Meeting Minutes, November 2018

Contents

Summary
Call to Order and Approval of July 18, 2018, Meeting Summary
Director's Welcome and Update
Update on AHRQ's Data Enterprise Workshop
Update on AHRQ Support of Secretarial Priorities: Opioids
Update on AHRQ Support of Secretarial Priorities: Value
Update on AHRQ Support of Secretarial Priorities: Drug Pricing
Open Discussion on AHRQ Support for Secretary Azar's Priorities
AHRQ Partnerships
Public Comment
Chair's Wrap-Up and Adjournment

Summary

NAC Members Present

Donald A. Goldmann, M.D., Institute for Healthcare Improvement, Harvard Medical School, Harvard T.H. Chan School of Public Health  (Chair)
Karen S. Amstutz, M.D., M.B.A., Magellan Healthcare
Alice S. Bast, Beyond Celiac (via telephone)
Cathy J. Bradley, Ph.D., M.P.A., University of Colorado School of Public Health
Sheila P. Burke, M.P.A., R.N., FAAN, Harvard University
Christina J. Calamaro, Ph.D., CRNP, Emory University, Children’s Healthcare of Atlanta (via telephone)
Beth Ann Daugherty, M.P.H., R.N., Sparrow Clinton Hospital
Robert S. Dittus, M.D., M.P.H., Vanderbilt University Medical Center (via telephone) 
Barbara A. Fain, J.D., M.P.P., Betsy Lehman Center for Patient Safety
Tina M. Hernandez-Boussard, Ph.D., M.P.H., M.S., Stanford University School of Medicine
Andrew L. Masica, M.D., M.S.C.I., S.F.H.M., Baylor Scott & White Health
Sally C. Morton, Ph.D., M.Sc., M.S., Virginia Tech
Lucy A. Savitz, Ph.D., M.B.A., Intermountain Healthcare   

Alternates Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Michael Lauer, M.D., National Institutes of Health
Paul McGann, M.D., Centers for Medicare & Medicaid Services (for Kate Goodrich)

AHRQ Staff Members Present

Gopal Khanna, M.B.A., Director
Francis D. Chesley, Jr., M.D., Acting Deputy Director
Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement
Jeffrey Brady, M.D., M.P.H., Director, Center for Quality Improvement and Patient Safety
Steven C. Hill, Ph.D., Center for Financing, Access, and Cost Trends
Howard E. Holland, Director, Office of Communications
Kamila Mistry, Ph.D., M.P.H., Office of Extramural Research, Education and Priority Populations
Mamatha S. Pancholi, M.S., Center for Delivery, Organization, and Markets
Jenny A. Schnaier, M.A., Center for Delivery, Organization, and Markets
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator

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Call to Order and Approval of July 18, 2018, Meeting Summary

Donald A. Goldmann, M.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, participants, and visitors, including those viewing on the webcast. He noted the presence of new NAC member Sally C. Morton. He stated that, subsequent to this meeting, the following members will be rotating off the council: Alice S. J. Bast, Christina J. Calamaro, Robert S. Dittus, José Escarce, Monica E. Peek, Lucy A. Savitz, and himself.

The NAC members and participating AHRQ staff introduced themselves.

Dr. Goldmann asked for changes to and approval of the draft minutes of the previous NAC meeting (July 18, 2018). The NAC members voted unanimously to approve the July meeting minutes with no changes.

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Director's Welcome and Update

Gopal Khanna, M.B.A., Director, AHRQ, and Francis D. Chesley, Jr., M.D., Acting Deputy Director, AHRQ

AHRQ Director Gopal Khanna welcomed the NAC members, noting the importance of the advice and counsel that they offer to the Agency. The expertise of the NAC members is broad and deep, and the Agency, with the NAC’s help, has achieved great things. The Agency will stay in touch with those members who are rotating off the council. Director Khanna stated that these are exciting times, offering opportunities for AHRQ, the lead Federal Agency supporting healthcare quality and safety. Next year will be the 20th anniversary of the Agency, which is considering ways to provide leadership into the future. Next year also will be the anniversary of the influential Institute of Medicine report To Err Is Human: Building a Safer Health System, which was a call to action for patient safety and has led to many lives saved.

The National Academy of Medicine’s new report on health services research is yet another call to action and will inform further the conversation about improving health services. Congress recently called on AHRQ to support contracts to support health services and primary care research. As a result, a new contract with RAND will identify research gaps and areas of consolidation of policies as we move into the future.

AHRQ’s focus features attention to improving the lives of patients and establishing healthcare that is of high quality and value by leveraging competencies, providing research and data analytics, and supporting a holistic, 360-degree view of the patient.

Dr. Chesley reported that AHRQ’s fiscal year (FY) 2019 budget appropriation was signed on September 28. The $338 million budget is an increase of $4 million over the FY 2018 appropriation. The increase will fund grants to address diagnostic errors and a program to explore the effectiveness of data computing analytics that can identify trends in chronic disease management. The main appropriation did not support a proposal to consolidate the Agency within the National Institutes of Health. AHRQ also will receive $120 million from the Patient-Centered Outcomes Research (PCOR) trust fund.

The FY 19 appropriation provides $72.3 million for patient safety, $70 million for the Medical Expenditure Panel Survey (MEPS), $96.3 million for health services research, data, and dissemination, $16.5 million for health information technology, $11.6 million for the U.S. Preventive Services Task Force, $14.8 million for new investigator-initiated research grants, and $10 million for patient safety learning laboratories.

Dr. Chesley reported that AHRQ staff received a number of honor awards during an October 25 ceremony. These included awards for the following:

• Outstanding contributions to the production and dissemination of high-quality, policy-relevant health services research and technical assistance.
• Exceptional leadership and contributions to a community as volunteer and executive director of My Sister’s Closet.
• Envisioning, planning, and delivering an entirely new Intranet, AHRQ Connect, for the AHRQ staff.
• Exceptional innovation and creativity in revamping the hands-on programming portion for the biannual MEPS Data Users Workshop.
• Outstanding service to the Center for Evidence and Practice Improvement (CEPI) in enhancing grant operations across the Center and supporting CEPI staff in excelling as program officials.
• Outstanding support staff performance and teamwork efforts, which have had a substantial impact on AHRQ’s peer review process contributing toward advancing the mission of the Agency.
• Exemplary performance in evaluating and testing the modernization and technical upgrade of the employment section of the MEPS Household Component.

Discussion

Dr. Goldmann asked about the new career development K12 awards. Dr. Chesley responded that those awards will support learning health system career development, with a focus on systems and data. The program will train researchers to be embedded in health systems and is being conducted in partnership with the Patient-Centered Outcomes Research Institute. The grants are built on a menu of core competencies. AHRQ also is supporting learning collaboratives and developing core curricula.

Dr. Chesley added that the new RAND report features a call to action across a variety of stakeholders, with an intention to look at the healthcare landscape.

Dr. Savitz asked for additional details about the new RAND study noted by Mr. Khanna. Dr. Chesley responded that work began recently and is pursuing a couple of streams of data input. AHRQ’s efforts include obtaining input from leaders of health services research and conferring with Federal funders, leading to a defining of priorities and possible collaborations. To inform the RAND study, AHRQ will convene roundtables of leaders to identify system needs.

Dr. Michael Lauer asked about grants in addition to the investigator-initiated grants. Dr. Chesley responded that the support for grants includes other areas, including general patient safety and learning laboratories.

Dr. Lauer inquired about the money derived from the PCOR Trust Fund. Dr. Chesley explained that those funds are in addition to AHRQ’s main budget appropriation. The PCOR contribution to AHRQ will end after FY 2019.

Cathy J. Bradley asked about the support for the K12 training grants. Dr. Chesley responded that, despite the cessation of the PCOR Trust Fund contribution after 2019, particular financial support for the K12 program and other training activities will continue.

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Update on AHRQ's Data Enterprise Workshop

Mamatha S. Pancholi, Center for Delivery, Organization, and Markets, AHRQ

Ms. Pancholi reported for the Data Enterprise Workgroup on AHRQ’s responses to suggestions by the NAC at its July meeting to address issues of data. Questions being considered include the following:

• What future challenge or question do you see facing the healthcare system nationally or in your area over the next 10 years?
• What kinds of problems are you trying to solve with data?
• What information/data are you missing to be able to solve those problems?
• What kinds of challenges do you face in obtaining and working with data?
• How can we make data more actionable and address critical local, State, and national priorities in health?

Ms. Pancholi cited the NAC members’ call to bridge the gap between traditional health services research and implementation research and to integrate information about social determinants of health into the research. In response, AHRQ is supporting an upcoming special-topic issue of eGEMS (AcademyHealth’s online journal) that will address research on how data are being leveraged to drive health system transformation. NAC members Dr. Escarce and Andrew L. Masica are serving as guest editors of the issue.

AHRQ also is offering a challenge to design, develop, and pilot user-friendly tools that efficiently collect, aggregate, and share patient-reported outcome data. AHRQ is supporting two additional competitions. These are:

1. To develop data visualization resources that illustrate the clustering of area-level social determinants of health and rates of healthcare utilization.
2. To create algorithms or tools by using innovative analytic methods and Healthcare Cost and Utilization Program (HCUP) Nationwide Inpatient Sample databases to predict estimates of overall and condition-specific utilization rates at national and regional levels.

Other AHRQ initiatives regarding data include the following:

• Three more States have agreed to provide AHRQ with quarterly inpatient and emergency department data.
• AHRQ is compiling a set of county-level social determinants of health databases.
• AHRQ is updating the MEPS data collection to include more social determinants of health information.
• AHRQ is supporting research to study how innovations in treatments, diagnoses, preventive strategies, and organization of care delivery can be deployed most effectively. This effort features the use of the new National Instituted of Health State Health Practices Database for Research.
• AHRQ is improving its website-based data platforms to increase usability, AHRQ branding, and access to data.

Discussion

Tina M. Hernandez-Boussard asked about progress in addressing social determinants of health. Ms. Pancholi responded that the Agency is attempting to identify aspects for which the research field has access. It is considering publicly available data (State and local), resources, domains, and gaps.

Dr. Morton asked about the eventual results of the challenge competitions: Will the information be disseminated? Ms. Pancholi responded that AHRQ will disseminate information when possible. Other next steps are being developed. Dr. Chesley noted that competition winners will receive intellectual property rights, which might lead to public-private partnership activities.

Dr. Lauer asked whether AHRQ is examining how its data are being accessed today. Ms. Pancholi responded that the methods vary, based on the data themselves. AHRQ programs (its data center, HCUP, etc.) are considering new methods for providing additional access. As for how data are being used, Dr. Chesley noted that AHRQ has been observing increases in demand for more data and requests for special datasets.

Dr. Goldmann, in reviewing the discussion, recognized four important dichotomies relating to data collection: (1) the platform versus the data or method, (2) private and entrepreneurial data versus public data, (3) accretion of data versus the creation of data (new visions and sources), and (4) foraging for data versus harvesting data. He urged the Agency to consider these dichotomies.

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Update on AHRQ Support of Secretarial Priorities: Opioids

Arlene S. Bierman, Center for Evidence and Practice Improvement, AHRQ

Dr. Bierman described her center’s work to address the opioid-use epidemic, as encouraged by the priorities described by U.S. Department of Health and Human Services (HHS) Secretary Alex Azar. Dr. Bierman recounted the burgeoning problem of opioid misuse in the United States, noting the finding that, in the year 2017, about 11.4 million Americans misused opioids, including pain relievers and heroin.

Dr. Bierman reported on ways in which AHRQ has been addressing the epidemic. In the area of health services research, the Agency has provided medication-assisted treatment research grants and systematic reviews. In the area of practice improvement, it has developed a pain management dashboard and a Web resource on pain management and opioid prescribing for primary care practices. In the area of data and analytics, AHRQ’s MEPS and HCUP programs have provided analyses of opioids used by the elderly. The Agency has supported demonstration and training grant programs in rural areas to identify and overcome barriers to the provision of medication-assisted treatment in primary care, including the development of tools, policies, and training materials.

In August, AHRQ released a special emphasis notice, calling for research to evaluate State, local, and health system policies to address the opioid crisis, develop interventions, and understand the increase in hospitalizations among older adults. The Agency offered a number of research funding mechanisms. With the Centers for Disease Control and Prevention (CDC) and the Office of the Assistant Secretary for Planning and Evaluation, the Agency produced a document on noninvasive, nonpharmacological treatments for common chronic pain conditions. It is developing a website feature on the nonpharmacological treatment of chronic pain.

AHRQ’s Evidence-Based Practice Centers program has produced a series of systematic reviews relating to opioid use and misuse. The Agency has continued its efforts to advance the use of clinical decision support, including increasing a capacity for sharing and making the technologies standards based and publicly available. It has been developing a clinical decision support system, with a dashboard, focused on the opioid area and serving clinicians who are treating patients with chronic pain. It has helped to develop a pain management summary informed by the 2016 CDC guideline.

AHRQ has created a 2-year task order to extend a grant for developing a toolkit for primary care practices in rural settings. The toolkit will be based on the “Six Building Blocks” team approach to improve opioid management in primary care.

AHRQ will support an upcoming Patient Safety Organizations (PSOs) summit to address the opioid crisis, an event that will lead to a continuing working group. The working group will discuss how PSOs can disseminate information, refine AHRQ tools, and serve as implementation test beds.

AHRQ’s HCUP program has been providing statistics on opioid-related inpatient stays and emergency department visits by elderly age groups. It has provided such data with regard to U.S. regional differences. The MEPS program also has provided statistics, for example, relating to non-elderly adults who filled outpatient opioid prescriptions (and by poverty status).

Dr. Bierman asked the NAC members to consider how AHRQ might set priorities for new investments in research addressing the opioid crisis and to consider opportunities to increase dissemination, uptake, and impact of AHRQ tools and data resources.

Discussion

Dr. Masica asked about clinical decision support tools being developed and their distribution, especially in rural areas. Sharing platforms will be important. Dr. Bierman responded that digitalizing such tools to help users find them will help.

Dr. Morton stated the importance of combining science and statistics as we move forward, as with the development of evidence reports based on the patient level.

David Atkins asked about the impact of State-level initiatives regarding opioids. Dr. Bierman responded that the issue is ripe for study and one related AHRQ-funded study is underway. Dr. Atkins added that the Department of Veterans Affairs (VA) will support a September conference on opioid use and approaches to pain management. He suggested that AHRQ address the issue of integration of substance abuse treatment and primary care.

Dr. Hernandez-Boussard asked about the personal factors that inform the exposures of opioid use and whether they could be studied more. AHRQ could study patients regarding the influences of social determinants and the potential for opioid abuse. Dr. Bierman agreed, noting that AHRQ has looked at some statistics relating to race and age. Karen S. Amstutz raised the issue of how to capture adverse childhood events.

Dr. Savitz asked about ways in which AHRQ can inform the country about the work being accomplished. Dr. Bierman responded that more needs to be done in that area. She encouraged the NAC members to make suggestions. Dr. Atkins noted the VA strategy of allowing “friends” of the Agency to conduct a forum on Capitol Hill to discuss Agency activities and potential. Dr. Bierman added that AHRQ can educate but cannot lobby Congress.

Dr. Goldmann asked Beth Ann Daugherty for perspective on rural concerns and activities. Ms. Daugherty responded that AHRQ has an opportunity to share information in a user-friendly way. Rural areas do not, of course, have the resources that urban areas have. Telemedicine remains an important way forward. Human resources are crucial.

Dr. Goldmann offered final ideas. He noted the distinction of being clear in communication rather than lobbying. Where does the work of AHRQ fit in the national effort regarding the opioid epidemic? There is a proliferation of toolkits. It would be helpful to know better the extent to which toolkits are used and used effectively. How do demonstration projects fit into the work of AHRQ? Going beyond dissemination ideas, what are the scale-up plans following studies? Scale-up ideas should be considered during a demonstration phase. How can AHRQ fit into the arena involving clinical decision support? How can AHRQ efforts compete with the private efforts?

Dr. Bierman responded that AHRQ has perhaps underinvested in evaluation of the dissemination of its products, yet it wants to understand what works and what does not work. Dr. Chesley added that, more broadly, the HHS Secretary has a cogent plan for deploying resources to battle the opioid epidemic, featuring aspects such as milestones and tracking. AHRQ’s role is fully articulated by HHS.

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Update on AHRQ Support of Secretarial Priorities: Value

Kamila Mistry, Office of Extramural Research, Education and Priority Populations, AHRQ

Dr. Mistry reported on AHRQ’s support for a transformation to a value framework for healthcare. She listed the following challenges to value in healthcare:

• The approach to payment focuses on fees for individual services.
• Prices and quality are not transparent.
• The system is not organized around the patients.
• The focus is on treatment, less so prevention.
• Value is defined differently by patients, providers, health systems, and the Government.

AHRQ is working to support the efforts to redirect incentives from volume of care to value-based care and to improve quality. HHS Secretary Azar has described an overall goal of transforming our healthcare system into one that pays for value, in other words, that offers better healthcare at a lower price. Areas that need to be addressed include the promise of health information technology; transparency around price and quality; new models for Medicare and Medicaid; and removal of Government burdens and barriers, especially relating to care coordination.

The Secretary has listed four activities that will drive us toward value in healthcare:

• Making patients into empowered consumers.
• Making providers into accountable navigators of the health system.
• Paying for outcomes.
• Preventing disease before it occurs and progresses.

Making patients empowered consumers can mean increasing the use of health savings accounts, providing flexibility in costs, and sharing data. Making providers into accountable navigators will involve payment models that promote providers and a shifting away from fee-for-service models. Reducing inpatient services also will play a role. Paying for outcomes will mean attending to payment models and the metrics of care quality (incentives and determinants of health will play roles here). Preventing disease will feature paying attention to social determinants of health.

AHRQ’s Value Framework effort involves aligning with the HHS goals in four areas: healthcare delivery systems research, quality measurement/improvement, data infrastructure/analytics/tools, and primary care/prevention. Dr. Mistry asked the NAC members to consider how AHRQ can leverage its competencies to achieve the Secretary’s goals and to present questions that AHRQ can address to define new areas of effort to promote value-based healthcare.

Discussion

Dr. Masica raised the idea of ways to consider and measure total cost of care, for example, by including an evaluation of readmission rates. Dr. Savitz stressed the importance of focusing on providers. As for the total cost of care, we need to consider the out-of-pocket costs, which can be huge barriers to care.

Dr. Bradley cited a need to understand better how value is achieved in terms of quality of care and total cost. How should we deal with tradeoffs in response to high prices? What is the impact of the adoption of new treatment, as in the extremely high costs of new immunotherapy treatments for cancer? How will the excitement over new treatments affect costs?

Dr. Amstutz emphasized that the length of a health episode affects the total cost of care and the value. Discontinuities in the payer source can occur during lengthy health episodes.

Dr. Goldmann asked the NAC members to consider the extents to which policy drives research and research drives policy. Paying primary care physicians for performance appears not to have lasting effects on performance. How should AHRQ respond to such results? Should it seek to perform research that will inform policy? Dr. Chesley added the question of how data and analytics inform policy. Research timelines and new policy timelines differ. Dr. Lauer stated that new data resources and platforms and systematic reviews are critical parts of such considerations.

Dr. Savitz cited the importance of context in talking about value. Issues such as social determinants and scope of a problem are parts of the equation, which includes policy.

Dr. Goldmann proposed the creation of a NAC subgroup to consider the topic of value. The subgroup could address issues such as values, value, equity, and population health. The proposal was seconded and approved unanimously by the NAC members.

Dr. Dittus encouraged AHRQ to find ways to leverage its resources, for example, by partnering with healthcare systems to spread dollars in meaningful ways. He expressed enthusiasm for the subgroup idea.

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Update on AHRQ Support of Secretarial Priorities: Drug Pricing

Steven C. Hill, Center for Financing, Access, and Cost Trends, AHRQ

Dr. Hill discussed issues in drug pricing, as they are being considered and addressed by AHRQ. Today Americans are facing rising drug prices and out-of-pocket costs, especially for specialty drugs and for generic drugs that have little or no competition. HHS is seeking to address the problem by increasing marketplace competition, negotiations, incentives, and transparency regarding out-of-pocket costs. The Food and Drug Administration is supporting a drug competition plan and a biosimilar drug plan. Medicare Part B is including an international price index model for drugs. The Centers for Medicare & Medicaid Services (CMS) is planning to require list prices in drug advertising.

MEPS is collecting and disseminating representative prescription drug data. The Agency is supporting research on prescription drug expenditures and out-of-pocket costs. HHS Secretary Azar has assembled a workgroup on drug pricing for which AHRQ is performing data analyses. Strengths of the MEPS outpatient prescription drug data include the contribution from all payers and people without drug coverage, pharmacy-reported payments and sources, details on drugs themselves, conditions treated by the drugs, and patient characteristics (income, education, health status). MEPS does not report on drugs administered in hospitals.

Dr. Hill presented graphs of trends in drug prices, out-of-pocket payments, and drug types (single source, multisource, etc.). For the year 2016, the average out-of-pocket payment for one pill of a single-source brand name drug was $4.24. In that year, the average out-of-pocket payment for one pill of a generic drug was $0.24. For drug expenditure by type of drug, the decade from 2005 to 2015 saw regular yearly increases in the percentage of older multisource drug prescriptions (compared with new multisource and all single-source drug prescriptions). MEPS plans to track changes in price discounts and markups over time, to assess the capacity of MEPS for studying the role of specialty drugs, and to describe attributes of the various consumers in the distribution of drug spending practices.

Dr. Hill asked the NAC members to consider how MEPS prescription data may become more useful and to suggest new research on drug prices.

Discussion

Dr. Savitz proposed that MEPS analysts consider the growing population of people with dementia, who tend to experience changes in health insurance status and require very expensive drugs.

Dr. Bradley wondered whether MEPS analysts are able to drill down and obtain information on whether specific payers are doing better jobs at holding costs for consumers. Can they estimate the appropriateness of prescribed drugs—for example, expensive cancer-therapy drugs? Are rising prices causing increases in disparities? Can AHRQ measure the impact?

Dr. Masica stressed that the specialty aspect is a large problem for costs in health plans. He stated that comparative effectiveness reviews and guidelines can help with the cost problem.

Dr. Atkins suggested that MEPS analysts study ways to address the great expense of specialty drugs for cancer as well as new drugs for chronic diseases (hypertension, diabetes). AHRQ could study patterns of use and identify cases of overprescribing. The Agency could study how the States feature different approaches regarding drug formularies. Which States and methods have been more effective in controlling costs?

Dr. Amstutz cautioned about drug data that have been collected only for a short term. Dr. Lauer referred to the fact that the MEPS lacks data on drugs given in a doctor’s office, such as the new anti-inflammatory drugs. What proportion of the overall expenses might that be? Dr. Hill responded that CMS has analyzed Medicare Part B claims data, which suggested a low percentage from specialty drugs.

Dr. Goldmann asked whether the MEPS samples certain demographics, such as rural people. Dr. Hill responded that the survey does oversample some populations, including rural. It follows standards for response rates and is an in-person survey. The capacity to drill down, however, is limited. Some subpopulations are excluded from the survey (prisons, homeless, etc.).

Dr. Goldmann noted that the MEPS does not indicate who should or should not be taking a particular prescription drug. He suggested that the procedures for signing up for Medicare Part B are fairly inscrutable for most people. He suggested that a Pareto chart be used to stratify people by persona. Adding prescription drugs to the chart could reveal what accounts for disproportionate spending. Dr. Goldmann encouraged user-centric ways of looking at the data. One goal is for AHRQ to be clear about setting policy.

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Open Discussion on AHRQ Support for Secretary Azar's Priorities

Director Khanna asked the NAC members to consider further the Secretary’s list of priorities, noting that AHRQ is working to align its resources with the priorities to advance them. The Agency is seeking to deploy properly its competencies in a healthcare ecosystem featuring digital technologies, always respecting the goal of safety and quality. AHRQ’s focus is on care rather than cure. Dr. Goldmann suggested envisioning a matrix, featuring competencies and priorities. Where are the gaps?

Dr. Bradley asked how the idea of health equity can fit into efforts to conduct research on healthcare. Dr. Chesley responded that the idea of equity is a core concern and cuts across the competencies and priorities.

Dr. Amstutz asked the group to consider where critical data will exist in the future. Dr. Hernandez-Boussard called on AHRQ to leverage its large datasets and to identify additional data sources and types, in particular, to get at social determinants of health. Mr. Khanna noted the importance of the aging population and chronic conditions.

Paul McGann stated that CMS has learned from working with quality improvement programs that providers need to adopt a data culture in which their use of advances in health information technology will be adapted to their personal measurement capacities. It would be helpful if providers were not fully dependent on external sources of data (CMS or AHRQ data).

Dr. Atkins encouraged AHRQ to study ways to embed research in the healthcare system, causing healthcare workers to develop and employ research skills daily. The new K12 award is a good move forward. Dr. Lauer noted the National Institutes of Heatlh’s All of Us Research Program that is collecting large amounts of data on lifestyles, environments, and biology. Perhaps the program can lead to a platform for health services research.

Dr. Masica encouraged AHRQ to address the issues of healthcare culture, provider burnout, and measurement fatigue. Dr. Morton added the idea of bringing relevant research to the patient without being obstructionist.

Dr. Savitz stressed a need to develop standard measures of social determinants of health and to develop ways to use the measures in practice. Barbara A. Fain stated the importance of leadership and the development of incentives.

Dr. Goldmann suggested looking at AHRQ’s priorities through a lens of equity. Perhaps we could create or envision personas and simulate them. That idea could be applied in an area such as the opioid problem. Various lenses might be applied. We must acquire and apply the appropriate competencies and advance the learning health system idea.

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AHRQ Partnerships

Dr. Goldmann introduced a final discussion session on AHRQ partnerships, a topic that was raised at the previous NAC meeting. A goal was to offer advice to the AHRQ staff. Dr. Goldmann put forward the following questions:

• What types of organizations should AHRQ pursue for partnerships as it undertakes new research challenges, such as reducing diagnostic errors?
• What form will an innovative partnership take in the growing digital healthcare landscape?

Dr. Chesley stated that some AHRQ partnerships are strategic, and others are opportunistic. Partnerships can bring different competencies to bear and leverage them. The new learning system K12 program is an example of strategic partnering, featuring the training of future researchers. The key to all partnerships is movement toward a goal. Dr. Chesley asked the NAC members to consult a handout that described a number of AHRQ partnerships. These included external (outside Government) and internal (inside Government) partners. Dr. Chesley cited one example—a CMS and AHRQ program to study quality in the Federal Children’s Health Insurance Program—pointing to the competencies and common goals for CMS and AHRQ and how they complement each other. The program has continued for 8 years.

Dr. Masica asked about partnerships with the U.S. Department of Defense. Dr. Chesley responded that AHRQ does not have many partnerships with U.S. Department of Defense, although there is AHRQ’s successful TeamSTEPPS training program for healthcare teams.

Considering public/private partnerships, Dr. McGann stated that CMS begins the process of development by initially ignoring components of the system and instead focusing on desired outcomes and aims. That leads to proposals and contracts. Dr. Chesley added that AHRQ partnerships are entity neutral and begin with a memorandum of understanding that features consideration of issues including confidentiality, conflicts of interest, and what the partners bring to the table. Dr. Goldmann suggested that a use case would be helpful for the NAC members.

Dr. Amstutz asked about the types of organizations that AHRQ pursues for partnerships. Are capacities for dissemination and knowledge considered? Dr. Goldmann noted that sharing tools and intellectual property can be difficult. Others noted that some partners share tools readily.

Dr. Morton noted AHRQ’s challenge to show relevance and uptake and asked which types of partnerships have been best regarding dissemination of results. Dr. Chesley responded that there is a challenge to develop specific metrics. Howard E. Holland of AHRQ also responded, stating that the most productive partnerships for AHRQ involve a stakeholder who will use the research results in identifying a need and addressing it. The Agency will seek to measure uptake and use. Its impact case studies program is examining specific examples. It is working with many professional societies.

Dr. Savitz noted the work in rural areas by the Area Health Education Centers and the possibility of partnering in terms of collected data.

Dr. Atkins wondered whether AHRQ uses cooperative research and development agreements in its partnering. It is important to be careful what you are looking for in a partnership. Sometimes resources or simply funding are important; sometimes the key is a vehicle for what is to be developed. Dr. Goldmann added the importance of defining the purpose and taxonomy of the partnership. There are gradations in the levels of involvement in partnering.

Dr. Hernandez-Boussard asked how AHRQ might leverage current partnerships to acquire new or additional data. Perhaps it could collect other types of data from State agencies (education, food stamps). Such data might augment data already collected by AHRQ’s programs. It was noted that about two-thirds of AHRQ partners are State agencies. AHRQ asks these partners to inform it of any new data collections that might be relevant.

Dr. Goldmann wondered where AHRQ health services research fits in the distribution of Federal funding. Which Agency is defining the social determinants of health today? Will the Center for Medicare and Medicaid Innovation call on AHRQ to help? Dr. McGann noted the potential for interagency agreements.

Dr. Goldmann noted the perinatal care partnership, in which AHRQ is working with HRSA, and wondered about AHRQ’s role (evaluation methods?). He asked about the diagnostic error initiative and how it fits into the broader effort underway. He suggested that AHRQ develop a pitch or brief statement of its potential contribution to and role in such initiatives. What is the Agency’s standard approach and unique capacity in a partnership? This Agency brings the care perspective.

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Public Comment

There were no public comments.

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Chair's Wrap-Up and Adjournment

Dr. Goldmann and Director Khanna thanked the NAC members and speakers for their input and an energizing conversation. Dr. Goldmann suggested that the members continue to consider development of a brief pitch for the Agency. He noted that the next NAC meeting will take place April 11, 2019. He adjourned the meeting at 2:30 p.m.

Respectfully submitted,

Donald A. Goldmann, M.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality

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