Originally Broadcast July 18, 2009
Welcome to The Business of Government Hour, a conversation about management with a government executive, who is changing the way government does business. The Business of Government Hour is produced by the IBM Center for the Business of Government, which was created 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. Now, The Business of Government Hour.
ALBERT MORALES: Welcome to another edition of The Business of Government Hour. I'm Albert Morales, your host, and managing partner of the IBM Center for the Business of Government. Healthcare remains one of the most pressing issues facing us today. Our system of healthcare faces challenges around areas such as quality, safety, access to care and value. There's also a strong demand for the use of health information technology and finding new avenues for translating research into practice. With us, today, to discuss her efforts in this area, is our very special guest, Dr. Carolyn Clancy, Director at the Agency for Healthcare Research and Quality, within the U.S. Department of Health and Human Services. Dr. Clancy, welcome to the show. It's a pleasure having you.
DR. CAROLYN CLANCY: Thank you. It's a pleasure to be here.
ALBERT MORALES: Also joining us, today, is Janet Marchibroda, IBM's GBS Public Sector, Chief Healthcare Officer. Janet, welcome.
JANET MARCHIBRODA: Thank you. It's great to be here.
ALBERT MORALES: Dr. Clancy, before we get started, let's set some groundwork around the Agency for Healthcare Research and Quality, otherwise known as AHRQ, within HHS. Can you give us an overview of the history, the mission, and some of the activities your organization supports and how it supports the overall mission of HHS?
DR. CAROLYN CLANCY: Sure. So the mission of the Agency for Healthcare Research and Quality, or AHRQ, as we call it, is to improve the quality, safety, efficiency and effectiveness of healthcare for all Americans. Ultimately, our goal is to improve the quality and safety of healthcare, so that every American can know, no matter where they get healthcare, that it will be predictably high quality and safe. They won't have to worry about everything that's going wrong. Now we achieve this goal by supporting research and working very closely with those who provide care: clinicians of all disciplines, with patients, with policymakers, so that they can use this information to improve the delivery of healthcare itself. Ultimately, disseminating the findings from our research, we hope helps support a nation of healthier, more productive individuals, and frankly, a much greater return on the substantial investment that we make in healthcare today.
Now, AHRQ is about 20 years old. It was first authorized in 1989, so this will be anniversary for us this year, although it's been too busy to actually think about celebrations. How we help HHS is to achieve its strategic goals to improve safety, quality, affordability and accessibility of healthcare and so forth. We work very closely with a number of other components of the department.
ALBERT MORALES: Now this is a very broad and critical mission that you have. Can you give us a sense of the scale, in terms of how your agency is organized; perhaps the size of its budget; the number of employees; and your geographic footprint?
DR. CAROLYN CLANCY: Yes. We now fund work in almost all 50 states. There might be one or two we've missed, but that's a relatively new development, in the past five years or so. Our budget is $372,000,000 for this fiscal year. That does not include additional resources that were allocated to the agency through the Recovery Act. We have about 300 people who work at AHRQ. And about 80% of our budget is invested in grants and contracts focused on improving healthcare, many to academic institutions, but not exclusively. We've also partnered with community health centers, with hospitals and so forth.
JANET MARCHIBRODA: So, Dr. Clancy, with that overview, could you tell us a bit more about your specific responsibilities and duties as the Director of AHRQ?
DR. CAROLYN CLANCY: Yes. So my responsibility is to make sure that all of the parts of AHRQ work together to make a whole, that's greater than the sum of its parts. I'm totally privileged to work with a team that is completely fantastic. A big part of my day-to-day work is actually communicating what it is that we're trying to do. How do you connect the dots between the research that we're supporting, which can be pretty technical at times, to the healthcare that you're going to get, or that you're worried about on behalf of a family member or someone you care about? That part is a great deal of fun and I think it keeps us all grounded. And it gives me a chance, as well as many of my colleagues, to hear Americans' concerns about what's going on with their healthcare.
JANET MARCHIBRODA: What about the composition of the research portfolio that is under your purview?
DR. CAROLYN CLANCY: So we have, as most government organizations do, an org chart, which displays the anatomy of the organization. We've got five Research Centers and three offices that make everything work, but we really organize our work around portfolios. That's really the physiology or how we do our work. So the portfolios are Effectiveness and Comparative Effectiveness. Another portfolio is Patient Safety and Quality. A third is Health IT, and our role there is evaluating selected applications of Health IT for their impact on safety and quality. A fourth is Improving Value in Healthcare. A fifth is Prevention and Care Management. How do we present disease? How do we optimally manage chronic illnesses? And then the sixth is something called Innovations. Because we understand that, just as innovations are important in developing new products, the notion and concept of innovation is also critical to improving healthcare delivery.
JANET MARCHIBRODA: In thinking through your roles, your responsibility and your duties, what would you say are the top three challenges that you face in your position? And can you describe how you've addressed those challenges?
DR. CAROLYN CLANCY: Well, one challenge is, which I think is generic to all large organizations, possibly even small organizations, is communication. On one level, we of course have email and many different routes of communication. On another level, our business is information. So sorting through all that and trying to make sense of it and assuring that we're all on the same page, not just at 5,000 feet above the ground, but literally in our day-to-day work, I would say is a big challenge. It's fun, and it's fun to work through it with people who are not only really smart, but actually very passionate about what they do and about making a difference in healthcare.
Another challenge that I think all of us share these days is just 24/7. How do you manage to fit it all in, in a particular day? To some extent, interestingly, I think advances in information and communications technology have both made this easier and harder at the same time, because you're always reachable.
A third challenge, frankly, is personal balance for me, because I love the work that we do and I love the people work with. So trying to turn it off, on occasion, to do other things is sometimes challenging.
ALBERT MORALES: Now, Dr. Clancy, I understand that you've been the Director of the agency now for about six years, and you're also a general internist by training. Can you tell me a little bit about your career path and perhaps how you got started?
DR. CAROLYN CLANCY: I'd be delighted to. So I grew up just outside of Boston. Somewhere around age nine, I decided I wanted to be a doctor, based on, I have no idea what. Over the years, I realize it was probably a good idea that I recognized in maybe a preconscious way in fourth grade, because I really liked science, but I also liked working with people. So I went to Boston College. I then went to medical school in Massachusetts and ultimately did residency there and went on to do a Fellowship at the University of Pennsylvania. I had been encouraged by a mentor, when I was doing my clinical training, to at least consider academic medicine, that I should make a explicit decision not to do it, rather than sort of drift and not think about it. So I actually did a Fellowship in something called General Medicine, which was all about the kind of research that AHRQ does. I was particularly interested in clinical decision-making. How is it that doctors can keep many factors in their heads and try to tailor all the science that we've learned to meet the needs and preferences of the specific individual you're dealing with? That's what makes it fun. That's what makes it totally not an algorithm or a protocol. That is the part that doctors talk about as being incredibly meaningful about their daily work. But I wanted to know more about what were the kinds of factors that affected that, and so forth.
I took a position with the Medical College of Virginia, in Richmond, Virginia, on the faculty, and continued to do some research and did a lot of teaching. Ultimately, I became the Medical Director of our Primary Care Clinic. Now, in Virginia, care for those who have no insurance is often augmented in addition to Medicaid and other public programs, by money from the state that goes to the medical schools. So we probably served something like 30,000 patients, two-thirds or so of whom came from the city of Richmond. But another third came from outlying areas. So providing them with continuity of care was very challenging. Increasingly, I began to worry about what were the policies that might actually make this situation better for all of those patients? We were trying as hard as we could. I was very impressed by the residents and how much they cared about their patients. But at the end of the day, I could see that what we needed were policies that actually helped us expand access to care for those patients. So that interest in policy was really what brought me to Washington.
ALBERT MORALES: So to expand on that a little bit, as you reflect back on your career, what might be some of the experiences that perhaps have shaped your management approach and your leadership style today?
DR. CAROLYN CLANCY: Well, probably the first experience, but it's always fundamental, it's that I'm the oldest of a large family. I'm the oldest of seven. I, of course, think I was never bossy, but my siblings might have a different story to tell. A lot of experiences I had at the Medical College of Virginia were incredibly helpful. The first was that we actually began to explore how do you assess the quality of care in outpatient settings? This was before health plans were reporting on quality and so forth. I called everyone I knew around the country, to say, 'So how do you do this?' People didn't have a whole lot to say. So we just did the very best that we could. That included actually evaluating some of how we were educating patients, which no one had done, that I could find out about, or certainly read about in the literature.
So that was a great learning, about what does it take to figure out, where are the areas where we can improve care; how can we figure out, relatively easily and efficiently, how we're doing; and then what is the strategy for trying to make sure that we do a better job? That was very exciting for me. Being the Medical Director for this clinic also gave me the opportunity to work with pharmacists who were incredible partners for us, as well as nurses and nurse practitioners and the hospital administrators, because we were a hospital-based clinic. From the get-go, I could see that to actually make an organization effective, you had to have everyone at the table making shared decisions. Some would call this matrix management. It's not always easy, but it's incredibly important.
ALBERT MORALES: That's great. How does AHRQ work to improve healthcare quality? We will ask Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality to share with us, when the conversation about healthcare continues on The Business of Government Hour.
ALBERT MORALES: Welcome back to The Business of Government Hour. I'm your host Albert Morales. And today's conversation is with Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality within HHS. Also joining us today, from IBM, is Janet Marchibroda. Dr. Clancy, as a country, the U.S. spends far more on healthcare than any other nation, yet numerous studies have found that there is really no relationship between spending and the quality of care. First, what is quality in healthcare? And to that end, could you elaborate on the three basic dimensions for getting the right care, to the right patient, at the right time, every time?
DR. CAROLYN CLANCY: Yes. I'd be delighted. I think you just gave, what I think of, as the best definition of healthcare quality -- the right care, for the right patient, at the right time, every time. The every time really refers to your confidence in knowing that if you went to Practice A, as opposed to Practice B; or if you live in one state or region versus another, that you'd be getting the same care, that's consistent with the best that we know in science, as it applies to you, as a unique individual.
In general, we think about healthcare quality as having three components. The structure are literally the structures: the hospitals, the professionals who provide care, and so forth. Historically, we have put a great deal of emphasis on that. We want to know that hospitals have all the right facilities and equipment; that they can sterilize things and so forth; that the professionals who are on staff have had good training and can do a good job; and have the kind of training that we would expect in this country. Unfortunately, what we've learned over the past 20 years, is that structure doesn't always predict accurately what happens to people. That is to say the process, what kind of care they get, or the outcomes or end results. So process of care is literally what kinds of treatments you're given; what kinds of tests are ordered to make a diagnosis and so forth. Do you get a mammogram, for example, if you're a woman in the right age range, looking for a way to detect possible breast cancer early? If you are unfortunate enough to have a heart attack, do you get timely treatment and so forth? That's all about the process, what's going on.
What all of us care about is the end result. Am I better off as a result of all this healthcare? That can get a little bit tricky to measure because there's many things that affect end results. For example, people who are wealthier tend to do better than poor people. We know that people who are well educated tend to do better than people who are not so well educated. But overall, what we want to make sure is that what we do for patients matches their needs and preferences and actually helps them to get on with their lives and not worry so much about what's going on in healthcare.
ALBERT MORALES: Now, according to your statistics from the National Healthcare Quality Report, healthcare quality improved by about 3.1% in 2006. However, in the last couple of years, the rate of improvement in healthcare quality has actually gone down. Can you tell us more about the causes behind either the slow progress, or decline in improvement? But more importantly, what are some of the key actions for accelerating improvement altogether?
DR. CAROLYN CLANCY: I'm so glad that you mentioned that National Healthcare Quality Report. We are required by the U.S. Congress to report, every year, on the state of healthcare quality in America and also on disparities in care associated with patients' individual characteristics, including race, ethnicity, their income, education, where they live, and so forth. On one level, we have seen, since we started in 2003, steady improvements every year. So I will celebrate that movement in the right direction. At the same time, that movement is pretty modest. I don't want to say glacial, but it would be close. We're not moving as rapidly as we can and really must do, to meet the needs of the people that we're serving. Just by way of example, only one-half of obese adults and children report that they've actually had the issue discussed by a clinician with them. One in seven hospitalized Medicaid beneficiaries has actually experienced a serious adverse event in the past year.
When we look at specific aspects of safe care, we see that that's actually declined about 1% a year over the past six years. So at the end of the day, we haven't really made a lot of progress on the overarching finding in all quality studies, which is that there's a substantial gap between best possible care and that which is routinely delivered to all of us, and that that gap is larger still for people who are members of racial or ethnic minority groups, people who are poor, not well-educated and so forth. There's absolutely no reason we can't move faster on this, and I think that's going to be a critical part of health reform.
JANET MARCHIBRODA: On a somewhat related note, according to the CDC, nearly 2,000,000 patients suffer from a healthcare-associated infection in U.S. hospitals each year, resulting in 99,000 deaths and incurring an estimated $28-$33,000,000,000 in excess healthcare costs annually. Could you tell us about AHRQ's efforts to improve and expand healthcare-associated infection prevention efforts? Specifically, Dr. Clancy, what are some of the ways to reduce or eliminate such infections?
DR. CAROLYN CLANCY: This a growing problem and it's one that people understand very, very easily. You know, what's wrong with this picture? My family member went into the hospital with one problem, and they came out with a second problem, a very serious infection. We've seen famous people and not so famous people at all, suffering serious consequences because of these infections, which are largely avoidable. There are many causes of the infections. But one of the areas that I'm very proud of has to do with some work we supported a few years ago in the state of Michigan. We supported a team from Hopkins to do something that was ultimately called the Keystone Project. What they were focusing on was reducing serious bloodstream infections. Now, these can be deadly, make no mistake about it. These infections can be caused by IV lines that are put in centrally. Some relatively straightforward steps can actually reduce the infection rate dramatically.
What they did was to test their strategy at Hopkins. They came to AHRQ for a grant, although most of the project was funded by Blue Cross and Blue Shield in Michigan. We were supporting the specific evaluation and so forth. What they did was to come up with a fairly simple strategy. It sounds simple, but it's deceptively simple, a checklist, for what all members of the healthcare needed to do. They had leadership at every hospital in Michigan. Now we're talking from the major academic medical centers, right down to very tiny hospitals. They had them engaged at all of these hospitals, and they made data collection very easy. That was done through the Michigan Hospital Association. The teams got quarterly feedback. So shared commitment, engagement of leadership, relatively straightforward data collection and quarterly feedback. So that people could see the connection between their daily work and what was happening with the infection rates. The results were profound and dramatic. In some cases, many of these hospitals have not had one of these infections for many months.
So right now, starting about six months ago, we are working with the American Hospital Association's Health Research Education Trust, their research arm, to partner with 10 states to do what happened in Michigan all over again. We got additional funding in this year's budget to expand to an additional 20 states. We think that we can make a big dent in this problem, if not wipe it out entirely over the next couple of years. It is probably the single largest example of success at improving quality and safety and one that's been done to scale. I think there's a lot of very important lessons to be learned from them.
JANET MARCHIBRODA: That's very exciting. What would you say are some the barriers or challenges to fostering a culture of infection safety?
DR. CAROLYN CLANCY: I think one of the challenges, in terms of establishing a culture, is that all of the nation's hospitals, and other facilities, have incredibly well-trained professionals working there. But they're not always working on exactly, to the same music, if you will. Nursing is doing what they know well. Doctors are doing what they know. At the end of the day, what we know is that high quality safe care is a team sport. That's much easier to say than to make it happen. But creating the spirit of a team, so that we're all on the same page, or checklist in the case of the Keystone Project, is incredibly important.
I think it's also very important that ultimately we figure out, in a scalable way, how to make data collection, to let us know how we're doing, really easy, with pretty timely feedback. I think this quarterly feedback that the Keystone Project had is going to be very, very important. So as we anticipate reforming the healthcare system, a lot of emphasis on improving healthcare delivery. I think the same issue of making data collection as easy as possible and Health IT should be helping with that, and feeding the information back, so that everyone, from the person who transports patients, up to the highest trained physician, to the CEO, understands how all these dots connect.
JANET MARCHIBRODA: I understand that the purpose of AHRQ's Prevention Care Management Portfolio is to increase the adoption and delivery of evidence-based clinical services, both preventative and chronic disease-related, to improve the health of all Americans. Could you elaborate on how your agency makes this happen? And also, what role does the United States Preventative Services Taskforce play in your efforts?
DR. CAROLYN CLANCY: I would say almost 30 years ago, something fairly dramatic happened in the practice of clinical medicine. Up until that point, when patients came in to see a doctor, the very common question that both patients and doctors had, although they didn't always speak to each other about it directly, was, What test should I have? Or what test should I order? What happened, starting in the late '70's, up in Canada and then ultimately here, was to shift the focus from, What tests should I order? To, What diseases or conditions can we detect early, where we know there's an effective treatment and that we know where that early detection will make a difference?
The Preventive Services Taskforce was born. It was actually initially sponsored by the department, the Office of the Assistant Secretary for Health. It moved to AHRQ about 15 years ago. So this is an independent group of nationally renown researchers and scientists and their focus is on making evidence-based recommendations about preventive care. Now, they take their job incredibly seriously. We support their work, but we don't have to agree with them. They are an independent team. That taskforce relies on the support that AHRQ provides to give them the best science. We support this through systematic reviews of the literature and so forth. They go through a very deliberative process to make recommendations that are graded on the strength of the evidence. So A is the gold star rating. The evidence is outstanding, absolutely this should be done. B is the evidence isn't quite as good as A, but it's still impressive. C is sort of neutral. D means the service may actually cause harm. And the I rating means there's insufficient evidence to say for or against doing this. All of these recommendations are framed in the context of good clinical judgment, because there's no substitute for that.
We do sometimes have challenges explaining the I rating. Insufficient evidence that something is effective is not the same thing as saying that it's ineffective. People are extremely excited about prevention. So sometimes when a service that they think just has to be important and good to do, it gets an I rating from the taskforce. They're a little bit disappointed. But we think, and the taskforce thinks, it's incredibly important to stick to the science and not to go beyond the science. So if the science stops, they will say, We don't have enough evidence. Sometimes that actually prompts our colleagues at NIH to support research that will help us develop better evidence. That's happening right now, for example, at the National Institute on Drug Abuse, because the taskforce gave an I rating to screening people for evidence of substance abuse. So that's very exciting when it happens.
We also make the findings available to clinicians. There's a terrific application that you can download from our website or just use it online. The Electronic Prevention Service Selector. The reason for this is the prevention recommendations tend to be framed in terms of age, gender, some family history characteristics and so forth. It's a little bit hard to do in two dimensions. This immediately gives you the recommendation. It's framed the way doctors want the information. We talked to lots and lots of physicians. They want the bottom line first, but they also want to know that they can get to the underlying evidence. So that's exactly how this application works.
ALBERT MORALES: Dr. Clancy, I'm increasingly hearing the term, Patient-Centered Medical Home. Can you tell me what this is and how does this patient model represent a fundamental shift in the relationship between a patient and their primary care physician?
DR. CAROLYN CLANCY: Yes. This is a development that we're very, very excited about. In the interest of full disclosure, I'll tell you that I am a Primary Care Internist, so I care a lot about primary care. Healthcare, these days, is incredibly fragmented. And if I ever forget, I talk to my father, who's 80 and sees multiple physicians in the context of a large organization, where there is more information-sharing then necessarily occurs routinely between individual practices that don't share a common infrastructure. But it gets very, very confusing to navigate. One of the key tenants of a medical home is that many, many people would do much better if they were working with a clinician whose job it was to be the medical quarterback, if you will. To help them coordinate care, and not necessarily provide all of it, but actually to know which specialist to refer to, to track what happened to them and so forth. This is an idea-- The term originally comes out pediatrics but it's been one that's been embraced by internists, by family physicians, nurse practitioners and many others.
This year, the Federal government for Medicare is actually going to sponsor a demonstration to see how well this works for Medicare beneficiaries. Now, if you think about it, take the responsibility for being a Medical Home. Practices actually have to be able to track patients' test results; what happens when they're referred to specialists; you know, review their medicines with them. Electric health records can be a big help here. We'll see how well this works. Clearly, people who are relatively healthy may not have such a high need for this kind of approach; whereas people like my father, or other people with multiple chronic illnesses would do incredibly well.
ALBERT MORALES: So the ultimate goal of your mission is to disseminate AHRQ's research findings, which hopefully result in healthier, more productive individuals and an enhanced return on our nation's substantial investment in healthcare. Could you elaborate on AHRQ's efforts to translate these research findings into clinical practice, and to disseminate them to the key stakeholders? And are you using some of the Web 2.0 and social networking technologies in facilitating this process?
DR. CAROLYN CLANCY: You know, we work extensively to communicate what we're doing and to disseminate that in a way that's practical. That ranges from everything, from like the Prevention Test Selector Tool to actually providing technical assistance, on occasion, to writers for TV shows, who want to know about a medication error, what does that look like, and so forth. We do a lot of work, in terms of direct outreach to the media; in terms of publishing in many specific journals, which may be both scientific peer review journals as well as sort of professionally organization based. We do a lot of speaking at meetings. But we also work with the Ad Council, to try to make it seem fun for patients to ask questions, because we know that patients who are active in managing their own health and healthcare tend to have better outcomes than those who are more passive. And we do podcasts, and I think we're Tweeting now. There's no media that we won't take advantage of.
ALBERT MORALES: I guess you're out there then. (laughs)
DR. CAROLYN CLANCY: Yes.
ALBERT MORALES: What is Comparative Effectiveness Research? We will ask Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality to share with us when our conversation about healthcare continues on The Business of Government Hour.
ALBERT MORALES: Welcome back to The Business of Government Hour. I'm hour host, Albert Morales, and today's conversation is with Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality within the Department of Health and Human Services. Also joining us, from IBM, is Janet Marchibroda. Dr. Clancy, the 2009 American Recovery and Reinvestment Act allocated about 1.1 billion dollars for comparative effectiveness research, with some $300,000,000 dedicated to your agency. First, what is Comparative Effectiveness Research and what is AHRQ's role in pursuing this research and the priority conditions undergoing such research?
DR. CAROLYN CLANCY: Thank you. Comparative Effectiveness essentially compare how different treatments or diagnostic strategies have worked and for which patients. So patients and their doctors, or other clinicians, can use this information to make personalized healthcare decisions informed by current science. In other words, you get to get a sense as an individual patient of, what has happened to people like me if they took this kind of approach to treating their disease versus another one? We live in a very exciting time right now, because of all of the advances in biomedical science. More and more, it's not the case that there's one thing to do for a particular condition. There's choices. Well, how do you make those choices? That's the gap that Comparative Effectiveness Research is struggling to fill. So it's all about focusing on patients' needs and applying the best of science to meet those individual needs.
We think that this research will help the healthcare system make sense of all of the rapidly expanding options and innovations in medicine. You know, just pick your condition: high blood pressure, heart failure, HIV, mental illness. The list goes on. There are multiple options, and that's a good place to be. But it's really a great place to be if you've got good information to help you understand what's the right treatment for you. While we've got all these options, one of our biggest challenges is figuring out how do you evaluate these, so the patients and clinicians can make the best possible decisions together?
Now AHRQ has had explicit authority to do this work since the end of 2003. We got funding to do this work starting in 2005. So this additional $300,000,000 comes on top of an appropriated investment over the past four years, of a total of $125,000,000. So we've built the infrastructure to do that. There are a number of studies at the National Institutes of Health and at the Veterans Affairs Research Group that actually meet all the criteria for Comparative Effectiveness, comparing treatment options as well. Now, our authority, because it comes from the Medicare Modernization Act, or the Drug Bill as some people know it, actually directs the Secretary of Health and Human Services to establish priority. So we went through a very transparent priority-setting process with a lot of input from the public and private sectors, and ultimately concluded what should frame our work, our priority conditions. So that includes arthritis; cancer; cardiovascular disease, including stroke and high blood pressure; cystic fibrosis; dementia, including Alzheimer's disease, depression and other mental health disorders; developmental delays; Attention Deficit Hyperactivity Disorder and Autism; diabetes; functional limitations; infectious diseases, including HIV; obesity; digestive system conditions; pregnancy and childbirth; pulmonary or lung disease and asthma; and substance abuse.
Now, I know I went through that relatively quickly, but just reflecting on just even hearing a few of those, these are big ticket items for healthcare delivery. We've produced a number of reviews so far and expect to be accelerating that in the period ahead. What we're saying to clinicians and patients is, 'Here's the facts. You can use these to make an informed decision.'
JANET MARCHIBRODA: Dr. Clancy, could you tell us more about the Federal Coordinating Council for Comparative Effectiveness Research? What is the purpose and composition of this Council? And to what extent, does the establishment of this Council impact the possible creation of a dedicated Center for Comparative Effectiveness Research? Similar, to say the Federal Reserve Board or the Institute of Medicine.
DR. CAROLYN CLANCY: Well, that's a complicated question, so I'll take it. The Recovery Act actually allocated a total of 1.1 billion dollars for Comparative Effectiveness Research, and we are just so excited about this, because we think it's a huge opportunity for the American people. $300,000,000 goes to AHRQ, over the next two years; $400,000,000 to the National Institutes of Health; and $400,000,000 will be allocated at the discretion of Secretary Sebelius. Now to guide the work of the Secretary, or how she will make these decisions, the law also established the Federal Coordinating Council. In addition to that, asked the Institute of Medicine to make recommendations about that particular $400,000,000. So the Federal Coordinating Council has 15 members, by law; all Federal employees, also by law. A few agencies within HHS were specified in the legislation, as was a representative from Veterans Affairs and the Department of Defense, but then there was some discretion about who would be included as well. The law also specified that at least half of the members had to be physicians or other clinicians with expertise in providing care.
So what we've got now is a diverse set of people, which includes the top scientific leadership in the department. It also includes very strong voices for patient groups who are often not well represented in research: people with disabilities, people who are members of racial or ethnic minorities, and so forth. Right at this moment, what we've been doing is meeting on a fairly hectic pace, as you might imagine. But at least as importantly, we've been following the same transparent collaborative process that we've been using at AHRQ at a much smaller scale, for the past few years. The Council has used a very similar strategy to get submissions from the public via the website, which ranged from opinions about whether we should be doing this work, to specific topics, to specific policy issues that we should be thinking about. We've had three listening sessions, a couple of which required overflow rooms. Two of those sessions were in D.C., one was in Chicago. Again, we're trying very much to make this a joint enterprise and making sure that we've heard from many, many different points of view before submitting a report to the Congress at the end of June.
JANET MARCHIBRODA: There has been a lot of talk about healthcare reform, how does this connect with Comparative Effectiveness Research?
DR. CAROLYN CLANCY: Comparative Effectiveness Research is really an essential part of reform, because it will help us build an evidence base about treatment decisions made by patients and their clinicians. To say it a different way, if you've looked at or heard about variations in healthcare, a recent article actually compared two towns in Texas, in terms of how much money is spent on healthcare and are there differences in outcomes for that greater allocation, in terms of resources? Some part of that variation is due to clinical uncertainty. We simply don't know what is the best option for a particular patient. To that extent, Comparative Effectiveness Research can help address that gap of clinical uncertainty.
JANET MARCHIBRODA: Dr. Clancy, AHRQ's research on health information technology is a key element to the nation's 10 year strategy to bring healthcare into the twenty-first century. Can you tell us more about your efforts in this area? And specifically, how do these initiatives support and stimulate investment in health IT?
DR. CAROLYN CLANCY: It turns out that AHRQ, or its predecessors, have been supporting research in this area for close to 30 years. Now, early on, until 2004, the amount of resources we had were very, very modest, so we tended to support grants to those institutions that many people would recognize that had the foresight or vision to be seeing in the late '70's, that this is where healthcare needed to go. That includes Regenstrief Institute, which is connected to Indiana University, which really is a public hospital, when you get right down to it. It includes Intermountain Healthcare in Utah; Veterans Affairs; Brigham and Women's Partners Healthcare system in Boston and so forth. Starting in 2004, because many, many policymakers, the then-Secretary of Health and Human Services, the members of Congress and so forth, from both sides of the aisle, could see the power of health IT. We've had dedicated resources of about $50,000,000 a year. So this is a big chunk of our budget. We've been working to make sure that health IT works to help clinicians and patients actually make the right thing, the easy thing to do. We believe that it can improve the quality of care and have supported a systematic review, which shows that pretty conclusively. But it's not about health IT by itself.
If we're only about hardware and software, this would be so easy. It would be a blast. We would just call in the computer teams and we'd be done. That's maybe a third of the solution. The rest of it is literally rethinking how we do our work, and that is human behavior and it's much more challenging and interesting. What that's going to look like in a small hospital or a small clinic is very different than in a highly structured enterprise like say the Mayo Clinic, or some other big entity you can think of. So our work is very much focused on both using the applications but also figuring out, are they having the impact we expect on quality and safety? Moving electrons around, we all know, can drown us in information. The question is how do we harness that in a way that protects the privacy and security of patients' personal health information, but at the same time delivers customized information to the point of decision-making, based on scientific evidence. That's our goal. And if I sound excited, that's a good thing, because we are very excited about it.
ALBERT MORALES: So on that point, what might be the specific role of IT in Comparative Effectiveness Research?
DR. CAROLYN CLANCY: Well, a big part of Comparative Effective Research-- Comparative Effectiveness, let me say, relies on a variety of different study techniques, from randomized trials to observational studies and so forth. And there's a growing belief, and we have funded a lot of work in this area, that we can take advantage of electronic data using a variety of methods to actually learn about what happens in clinical care. What happens to a selected group of patients who do nothing, or who take a medicine or have surgery, and so forth. In fact, in a funny way, that was the genesis of AHRQ, was the belief that we could do this with Medicare data. Billing claims can be incredibly helpful and we still use that as a resource, but they're also limited. So the promise of health IT, in terms of work that has been going on for the past five years or so and a huge surge of interest; as well as the Recovery Act, which took that surge and made it a huge opportunity, is to get more clinically-detailed data in electronic format. I think many people don't actually grasp that how healthcare is done these days is, by and large, a paper enterprise. Notes are written in a fairly nonstandard fashion, a lot of shorthand and so forth. It's almost impossible to learn from the delivery of care. Health IT will make it possible for us to actually create what some have called Learning Healthcare Systems. So we can understand what has happened as a result of a new treatment on the market; which patients have benefited and which have had side effects and so forth.
ALBERT MORALES: So you alluded to the fact that health IT, or at least the IT side of it, is really just one component, but that the successful implementation and user acceptance of information technology really rests on a solid change management foundation. How do you get the users to change behavior and accept something new and different like this?
DR. CAROLYN CLANCY: We're not in the business of telling people how to change. It turns out, as you might imagine, it's very easy to tell someone to change. What's harder is to actually do it. Through our work, we focus on the high impact opportunities in healthcare. Inevitably they require changes in how healthcare is delivered, including redesigning and rethinking every step of the process, hopefully to make it more patient-friendly. So some of the areas where we're investing are supporting research through contracts and grants that examines how to improve the safety and quality of prescription drug management. Another is improving the delivery and utilization of evidence-based care in ambulatory settings. Right now, in that paper-based enterprise, doctors are trying hard to remember what they read. Sometimes they can actually get to a computer terminal and look up quickly, but it's often not instantly available. Health IT can actually help us in the form of clinical decision support, to really target the delivery of information. Technically, we know how to do this. My favorite book store online actually knows what I might be interested in and, thankfully, spares me details about things I'm not interested in. Right? So it's not a technical problem, it's really much more of a sociological problem that has to do with organizing information and so forth. When we do support this work, we make the lessons broadly available so that hopefully we can avoid, or help others avoid, with is called the NIH Syndrome -- you know, Not Invented Here? Where every organization has to relearn a lot of the same lessons and so forth. That notion of technical assistance, what some have called Geek Squads and so forth, is a big feature of the Recovery Act for just that reason.
ALBERT MORALES: That's fantastic. What does the future hold for AHRQ? We will ask Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality to share with us, when our conversation about healthcare continues on The Business of Government Hour.
ALBERT MORALES: Welcome back to our final segment of The Business of Government Hour. I'm your host, Albert Morales, and today's conversation is with Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality within the Department of Health and Human Services. Also joining us today, from IBM, is Janet Marchibroda. Dr. Clancy, will all of the investments we've discussed today, what are the steps to insure we are getting value from these public investments?
DR. CAROLYN CLANCY: You know, our goal is to make sure that the best information is not only easily available, but that it's almost impossible to avoid. A lot of the ways that we work to achieve that, in addition to disseminating information through our websites and through a variety of other media, as we discussed, is actually to partner with organizations who have a bigger reach than we do. For, example, we partner very closely with AARP, because they have a huge outreach to their members, and any other organizations and multiple professional organizations for physicians and other clinicians and so forth.
JANET MARCHIBRODA: From our discussion, it has become clear that partnering and collaboration are critical to AHRQ's efforts and success. Would you tell us more about your intra or interagency collaboration with key federal agencies, such as the FDA, the CDC, the VA and CMS? And just building on your response about AARP, I'm curious, since there are so many stakeholders in the healthcare industry, could you share also to what extent you partner and collaborate with perhaps others in the private sector?
DR. CAROLYN CLANCY: I'm so glad you asked this, because literally collaboration is a huge part of our daily work. We produce information to improve healthcare, but we don't regulate care. We don't pay for it and we don't provide it directly, so we can't possibly achieve our mission without partnering with those who do, either regulate care, provide it directly or frankly use it, as all of us do as patients. So just to give you a couple of examples from how we work with our government components. We do a great deal of work with CMS, particularly on the issue on quality of care. I was very proud of the fact that, about a year ago, for the first time, everyone can see how patients think about their experience in the hospital. It's a really big deal. That information was never publicly available before. It took a few years to make that happen, but now people can actually see how other patients have reacted to their hospital stay. In addition to that, I'm very excited that the new reauthorization of the Children's Health Insurance program has new specific provisions for quality of care. We're taking a lead role, working very closely with CMS on the first phase of that work and are very excited and we'll be having big, open to the public meeting, July 22nd and 23rd, in Washington. Because we've created a Advisory Council that's a subcommittee to our overall National Advisory Council.
One that I just have to mention, that we did with the Department of Defense, is something called Team Steps. As you might imagine, the Department of Defense is accurately sensitive to the issue of turnover and needing to retrain people and so forth. So we actually created a curriculum that makes it much easier for healthcare professionals to learn how to work in teams, and in particular, teams where you expect a fair amount of turnover either because of shifts, transfers and their mission and so forth. We recently got a huge award and in accepting it, our partner from Defense said, we believe in this, because we know that expert teams are performed, teams of experts every time.
We also partner with states in terms of making hospital data available, and partner with health IT organizations, the American Medical Informatics Association, and many, many others. So partners are us, I guess.
ALBERT MORALES: (laughs) So I'd like to transition to the future now. You've clearly been a leader in healthcare for some time. With all the talk about healthcare and healthcare reform, can you share with us your vision for the future of healthcare? What are some of the key insights you would like our listeners to take away from this conversation?
DR. CAROLYN CLANCY: Wow! That's a great question. Thank you very much, particularly for how you framed that. One of the biggest changes we saw in the twentieth-century was the increase in life expectancy. I think in this country, we are actually still getting our heads around what does that mean? In practical terms what it means, in healthcare, is that what's killing us are not acute diseases, but actually chronic illnesses. For healthcare in the future, first of all, you have to be able to have access, period. I mean, this needs to be removed from the lists of ongoing challenges. I'm very optimistic that that's going to happen this year. It's not going to be easy, but it's incredibly important.
Secondly, people have to have confidence that wherever they go, they're going to get the best quality of care and that that care will be safe. They won't be inadvertently harmed, because practitioners and organizations are always going to be vigilant to make sure that they're not inadvertently harming patients, as a byproduct of trying to make them better. The other piece of the future that I think is critical is that patients need to be in a place where they have the opportunity and the skills and support to play a more active role in their own health and healthcare. Getting to superb dramatic improvements in chronic illness care is simply not possible without it. It's not a matter of saying, Hey, it's your problem. You're the one who has to do this. It's much about an effective partnership between clinicians and patients, where clinicians celebrate actually that their patients may know more about their conditions than they do. I think that we'll look back, in a not huge number of years, and say, Wow! This was the year that we finally figured how to put all the pieces together. I think this year is just incredibly exciting.
ALBERT MORALES: So Dr. Clancy, with that vision, what are some of the major opportunities and challenges that your agency, will encounter in the future and how do you envision your office will need to evolve over the next say three to five years?
DR. CAROLYN CLANCY: Some of the major opportunities and challenges are that, while we all know that quality of care is really important, when you start to get into the details, it's pretty dense and abstract. But those details actually matter a whole lot. In addition to that, I think one of the changes that we're seeing in quality now is if we don't make the collection of information very, very easy and something that can be easily done as part of providing care, we're going to overwhelm providers with collecting data, to the point where they no longer even think about, What do I do with this information? Right? The point of collecting data is, frankly, to let the public know how we're doing, but also to tell us where do we need to focus our efforts on improvement. I think we very much need to build better science, in terms of improving healthcare. That can be actually a difficult message to get across, that we actually don't know how to do this better. But we understand the urgency and we need to move rapidly, but to learn and evaluate and get smarter as we do that. We know that this has been done in other industries. I don't see any reason why we can't do it in healthcare, and we will. The question is how rapidly can we get there? So making the case for that investment has its own challenges. I try to stay away from the extremely technical details.
In terms of how our work will evolve, if anything, we are going to be more tightly aligned, both with public and private sector partners, in a much more strategic way. So that I would envision over the next five years and beyond, that our partnerships will be a routine part of our work, rather than a kind of one at a time. It'll be more systematic and part of the backbone of our work, which I think would be incredibly exciting.
ALBERT MORALES: Dr. Clancy, you started the show with describing a decision that you made and a passion that you had at the tender age of nine years old. You've obviously had a very interesting and successful vocation in the field of medicine and also as a public servant. What advice might you give to someone out there, who perhaps is thinking about a career either in medicine or public service, or perhaps ideally both?
DR. CAROLYN CLANCY: I have both to be incredibly exciting and gratifying. So anyone who's interested, I would say go for it, because there are going to be multiple possible paths. But also be open to the idea that there'll be many different opportunities. I never ever, as a resident, would have thought I would be doing anything like what I'm doing today. I hear that from healthcare professionals in all walks of life. Many people have changed careers multiple times. But that's actually a terrifically good thing, because you get to test different skills and so forth. I would give them as much encouragement as possible.
Let me also just say that I'm also a bit humbled by this question because I originally came to AHRQ at late 1990, to stay for two years, and my expectation was I'd go back to academic medicine, and I've been there every since, and it's been fabulous. It always does temper my sense of being too confident when giving career counseling.
ALBERT MORALES: (laughs) That's a wonderful perspective, and wonderful advice. Unfortunately, we have reached the end of our time. I do want to thank you for fitting us into your busy schedule. But Janet and I would like to thank you for your dedicated service to our country, both as a physician and as a public servant.
DR. CAROLYN CLANCY: Thank you so much. For listeners, I would encourage you about two things. One is to visit our website, which is AHRQ.gov. For those of you, who really have a bug or passion for the kind of work we do, our Annual Meeting, which we also call AHRQ-a-palooza, will be September 13-16 in Bethesda. The registration is free. Information is on our website.
ALBERT MORALES: Excellent, thank you. This has been The Business of Government Hour, featuring a conversation with Dr. Carolyn Clancy, Director of the Agency for Healthcare Research and Quality, within the U.S. Department of Health and Human Services. My co-host has been Janet Marchibroda, IBM's GBS Public Sector, Chief Healthcare Officer.
As you enjoy the rest of your day, please take time to remember the men and women of our armed and civil services abroad who may not be able to hear this morning's show on how we're improving their government, but who deserve our unconditional respect and support.
For The Business of Government Hour, I'm Albert Morales. Thank you for listening.
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