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Checking In About Innovation

January 31, 2011
by Mark Hagland
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AHRQ's Carolyn Clancy Examines the Current Quality Landscape
Carolyn Clancy
Carolyn Clancy

Late last year, Carolyn M. Clancy, M.D., director of the federal Agency for Healthcare Research and Quality (AHRQ) spoke with HCI Editor-in-Chief Mark Hagland regarding her perspectives on current developments in healthcare, and her agency's involvement in pursuing innovation and change. Dr. Clancy will be the closing keynote speaker at the Healthcare Informatics Executive Summit, to be held May 11-13, in San Francisco. Below are excerpts from Dr. Clancy's interview with Mark Hagland:

Healthcare Informatics: What is your perspective on where healthcare is right now in terms of the ability to leverage information technology strategically to improve care delivery, quality, patient safety, and efficiency?

Carolyn Clancy, M.D.: There are so many opportunities right now, and we're making progress. I'm thinking in particular about all the opportunities from the work that really began in 2004, and obviously was built on work done previously at AHRQ and the National Library of Medicine-work using health IT in clinical care.

ONE AREA OF OPPORTUNITY INCLUDES LEARNING IN A SYSTEMATIC WAY FROM THE OFF-LABEL USE OF MEDICATIONS. ABOUT 20 PERCENT OF OFF-LABEL PRESCRIBING IS LEGAL AND OFTEN VERY APPROPRIATE, YET WE DON'T LEARN A THING FROM IT TODAY.

For example, one area of opportunity includes learning in a systematic way from the off-label use of medications. About 20 percent of off-label prescribing is legal and often very appropriate, yet we don't learn a thing from it today. And another area-and Peter Pronovost [intensive care specialist and healthcare innovation leader Peter J. Pronovost, M.D., whose work with intensive care checklist protocols has become widely known] refers to this as ‘feed-forward’-and that is, getting information way upstream in the care delivery process. So, imagine that a new breakthrough treatment is identified, and is applied to a particular patient and doesn't yield the results expected. In real life today, if that signal gets back to researchers doing the basic research work, it's only very weakly communicated; and really, you'd like to get that signal to the researchers much earlier. So that area of potential innovation includes using evidence in clinical care, and changing the metaphor to one from hunting to farming-growing information, and learning as a byproduct, and taking advantage of the data generated every day from taking care of patients.

HCI: Regarding the data that's essentially discarded now, what could it do for clinicians?

Clancy: It could help us learn from exceptions. Sometimes, for example, a clinician opts out from a clinical protocol or guideline, saying that their patient doesn't meet certain criteria that would make it appropriate to follow a protocol. In such a situation, what I'd like to see happen is for us to learn from that situation, and to use the data from that encounter in the future. In that sense, there is a real potential to change the use of care pathways towards being proactive rather than reactive. One of the very first things you learn in medical school is to take a patient's history and physical. In preparing physicians to do this, you can actually give them a printed-out sheet, based on your organization's performance metrics, that will show them exactly where they're behind in preventive services or in managing patients' diabetes; in other words, this is all about customizing data based on what we know already.

The other really cool potential is being able to identify what's going on with patients over a period of time. Most of the quality measures we use now are snapshots in time, and describe only what happened in an individual encounter. What we really need to know instead is, how is the new arthritis treatment helping a particular patient, Mrs. Smith, specifically, and over time? And so forth. And if a new treatment isn't benefiting individual patients, learning about and understanding those exceptions not only accelerates advances in delivering care, but also can help transform practice. We need to begin to help shorten the translation lag, the time between the introduction of new treatments, and our understanding of their effectiveness. And if I can get a customized sheet-either on paper or electronically-before I see each of my individual patients, that can help improve the care of those patients. Think of it this way: it's analogous to what Amazon does for us as customers of its products.

IF A NEW TREATMENT ISN'T BENEFITING INDIVIDUAL PATIENTS, LEARNING ABOUT AND UNDERSTANDING THOSE EXCEPTIONS NOT ONLY ACCELERATES ADVANCES IN DELIVERING CARE, BUT ALSO CAN HELP TRANSFORM PRACTICE.

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