now the two areas are somewhat related, outcomes and results of health care. You would think we know about that because we’re always hearing about information in health care. Oh, good, you got a lab test and you were better. These end results are really focused much more on the patient’s perspective. So for many chronic illnesses, for example, we assume that if your lab test is better, so are you. This is actually trying to figure out if that’s true and developing better measures, which are usually very short surveys to get the patient’s perspective on health care.

And then in 2002, John Eisenberg passed away very young from a terminal illness. And at that point, Secretary Thompson asked me to become acting director and, a year later, appointed me as permanent director.

Mr. Lawrence: Tell me about your own career, because as you described your progression, I saw your early years as a practitioner delivering medicine, and now you’re a director. So I’m guessing you do less of that, but more direct people who actually do the research and the like. Is that correct to say in terms of the progression from doing versus managing?

Dr. Clancy: That’s true. I started off in an academic job, so I was doing a little bit of everything: some patient care, some administration because I was the medical director for our clinic, and directed the residents education there, which was a lot of fun. And in addition to that, I also developed some early programs to try to assess the quality of care we were providing, and to put in place some strategies to try to improve that care, which is a big part of what we do at the Agency. So again, there was sort of a natural link between what I was doing then. And I spend a fair amount of time in direct patient care.

When I came to the Agency, I still continued to see patients a half a day a week, but because I had fewer distractions, if you will, from clinical -- the demands of clinical care or people calling at odd times and so forth, I had a lot more time to write. So in terms of doing research, it was a very productive time for me. But you’d be right, right now, I tend to direct more, or try to make sure that the various projects fit together, that we’re not missing pieces and so forth.

Mr. Lawrence: How would you compare the different management skills you use as a doctor versus now as the director?

Dr. Clancy: Well, it’s interesting. In some ways, particularly in my administrative role at the Medical College of Virginia, they’re very similar, trying to get people to work effectively in teams. Medicine culturally is a very individual enterprise, you know. Throughout medical school and training, the guiding metaphor is, you know, it’s you and your patient and you’re going to figure out the problems and then ride off into the sunset, so to speak. In reality, much of medical care is very much a team sport. If I see a patient who needs help, I may need to draw on other colleagues, I’m going to need to be working with nurses and others. So to that extent, there’s a lot of similarities.

Clearly, you rarely see 300 patients in an exam room at one time. It would be more like a coliseum. But many of the issues are quite generic, I think, particularly as it relates to teamwork. Most of the research that we conduct and support draws on multiple disciplines.

Mr. Lawrence: That’s an interesting point about the teamwork.

What’s the quality of care in our health care system and how might it be improved? We’ll ask Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality, when The Business of Government Hour returns.

(Intermission)

Mr. Lawrence: Welcome back to The Business of Government Hour. I’m Paul Lawrence, and this morning’s conversation is with Dr. Carolyn Clancy, the director of the Agency for Healthcare Research and Quality in the Department of Health and Human Services.

And joining us in our conversation is Vernecia Lee.

Well, Dr. Clancy, you mentioned the Institute of Medicine and the study that talked about that the current health care system has some quality problems that result in inadequate delivery of services. Given the mission of AHRQ and the current structure, what role do you see AHRQ playing in sort of redesign or working on the problems?

Dr. Clancy: Essentially, we see the Agency as a science partner to those who provide health care, and not just those who provide health care, but those who are buying health care services; for example, employers who are buying on behalf of their employees or other large purchasers. And we’re also very helpful to public programs, such as community health centers, the Medicare and Medicaid programs, and so forth.

I think most people are aware that in this country we have an embarrassment of riches in terms of biomedical knowledge, and all kinds of knowledge to help us provide the best health care in the world, and by some metrics, we don’t. And by any metric of evidence-based care is what we would call it, matching the content of that science to the care that’s provided, we often fall short. So part of the Agency’s role is actually helping develop the metrics for assessing quality of care.

In addition to that, we support a lot of studies that try to address the question why aren’t we doing a better job? Let me give you an example. Recently, we issued the first of an annual series of quality reports. It’s sort of a national report card on quality of care, and it’s about the most comprehensive report ever produced. It includes care provided in hospitals, in outpatient settings, nursing homes. And the Institute of Medicine was very helpful to us in providing recommendations about the content of the report and the framework and so forth.

But I mean, there are stunning examples in there of where we collectively could be doing a better job. So a little less than one patient in four with diabetes has had all recommended tests in the past two years. Of all the people who are admitted to the hospital and have a heart attack, about 48 percent are given advice to quit smoking before they’re discharged home. Now I’m a doctor, I know what’s going on here. Everyone assumes that this is so self-evident they don’t need to say it, or that one of their colleagues has already covered that. But the reality is if you ask patients did anyone talk to you about quitting smoking, less than half the time, this happens.

You know, a lot of people are not getting preventive care that they need. And in general terms, we’re doing well when we’re providing the right care somewhere between 80 and 90 percent of the time. Well, what’s going on here? We have a world-class scientific enterprise, we should have a world-class delivery system. And providing the scientific knowledge and providing it at a time when people can use it to make decisions, that’s where I see us being a part of the solution to improving health care.

Ms. Lee: Dr. Clancy, you just mentioned a little bit about the Institute of Medicine. They basically said that there are several ways that we could improve it, and one was through health information technology. Can you briefly describe what health information technology is and why it’s considered important?

Dr. Clancy: Very broadly, health information technology consists of an array of components of information and communications technology that can be applied to improve health care. So that can include everything from little handheld PalmPilots; there are software programs where we can beam information to doctors about the latest evidence about preventive care, for example, or information about symptoms related to potential bioterrorist attacks. So that’s one example of information technology.

More sophisticated examples are computerized physician order entry. And when I first joined an academic medical center, they had that kind of system, and it was quite different than simply writing orders in charts. Everyone could see and, more importantly, read the orders that you wrote. There are full-blown electronic medical records, which can include reminders in them so that I don’t just have to rely on my faulty memory in the article I read two weeks ago, but actually, it reminds me based on the content of the patient’s particular information. It also includes e mail between patients and doctors, telemedicine. So it’s a broad array of technologies.

Ms. Lee: Dr. Clancy, so much of what AHRQ does is around patient safety. The Institute of Medicine estimates that between 44,000 and 98,000 lives are lost annually due to medical errors. What role do you see AHRQ playing in improving patient safety?

Dr. Clancy: It’s a really important question and one that we focus on all the time because of the urgency of the problem. First, just to be clear about one point, the 44- to 98,000 number comes actually from two very large studies that were conducted in New York state and then repeated in Utah, actually looking at the malpractice problem. The question then was is bad care what leads to lawsuits? And it turned out that the overlap between poor care and lawsuits was pretty modest. In other words, a lot of people get poor care and don’t sue, and a lot of people who sue have not received poor care. So this was quite a breathtaking revelation. And when the Institute of Medicine published their report in 1999, they made those facts pretty glaringly obvious.

But the point is that that number applies to hospitalized patients. We have very little systematic information about what happens in outpatient settings in nursing homes, in other types of settings, and, very importantly, I believe, at transitions in care. It’s a lot of opportunities to not communicate information effectively at those transitions, which is another place where information technology could be helpful. So our research spans a spectrum from trying to develop better information about those other settings to realize just how far and deep the problem is, to focusing on strategies to improve health care right now.

So for example, in the latter category, we developed a campaign to help patients and their families understand what they can do right now to improve their health care, called “Five Steps to Safer Health Care”; fairly basic commonsense things that I can tell as a physician never happen or rarely happen. Always write down the names of the medications you’re taking, all of them, and bring them with you when you come to see the doctor. Now, you can always tell an internist office because you’ll see a lot of people sitting out in the waiting room with little brown bags, but those patients have been trained.

More often than not, what’s happening is patients are seeing several different doctors. For example, they might see a specialist for their heart problem and have a primary care doctor and then maybe had to go to an orthopedist because they had an injury, none of whom have an easy way to share information with each other. They tend to send each other letters, but it’s very common that one doctor makes a change in medication without taking the others. You can see that the potential for errors for adverse interactions from medications and so forth begins to multiply. So that’s, again, another point where information technology comes into play.

One new thing that we’re doing that I think is very important is that all of our priorities for research and patient safety have been guided by input from stakeholders across the health care system: doctors, the public, those who run hospitals, those who run health care organizations, and so forth. We’ve had a couple of summits to help people come testify and tell us what they saw as the most important problems facing them in trying to provide safe health care. The first time we did this, what states said to us was, you know, we have a lot of data already. What we don’t have actually is a lot of manpower or person power to help us analyze the data.

So this past year, we started a new program called the Patient Safety Improvement Corps. And every year, we’re going to be training 50 health care professionals from multiple backgrounds. Most of that is done back at this home institution where they work on very specific projects. And a lot of this includes learning and applying skills in change management. I might know what went wrong, but if I can’t persuade people to work together to develop and implement a solution to solving that problem, we’re not going to go too far. They spend three or four weeks on-site with us, and this is something we do in partnership with the V.A., because they’ve developed a very, very safe health care system. So they get to see whether their techniques can be generalized to a much more heterogeneous and fragmented health care system, and we get to take advantage of their expertise. But we think that we’re going to begin to grow a cadré of professionals who will actually understand and be able to apply these new skills and techniques on the ground.

Ms. Lee: Is there a national strategy for implementing health IT?

Dr. Clancy: That’s a really good question. It certainly feels like national excitement these days. There’s a lot of excitement on Capitol Hill. And Secretary Thompson, who is the Secretary of Health and Human Services, has been completely passionate about this. He keeps asking me when can we make health care paperless? Can’t we do it next week? Or, all right, you can have two weeks. Very, very insistent that we get this done right now.

It’s easy enough for me to say as a doctor, for example, that no one should get a handwritten prescription in the 21st century, period. I mean, I still write them, but, you know, the opportunities for errors and so forth are just all over the place. So this year, AHRQ will be investing $50 million in grants focused on the use of health information technology to improve quality and safety.

I think it’s very important to understand that information technology is not strange to health care, okay? The billing enterprise has long been electronic for the most part. What’s new is actually drawing on the power of this technology to influence the core clinical enterprise itself, and that’s where I think our investments will make a big difference. We have funded a variety of projects over the years, but they tended to be at fairly select sites that had already made those investments in the technology. So our resources were able to support projects to evaluate, for example, the use of reminders to improve the delivery of preventive care, and in one case, interestingly enough, to even remind doctors and patients to have those fairly difficult conversations about end-of-life care. Fairly simple, straightforward reminders, but because they came up at the point of care, people remember to do it even though it’s not an easy conversation to have. But now, we’ll actually have enough resources at one time to be able to build on those earlier findings, and hopefully spread the diffusion of that.

In addition to that, the Department has additional resources next year which will complement our investments very closely, which are going to focus on making sure that the information technology within health care organizations, physicians offices, and so forth can actually be shared and connected across a community. So for example, the information problem I mentioned before about a patient seeing multiple doctors, well, they could each have a fabulous electronic medical record system, but if they can’t talk to each other, you still have the same problem. Their offices are just neater, there’s less paper around. The strategy of developing programs for sharing health information in a secure and confidential way within a community is something that we’re going to be starting on this year, but will be amplified and expanded next year.

Mr. Lawrence: Millions of dollars are invested in health care research. How is the success of such an investment measured? We’ll ask Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality when The Business of Government Hour continues.

(Intermission)

Mr. Lawrence: Welcome back to The Business of Government Hour. I’m Paul Lawrence, and this morning’s conversation is with Dr. Carolyn Clancy, the director of the Agency for Healthcare Research and Quality in the Department of Health and Human Services.

And joining us in our conversation is Vernecia Lee.

Ms. Lee: Dr. Clancy, AHRQ invests millions of dollars in research to really address the issues that we talked about earlier. What types of metrics are you using to measure the success of these investments?

Dr. Clancy: Critical question, because ultimately, we don’t think that we’re successful unless we can demonstrate that the findings from our research have had a positive impact on health care, and ultimately on people’s health. You know, clearly that’s a pretty tall order when we give a check to an investigator to start their grant to say, gee, tell me how many people are better off as a result of your work. So looking across the body of work that we fund, early in the phase of research, we’re looking to make sure that the grants and other investments that we fund are consistent with our goals and strategies going in.

As the research progresses, we’re looking to the investigators to tell us how many decision-makers, and those who are going to use the work have been able to understand it and use it. And ultimately, we hold ourselves accountable for at least making sure that that information gets to decision-makers in a way that’s usable for them and useful. And what we’d like to see is that health care is actually better.

Mr. Lawrence: Could you take us through the process of, you know, funding a grant that has to do with health information technology and then turning this into a business solution that’s adopted by health care providers?

Dr. Clancy: Sure, let me give you one example. We funded a project some years ago that was not specifically about health information technology. It was actually about developing a model to help doctors understand which patients coming into the emergency room with chest pain, which might be cardiac, would benefit from getting thrombolysis or the clot-busters. Some patients come in with an EKG that’s completely diagnostic and it’s clear what to do. Other patients come in with a history, which is often more predictive of whether someone’s having a heart attack, but the EKG is sort of nonspecific.

So based on a few items of information about the patient’s history, how long they’ve had the pain, risk factors, and so forth, as well as the EKG, these investigators developed and tested very thoroughly a model that could predict which patients were more likely to benefit from this therapy. And as a result, two of the leading manufacturers of EKG machines have now incorporated that into their strips, so when a patient is rushed in with chest pain, you get the EKG. And in addition to looking at the strip, there’s also the output from this model at the bottom of it. I’ve often thought it would be a nice sort of example to put on a video. So that’s one example of a business solution.

In some cases, we’ve simply supported research evaluating the impact of a solution that was already in place. In other cases, we’re providing content from the work that we support; for example, the evidence about how to measure quality, or what’s the right thing to do for a particular patient, to those businesses that are in the business of providing information to electronic medical record systems and so forth. But it’s a series of pathways that we’re still trying to discover what’s the most efficient and effective way to do that.

Mr. Lawrence: In the example of the EKG and the strip, how long did that take from sort of start to the adoption by the manufacturers?

Dr. Clancy: There was some serendipity involved. The research itself started in the early ‘90s, and they had incorporated this into EKG strips by the late ‘90s, so I’m saying about seven or eight years; a little bit hard to put a precise date on the starting time. And there was an awful lot of work that went into making sure that this was valid. I mean, developing a model is a great idea. Making sure that it’s the right model and that you’re not misclassifying patients and the people are accurately put into the right group, that took a lot more time.

Mr. Lawrence: I was going to ask about the management challenges that lead to people adopting it. What are those and how are those worked?

Dr. Clancy: To some extent, this is I think a very good example of something that comes up to you at the point of care. So to that extent, one of the usual barriers to adopting evidence into practice is overcome immediately, right, it comes to you, you don’t have to go find it. You don’t have to think, oh, boy, do I have time to go run and find out a piece of information or where is that guideline or other source of information when I need it, it’s right there. So I think to that extent, it’s a good model.

I can’t say that it was entirely strategic. We didn’t know when the investigator started all of this work that this was going to happen. There was a fair amount of serendipity involved, which I think there always is. What we’re trying to do now, again, looking at the challenges facing the health care system, is to try both within the Agency as well as with the researchers we support to figure out earlier in the process who’s likely to take this up, how can we link these research findings to levers of change, because knowledge of itself is likely to have a very modest impact.

This is not about people getting smarter. Every Institute of Medicine report has told us that. This is not about telling health care professionals to read faster and pull their socks up, so to speak. This is about creating a system where the right thing to do is the easy thing to do. So we see that as very much within our research domain.

Ms. Lee: Dr. Clancy, again, going back to AHRQ’s mission, is there interagency collaboration with agencies like Food and Drug Administration, Centers for Disease Control, Veterans Affairs?

Dr. Clancy: Absolutely.

Ms. Lee: Can you talk to us about that?

Dr. Clancy: Yes. In fact, we collaborate with all of those quite a bit. In this country and around the world, we have a broad array of drugs to choose from for multiple conditions, which is a great position to be in; there’s not just one. So for example, the treatment of high blood pressure has been revolutionized in the past 30 years. It used to be here were your choices. You could not treat it and have a stroke young or you could treat it and take incredibly unpleasant medication. This is not a great choice to be offering to people. Now there’s a very broad array of drugs, so it’s highly likely that when doctors see a patient with high blood pressure, they’ll find a good drug that will meet their needs and treat them effectively.

Now when drug manufacturers submit a drug to be approved for the market by the FDA, most of the time, the trials that they submit compare that drug to a placebo. Of course, that’s great and the drug gets approved and that’s another option to use -- it makes it challenging at times for doctors and patients to choose among multiple alternatives. So we support a variety of research that looks at the safe use of those medications once they’re approved, and also helps people understand what are the risks and benefits of a particular agent. So it helps them understand how to customize and, you know, make the right choice based on their particular circumstances. So that’s one example of how we collaborate with the Food and Drug Administration.

We were very fortunate and excited about some work we’ve done with the CDC in Minnesota, working with an organization called Health Partners, which is a community-based -- it started off as a health maintenance organization; now, like many of those organizations, has multiple product lines. But we worked very closely with them so that we could bring the clinical sector as well as the public health sector to work together to address the problem of diabetes. And there have been some very important and dramatic improvements as a result of that partnership. So again, our work with the CDC focuses on bringing those who see patients one at a time working in partnership with those who think about community health strategies, namely the public health sector. So that’s another example.

The V.A. has a very interesting challenge because, as you know, they provide care to millions of veterans. And they have a research enterprise which is pretty much focused on meeting the needs and figuring out how their health care system can work better. But their research and evidence tends to be stronger if it’s also done in partnership with others testing exactly the same questions in a much broader population, so that when they then turn to their network leaders and so forth and say this looks like the right strategy to improve quality of care, their network leaders have confidence knowing that it’s been tested in a very broad array of populations. This isn’t just something we tried in one corner of the V.A. system and now you’re asking me to roll it out for everyone.

Ms. Lee: Can you talk a little bit about CMS and your collaborations with CMS, or Centers for Medicare and Medicaid Services?

Dr. Clancy: Sure. We work with them very closely on a lot of different projects. One way that we work with them, for example, is when they have to make decisions about should they cover a particular service, they often turn to us for something called a technology assessment. So sometimes internally -- more often, we contract it out -- what we do is review all the research on a particular topic, and we give them a very comprehensive report that gives what’s known about the benefits and potential adverse effects or harms of a particular service or intervention. They then give it to a coverage advisory committee, which makes recommendations. So we’re not making the decision for them, but, again, we’re the science partner for their efforts.

We collaborate on some types of research. Very recently CMS, because they are responsible for assessing and improving the quality of care for people enrolled in the Medicare program, has been working collaboratively with a variety of hospital organizations and others to try to improve the quality of hospital care. So we’ve been part of that initiative. And one unique contribution we’re making is that we’re developing for them a measure of patients’ perspectives on care in the hospital. Was information provided to you in a timely fashion? And it’s a short survey that asks patients lots of questions about their experience of care, because that makes a big difference in terms of making sure that patients are understanding the information that’s given to them, you know, that they’re pain-free as much as possible, that all the right things are done. So that’s another example of where we work together with them.

Mr. Lawrence: That’s very interesting. What does the future hold in terms of new health care technology? We’ll ask Dr. Carolyn Clancy of the Agency for Healthcare Research and Quality when The Business of Government Hour continues.

(Intermission)

Mr. Lawrence: Welcome back to The Business of Government Hour. I’m Paul Lawrence, and this morning’s conversation is with Dr. Carolyn Clancy, director of the Agency for Healthcare Research and Quality in the Department of Health and Human Services.

And joining us in our conversation is Vernecia Lee.

Well, Dr. Clancy, in our last segment, you were talking about the partnerships with other government agencies. And I’m curious about, since there are so many stakeholders in the health care industry, how you work with the private sector.

Dr. Clancy: We work with the private sector in a variety of different partnerships, which have been, we think, successful and also enormously rewarding for both sides, which I think is the key to any kind of partnership. Probably the simplest type of partnership we often have is around disseminating information; the idea being that information sent out from a government agency might be helpful, but if I see it coming, for example, from the American Academy of Family Physicians if I’m a family physician or the American Academy of Pediatrics, I may pay more attention to it because that organization has deemed that it is credible.

So we do a lot of partnerships like that, some for information targeted at professionals, some for information targeted to the public. So for example, we worked with the AARP to disseminate information about staying healthy over 50. And it’s a very simple checklist based on the best possible evidence about which tests and procedures you should be getting, which is, in turn, derived from what conditions should you be worried about getting, what steps can you take to prevent those conditions or at least postpone or delay them? And so that’s one kind of partnership.

Another type of partnership is when an organization essentially says to us, you know, we’re having problems with safety and quality. Could we work together to try to do better? And we have a couple of networks that have established capacity to begin to support that kind of partnership.

We have a research network of integrated delivery systems across the country, and we also have a network of primary care practices. This is sort of doctors in practice across the country who see patients. Some of them are in small practices, some are in slightly larger practices, but who are very interested in providing the best possible care and also contributing to a larger collegial enterprise. So that’s been another type of partnership that we support.

Ms. Lee: In Fiscal Year 2000, AHRQ received $5 million to support and conduct research to improve the ability of the nation’s health care system to respond to possible incidents of bioterrorism. Can you tell us how AHRQ’s bioterrorism research differs from that being conducted by other agencies?

Dr. Clancy: Sure. You said it well. The focus of the investment and the resources we were given was to focus on the role of the health care system. At that time, which was before 9/11 and before the anthrax and other episodes, there was a great deal of interest in strengthening the public health infrastructure, but very little public resources going in to enhance the health care system’s response, but health care systems were very, very worried about this. Once anthrax hit, of course, suddenly there was a huge demand for information. So the timing of this investment was very, very helpful for us. We had determined that two areas where we could be helpful was, one, on the use of information technology to provide critical information to the public health enterprise about potential early warning signs. It’s still an area of great interest, both within the health care system as well as within public health.

In addition to that, we were very interested in learning how clinicians could be trained to potentially think about this if they saw patients with unusual symptoms. Because one of the scenarios then that people talked about a lot was suppose someone releases an agent which is not immediate and rapid-acting as anthrax was, but is slower and they release it somewhere like the Super Bowl? So you imagine all these people who are exposed who then disperse and go back to multiple communities, are being seen by multiple doctors who aren’t talking to each other, and so forth. So what could we do to help clinicians keep this in the background of their minds as to be suspicious?

So at the time, one of the projects we supported was at the University of Alabama. And in order to keep it on people’s minds, they had this idea of screensavers. They were focused on emergency department physicians and other professionals. So their idea was to have screensavers that if anytime you walked by one of the computers in the emergency department, you know, you might see anthrax or smallpox, keeping it in the back of your mind. Well, once the actual anthrax episodes hit, they didn’t need the screensavers anymore.

But the good news was that they had developed a website where clinicians could turn, and it’s not just a lot of information, although it is a lot of information, but the information is organized in a way to respond to questions that clinicians would have as they’re seeing a patient. So instead of being a textbook on anthrax, it’s actually organized in terms of the symptoms the patients might present with, what laboratory findings you might see, what the X-ray might look like. And in addition to being a very useful source of information, people can also get continuing medical education credits. So a week after the first episode of anthrax, that website was live and, needless to say, was incredibly popular. So that’s one kind of work that we support.

Another area that we’ve supported -- you’ve probably guessed that mathematical models are not a trivial part of what we do. In one instance, we were funding a team in New York City to develop a model for how would you provide mass prophylaxis? Anthrax hits and you’ve got to get antibiotics to those people who are at highest risk rapidly. So they’ve developed a model based on the best information that they had, and they were due to test it on September 12th of 2001. Needless to say, that testing was postponed a number of months.

But essentially, having developed the model, what they then worked with was the Police Academy. So they had police cadets sort of running down this pier, someone would ask them questions and would either give them a placebo or the actual drug. They weren’t giving out drugs, of course, they were using different colored M&Ms. But they then went back and refined their model, and this has been something that a lot of states and communities around the country are using.

Mr. Lawrence: Let’s look out to the future. What role do you envision AHRQ playing in the health care system, say, 10 years from now?

Dr. Clancy: The health care system is sort of slowly lurching and catching up to other sectors in terms of becoming part of what might be called the Information Age. Although we’re incredibly excited right now about the power of information technology and the investments we’re going to be making this year and into the future, we’ve begun to see, based on our prior investments, the difference that can make. The reality is that much of medical care still looks a lot like Marcus Welby. A lot of paper, literally all over the place.

So what that means is that all of our models for providing care mean that it’s rare or unusual to have the information you need literally at your fingertips. What you’ve got at your fingertips is a chart. You need to leave the room or in some way go elsewhere to get the information that you need. With information technology and the interest in making sure that the inputs to that technology are as evidence-based as possible, what I see happening in 10 years is that more and more people have the information they need, and the best and most current information at the point of care and/or be customized to what they need.

So for example, some of us use Amazon.com. Some of us ought to stop using it so much, but -- and you know that you cannot only buy books there, but periodically they send you e-mails, so when you log on it says, gee, based on your prior purchases you might want this. Well, you can imagine a smart system that knows the type of patients I see, that might even know some of the errors that I’ve made or difficult challenges or things that I’ve forgotten before, and is sending me prompts. It’s that customized. That would be one part of it.

Essentially what I see is that the growth in information technology as well as the demand for the best possible evidence to guide health care decisions means that the actual delivery of health care will not only be a lot better, but our information will essentially be the Intel inside, if you will.

Ms. Lee: Dr. Clancy, the White House announced earlier this year that it was going to expand the E-government initiatives to include grants and health case management. Have these initiatives impacted plans for the future of your agency?

Dr. Clancy: Well, some of those initiatives focus on making the business of running the Department more efficient. So for example, there’s always been a little industry in academia and other places where people track grant announcements, you know, and it’s someone’s job. It actually could be the job of several people to put out a weekly, sometimes daily, bulletin of what grant opportunities there are at the Agency or at the NIH and CDC and so forth. You kind of have to know a lot of lingo to do that in a way that’s timely and meaningful, because a lot of solicitations are time-limited.

Part of the E-gov initiative is actually going to allow for one storefront for grants. So that’s definitely going to change how we do business, although we think it’s actually going to be incredibly helpful to us. Right now, investigators send in paper applications and they all go to a central place, and then many copies have to be Xeroxed. So there’s this time window of four to six weeks where I know that someone’s submitted a grant and it may be at the Agency, but it may be somewhere in that process of the massive Xeroxing and so forth. All that will go away.

Now some of that requires, you know, the support to have authentication that it’s your application and so forth. But that I think is going to very, very helpful to us.

Mr. Lawrence: You’ve had an interesting career serving the public, and I’m curious, what advice would you give to someone considering a career in public service?

Dr. Clancy: Well, you know, the Department just launched a program two years ago called the Emerging Leaders Program. But we’re not as concerned looking at the demographic changes affecting the public workforce as they are in many areas showing that a very high proportion of people will be eligible to retire over the next few years, and also concerned that they weren’t attracting some of the best and brightest young people. This program is unbelievable. We’ve had a number of folks. We’ve had some who work at the Agency for most of their two-year rotation, sort of similar to the presidential management -- PMI program, but they just stay within HHS.

A lot more rotate and help us, and they are fabulous. And what’s been very gratifying is I think that most of them can see that the work that we do and that others in the Department do is very exciting and is making a difference. So my highest hope is that young people coming out of college or graduate school would give a government career serious consideration. There’s going to be a huge array of opportunities.

Mr. Lawrence: I’m afraid that’ll have to be our last question; we’re out of time. We want to thank you for joining us this morning.

Dr. Clancy: Thank you. For your listeners who are interested in finding out more about the Agency and, in particular, are interested in information that they can use right now in terms of making their own health care better and safer, our website is www.ahrq.gov.

Mr. Lawrence: Thank you very much. This has been The Business of Government Hour, featuring a conversation with Dr. Carolyn Clancy, director, Agency for Healthcare Research and Quality in the Department of Health and Human Services.

Be sure and visit us on the web at businessofgovernment.org. There, you can learn more about our programs and get a transcript of today’s very interesting conversation. Once again, that’s businessofgovernment.org.

This is Paul Lawrence. Thank you for listening.

Dr. Carolyn Clancy interview
03/25/2004
Leadership,Strategic Thinking, Missions and Programs, Organizational Transformation, Innovations

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