1. Implementation of Evidence-
Based Medicine in Practice
Carolyn M. Clancy, MD
Director
Agency for Healthcare Research and Quality
CMIO Leadership Forum:
Transforming Healthcare through Evidence-based Medicine
Chicago, IL – October 4, 2012

2. Understanding a
Changing Landscape
 Health care reform, including
payment reform, has already
begun
– How is evidence integrated into
the new environment?
– How has the nature of CHANGE
evidence changed? AHEAD
– How do these changes affect
providers, payers and
patients?
 How do we ensure that these
changes are beneficial?

3. Maintaining the Status Quo
is Not an Option
 Evidence is being produced at an extremely
rapid rate, but its incorporation into clinical
practice is happening much more slowly
 Transparency efforts don’t offer enough
usable data for decisions regarding a specific
disease and selection of a treatment option
 We face an underperforming health
care system and untenable cost
forecasts
 Too often, the patient is an
afterthought

4. Aiming for the Sweet Spot
 There is an overlap
among patient-centered
care, population
health, and advanced
modern medicine
 All three call for
organizing care around
the patient rather than
around systems of care
 All three call for a fresh
examination of how we
conduct and disseminate
research

5. Implementation of
Evidence-Based Medicine
 Making the Case: AHRQ and Its
Role in Advancing High-Quality
Health Care
 Patient-Centered Outcomes
Research: The Collection of Modern
Evidence to Enable Modern
Medicine
 Putting the Patient at the Center of
Care
 21st Century Health Care

6. AHRQ’s Mission
Improve the
quality, safety, efficiency, and
effectiveness of health care for all
Americans

7. AHRQ’s Focus and
Strategic Goals
 Quality: Deliver the right care at the right
time to the right patient
 Safety: Reduce the risk of harm by
promoting delivery of the best possible
health care
 Efficiency: Enhance access to effective
health care services and reduce
unnecessary costs
 Effectiveness: Improve health care
outcomes by encouraging the use of
evidence to make more informed health
care decisions

8. HHS Organizational Focus
NIH CDC AHRQ
Biomedical Population health Long-term and
Research to and the role of system-wide
prevent, diagnose community based improvement of
and treat disease interventions to health care quality
improve health and effectiveness

9. AHRQ Priorities
Patient Safety
 Health IT
 Patient Safety
Organizations
Ambulatory  Patient Safety Effective Health
Patient Safety Grants (incl. Care Program
simulation)  Comparative
 Safety & Quality Measures,
Effectiveness Reviews
Drug Management, &
Patient-Centered Care  Patient-Centered
 Survey of Patient Safety Culture Outcomes Research
 Diagnostic Error Research  Clear Findings for
Multiple Audiences
Other Research &
Medical Expenditure Dissemination Activities
Panel Surveys
 Quality & Cost-Effectiveness, e.g.,
 Visit-Level Information on Prevention & Pharmaceutical
Medical Expenditures Outcomes
 Annual Quality &  U.S. Preventive Services
Disparities Reports Task Force
 MRSA/HAIs

10. AHRQ 2011 National Healthcare
Quality and Disparities Reports
 Overall, improvement in the
quality of care remains
suboptimal and access to care
is not improving
 Few disparities in quality are
getting smaller and almost no
disparities in access are
getting smaller
 Quality of care varies not only
across types of care but also
across parts of the country

11. Progress is Uneven Toward
National Priority Areas
 2011 Findings:
– Health care quality and access are
suboptimal, especially for minority and low-income
groups
– Quality is improving; access and disparities are not
– Urgent attention needed to ensure continued
improvement in quality and progress on reducing
disparities for services, geographic areas and
populations, including:
 Diabetes care and adverse events
 Disparities in cancer screening and access to care
 States in the South
Reports include evidence of progress toward priorities identified in
National Quality Strategy and HHS Plan to Reduce Racial and Ethnic
Health Disparities

12. Quality Is Improving Slowly
Quality measures that are improving, not changing
or worsening, overall and for select populations
 Nearly 60 percent of
health care quality
measures tracked
showed
improvement
 However, the
median rate of
change was 2.5
percent per year
AHRQ 2011 National Healthcare Quality and Disparities Reports

13. Few Disparities in Quality
of Care Are Getting Smaller
Quality measures for which disparities related to
age, race, ethnicity and income are improving, not
changing or worsening
 Few disparities in
quality showed
significant
improvement.
 The number of
disparities that were
getting smaller
exceeded the number
that were getting larger
AHRQ 2011 National Healthcare Quality and Disparities Reports

14. Illinois: Overall Quality of Care
Compared with All States
Average
Weak Strong
Very Very
Weak Strong
Performance Meter: All Measures
= Most Recent Year
= Baseline Year
National Healthcare Quality Report, State Snapshots

15. Illinois Snapshot:
Quality Measures
Measure Performance
ESRD: Renal failure – received a Better than
transplant average
Diabetes: Diabetes eye exams Average
Cancer: Prostate cancer deaths Worse than
average
National Healthcare Quality Report, State Snapshots

16. Implementation of
Evidence-Based Medicine
 Making the Case: AHRQ and Its
Role in Advancing High-Quality
Health Care
 Patient-Centered Outcomes
Research: The Collection of
Modern Evidence to Enable
Modern Medicine
 Putting the Patient at the Center of
Care
 21st Century Health Care

17. What We Know
―The truth is that for a
large part of medical
practice, we don’t know
what works. But we pay
for it anyway.‖
H. Gilbert Welch, MD
Geisel School of Medicine
at Dartmouth
Testing What We Think We Know. New York Times - August 19, 2012

18. Research that Addresses
Patient Outcomes
Patient-Centeredness: The final frontier?
 Patient-centeredness may
be the most challenging of
all 6 domains of
quality, because it is so
difficult to define and
measure
 But, it is also likely the
most important, because it
includes elements of all
other domains

19. Until Recently, Few Tools to
Get From Evidence to Practice
 AHRQ is working to:
– Translate scientific
advances into actual
clinical practice
– Translate scientific
advances into usable
information for clinicians
and for patients
– Deliver information in the
right places at the right
time

20. Effective Health Care Program
Summaries
Policymakers Clinicians Consumers
Summarize research review findings on the benefits and harms of different treatment
options. Provide useful background on health conditions. Medication guides contain
basic wholesale price information.

21. AHRQ’s Effective
Health Care Program

22. Implementing Evidence-
Based Treatment Decisions
 Which treatments work, for which patients, and what
are the trade-offs?
– Patient-centered outcomes research informs
decisions by providing evidence and information on
effectiveness, benefits and harms
 How can evidence-based improvements be
translated and shared with providers, patients?
– Effective Health Care Clinician and Consumer
Guides
– Continuing Medical Education
– Center for Medicare and Medicaid Innovation; AHRQ
Innovation Exchange

23. The Patient-Centered Outcomes
Research Institute and AHRQ
 Provides funding for AHRQ
to disseminate research
findings of the Institute and
other government-funded
research, train and build
capacity for research
– Up to 20% of Patient-Centered
Outcomes Research Trust www.pcori.org
Fund can be used to support
research capacity building and
dissemination activities

24. Implementation of
Evidence-Based Medicine
 Making the Case: AHRQ and Its
Role in Advancing High-Quality
Health Care
 Patient-Centered Outcomes
Research: The Collection of Modern
Evidence to Enable Modern
Medicine
 Putting the Patient at the Center
of Care
 21st Century Health Care

25. Assumptions
 We’ve always assumed flawless
execution
 We’ve also always assumed that
any issues that arise are caused
by a knowledge problem
 Neither is always true
 A case in point…

26. Sometimes,
It’s The Little Things

27. AHRQ HAI
Research Portfolio
 Healthcare-associated infections
(HAIs) are infections that patients
get in the course of medical care
 HAIs affect up to 1 in 20 patients in
hospitals at any one time
 $34 million in support of goals of
Partnership for Patients and HHS
Action Plan to Prevent HAIs
www.ahrq.gov/qual/haify11.htm
 Projects include:
– Three new modules for the
Comprehensive Unit-based Safety
Program (CUSP)
– Research on ways to reduce MRSA
and Clostridium difficile (C-diff)
– Use of health system facility design to
reduce HAIs

28. CUSP Cuts CLABSIs by 40
Percent in 1,100 Hospital Units
 Nationwide patient safety
project
– Developed at Johns
Hopkins, tested in Michigan
– Implemented in more than 1,100
hospital units
 Results:
– CLABSIs reduced from 1.903
infections per 1,000 central line
days to 1.137 per 1,000 days
– Savings: more than 500
lives, $34 million in costs
 New toolkit for implementation
AHRQ Patient Safety Project Reduces Bloodstream Infections by 40 Percent.
Press Release, September 10, 2012. www.ahrq.gov/news/press/pr2012/pspclabsipr.htm

29. Keystone: Maintaining
Improvement Practices
 Example of building improvement into the
research
– Partnership with grants from AHRQ and various
commitments from Blue Cross Blue Shield of
Michigan, the Michigan Hospital
Association, Johns Hopkins University and others
– Stakeholders, end users and others are able to
use the data to monitor progress
– Innovative methods of dissemination and
communication
– An ongoing effort to learn and improve

30. AHRQ Health IT
Research Portfolio
 AHRQ has invested more
than $300 million since 2004
in contracts and grants
 More than 200
communities, hospitals, provi
ders, and health care
systems in 48 states AHRQ Health IT
Investment: $300
Million

31. Enabling Evidence-Based
Medicine through Health IT
Streamlining Information and Clinical Processes
 Faster and broader dissemination of
new evidence
 Inclusion of new evidence and
treatments into electronic quality
reporting systems, EHRs, etc.
 Registries

32. Who Benefits from AHRQ’s
Health IT Work?
 Patients get the right treatment at the right
time; and when their records are shared, tests
don’t have to be repeated
 Doctors manage information in the office, and
get decision support and helpful reminders
 Hospitals coordinate care among units and
among each other
 Payers get faster, more accurate data
 States get real-time data on services
statewide

33. Preparing the Field for
Innovation: Project ECHO
Project ECHO
Develops capacity to safely and effectively treat
chronic, common, complex diseases in rural,
underserved areas and monitor outcomes

34. MEADERS
Medication Error and Adverse Drug Event Reporting
System (MEADERS)
 Web-based and downloadable reporting
system for ambulatory care settings to
document medication errors and adverse
drug events
 ―Cloud‖ reporting system users can
compare their results to national data
 Piloting testing underway at Cleveland
Clinic and two sites that are part of the
HRSA ―Patient Safety and Clinical
Pharmacy Services Collaborative

35. AHRQ Hip and Knee Registry
 Function and Outcomes Research for
Comparative Effectiveness in Total Joint
Replacement (FORCE-TJR)
– Collecting data on 30,000 patients on functions
including:
 Longitudinal patient pain and function
 Post-procedure complications and revisions
 Characteristics of patients, procedure, physician and hospital
– Developing tools for patient-centered outcomes
research:
 Establish consensus on the definition of ―functional failure‖
 Construct, validate and refine prediction algorithms for patients
at risk for early post-TJR functional failure
 Develop and institute an integrated, brief TJR-specific physical
function outcome measure

36. Generating Information and
Evidence with Registries
 Registries increasingly used
to inform clinical decision-
making
– Revised AHRQ guide (2010)
includes 4 new chapters:
 When to Stop a Registry
 Use of Registries in
Product Safety
Assessment
 Linking Registry Data
 Interfacing Registries and
Electronic Health Records

37. How Do We Engage Patients?
 Two requests to
make of patients:
– ―Tell me your
goals.‖
– ―Tell me what
you heard.‖

38. A Decent Meal,
Or a New Model of Care?
 The challenge:
– Serving millions of people
– Delivering a range of services
– Keeping costs reasonable
– Attaining a consistently high
level of quality
 Can care be mechanized?
Should it be?
 Are there models we can use?
Gawande A. Big Med: Restaurant chains have managed to combine
quality control, cost control, and innovation. Can health care? New
Yorker. August 13, 2012

39. Implementation of
Evidence-Based Medicine
 Making the Case: AHRQ and Its
Role in Advancing High-Quality
Health Care
 Patient-Centered Outcomes
Research: The Collection of Modern
Evidence to Enable Modern
Medicine
 Putting the Patient at the Center of
Care
 21st Century Health Care

40. This is an Evolving Enterprise
Evidence, quality assessment, and other
tools are important—but only inasmuch as
they improve care for patients

41. Getting There will Be a
New Learning Model
 We will develop a more intuitive grasp of the
power of data over time
– Young physicians tend to be first adopters of
health IT
– Older physicians generally experience more
difficulty in adapting to the rapidly changing
practice environment
– New practice arrangements are increasingly
offering more alternatives to physicians entering
practice

42. Key Considerations
 Interest in assessing clinician
performance will continue
 Much of the measurement
enterprise is ―evolving‖
 Collective interest in using
quality measures that reflect
the profession’s knowledge
and authority
 ―Some day‖ health IT will
make data
collection, reporting and
updating of measures easy –
but not today!

43. How Will We Know
We’re On Track?
 The quality enterprise adds value to
clinical practice
 Care includes focus on missed
opportunities and dropped balls:
transitions; handoffs; anticipating
errors
 Physicians say, ―we‖ rather than ―I‖
 Patient activation and engagement
is welcomed and encouraged
 ―Best doctors‖ are evaluated in
terms of care for individual patients
and leadership in health of
population

44. Health System Transformation:
Current and Future
Current Future
Variable quality; expensive, Consistently better quality;
wasteful lower cost, more efficient
Pay for volume Pay for quality
Pay for transactions Care-based episodes
Quality assessment based Quality assessment based
on provider and setting on patient experience
(process) (outcomes)

45. The Journey:
From Knowledge to Practice
 System transformation is
a long-term endeavor
 It requires
research, incentives, and
desire to improve
 Communication at every
juncture is critical
 So is measurement!
 Change is not only
possible, but it is
inevitable if we are
committed to it

46. Thank You
AHRQ Mission
To improve the
quality, safety, efficiency, and
effectiveness of health care for
all Americans
AHRQ Vision
As a result of AHRQ's
efforts, American health care
will provide services of the
highest quality, with the best
possible outcomes, at the
lowest cost
www.ahrq.gov