Director's Corner

The Digital Healthcare Research Program at AHRQ provides foundational research to ensure that digital healthcare systems are designed and implemented in ways that improve quality and safety, while not resulting in excessive burden on physicians and other members of the care team. Current research areas include usability, consumer-focused digital healthcare, clinical decision support, safety, patient-reported outcomes, and care transitions.

Current Priorities

Usability

AHRQ’s usability research focuses on how to design and implement digital healthcare systems so that they are more intuitive and safe to use and more readily support healthcare workflow. Two areas of research, supported by the AHRQ-funded projects below, are how usability issues can affect patient safety and how clinical data can be made more usable for clinical decision making.

Dr. Raj Ratwani and his team at Medstar Health Research Institute explored how EHR usability can adversely affect safety among pediatric patients, using data from three large academic healthcare institutions. They found that over a five-year period, more than one-third of the medication-related patient safety reports in the study were due to EHR usability issues.

Reviewing clinical notes, a necessary part of making diagnostic and therapeutic decisions, is hindered by many factors including the sheer volume of electronic clinical data in the EHR and limited time to interact with patients. Dr. Foster Goss at the University of Colorado Denver developed an NLP search tool that automatically identifies and ranks relevant clinical information based on a patient’s presenting complaint within the ED setting.

Consumer-focused Digital Healthcare

Increasingly, innovative computer and information systems are being developed to help people manage health concerns, monitor important indicators of their health, and communicate with their caregivers. AHRQ supports research to determine how these patient-facing technologies can best improve the quality and effectiveness of care.

For example, recognizing the importance of symptom management in at-risk populations, Dr. Rebecca Schnall and her Columbia University-based research team developed an mHealth app, called the mobile Video Information Provider (mVIP), with evidence-based self-care strategies that guide people with HIV in self-managing their HIV-related symptoms. mVIP use was associated with an improvement in symptoms, high user satisfaction, and a self-reported increase in medication adherence. Persons who had access to mVIP’s care strategies reported less anxiety, depression, fevers, neuropathy, and weight loss than persons who did not have access to the care strategies.

Also, Dr. May May Leung found that reducing childhood obesity in urban, minority youth may be aided by age-appropriate, mobile-enabled dietary self-management interventions. Technology-based interventions focused on dietary behavior change can allow users to engage with culturally-relevant and tailored health information on their own time, at their own pace, and in their preferred environment.

Clinical Decision Support

Clinical decision support (CDS) makes new and targeted evidence available to clinicians, other care team members, and even patients, facilitating their ability to act more readily on this information. We know that CDS, when inappropriately implemented for clinicians, can lead to alert fatigue, high override rates, and physician frustration. When effectively implemented, CDS provides the right information to the right audiences in the right ways and at the right times. AHRQ has a long history of investing in research about how to make CDS more effective and usable. In 2016, AHRQ embarked on an ambitious multi-component program to advance patient-centered CDS and to make CDS a more effective tool: to help advance research evidence into clinical practice and to help make the right thing to do, the easy thing to do.

AHRQ has created a platform called “CDS Connect,” which makes developing and sharing interoperable CDS easier. Contributors can disseminate and share their CDS through the platform, while others can reuse and adapt the CDS for their own settings. Through CDS Connect, a community of CDS developers and implementers can build on each other’s experiences so that the CDS is improved for everyone.

Safety

Research is needed in two key areas: how health IT can improve patient safety and how health IT itself can be safely used and implemented. AHRQ-funded research provides critical evidence in both areas.

For example, research by Dr. Gordon Schiff, Associate Director, Center for Patient Safety Research and Practice, Brigham and Women’s Hospital, developed and pilot tested a prototype CPOE system that incorporated indications into the prescribing process. Providers testing the prototype CPOE correctly placed medication orders 95 percent of the time, compared to 61 percent and 85 percent with two commercial systems.

Research by Dr. Jason Adelman, Chief Patient Safety Officer and Associate Chief Quality Officer at Columbia University Medical Center, suggests health care systems have flexibility in configuring the number of simultaneous, open records by individual clinicians without affecting the likelihood of wrong patient errors.

Health systems need such practical research evidence to guide policy decisions when implementing EHRs, especially when those policy decisions can impact efficiency and patient safety. The Digital Healthcare Research program recently renewed a special emphasis notice reaffirming the intent to support research regarding the safety of health IT systems.

Patient-Reported Outcomes

The patient’s perspective is central to healthcare decisions affecting prevention, diagnosis, treatment, and long-term care. Patient-reported outcomes (PROs) offer a complementary perspective to that of clinician assessments, and may provide greater insights into health status, function, symptom burden, adherence, health behaviors, and quality of life. While some EHR systems are currently able to capture some structured PRO data, such information is not commonly collected and integrated at the point of care. Thus, PRO data are not routinely available for clinical care, research, and quality improvement.

AHRQ released funding opportunities to advance the collection and use of PROs through the implementation of new health IT strategies as well as scaling and spreading successful health IT models. In addition, AHRQ also conducted a project to develop and pilot test user-friendly applications that incorporated Fast Healthcare Interoperability Resources technical specifications to collect standardized PRO data.

Care Transitions

Transitions of care are the movements of patients between providers or clinical settings which typically occur when primary care providers refer patients to specialty care, or when patients are discharged from the hospital to subsequent care settings. Poorly managed transitions can lead to costly, unsafe, and low quality health care. Additionally, deficient care transitions expose some of our health system’s most vulnerable patients to a high risk of complications, emotional distress, and hospital readmissions.

AHRQ’s Digital Healthcare Research program is exploring how the digital healthcare ecosystem can best support organizations, health professionals, patients, and family-caregivers during care transitions. For example, Dr. Michael Usher and his team from the University of Minnesota are conducting research to generate best practices on how to coordinate the care of patients during inter-hospital transfers. Also, Dr. Anuj Dalal from the Brigham and Women’s Hospital is conducting research on the use of an interactive, patient-centered discharge toolkit that will improve provider and patient communications, patient engagement, and self-efficacy during transitions from the hospital to ambulatory settings.

Additionally, AHRQ hosted a free national Web conference on care transitions in September 2019. The presenters discussed their work on smartphone-based applications to improve care coordination, an interactive patient-centered discharge toolkit to promote self-management, and the role of clinical decision support in improving care transitions for patients with multiple chronic diseases.

AHRQ recently issued a funding opportunity to solicit investigator-initiated research to improve the quality of care and patient outcomes during care transitions.

The Division's Past Achievements

Since 1968, AHRQ has invested in research grants and contracts awarded to over 289 distinct institutions in 48 States, the District of Columbia and Puerto Rico, producing foundational work on many uses of IT to improve health delivery including telemedicine, health information exchange, and e-prescribing.

Select examples of some of the many contributions of AHRQ’s health IT work follow.

Telehealth

Telehealth can extend patient care by enabling clinicians to engage with patients or with other teams of clinicians remotely when they cannot meet in person. Project ECHO developed and evaluated a tele-consultation platform to provide clinical support to rural primary care physicians to help them to care for complex patients. Through Project ECHO, rural physicians were able to care for patients with Hepatitis C, achieving outcomes equal or exceeding patients cared for at an academic medical center. The model has been expanded to provide specialty consultation to primary care teams caring for people with asthma, heart failure, chronic pain, mental health conditions, and complications of pregnancy. The VA is now implementing Project ECHO across the country to improve access to quality care.

Health Information Exchange

Health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers, and patients to access and share a patient’s medical information electronically across organizations and systems, for example between the emergency department and physician’s offices. This can enable better coordination of care and increased safety. AHRQ funded the first large-scale demonstrations of HIE in the United States. The projects developed best-practices regarding all aspects of HIE including establishing health information organization, technical considerations for implementation, and demonstrating value. These projects laid the foundation for national health information exchange efforts and informed the ONC State HIE grant program. There are currently active HIEs in many states, and the success of these HIEs is due to the lessons learned from AHRQ’s investments.

E-prescribing

E-prescribing allows clinicians, pharmacies, and health plans to communicate prescription information electronically, which can make coordinated care safer and more efficient. AHRQ funded the evaluation of a statewide program that implemented an e-prescribing system that indicated whether medications were covered by insurance and found it to be cost saving. Another project developed an electronic system to create and securely transmit prescriptions for controlled substances. This research was used by DHHS and the Drug Enforcement Agency (DEA) to issue national e-prescribing standards for controlled substances, resulting in over one billion electronic prescriptions in 2014 and allowing e-prescribing of controlled substances in 49 States.

Clinical Decision Support

Clinical decision support (CDS) brings together patient-specific information with different treatment options in a way that allows clinicians and patients to choose the most appropriate care. AHRQ-funded demonstration projects created processes and tools for translating clinical knowledge and narrative guidelines into formats that can be used by multiple EHR systems for implementing CDS across a range of health care settings. One team implemented evidence-based guideline recommendations that address coronary artery disease, diabetes, and hypertension management; while another focused on prevention of pediatric obesity and chronic management of asthma for children. The tools, standards, and technology created by these demonstrations are being used by ONC and have become the basis for health IT standards established by ONC to make it easier to share CDS between systems.

Learning Health Systems

AHRQ’s previous work in this area helped individual patients and their doctors find answers to questions by pioneering innovative ways to gather and analyze multiple sources of health care data for evidence about what works. The Inflammatory Bowel Disease Registry (ImproveCareNow), as part of the AHRQ-supported Enhanced Registries grant program, improved health outcomes in children with inflammatory bowel disease. The remission rate of children in the registry improved from 55 percent in 2007 to 79 percent in 2015, enabling thousands of children to attend school more regularly, actively engage in sports, and overall improve their health and well-being. Use of these data also enabled 49 percent of these children to sustain remission for at least 1 year and 94 percent have achieved satisfactory growth. Another example, the AHRQ-supported Surgical Care and Outcomes Assessment Program (SCOAP)/CERTAIN project produced a safety and quality checklist for the operating room, which is being implemented in all hospitals in Washington State. The sharing of surgical checklists, and clinical data about procedures and outcomes, among Washington hospitals involved in SCOAP has resulted in reduced complication rates, shorter stays, and fewer 30-day rehospitalizations.

Distributed Research in Primary Care

Distributed research allows information to be shared across organizations without sharing data, which improves our understanding of barriers to care delivery and ability to test solutions that improve quality of care. AHRQ pioneered a distributed research network in primary care through the DARTNet project funded in 2006. DARTNet demonstrated the feasibility of using routine clinical data collected in EHRs in diverse primary care sites for comparative effectiveness research in diabetes and depression. Although the United States Preventive Services Task Force (USPSTF) has recommended screening for depression in primary care for many years, few practices have implemented this recommendation. DARTNet customized screening for depression to workflow of each practice site. The customization enabled a majority of DARTNet practices to continue with depression screening even after the end of AHRQ support for that project. AHRQ’s initial investment to create the DARTNet network met a critical need and led to its rapid growth independent of AHRQ. DARTNet has grown into a non-profit institute that now supports 12 research networks that offer access to approximately 12.5 million patient visits per year, five million patient lives, and five billion data points. These networks blend quality improvement, effectiveness, and translational research with a data driven-learning system. It is important to note that several networks focus on under-served patients including SAFTINet, Appalachian Research Network, and LA Net.

Creating Learning Communities

The Electronic Data Methods (EDM) Forum supported a learning network of researchers, clinicians, informatics experts and other stakeholders. It developed new open-access resources (e.g., eGEMs journal, issue briefs, Webinars, toolkits, Web sites) to share innovations and lessons learned, and to advance methods by supporting small-scale, rapid turnaround collaborative methods projects. The EDM Forum has also created several resources to improve governance of data and information for research and quality improvement, including a governance toolkit. Among the achievements: eGEMs, less than 3 years old, is now in PubMed Central and has over 58,000 downloads and over 100 papers; the patient-centered portable consent project led to an e-consent module, which is present in all five applications of Apple’s ResearchKit.

Current AHRQ work builds on this extensive body of evidence to support projects that develop, evaluate, and scale digital healthcare systems interventions that facilitate practice improvement and better patient outcomes.