Question and Answers (Q&A) Session: Transcript
Town Hall Meeting at the AHRQ 2007 Annual Meeting
September 27, 2007
Carolyn Clancy:
Well, thanks to a terrific panel, and now we're going to move to the part where you get to ask questions. I should have told all of you, the panel knows this, that we're actually taping these sessions for the people who wanted to register for this conference and we had to tell them, "Not this year, but stay tuned for our next AHRQ-a-palooza." So we have microphones throughout the room, and we will be asking you to identify yourselves. So, any of the panelists are open to questions.�
While you're gathering your thoughts, let me just comment on a few things I heard. First, Dan, I do have to say, you probably give the most quotable comments here, "tweaking ourselves to glory" and "gloriously mediocre." I think those are phrases I'll use with full attribution, of course. I think we heard some very important themes about the power of collaboration, about the power of transparency in information, about the power of activation, and also about how challenging that is. I think all of us recognize that activated consumers and patients can be a very powerful game changer, but actually getting people over that hurdle and getting information that is accessible and understandable to them is tricky. And we heard a lot, particularly from Tom, about the power of shared learning. I think we've also heard from these five people about their capacity to just say, "Well there isn't a path, but we're just going to make one." And I think that that is an experience that many of us are going to have to share, and I think that our next big transition is going to be try to figure out how do we hard wire some of this, so Jeff, I'm deeply impressed with the Virginia initiative, but at the same time, it feels like something that was done outside of our usual structures, and the question is, "How does that become sort of a cost of business, ultimately?" Because this is the business that we're in.
I see a couple of people standing up, so I'm going to turn to the microphone here. If you could just identify yourself.
Barbara Fahmy:
Hello, I'm Barbara Fahmy. I'm with the Division of Worker's Compensation in Colorado. And, I have to tiptoe here a little bit. I have a suggestion for the speaker from the Marriott... I'm sorry I didn't get your name. [Dr. Clancy: Jill Berger.]� I'm sorry? [Dr. Clancy: Jill Berger.]� My suggestion is that when you hire on new employees, try to think of each employee as a potential patient and at employee orientations, when people are very enthusiastic about their jobs and very alert and everything like that, bring forth some simple preventive measures for their own care, so they can take ownership into their own care. For example, things like the dangers of overdosing on over-the-counter medication. When you go to the doctor or nurse, it's okay to have a list of questions and have those questions answered.� Hands-on training of proper lifting and demonstrating the ability to lift properly. That's probably big for those who work at hotels. And not just where to go if you get hurt on the job, but what should you do? What does an incident report look like? What kinds of things should I be reporting? What time did this injury occur, etc.? So, it might be a good way to attack it at the beginning before it occurs. So, that's my suggestion.
Jill Berger:
Great suggestion, thanks.
Ann Barber:
Hello, I'm Ann Barber from Providence Hospital. Thank you for your comments about transparency, and can you give us some guidance on how to take the first steps?� For instance, there's an Asian concept of saving face, and I struggle with how do you protect individual egos from feeling hurt, and how do you still help everybody understand the benefits of transparency?� Thank you.
Carolyn Clancy:
Dan?
Dan Varga:
It's a great question, and I think that to talk about some constituency groups.� When we took this initiative in both settings in which I worked, we took this to the medical staff.� The first thing that we made clear was that there was no individual reporting associated with this, that health care is a team sport.� It's a combination of physician clinical competence and hardwired processes and the capital and the technologies that the facilities bring together, and so forth.� So, we started off saying this was going to be a collective report.� There was going to be no individual-level reporting.� What's interesting about that is that, as we started to work through the report, the demand for individual-level information was overwhelming.� And in fact, to be quite honest, while in neither situation have we had to add a lot of FTEs as we built the report, what we've had to add is data capacity to be able to meet the demand of nursing units, physicians, physician groups asking for their own personal data, so that they can look and see how fit into this milieu—how they can contribute to the overall improvement and performance.� So, I think the first thing was that we made it clear it was a collective effort, number one.� So there's really no "blaming" here.
The other piece of it, was to make sure that we understood that we weren't singling out the organization for any sort of particular or specific level of performance in the get-go.� Everything we did had to be a comparative indicator.� So, I mean, I can tell you that getting over the face-saving piece—getting over the initial fear of this—it's pretty easy when you sit down and look at the fact that you're, you know, AHRQ patient safety indicator #13 on postoperative sepsis that your rate was four times the national average.� People don't feel very good about that, but there's also a dramatic move very quickly to improving that indicator.� So, I think the big take-away on that is make it a collective initiative.� Don't make it an individual-level initiative.
Carolyn Clancy:
Over here on this microphone.� Yes.
Joe Carter:
Hi, I'm Joe Carter from Vanguard in Boston.� I'm sorry to keep peppering Dr. Varga with questions here, but that aspect of experiencing other organizational unintended consequences that came out of doing this kind of transparency—have you found other things outside from analytic requirements in terms of either gaming or anything else that's starting to happen from that kind of transparency? And then second, have you moved it along to high excellence incentives around performance at individual levels?
Dan Varga:
Sure, I'll take both of them.� I think we have all seen in the public reporting arena the issues around unintended consequences and, you know, as we're looking at the core measures now, we're looking at, you know, the antibiotics for pneumonia and the timing for that, and so forth, but... one of the reasons, I think, to be quite honest that we made the big report, was, not to say it again, but it prevents you from trying to tweak yourself to a higher-level performance.� You actually had to deal with the big indicators.� And I think that what we ultimately found with that is that you have to develop a certain dexterity, looking at this big indicator set and finding out how these things map back and where you can get the ultimate leverage around that. And I think that that drives it far more down to the process level as opposed to the indicator level.� So the big report, I think, helped us avoid that.� Relative to getting to individual incentives, I was talking with Jeff before the session.we had a catastrophe in St. Louis around cardiovascular surgery, and a couple of the big groups blew up, so we had to "employ" our cardiovascular surgeons to keep the program together. It's about a 1,000 heart program a year, but we've got 50 percent of the compensation of this cardiac surgery group based entirely on their performance against the STS database, and how they performed internally.� To be quite honest with you, we really didn't have a lot of pushback on that.� I think there's a lot of comfort around that database, and the folks are good with it.� I think we're going to see an incredible improvement in our cardiovascular surgery program there, but yeah, I think you can start to push that down pretty quickly.
Carolyn Clancy:
Here?
Perry Cohen:
Thank you.� My name is Perry Cohen and I'm with the Parkinson Pipeline Project, which is a patient-advocacy organization, grassroots. I'm also a participant on the working group for evidence-based health care, which is a coalition of 45 patient organizations that are interested in getting involved with health services research and some of the things you're talking about. I thank Carolyn for all her support for the patient perspective and, of course, patients are critical for developing the clinical research as participants in research.� But we're more than rats, and so we want to be at the table when the policies and decisions are made also.� My question has to do with the use of information technology for self-help and patient empowerment, and one of the speakers was from Medicaid, and he mentioned the challenging population. I want to ask him if he felt that this population would be ready or how he might like to address the issue of information technology support for this population considering they might not have computers or Internet access or some things that those of us who have become empowered through the Internet enjoy.� Thank you.
Carolyn Clancy:
Tom?
Tom Kline:
Well, talking about information technology as it applies to members is certainly a difficult situation and challenging in the Medicaid population.� When we first began our first disease management program, which was asthma, we identified approximately 2,500 members, which we thought were our greatest risk, were having hospitalization or E.D. visits, and of that 2,500, unfortunately, we were only able to reach about 300 because of availability of telephones for our population, not necessarily Internet.� We tried writing them, and we wrote 1,000 letters, and we got 18 responses, so communication's a very, very difficult, challenging situation for us.� The Internet—we have developed, at the Medicaid office, a Medicaid electronic record system where we've made information available to providers.� Currently, it's not available to members, but that would be one of the next steps that we'd like to pursue.�
Did you actually mention something about behavioral health issues?
Perry Cohen:
Did I?
Tom Kline:
Well, our behavioral health provider is a carve-out from the Medicaid program, and we have access to encounter information, but not necessarily any kind of behavioral health utilization information.� In our particular population of membership, I don't see information technology from the patient or member's perspective being an important issue at this time.
Perry Cohen:
Okay—thanks.
Carolyn Clancy:
I think I would just add one thing to that, based on some of the work that we have funded for people with selected illnesses where they need information and when they're under a lot of active treatment. We have certainly funded a lot of centers that have included and enrolled folks very similar to your population; people who didn't have their own computers, people who often didn't have phones and so forth. But if you're being actively treated for HIV, for example, you've got some incentive to be part of this and so, in an isolated project-specific basis that seems to work.� I think we're going to need to make a distinction between that kind of approach where we know that at least under some circumstances it can work and a scaleable approach that gets everyone actually recognizing that being informed about your care is part of what it's about.�
Tom Kline:
One of the things we have tried to do is, our Department of Public Health has a presence in 98 or 99 counties in Iowa, and they also have Internet access.� We were trying to develop a health-risk assessment tool for our entire population, and the strategy was to involve the Public Health Regional Offices and bring patients to the Public Health to give them access to the Internet and the information.
Carolyn Clancy:
Thank you.� One more question?
Maureen Street:
Hi.� I'm Maureen Street, and I'm a medical director in Community Health Center in Michigan, and I have a question for Dr. Kline.� Can you comment on the impact that the Medicaid HMOs, in particular the for-profit Medicaid HMOs, have on your ability to do case management?
Tom Kline:
Sure. HMOs in the State of Iowa does not have a large presence.� A few years ago, we had three managed care organizations that provided services to the Medicaid population, and it was a total of about maybe 15,000 members.� Currently, we have one with about 5,000 members.� Again, it's a situation of collaboration.� I know the medical director for the Medicaid managed care very well, and when we've instituted our disease management program, we included many of the elements that they had in their disease management program, so it would not be different, and the Medicaid population would be getting consistent care.� Unfortunately or fortunately, except for our primary care case management program, managed care doesn't have a big issue in Iowa.
Maureen Street:
Thank you.
Carolyn Clancy:
Well, I'm sure that all of you share my sense of inspiration and hoping to run and to catch up with some of the efforts that we've heard here.� So I hope you'll join me in thanking the panel for a terrific conference.
Current as of July 2008
Internet Citation:
Question and Answers (Q&A) Session during the Town Hall Meeting at the AHRQ 2007 Annual Meeting, September 27, 2007. Video transcript. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/trqa092707.htm
